Every finding on record at The Waters of Clinton, LLC

Based on facility policy review, observation, and interview the facility failed to maintain a clean and sanitary kitchen which had the potential to affect 90 of 90 residents of the facility.The findings include:Review of the facility's policy titled, Labeling and Dating, dated 7/30/2023, revealed .leftovers and opened foods shall be clearly labeled with date food item is to be discarded .Review of the facility's undated policy titled, Equipment Cleaning and Sanitizing revealed .Equipment is washed, rinsed, and sanitized after each use to ensure safety of food served to residents .Employees who use equipment will be responsible for washing and sanitizing removeable parts after each use. Steps include .Disassemble removable parts from equipment .wash, rinse, and sanitize all food contact surfaces and the equipment that are sanitary .During an observation and interview on 9/21/2025 at 10:30 AM, 6 sandwiches in plastic bags identified by staff as peanut butter and jelly were in the kitchen refrigerator. Continued observation revealed 5 of the 6 sandwiches were unlabeled and undated. The Dietary Manager (DM) confirmed 5 of the 6 peanut butter and jelly sandwiches were unlabeled and undated and were available for resident use.During an observation with the DM on 9/21/2025 at 10:40 AM revealed the following:a. Debris was observed in and on the commercial can opener next to the cutting blade. b. The ice machine drain extended inside the rim of the floor drain; the ice machine drain tubing had a thick black substance inside the drain matching the appearance of the substance inside the floor drain. c. 108 eggs stored on a bottom shelf in the kitchen refrigerator and were uncovered. Desserts, fruits and vegetables were stored on shelves above the eggs.d. Dirt and debris were observed on the floor behind the dry food storage room, the ice machine, and under the dishwasher.e. There was a buildup of grease with a collection of lint and hair on 3 of 3 of the fire suppression piping located directly above the stove. During an interview on 9/21/2025 at 10:40 AM, the DM confirmed the facility failed to maintain a sanitary kitchen.

Based on facility policy review, medical record review, and interviews, the facility failed to obtain consent for administration of psychotropic medications for 2 of 5 residents (Resident #10 and Resident #24) reviewed for unnecessary medications. The findings include:Review of the facility's undated policy titled, Psychotropic Drugs Usage, revealed .Any resident receiving psychotropic medication will have a signed informed consent for the use of the medication .Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including Severe Dementia with Psychotic Disturbance and Delusional Disorder. Review of an annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #10 scored a 7 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Further review revealed the resident received an antidepressant medication.Review of current Physician Orders for Resident #10 revealed Sertraline (medication used to treat Depression) 25 mg (milligram) at bedtime was ordered on 6/10/2025.Review of the Medication Administration Record (MAR) for Resident #10 dated 6/10/2025 to 6/30/2025, revealed Resident #10 received Sertraline 25 mg daily at bedtime.Review of the MAR for Resident #10 dated 7/1/2025 to 7/31/2025, revealed the resident received Sertraline 25 mg daily at bedtime.Review of the MAR for Resident #10 dated 8/1/2025 to 8/31/2025, revealed the resident received Sertraline 25 mg daily at bedtime. Review of the MAR for Resident #10 dated 9/1/2025 to 9/23/2025 revealed the resident received Sertraline 25 mg daily at bedtime.Review of the medical record for Resident #10 revealed no consent for the use of Sertraline. Review of the medical record revealed Resident #24 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Major Depressive Disorder, Mood Disorder Due to Known Psychological Condition with Depressive Features, Generalized Anxiety Disorder, Adjustment Disorder with Depressed Mood.Review of a quarterly MDS assessment dated [DATE], revealed Resident #24 scored a 12 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Further review revealed the resident received antianxiety and antidepressant medications.Review of current Physician Orders for Resident #24 revealed Alprazolam (medication used to treat anxiety) 0.25 mg two times a day was ordered on 6/16/2025. Review of current Physician Orders for Resident #24 revealed Buspirone (medication to treat anxiety) 10 mg three times a day was ordered on 6/25/2025.Review of current Physician Orders for Resident #24 revealed Sertraline 50 mg one time a day was ordered on 6/26/2025.Review of current Physician Orders for Resident #24 revealed Trazodone (medication used to treat insomnia) 100 mg, give 2 tablets (for a total of 200 mg) at bedtime was ordered on 9/9/2025.Review of the MAR for Resident #24 dated 6/16/2025 to 6/30/2025, revealed the resident received Alprazolam 0.25 mg two times daily. Further review revealed the resident received Buspirone 10 mg three times daily from 6/25/2025 through 6/30/2025, and Sertraline 50 mg one time daily from 6/26/2025-6/30/2025. Review of the MAR for Resident #24 dated 7/1/2025 to 7/31/2025, revealed the resident received Alprazolam 0.25 mg two times daily, Buspirone 10 mg three times daily, and Sertraline 50 mg one time daily. Review of the MAR for Resident #24 dated 8/1/2025 to 8/31/2025, revealed the resident received Alprazolam 0.25 mg two times daily, Buspirone 10 mg three times daily, and Sertraline 50 mg one time daily. Review of the MAR for Resident #24 dated 9/1/2025 to 9/23/2025, revealed the resident received Alprazolam 0.25 mg two times daily, Buspirone 10 mg three times daily, and Sertraline 50 mg one time daily. Further review revealed the resident received Trazodone 200 mg at bedtime from 9/9/2025 through 9/22/2025. Review of the medical record for Resident #24 revealed no consent for the use of Alprazolam, Buspirone, Sertraline, or Trazodone.During an interview on 9/23/2025 at 5:40 PM, the Director of Nursing stated the nurse who admitted the residents to the facility was responsible for obtaining psychotropic medication consents. The DON confirmed the facility failed to obtain consent forms for psychotropic medications for Resident #10 and Resident #24.

Based on facility policy review and interview, the facility failed to ensure the electronic medical records of the facility were protected by using safeguards to ensure the electronic medical records were not available for direct public to view within the facility. The findings include:Review of the facility's undated policy titled, What is HIPAA, revealed .It is the health insurance portability and accountability act of 1996 (HIPAA) .A major goal of the privacy rule is to assure that individual's health information is properly protected while allowing the flow of health information needed to provide and promote high quality health care and to protect the public's health and well-being .Any and all health information on a resident or employee that identifies an individual. This can be in any form, such as paper records, electronic records, and even spoken communication .It shall be the policy of the facility to protect and safeguard the PHI (personal health information) created, acquired and maintained in accordance with the Privacy Regulation pursuant to the Health Insurance Portability and Accountability Act of 1996 .During an observation on 9/22/2025 at 2:20 PM, the south hall medication cart was unattended. The computer atop the medication cart was open, logged into an electronic medical record, and available for the public to view. During an observation and interview on 9/22/2025 at 2:22 PM, Charge Nurse (CN G) stated Registered Nurse (RN F) had .parked the medication cart in front of the nurses' station and went to lunch about 10 minutes ago (2:10 PM) . CN G stated RN F had used the medication cart previously for the mid-day medication administration. CN G confirmed the computer screen had been left open to an electronic medical record and was available for public view. CN G confirmed the facility failed to ensure electronic records were secured and protected.

Based on Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual review, medical record review, and interviews, the facility failed to ensure MDS assessments were accurate for 1 resident (Resident #65) of 22 residents reviewed for MDS assessments. The findings include: Review of the MDS (Minimum Data Set) 3.0 RAI Manual Verson 19.1, dated 10/2024, revealed .SECTION H: BLADDER AND BOWEL .The intent of the items in this section is to gather information on the use of bowel and bladder appliances .provided with individualized treatment .Appliances .INDWELLING CATHETER A catheter that is maintained within the bladder for the purpose of continuous drainage of urine .Health-related Quality of Life .It is important to know what appliances are in use and the history .Steps for Assessment .Check next to each appliance that was used at any time in the past 7 days. Select none of the above if none of the appliances .were used in the past 7 days . Review of the medical record revealed Resident #65 admitted to the facility on [DATE] with diagnoses including Benign Prostatic Hyperplasia, Obstructive and Reflux Uropathy, and Retention of Urine. Review of a Physician's order for Resident #65 dated 11/12/2024, revealed .Remove .cath [indwelling urinary Catheter] after 48 hours .Review of an MDS Note for Resident #65 dated 3/17/2025, revealed .cath [indwelling urinary catheter] has been removed .is occasionally incontinent of bladder .Review of a Nurse Practitioner Progress note for Resident #65 dated 3/31/2025, revealed .History of urinary retention: Resident has been urinating effectively since discontinuation of .catheter .Review of a MDS Note for Resident #65 dated 6/13/2025, revealed .Resident is occasionally incontinent of bladder and bowel .Review of a quarterly MDS assessment dated [DATE], revealed Resident #65 scored a 11 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. Further review revealed Resident #65 had an indwelling catheter. During an observation on 9/21/2025 at 3:19 PM, revealed Resident #65 was sitting in his wheelchair. Further observation revealed Resident #65 had no indwelling urinary catheter in place. During an observation and interview on 9/22/2025 at 3:40 PM, revealed Resident #65 was sitting in his wheelchair. Further observation revealed Resident #65 had no indwelling urinary catheter in place. Resident #65 stated he used to have an indwelling urinary catheter. During an interview on 9/23/2025 at 10:37 AM, MDS Coordinator (MDS C) reviewed the quarterly MDS assessment dated [DATE] and the medical record for Resident #65. MDS Coordinator C confirmed Resident #65 did not have an indwelling urinary catheter during the 7-day look back period (6/7/2025 through 6/13/2025) of the quarterly MDS assessment dated [DATE]. The MDS Coordinator C further confirmed the quarterly MDS assessment for Resident #65 dated 6/13/2025 was not accurately coded. During an interview on 9/23/2025 at 10:42 AM, the Director of Nursing confirmed the facility failed to ensure the accuracy of the quarterly MDS assessment dated [DATE] for Resident #65.

Based on facility policy review, medical record review, and interview, the facility failed to obtain a Physician's Order for isolation precautions for 1 resident (Resident #12) of 16 residents reviewed for isolation orders. The findings include: Review of the facility's policy titled, Infection Control/Isolation Guidelines, undated, revealed .to prevent unprotected exposure of residents, visitors, and staff to potentially infectious microorganisms .to decrease the spread Contact precautions used for multidrug-resistant organisms [MDRO's] [microorganisms, primarily bacteria, that have developed resistance to 3 or more antimicrobial drugs making them difficult to treat with standard antibiotics] .and order must be obtained from the physician .Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including Schizophrenia, Anxiety Disorder, and Major Depressive Disorder. Review of a Laboratory Result reported to the facility on 9/16/2025, revealed Resident #12 had a urine culture which revealed the resident grew out Extended-Spectrum Beta-Lactamases (ESBL) (bacteria is resistant to a wide range of antibiotics) in her urine. Review of a Physician's Order for Resident #12 dated 9/16/2025, revealed .ertapenem sodium [medication used to treat infection] 1 gram intravenously [IV] every 24 hours for ESBL UTI [Urinary Tract Infection] for 7 days . Further review revealed no Physician's Order was obtained for isolation precautions.Review of a comprehensive care plan dated 9/17/2025 for Resident #12 revealed, .receiving IV meds R/T [related to] a UTI . with intervention, .contact precautions per facility policy .During an interview on 9/23/2025 at 1:30 PM, the Assistant Director of Nursing/Infection Preventionist (ADON/IP) confirmed Resident #12 was being treated currently for a UTI with ESBL, and there was no Physician's Order for isolation precautions.

Based on facility policy review, observation, and interview, the facility failed to ensure medications were securely stored in 1 medication cart (North medication cart) of 4 medication carts reviewed.The findings include: Review of the facility policy titled, Medication Storage in the Facility, dated 3/2023, revealed .Medications are stored safely, securely, and properly .accessible only to licensed nursing personnel .Medication rooms, carts, and medication supplies are locked and attended by person with authorized access . During an observation on 9/21/2025 at 1:14 PM, the North medication cart was located in the North hallway against the wall, and the drawers were facing the hallway. The medication cart was unlocked and there were no employees present. During an interview on 9/21/2025 at 1:15 PM, LPN D confirmed she had been in a resident room with the door closed and the North medication cart in the hallway was unlocked, and out of LPN D's view. LPN D also confirmed medication carts are to be locked when unattended by the licensed nurse.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure appropriate Personal Protective Equipment (PPE) was donned for 1 resident (Resident #9) of 16 residents observed on Enhanced Barrier Precautions (EBP), and the facility failed to perform hand hygiene during medication administration for 1 resident (Resident #10) of 4 residents observed during medication administration.The findings include: Review of the facility's policy titled, Guidelines for Enhanced Barrier Precautions, undated, revealed .Enhanced Barrier Precautions (EBP) is defined as the use of PPE (gowns and gloves) during high-contact resident care activities that generate opportunities for transfer of multidrug-resistant organisms [MDRO's] [microorganisms, primarily bacteria, that have developed resistance to 3 or more antimicrobial drugs making them difficult to treat with standard antibiotics] .onto the hands and/or clothing of the rendering caregiver .for residents at high-risk for acquiring or spreading a MDRO .residents with an indwelling medical device including .central venous catheters .examples of high-contact activities include .transferring .providing hygiene-ADL's [activities of daily living] .when engaging in .high-contact resident care activities with a resident .who would be at high-risk .use gloves and gowns .Review of the facility's policy titled, Medication Administration Policy and Procedure, dated 8/2014, revealed .This facility considers hand hygiene the primary means to prevent the spread of infections .Use an alcohol-based hand rub .or .soap .and water .after direct contact with residents .Before donning [applying] .gloves . After removing gloves .Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including End Stage Renal Disease, Dialysis Dependent, Diabetes, and Chronic Obstructive Lung Disease.Review of a Physician's Order for Resident #9 dated 7/16/2025, revealed .Enhanced Barrier Precautions for Dialysis Perma Cath .Review of a Physician's Order for Resident #9 dated 8/12/2025, revealed .RT [right] .Perma Cath . During an observation on 9/22/2025 at 2:25 PM, revealed a PPE bin hanging on the outside of Resident #9's room door, with a Centers for Disease Control (CDC) sign for Enhanced Barrier Precautions, .Providers and staff must .wear gloves and a gown for the following High-Contact Resident Care Activities .Dressing .Transferring .Providing Hygiene . Further observation inside the room revealed Resident #9 was lying in bed with pants part way up the legs. CNA E was at the bedside assisting the resident with the pants. The CNA was wearing gloves but did not have a gown in place. During an observation and interviews on 9/22/2025, a Physical Therapy Assistant (PTA) and a Physical Therapist (PT) entered Resident #9's room at 2:46 PM. The PTA and PT did not retrieve PPE from the bin on the resident's door. The PT and PTA exited the room at 3:12 PM. During an interview, the PT and PTA stated they were providing therapy for Resident #9 including transferring. The PT and PTA confirmed they wore PPE for EBP when providing care for the reason the resident was on EBP, for example wound care, or catheter care. Both PT and PTA confirmed they did not wear a gown when they provided therapy which included transferring for Resident #9. During an interview on 9/22/2025 at 2:52 PM, CNA E stated EBP was to be used for the reason the resident was on EBP such as catheter care or if the resident had a wound. CNA E confirmed Resident #9 was on EBP and the EBP sign on the door stated a gown and gloves were to be worn .for dressing, bathing, and personal hygiene . CNA E confirmed she did not wear a gown when she provided hygiene and dressing for Resident #9.During an interview on 9/22/2025 at 3:25 PM, the Staff Development Coordinator (SDC) confirmed Resident #9 was on EBP. The SDC stated residents with an indwelling device, wounds, catheter, and some other conditions require EBP. The SDC stated residents on EBP only required staff to don gowns for direct contact with the reason for EBP, for example indwelling device care, and open wounds. During an interview on 9/23/2025 at 1:30 PM, the Assistant Director of Nursing/Infection Preventionist (ADON/IP) confirmed Resident #9 was on EBP. The ADON/IP stated residents on EBP only required donning gowns for direct contact with the reason for EBP, for example indwelling device care, care for foley catheters, and care for open wounds. After ADON/IP reviewed the CDC EBP signage, and the facility's policy, ADON/IP confirmed the EBP required wearing gowns for all high-contact care including dressing, transferring, and providing hygiene to protect residents at high-risk of acquiring or spreading a MDRO.Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including Dementia, Diabetes, and Kidney Failure.During an observation of medication administration on 9/22/2025 at 8:20 AM, revealed Licensed Practical Nurse (LPN) D applied gloves, prepared insulin medication for Resident #10, entered the resident's room, checked the resident's blood glucose level, exited the room, did not remove the gloves (dirty gloves), and failed to wash or sanitize the hands prior to exiting the room. LPN D returned to the medication cart, retrieved an alcohol pad, reentered the resident's room, administered insulin, exited the room, removed the gloves and failed to wash or sanitize the hands. LPN D applied gloves, sanitized the blood glucose monitor, removed the gloves, and failed to wash or sanitize the hands. During an interview on 9/22/2025 at 8:30 AM, LPN D confirmed she failed to wash or sanitize her hands during medication administration.During an interview on 9/23/2025 at 6:23 PM, the ADON/IP confirmed LPN D failed to follow proper infection control practices when she failed to wash or sanitize the hands during medication administration.

Based on facility policy review, medical record review, and interview the facility failed to ensure staff arranged for care, services, and provided care for 1 resident (Resident #5) of 7 residents reviewed for quality of care. The findings include: Review of facility's policy titled, Quality Processes for Waters of Infinity Buildings undated revealed, .As a company quality resident care is of the utmost of importance We envision quality as a whole team interactive approach .Effective, coordinated communication between all team members is essential to facilitate resident care to the highest possible standards .It is the responsibility of the CEO and Director of Nursing to set the daily communication standard for the building . Review of facility's policy titled, Transportation Policy and Procedure Manual The Waters Facilities Benchmark Facilities Infinity Health Care Management, dated 4/1/2020 revealed, .Policy .The transport driver will coordinate the schedule for resident transports .The transport driver will keep a schedule of appointments and facilities will contact the transport driver to schedule appointments .If a resident's appointment is cancelled then facility must notify the transport driver immediately in order to get another appointment scheduled . Medical record review revealed Resident #5 was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses including Anemia, Chronic Kidney Disease Stage 3, Rheumatoid Arthritis, and Presence of Right Artificial Knee Joint. Medical record review of Resident #5's hospital's Discharge Summary dated 11/22/2022 revealed the resident had right knee pain and had a right total knee replacement and was hospitalized following the procedure. The resident was transferred to the nursing home on 12/1/2022 for rehabilitation. Medical record review of Resident #5's Discharge Documentation dated 11/29/2022 revealed Resident #5 was discharged from the hospital and transferred to the nursing home on 12/1/2022 with appointments for the following: -12/1/2022 at 11:00 AM lab appointment with an Advance Practical Nurse. The name of APN was documented, address, and contact telephone number of facility was documented. -12/1/2022 at 12:00 PM an appointment for an IV injection. The address of the facility and the contact telephone number was documented (The IV injection appointment was located at the same facility). -12/15/2022 at 12:30 PM, lab appointment. The facility's address and contact telephone number were documented. (The lab appointment was located at the same facility) -12/15/2022 1:00 PM, Resident #5 had an office visit scheduled with an APN. The name of the APN was documented the facility's address and contact telephone number were documented. (The APN office visit appointment was located at the same facility). -12/15/2022 at 2:00 PM, an appointment for an Intravenous (IV) injection (name of medication not listed). The address of the facility and the contact telephone number was documented (The IV injection appointment was located at the same facility). -12/29/2022 at 11:15 AM, lab appointment. The facility's address and contact telephone number were documented. (The lab appointment was located at the same facility) -12/29/2022 at 12:00 PM, an appointment for an IV injection. The address of the facility and the contact telephone number was documented (The IV injection appointment was located at the same facility). Review of Resident #5's five-day Admission Minimum Data Set (MDS) dated [DATE] revealed the resident had a BIMS of 13 which indicated the resident was cognitively intact. Resident #5 required extensive assistance of 2 staff for bed mobility. The resident required limited assistance of 1 staff for transfers. Medical record review of an Administration Note dated 12/5/2022 written by Unit Clerk #1 revealed, .spoke with resident [Resident #5] about upcoming appointments, and resident has to see . Ortho[orthopedic],[Doctor's name] on 12/7/2022 at 1PM, Resident also came with 3 appointments, to [name of the facility] .Spoke with DON [Director of Nursing] about theses [these] appointments, and she was going to call the pharmacy and see if we can do the injections in house .Resident is aware of these changes .Facility will transport resident [Resident #5] to appointment . Medical record review of Resident #5's Care Plan dated 12/8/2022 revealed, . [Resident #5] has Dx [diagnosis] anemia and at risk for altered tissue perfusion . Interventions in place included to monitor labs per medical doctor order and administer medication as ordered. Review of the facility's transportation logbook dated 12/1/2022-12/16/2022 revealed no documentation of Resident #5's appointments dated 12/1/2022 and 12/15/2022 for labs, an office visit, or injections related to her treatment for Anemia and Chronic Kidney Disease. No documentation was noted the resident had been transported by the facility to her appointment on 12/1/2022 or 12/15/2022. There was no documentation noted of Resident #5's missed appointment on 12/1/2022 was rescheduled by the nursing home. Medical record review of Resident #5's physician orders dated 12/1/2022-12/16/2022 revealed no documentation of an order for Resident #5 to receive an injection of Retacrit (a medication used to treat anemia caused by Chronic Kidney Disease) from nursing staff at the facility. There was no order for Retacrit noted. Medical record review of Resident #5's medication administration record dated 12/1/2022-12/16/2022 revealed no documentation Resident #5 received an injection of Retacrit from nursing staff at the facility. During a telephone interview on 1/10/2023 at 9:20 AM, Unit Clerk #1 stated Resident #5 had 3-4 appointments at (named facility) for injections. The Unit Clerk stated he called (named facility) and was informed of the resident's appointments. The Unit Clerk revealed he informed the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) of Resident #5's missed appointment (12/1/2022) and her upcoming appointment on 12/15/2022. The Unit Clerk stated, .I asked the ADON and DON if we can give the injections here .The DON said we can give the injections here at the facility [nursing home] .She [DON] called the Nurse Practitioner and at that point it was out of my hands .The resident's [Resident #5] shot fell through the cracks .I did my part I called [named facility] and told nursing .Once I told nursing it was in their hands . The Unit Clerk confirmed the facility failed to reschedule Resident #5's missed appointments on 12/1/2022 for labs, medication injection and failed to ensure the resident went to her appointments on 12/15/2022 for an APN visit, labs, and an injection. During an interview on 1/10/2023 at 10:15 AM, the DON revealed Resident #5 was transferred and admitted to the nursing home on 12/1/2022. The DON confirmed she was aware of Resident #5's appointments dated 12/1/2022 and 12/15/2022 which was listed on the resident's hospital discharge documentation. The DON revealed the nursing was going to administer Resident #5's injection (Retacrit). The DON stated, .The NP [Nurse Practitioner] was to call [named facility] and get an order to give the medication [at the nursing home] and lab work that needed to be done around 12/5/2022 . The DON stated, .We never got a contact back from [named facility] .No one here[staff] at the facility followed up with [named facility] .I asked the NP, and she didn't follow up with [named facility] . The DON revealed on 12/16/2022 the resident was scheduled for discharge from the nursing home. The DON stated, .On the morning of 12/15/2022 LPN [License Practical Nurse] #1 asked me if the patient [Resident #5] could get their shot [Retacrit injection] today . The DON revealed LPN #1 called (named facility) on 12/15/2022. The Nurse at (named facility) informed the LPN Resident #5 needed lab work prior to her injection. The lab work would determine the dosage of medication (Retacrit) administered to the resident. The LPN was informed by the (named facility) the nursing home could not administrator the resident's injection. The LPN was informed by the nurse at the (the named facility) the resident had an appointment to get lab work done and an injection on 12/15/2022 (the same day of the telephone call by the LPN). The DON stated .We had not set up another appointment because we were going to give her the injection that day on [12/15/2022] .On 12/15/2022 we had no order to administer the resident's injection [Retacrit] . The DON confirmed the resident did not receive any injections of Retacrit from admission on 12/1/2022- 12/16/2022. The DON confirmed the facility did not reschedule the resident's missed appointment on 12/1/2022. The DON confirmed the facility failed to ensure the resident went to her scheduled APN office visit, failed to facilitate the injection visit, or lab appointments from 12/1/2022-12/16/2022. During an interview on 1/10/2023 at 10:44 AM, LPN #1 revealed she admitted the resident on 12/1/2022 and had reviewed the resident's appointments and reconciled the resident's medications on 12/1/2022. The LPN revealed she was aware the resident had several appointments at the (named facility) on 12/1/2022, 12/15/2022 and 12/29/2022. The LPN stated, .I didn't know nothing about the shots [Retacrit injection] until 12/15/2022 the day before she got discharged . I was told by the DON we were suppose to have the medicine [Retacrit injection] in the building .The DON asked me to contact [named facility] . The LPN revealed she contacted the nurse at the (named facility) on 12/15/2022 (1 day prior to the resident's discharge). The LPN revealed the nurse at (named facility) informed her the nursing home could not administer Resident #5's Retacrit injection without lab work. The LPN confirmed the nursing home did not collect lab work on Resident #5 on 12/15/2022 and the resident did not receive a Retracrit injection prior to her discharge from the nursing home. The LPN stated .the 1st appointment she [Resident #5] missed was never rescheduled .The 2nd appointment was missed due to everyone's part due to oversight we missed it .We missed her scheduled appointment on 12/15/2022 . During an interview on 1/10/2023 at 11:23 AM, by telephone, Resident #5 revealed she did not receive her injection of Retacrit while hospitalized prior to admission to the nursing facility on 12/1/2022 and throughout her stay at the nursing home. Resident #5 stated, .They told me when it got there [within a few days of admission to the nursing home] .I had appointment to get my shot [Retacrit injection] and the nursing home would do the shot . The Resident revealed [named person] called the nursing home early in the morning on 12/15/2022 and reminded the facility of Resident #5's appointment and reminded the facility of the resident's injection which was scheduled for 12/15/2022. The resident confirmed she did not receive her injections, lab work, or go to her appointments related to her Anemia and Stage 3 Chronic Kidney Disease. During an interview on 1/10/2023 at 2:33 PM, the NP revealed 4 to 5 days after the resident missed her appointment on 12/1/2022 she called (named facility) and requested (named facility) fax an order for Resident #5's medication (Retacrit injection) to be administered by the nursing home. The NP stated, . [named facility] never responded .I didn't call to follow up . The NP stated, .I don't know if . [Resident #5] can skip the med [medication Retacrit] .I didn't ask nursing staff why she didn't go to her appointment .The resident did not receive any doses of Retacrit while here [at the nursing home] . The NP confirmed she expected the staff to ensure Resident #5 went to her appointments. During an interview on 1/11/2023 at 12:00 PM, the ADON confirmed she was aware Resident #5 had scheduled appointments for 12/1/2022 and 12/15/2022 for lab work, an office visit, and injections. The ADON stated, .I wanted to see if it [Retacrit medication] was something we could give here so she did not have to go out . The ADON revealed she spoke with the DON, and they involved the NP. The NP called (named facility) for an order to administer the medication. The ADON stated, .No one followed up .I would have expected someone [Licensed staff from the nursing home] to call and check [to ensure the resident received her medication] . The ADON confirmed the facility failed to ensure the facility followed standards of practice of care for Resident #5 to receive her lab work, injections, and go to her APN visit. During an interview on 1/11/2023 at 12:15 PM, the DON stated, .We should have gotten the resident another appointment when she missed her appointment on 12/1/2022 .and follow up after the fax was sent to [named facility] and when the NP didn't write orders [for the Retacrit injection] . The DON confirmed the facility failed to ensure staff followed standards practice to ensure the resident received her injections, received lab work, go to her APN office visit, and go to her appointments. During a telephone interview on 1/11/2023 at 12:47 PM, the Medical Director revealed it was his expectation residents attend their lab visits, office visits, appointments, and receive their medications. The MD stated, No harm resulted from the medication not being given .If the resident's hemoglobin above 7 it is not a serious problem. The MD stated the resident's kidney function was not affected negatively by not receiving her injections of Retacrit. During an interview on 1/11/2023 at 2:39 PM, the Administrator confirmed the facility failed to ensure staff adhered to appropriate standards of practice of care to ensure Resident #5 received her injections, had lab work done, attend office visits, attend her appointments, and missed appointment rescheduled.

Based on facility policy review, medical record review, observation, and interview, the facility failed to allow 1 resident (#1) of 4 sampled residents to return to the facility following a hospitalization of 4 residents reviewed for hospital transfers. The findings include: Review of the facility policy Discharge/Transfer of the Resident, dated 1/1/2020, showed .Transfer: to leave the facility with plans or intention to return . Medical record review showed Resident #1 was admitted to the facility on [DATE] with diagnoses including Paraplegia, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Parkinson's Disease, Schizoaffective Disorder, Bipolar Type, Major Depressive Disorder, Anxiety, and Impulse Disorder. Medical record review of Resident #1's Comprehensive Care Plan, dated 8/22/2022, showed .[Resident #1 sometimes have behaviors which include delusions .tried to set electrical fire ton [to] wall unit and plugs, cursed staff .tried to hit staff . Interventions included .attempt interventions before my behaviors begin .please refer to my psychologist/psychiatrist as needed . Review of a First Certification of Need for Emergency Involuntary Admission, dated 8/30/2022, and signed by the facility's Psychiatric Advanced Nurse Practitioner (ANP), showed .has threatened homicide or other violent behavior .needs treatment for acute psychosis .refuses treatment/failed treatment at current setting . Review of the hospital ED (Emergency Department) documentation dated 8/30/2022, of a Psychiatric Problem ED, Addendum, showed Resident #1 had been evaluated by the ER physician on 8/31/2022 and 9/1/2022 .cleared .for psychological abnormality. From our perspective she is cleared to be discharged back to her home at the .facility. The facility as of September 2 at 5 AM again declines to accept the patient back to her home at the rehab facility . Review of the hospital ED documentation, dated 8/31/2022, of an ER MD (Medical Doctor) follow-up note, showed Resident #1 arrived in the ER at 11:39 AM on 8/30/2022 from the facility .under commitment for evaluation of psychosis . Further review revealed .patient has been calm, pleasant and cooperative .not displayed psychosis .called and spoke with Assistant Director of Nursing [ADON] [named] at the Waters of [NAME]. She reports that patient is not welcome to return to their facility . Review of the hospital's Consultation Notes, dated 9/1/2022, from a psychiatrist, showed .patient's mental state has been essentially normal for the last 48 hours .not in need of any psychiatric hospitalization and there is no reason that she should continue to be hospitalized or held in the emergency room . Review of the Progress Notes, dated 9/3/2022 at 1932 (7:32 PM), showed .at 1245 (12:45 PM) resident return to the building .from [hospital] .no behaviors . Review of a Social Services Evaluation, dated 9/3/2022, showed .alert and oriented .independent with decision making and choices yet judgement can be poor due to her mental health history .many attempts have been made for alternate placement but have yet to find facility to accept .she has been denied by each facility due to psych and behavior issues .continue to be a long term patient . Review of a Mental Health Progress Note, dated 9/6/2022, showed .resident was sent out, due to an increase in behaviors, paranoia, and delusions. Resident denied any behavioral-related issues . Review of a Psychiatric Progress Note, dated 9/7/2022, showed .recently sent out for behaviors .she is delusional and paranoid .judgment and insight are poor .continue plan of care and monitor . Review of Resident #1's Annual Minimum Data Set, dated dated dated [DATE] showed a Brief Interview for Mental Status score of 15, indicating the resident had intact cognitive mental status, no behaviors, impairment to bilateral lower extremities, and used a wheelchair for mobility. Medications included Antipsychotics, Antianxiety, Antidepressants, and Opioids. During a telephone interview on 11/7/2022 at 10:30 AM, the hospital's Case Manager/Registered Nurse (RN) stated Resident #1 was brought to the ED for a psych (psychological) evaluation on 8/30/2022. She was cleared to return to the facility, but the facility would not take her back. She stated a hospital Administrator called the facility's Director of Nursing (DON). She stated the Administrator, DON, ADON, Social Services, or no one else at the facility would return her calls. She stated she notified the state Ombudsman on 9/1/2022. A telephone conference call, conducted on 9/2/2022, with Resident #1, the facility's Administrator, the state Ombudsman, and the Case Manager/RN was held, and Resident #1 agreed to appropriate behaviors and the facility arranged for her return to the facility. Resident #1 was returned to the facility on [DATE]. During an observation and interview on 11/7/2022 at 12:20 PM, Resident #1 stated in 8/2022 she went to the ED after washing her hair and .getting water everywhere . She denied the water went into the ventilation system but pointed to an electrical outlet that water seeped into, located below the ventilation system. She stated she was screaming from pain and the nurses wanted a psych evaluation. She stated she refused to go to the hospital but was transferred to the ED. She stated they refused to let her return .no one from the facility told me I couldn't come back . She stated she was in the ED from several days. She stated she was glad to be back in the facility. During an interview on 11/8/2022 at 11:30 AM, the Psychiatric ANP stated she called the hospital to ask about the plan for Resident #1. She was informed they could not find placement .the facility can meet her physical needs .the facility can meet her needs psychiatrically . During an interview on 11/10/2022 at 10:50 AM, the ADON stated she was the charge nurse for the facility from 8/28/2022 to 8/31/2022. She stated the DON was the charge nurse for the facility 9/1/2022 to 9/3/2022. She stated because the DON was new, acceptable referrals would be called to the Administrator. She stated the facility did not want Resident #1 to return to the facility until she had been evaluated by psych .it is their home .we are to take them back .corporate level was discussing what to do, if to take her back .[named Administrator] told me not to take her back at that time . During an interview on 11/10/2022 at 11:15 AM, the Administrator stated Resident #1's behaviors have not occurred since her last hospital stay. The Administrator stated she did not know if the facility had developed a care plan or service to meet Resident #1's psych needs that Resident #1 had declined, and confirmed she was seen regularly by Psych ANP and talk therapy (Licensed Clinical Social Worker). She stated the facility had not held an ethics meeting or include legal consultation to determine Resident #1's needs. She stated the facility was able to care for Resident #1 .when she's not cycling . She confirmed the facility was unable to produce documentation of discharge planning, a 30-day discharge notice, a discharge summary, discharge plan of care, or communication from 8/31/2022 to 9/3/2022 with the hospital. She stated there was a delay in Resident #1's return to the facility .yes, because of the holiday .I don't know why she wasn't brought back in time .EMS [Emergency Medical Services] .miscommunication .not sure . She stated she could not remember the date of when she spoke to the Ombudsman .my understanding was to see if she could get placement .we asked [hospital] to get her placement . She stated she wasn't aware the hospital called to return Resident #1 to the facility 8/30/2022, 8/31/2022, 9/1/2022, or 9/2/2022 but stated she should have been aware and confirmed the resident did not return until 9/3/2022. The Administrator agreed it was not the ER's function to find placement for Resident #1 when the facility was providing ongoing psych services. The Administrator stated it was her expectation the facility's policy for Transfer and Discharge be followed and a resident ready for discharge from a hospital to be transferred back to the facility in a timely manner. Refer to TN00058651

Based on review of the Centers for Disease Control (CDC) guidance, review of facility policy, interview, and observation, the facility failed to ensure 6 COVID-19 unvaccinated staff of 6 unvaccinated staff observed, donned appropriate Personal Protective Equipment (PPE) to ensure precautions were taken to properly prevent COVID-19 transmission in the facility. The findings include: Review of the CDC guidance titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 2/2/2022, showed .Eye protection (i.e. [for example], goggles or a face shield that covers the front and sides of the face) . Review of the facility policy titled, Mandatory COVID-19 Vaccination Policy, revised 11/5/2021, showed .Unvaccinated staff will need to wear a face shield, goggles and an N95 mask at all times . Review of the facility policy titled, COVID-19 Residents and Staff Testing, revised 3/31/2022, showed .Unvaccinated staff with exemptions .If a facility staff member has an exemption .Staff are required to wear an N95 mask at all times while in the facility and a face shield or goggles . Review of facility documentation showed 25 of 89 staff members had COVID-19 vaccination exemptions. During an interview on 4/24/2022 at 8:55 AM, Licensed Practical Nurse (LPN) #5 stated there were currently no positive COVID-19 infections in the facility. During observations on the 300 hall on 4/24/2022 at 9:40 AM and on 4/25/2022 at 10:50 AM, showed CNA #1 wore a surgical mask and no eye protection in the resident care areas. During an observation on the 300 hall on 4/24/2022 at 9:45 AM, showed LPN #1 wore a surgical mask and no eye protection in the resident care areas. During an observation and interview on 4/24/2022 at 12:00 PM, LPN #1 stated she had a religious exemption and had not been vaccinated against COVID-19. LPN #1 wore a surgical mask and no eye protection in the resident care areas. LPN #1 stated the required PPE was a surgical mask unless she provided care for a resident who was in transmission-based precautions. During an observation and interview on 4/25/2022 at 9:50 AM, CNA #2 stated she had a religious exemption and had not been vaccinated against COVID-19. CNA #2 wore a surgical mask and no eye protection in the resident care areas. CNA #2 stated she had been directed by administrative staff, due to the county's low COVID-19 transmission rate, a surgical mask was all that was required. During an observation and interview on 4/25/2022 at 2:30 PM, the Wound Care Nurse stated she had an exemption and had not been vaccinated against COVID-19. The Wound Care Nurse wore a surgical mask and no eye protection in the resident care areas. During an observation and interview on 4/25/2022 at 2:50 PM, CNA #1 stated she had an exemption and had not been vaccinated against COVID-19. CNA #1 wore an N95 mask, and no eye protection in the resident care area. CNA #1 stated until the surveyors entered the building, she had been directed by the administrative staff the required PPE was a surgical mask. CNA #1 stated on 4/25/2022 she was directed to don an N95 mask, due to being unvaccinated. CNA #1 stated she had not been instructed to wear eye protection unless she provided care in an isolation room. During an observation and interview on 4/26/2022 at 8:50 AM, CNA #3 stated she had an exemption and had not been vaccinated against COVID-19. CNA #3 wore an N95 mask and no eye protection in the resident care areas. CNA #3 stated she had used blue surgical masks .for over a month . until she was directed to don an N95 mask on 4/25/2022. CNA #3 stated she had not been instructed to wear eye protection. During interviews on 4/26/2022 at 1:48 PM, The Regional Nurse and LPN #5 confirmed the unvaccinated staff did not follow the facility's policy regarding PPE usage. During an observation and interview on 4/26/2022 at 2:00 PM, Registered Nurse (RN) #1 stated she had a religious exemption and had not been vaccinated against COVID-19. RN #1 wore an N95 mask and no eye protection in the resident care area. RN #1 stated she had been directed on 4/26/2022 that she was required to wear an N95 mask. RN #1 stated eye protection was not currently the required PPE. During an interview on 4/26/2022 at 3:30 PM, LPN #5 confirmed the unvaccinated staff had been directed on 4/25/2022 to don N95 masks. LPN #5 further confirmed she was not aware of the facility's policy which required the unvaccinated staff to wear eye protection at all times and confirmed the unvaccinated staff did not don the appropriate PPE.

Based on facility policy review, facility documentation review, and interview the facility failed to maintain ongoing written communication between the facility and the [CONDITION(S)] center for 1 resident (Resident #30) of 1 resident reviewed for [CONDITION(S)]. The findings include: Review of the facility policy titled Community Hemodialysis, undated, showed .A [CONDITION(S)] communication sheet will return with the resident after the [CONDITION(S)] session to communicate to the facility information regarding the [CONDITION(S)] session . Resident #30 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Comprehensive Care Plan initiated on 2/11/2022, showed Resident #30 was care planned for .[CONDITION(S)] .hemodialysis . Interventions included .Written communication form with review of weight and any changes in condition between [CONDITION(S)] provider and living center . Review of a physician's order dated 2/11/2022, showed .First [CONDITION(S)] .Monday 2/14 [2/14/2022] . Review of a physician's order dated 4/4/2022, showed .[CONDITION(S)] on M [Monday], W [Wednesday], F [Friday], at [named [CONDITION(S)] center] . Review of the Minimum Data Set 5-day assessment dated [DATE], showed Resident #30 was cognitively intact and received [CONDITION(S)] services. Review of Resident #30's hemodialysis communication forms showed no form was available for review for the following scheduled [CONDITION(S)] days: 2/18/2022, 2/25/2022, 2/28/2022, 3/2/2022, 3/4/2022, 3/7/2022, 3/9/2022, 3/11/2022, 3/16/2022, 3/18/2022, 3/23/2022, 3/25/2022, 3/30/2022, 4/1/2022, 4/4/2022, 4/6/2022, 4/8/2022, 4/13/2022, 4/15/2022, 4/18/2022, 4/20/2022, 4/22/2022, and 4/25/2022. During an interview on 4/25/2022 at 1:30 PM, Licensed Practical Nurse (LPN) #2 confirmed Resident #30's scheduled [CONDITION(S)] days were on Monday, Wednesday, and Friday and a communication sheet was sent to the [CONDITION(S)] center with the resident. LPN #1 then stated .the center will document .status while there .sometimes we get the papers back and sometimes we don't . During an interview on 4/26/2022 at 12:30 PM, the Administrator confirmed the [CONDITION(S)] communication forms should be coming back to the facility with the resident, and the facility had not maintained ongoing written communication with the [CONDITION(S)] center.

Based on facility policy review, medical record review, observation, and interview, The facility failed to develop and implement a behavioral health care plan for 1 resident (Resident #23) diagnosed with Dementia of 5 residents reviewed for Dementia and behavioral care plans. The findings include: Review of the facility's undated policy titled, BEHAVIOR MANAGEMENT [CONDITION(S)] MEDICATION PROTOCOL, showed .Residents who receive antipsychotic antidepressant sedative/hypnotic or antianxiety medications .will be reviewed routinely for effectiveness and monitored for side effects of those medications .Newly admitted residents .update the Care Plan to include the problem behavior, goals and approaches .establish behavior program and complete a Behavior/Intervention Monthly flow record for those residents identified as having behaviors. Appropriate updating and/or revisions to the Care Plan will be done .by the Interdisciplinary Care team [IDT] .The committee [IDT] will .routinely review the resident as long as the resident .continues to receive antipsychotic/psychoactive medications .Established resident receiving [CONDITION(S)]/psychoactive medications/behavior management program .The Committee will establish a behavior program and complete a Behavior/Intervention Monthly Flow Record for those residents identified as having behaviors . Resident #23 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive care plan dated 1/21/2022 showed Resident #23 had impaired communication due to impaired cognition, was at risk for increased confusion due to Dementia, and had the potential for drug related complications associated with use of [CONDITION(S)], anti-psychotic, mood stabilizer, and anti-depressant medications with interventions including monitor for side effects, and provide non-pharmaceutical interventions to decrease target behaviors, anxiety, or depression. Continued review showed the care plan did not include individualized, resident specific interventions for the resident's Dementia and related behaviors. Review of the Minimum Data Set (MDS) admission assessment dated [DATE] showed Resident #23 scored a 10 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. The MDS showed Resident #23 had not exhibited any behaviors and had received anti-psychotic and anti-depressant medications. During observations on 4/24/2022 at 10:07 AM and 12:38 PM; on 4/25/2022 at 9:40 AM and 11:52 AM; and on 4/26/2022 at 8:45 AM, showed Resident #23 lying in bed and no behaviors were exhibited. During an interview on 4/25/2022 at 4:15 PM, Licensed Practical Nurse (LPN) #6 stated Resident #23 had not exhibited any behaviors .recently .he can yell out and be resistant to care . LPN #6 further confirmed Resident #23's medical record did not contain individualized interventions for the resident's behaviors. During an interview on 4/26/2022 at 8:50 AM, Certified Nursing Assistant (CNA) #3 stated Resident #23 was .resistant to care and yelled out at times .he will push your hand away .he gets agitated and angry easy . CNA #3 stated she did not document the resident's behaviors and was not aware of any individualized, resident specific interventions for the resident's behaviors. During an interview on 4/26/2022 at 8:57 AM, CNA #1 stated the resident had .moments . of behaviors which included . striking out at staff .he slapped the hospice aide .yells out, and was resistant to care . CNA #1 further stated she did not document the resident's behaviors and was not aware of individualized interventions for the resident's behaviors. During an interview on 4/26/2022 at 3:30 PM, the Regional Nurse confirmed Resident #23 did not have a behavioral care plan with individualized interventions in place and further confirmed the facility did not follow their policy related to behavior management of the resident.

Based on facility policy review, medical record review, observation, and interview, the facility failed to provide behavioral monitoring and failed to monitor for side effects of [CONDITION(S)] and anti-depressant medications for 2 residents (Resident #23 and Resident #62) of 5 residents reviewed for behavior monitoring and [CONDITION(S)] medication use. The findings include: Review of the facility's undated policy titled, BEHAVIOR MANAGEMENT [CONDITION(S)] MEDICATION PROTOCOL, showed .Residents who receive antipsychotic antidepressant sedative/hypnotic or antianxiety medications .will be reviewed routinely for effectiveness and monitored for side effects of those medications .Newly admitted residents .update the Care Plan to include the problem behavior, goals and approaches .establish behavior program and complete a Behavior/Intervention Monthly flow record for those residents identified as having behaviors. Appropriate updating and/or revisions to the Care Plan will be done .by the Interdisciplinary Care team [IDT] .The committee [IDT] will .routinely review the resident as long as the resident .continues to receive antipsychotic/psychoactive medications .Established resident receiving [CONDITION(S)]/psychoactive medications/behavior management program .The Committee will establish a behavior program and complete a Behavior/Intervention Monthly Flow Record for those residents identified as having behaviors . Resident #23 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive care plan dated 1/21/2022 showed Resident #23 had impaired communication due to impaired cognition, was at risk for increased confusion due to Dementia, and had the potential for drug related complications associated with use of [CONDITION(S)], anti-psychotic, mood stabilizer, and anti-depressant medications with interventions including monitor for side effects, and provide non-pharmaceutical interventions to decrease target behaviors, anxiety, or depression. Review of the Minimum Data Set (MDS) admission assessment dated [DATE] showed Resident #23 scored a 10 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. The MDS showed Resident #23 had not exhibited any behaviors, and had received anti-psychotic and anti-depressant medications. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During observations on 4/24/2022 at 10:07 AM and 12:38 PM; on 4/25/2022 at 9:40 AM and 11:52 AM; and on 4/26/2022 at 8:45 AM, showed Resident #23 lying in bed and no behaviors were exhibited. During an interview on 4/25/2022 at 4:15 PM, Licensed Practical Nurse (LPN) #6 stated Resident #23 had not exhibited any behaviors .recently .he can yell out and be resistant to care . Continued interview and review of the medical record revealed Resident #23 did not have behavior monitoring documentation .it [documentation] should be here [Medication Administration Record] [MAR] that's where we put it [document] . LPN #6 stated behavior monitoring and the monitoring for side effects of psychoactive medications were .supposed to be documented on his [Resident #23's] MAR .and I [LPN#6] don't know why it's not . LPN #6 confirmed Resident #23's behaviors and the monitoring for psychoactive medications had not been monitored or documented on Resident #23. During an interview on 4/26/2022 at 8:50 AM, Certified Nursing Assistant (CNA) #3 stated Resident #23 was .resistant to care and yelled out at times .he will push your hand away .he gets agitated and angry easy . CNA #3 stated she provided 1 on 1 when the resident exhibited behaviors which .helped sometimes . CNA #3 stated she did not document the resident's behaviors. During an interview on 4/26/2022 at 8:57 AM, CNA #1 stated the resident had .moments . of behaviors which included . striking out at staff .he slapped the hospice aide .yells out, and was resistant to care . CNA #1 stated when Resident #23 exhibited behaviors she approached the resident calmly. CNA #1 further stated she did not document the resident's behaviors. Review of the MAR's from 2/1/2022-4/25/2022 showed no behavior monitoring or the monitoring of side effects for the anti-depressant or anti-psychotic medications had been documented for Resident #23. During an interview on 4/26/2022 at 3:30 PM, the Regional Nurse confirmed behavior monitoring, and the monitoring of side effects for [CONDITION(S)] and anti-depressant medications had not been conducted or documented on Resident #23's medical record from 2/2022-4/2022. The Regional Nurse confirmed the facility did not follow their policy related to behavior management of the resident. Resident #62 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS significant change assessment dated [DATE], showed Resident #62 had severe cognitive impairment. Further review showed antipsychotics and antidepressant medications were being administered. Review of Resident #62's comprehensive care plan initiated on 3/25/2022, showed .I have potential for drug related complications associated with use of [CONDITION(S)] medications related to: Anti-Depressant medication, anti psychotic medication . Further review showed interventions to include .Monitor for side effects . Review of a current Order Summary Report dated 4/26/2022 showed Resident #62 was ordered to receive the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] HCL ([MEDICATION(S)] acid) ER (extended release) 150 mg 2 times a day for antidepression [MEDICATION(S)] 25 mg 2 times a day for Lewy Body Dementia [MEDICATION(S)] 50 mg at bedtime for Depression [MEDICATION(S)] HCL 100 mg at bedtime for [CONDITION(S)] Review of the MARs dated 3/2022 and 4/2022, showed Resident #62 received [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] as ordered. Further review showed no documentation of side effect monitoring for the use of antipsychotics or antidepressants. During an interview on 4/26/2022 at 12:52 PM, the Regional Nurse confirmed Resident #62 received antipsychotics and antidepressants, and side effect monitoring for these medications had not been performed in 3/2022 or 4/2022.

Based on review of the Centers for Disease Control (CDC) and Prevention guidance, review of facility policy, observations, and interviews, the facility failed to ensure infection control practices were followed for 3 residents (Resident #85, Resident #340, and Resident #342) of 6 residents reviewed for transmission-based precautions and failed to ensure appropriate precautions were taken to prevent COVID-19 transmission in the facility. The findings include: Review of the CDC guidance titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 2/2/2022, showed .Eye protection (i.e. [for example], goggles or a face shield that covers the front and sides of the face) . Review of the facility's undated policy titled, COVID-19 PPE [Personal Protective Equipment] Zones Guidelines, showed .PPE for all zones .YELLOW ZONE- SUSPECTED OR PRESUMED COVID-19 UNIT .Mask (N95 if adequate supply, may use surgical mask if not), gown, gloves, eye protection, hair covering, shoe covering and face shields .YELLOW ZONE - PREVENTION/READMISSION/NONSUSPECTED COVID-19 Unit .Mask (surgical mask), gown, gloves .The prevention unit will be used monitoring of symptoms based on a preventative action and unknown COVID-19 exposure or transmission that do not present with symptoms consistent with COVID-19 .All readmissions .will be placed on the yellow zone prevention unit for a specified time frame .Readmission residents are required to reside on the yellow preventative zone for 14 days to monitor for symptoms due to unknown nature of exposure . Resident #85 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Order Summary Report showed an order dated 4/13/2022, that read .Yellow Zone . Review of the care plan dated 4/17/2022, showed .Preventative Isolation Precautions .at risk for developing a transmission-based infection (COVID 19) .UNIT: Yellow Zone Protocol .Transmission-Based Precautions (Contact and/or Droplet Isolation): Respiratory, until discontinued by the physician . During an interview on 4/24/2022 at 8:55 AM, Licensed Practical Nurse (LPN) #5 stated there were currently no positive COVID-19 infections in the facility. Observation on 4/24/2022 at 9:55 AM, showed Resident #85's door closed and a sign on the door that read, .YELLOW ZONE .TRANSMISSION BASED PRECAUTIONS .PPE REQUIRED: N95 MASK .FACESHIELD .Single Gown- with each encounter .GOWNS MUST BE SINGLE USE PER RESIDENT .*IF CRISIS CAPACITY- FOLLOW THIS RULE ONE GOWN PER EACH STAFF MEMBER, PER EACH RESIDENT, PER SHIFT) .GLOVES (hand hygiene donning/doffing) . Observation on 4/24/2022 at 11:39 AM, showed Licensed Practical Nurse (LPN) #2 entered Resident #85's room. LPN #2 donned an N-95 mask, gloves, and goggles and did not don a gown for the resident care interaction. During an interview on 4/24/2022 at 11:42 AM, LPN #2 stated Resident #85 was on transmission-based precautions and an N-95 mask, eye protection, gown, and gloves, were required to be worn for all interactions with the resident. LPN #2 confirmed she failed to don a gown for the resident care interaction with Resident #85. Observation on 4/24/2022 at 11:47 AM, showed LPN #2 exited Resident #85's room and doffed her gown outside the resident's room. LPN #2 walked down the hallway and discarded the gown in a garbage can in the nurses' station. During an interview on 4/24/2022 at 11:48 AM, LPN #2 confirmed she exited Resident #85's room with a gown on and discarded it in the garbage can at the nurses' station. LPN #2 stated PPE for residents on transmission-based precautions was to be discarded in the room prior to exiting. LPN #2 stated she did not discard the gown in Resident #85's room because the garbage can was full. Observation on 4/24/2022 at 12:23 PM, showed the Central Supply/Transportation Coordinator (CSTC) entered Resident #85's room and wore gown, gloves, and an N-95 mask. The CSTC failed to don eye protection. During an interview on 4/24/2022 at 12:26 PM, the CSTC confirmed he did not don eye protection prior to entering Resident #85's room and he should have donned goggles or a face shield. During an interview on 4/25/2022 at 8:35 AM, the Infection Control Nurse stated Resident #85 was hospitalized from 4/7/2022 - 4/12/2022. Resident #85 was placed in the Yellow Zone upon return to the facility because he was not vaccinated for COVID-19. Staff were required to don gown, gloves, eye protection, and an N-95 mask prior to entering the room. PPE required for residents on transmission-based precautions were communicated to staff via signage on the door. PPE was to be discarded prior to exiting the room. The Infection Control Nurse confirmed appropriate infection control practices were not maintained when LPN #2 failed to don a gown for an interaction with Resident #85 and when LPN #2 failed to discard a gown prior to exiting Resident #85's room. Further interview confirmed appropriate infection control practices were not maintained when the CSTC failed to don eye protection prior to entering Resident #85's room. Resident #340 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 4/18/2022, showed .Preventative Isolation Precautions . at risk for developing a transmission-based infection (COVID 19) .UNIT: Yellow Zone Protocol .Transmission-Based Precautions (Contact and/or Droplet Isolation): Respiratory, until discontinued by the physician . Review of the Order Summary Report showed an order dated 4/19/2022, that read, .Yellow Zone . Observation on 4/24/2022 at 10:17 AM, showed signage on the resident's door that read, .YELLOW ZONE .Mask (N95 if available) or surgical mask if no N95, Gown, gloves, eye protection . Observation on 4/24/2022 at 11:40 AM, showed Certified Nursing Assistant (CNA) #4 entered Resident #340's room wearing a gown, mask, and gloves. CNA #4 exited the room at 11:45 AM and did not discard the PPE worn in Resident #340's room. CNA #4 walked down the hall toward the meal tray cart. LPN #5 intervened and told CNA #4 that she should have removed the PPE in the room prior to exiting Resident #340's room. CNA #4 proceeded to a small alcove and removed the PPE. During an interview on 4/24/2022 at 11:47 AM, CNA #4 stated, .I just didn't realize I had the gown on . During an interview on 4/24/2022 at 11:48 AM, LPN #5 confirmed that CNA #4 should have removed PPE prior to exiting Resident #340's room and stated .I will do more training with her . During an interview on 4/25/2022 at 8:35 AM, the Infection Control Nurse confirmed PPE was to be discarded prior to exiting the room. During an interview on 4/25/2022 at 2:39 PM, the Infection Control Nurse stated Resident #340 was placed on Yellow Zone precautions upon admission to the facility because he had not received his COVID-19 booster. Resident #342 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 4/24/2022 at 12:55 PM, showed LPN #5 donned an N-95 mask, gown, and gloves. LPN #5 entered Resident #342's room and delivered the lunch tray. The LPN wore personal eye glasses and did not don goggles or a face shield. During an interview on 4/24/2022 at 12:59 PM, LPN #5 confirmed she did not don goggles or a face shield for the resident interaction. Further interview with LPN #5 revealed .I thought glasses were sufficient to use as eye protection . and .I see on the sign it states we need googles or a face shield . During an interview on 4/25/2022 at 8:50 AM, the Infection Control Nurse stated the facility follows CDC guidance. Resident #342 was placed on Yellow Zone precautions upon admission to the facility on [DATE] until they were able to confirm her COVID-19 vaccination status. The Infection Control Nurse confirmed appropriate infection control precautions were not maintained when LPN #5 failed to don goggles or a face shield for the interaction with Resident #342.

Based on facility policy review, facility documentation review, medical record review, and interview, the facility failed to timely order, obtain, and administer medications to prevent a significant medication error for 2 of 3 residents reviewed for medication errors. The findings include: Review of the facility policy and procedure Medication Administration, undated, ''Purpose: To ensure that resident medications are administered in a timely manner . Policy . medications will be administered within 60 minutes before or after the facility's dosing schedule . Review of the facility's Order Listing Report, generated from 9/1/2021 through 10/28/2021, showed 4 residents who received intramuscular antibiotics and 2 residents who received intravenous antibiotics during the time period. Review of the facility's Inventory Snapshot record, dated 10/15/2021, showed there was 2 doses of [MEDICATION(S)] (an medication used to treat infection) 0.5 gram available for use. Medical record review showed Resident #2 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing progress note dated 10/12/2021, showed Resident #2 had the results of a chest x-ray performed on 10/12/2021 related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's order dated 10/12/2021 showed [MEDICATION(S)] (an medication used to treat infection) 1 gram (gm) intramuscularly (IM) at bedtime for 7 days was ordered. Review of Resident #2's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review showed Resident #3 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review showed the resident arrived at the facility, post hospital stay, on 10/15/2021 at approximately 7:30 PM. Review of Resident #3's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed the medication was administered 14 hours after admission, at 10:00 AM on 10/16/2021. During an interview with the Director of Nursing (DON) and ADON on 10/28/2021 at 2:10 PM, the ADON revealed he had contacted the staff nurse responsible for the 27 hour delay in administration of Resident #2's initial dose of [MEDICATION(S)]. The ADON revealed the staff nurse stated she had entered the next day's date in error when doing the order entry for the antibiotic. The ADON revealed the staff nurse responsible for Resident #3's admission did not complete the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADON stated the reason for the IV antibiotic not being initiated for an additional 7 hours, until 10:00 AM, was unable to be determined by the facility. During an interview with the Administrator 10/28/2021 at 2:25 PM, she confirmed Resident #2 and #3 antibiotics were not given timely and the facility policy was not followed.

Based on medical record review and interview, the facility failed to develop a comprehensive care plan for 1 Resident (#61) of 3 residents reviewed for [MEDICAL TREATMENT]. The findings include: Review of medical record review showed Resident #61 was admitted on [DATE], readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the care plan, updated 12/23/2019, showed the resident had [MEDICAL CONDITION] and the potential for complications related to [MEDICAL TREATMENT]. The care plan did not address Resident #61's type of [MEDICAL TREATMENT] access or the location of the access site. Interview Assistant Minimum Data Set (MDS) Coordinator on 2/24/2020 at 2:00 PM, stated Resident #61's care plan was to address the type of [MEDICAL TREATMENT] access and where the access site was located. The resident's care plan does not address the type of [MEDICAL TREATMENT] access or the location of the access site.

Based on facility policy review, record review, observation, and interview, the facility failed to change oxygen tubing and replace humidifier bottles for 2 residents (#60 and #72) of 8 residents reviewed for oxygen use. The findings included: Review of the facility policy titled, O2, (Oxygen) undated, showed .Tubing, humidifier bottles and filters will be changed, cleaned and maintained by the facility . Review of the medical record, showed Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's order dated 4/11/2019, revealed an order for [REDACTED]. Observation of the resident's room on 2/23/2020 at 10:50 AM, showed Resident #60 was wearing oxygen at 3 LPM via nasal cannula and the tubing and water bottle for humidification was dated 2/13/2020. During an interview conducted on 2/23/2020 at 10:50 AM, Licensed Practical Nurse (LPN) #2 confirmed Resident's #60's tubing and humidification bottle was dated 2/13/2020, was to be changed weekly, and had not been changed in a timely manner. Review of the medical record, showed Resident #72 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician Recapitulation Orders for (MONTH) 2020, revealed an order for [REDACTED]. Observation of the resident's room on 2/23/2020 at 9:00 AM, showed Resident #72 wearing oxygen via nasal cannula, oxygen tube dated 1/5/2020, and water bottle for humidification was empty and dated 1/5/2020. During an interview conducted on 2/23/2020 at 9:31 AM, LPN #1, who was assigned to care for Resident #72, stated oxygen tubing is supposed to be changed weekly and the residents tubing had not been changed since the 5th (1/5/2020) and .she's out of water too (humidifier bottle empty and dated 1/5/2020) . During an interview conducted on 2/25/2020 at 9:09 AM, Director of Nursing (DON) confirmed the water bottle used for humidification should have been replaced if it was empty and the oxygen tubing should have been changed.

Based on review of facility policy, medical record review, facility records review, observation and interview, the facility failed to investigate the root cause of 7 falls and develop interventions to address the specific cause of 7 falls for 1 resident (#3) of 4 residents reviewed for falls of 21 residents reviewed. The findings include: Review of the facility policy Accident Incident Reporting Policy, undated, revealed .PURPOSE: To ensure accidents .are identified, reported, investigated .To provide a database to study the cause of accidents .to provide assistance in implementing corrective actions to prevent reoccurrence when possible .13. A thorough investigation will be completed within 5 business days . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set ((MDS) dated [DATE], revealed a score of 9 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. Continued review revealed Resident #3 required extensive assistance of 2 persons for transfer, ambulated in the room [ROOM NUMBER]-2 times per week with the assistance of 1 person and was able to move around facility independently with a wheel chair. Review of the facility record Incidents by Incident Type revealed Resident #3 had 11 falls from 8/3/18-12/4/18. Review of the Falls Incident Reports and concurrent review of the Manager Incident Review (identified by the Director of Nurses/DON as the fall investigation) revealed the following: 8/3/18 at 7:45 AM - .lying on bathroom floor on back .abrasion to (L) (left) middle back noted .w/c (wheelchair) in bathroom door way and wheels not locked .Intervention: Bathroom alarm applied to door . Review of the Manager Incident Review dated 8/6/18 revealed .poor safety awareness and has [MEDICAL CONDITION] .door alarm on bathroom door. 8/16/18 at 10:23 AM - .sitting on buttocks in the floor of his bathroom .Scrape noted to back .New batteries placed into bathroom door alarm. Scheduled battery changes began . Review of the Manager Incident Review dated 8/17/18 revealed Why did it happen .Doesn't remember to call for assistance. Battery on alarm going dead and soft chipper sound was heard .What will decrease likelihood of reoccurrence? Schedule door alarm battery (changes). 8/27/18 at 5:00 AM - .Heard someone yelling .entering resident's room, noted resident lying on right side on floor in front of bed .stated he was standing next to his bed to use the urinal and his knee gave out on him causing him to fall . Review of the Manager Incident Review dated 8/27/18 revealed .Stated knee 'gave on him' while using urinal .What will decrease likelihood of reoccurrence? 72 (hour) toileting. 8/31/18 at 6:10 AM - .Heard someone yelling .entered bathroom, noted resident sitting in floor .CNA (Certified Nursing Assistant) notified LPN (Licensed Practical Nurse) resident has been turning bathroom door alarm off. Intervention: Remove bathroom door alarm and apply to inside of bathroom door . Review of the Manager Incident Review dated 9/4/18 revealed .Resident removed door alarm from door. Unable to recall safety measures put into place .door alarm on inside of bathroom door. 9/5/18 at 9:45 AM - .Heard resident yell out .call light had come on .noted resident laying on (L) side with feet toward head of bed .I was trying to use urinal .' Intervention: PT (Physical Therapy) to eval (evaluate) . Review of the Manager Incident Review dated 9/6/18 revealed .Why did it happen? Res (resident) unable to recall safety precautions. He is unable to remember to use call light. He always self transfers .What will decrease likelihood of reoccurrence? Refer to PT for strengthening. 9/23/18 at 7:41 PM - .Resident .yelling from room .noted to be on floor lying on back .w/c unlocked and beside him .Resident stated trying to stand at sink to use his urinal . Review of the Manager Incident Review dated 9/24/18 revealed Why did it happen? Decreased cognition, unable to remember to push call light. Resident had pushed with foot the bedside table to the end of the bed .What will decrease the likelihood of reoccurrence? Place urinal within reach when resident is in bed. 9/26/18 at 8:50 PM - .resident was yelling from the room .lying on the floor .resident said 'I was standing and holding the sink and slipped . Review of the Manager Incident Review dated 9/27/18 revealed Why did it happen? Res has poor safety awareness, resident does not recognize physical limitations .What will decrease the likelihood of reoccurrence? Grip strips in front of sink. 10/23/18 at 9:30 PM - .Witness .Statement .'walking past resident room and noticed resident was going to sit in wheelchair and before could assist he sat in the floor and missed his chair and fell in floor' . Review of the Manager Incident Review dated 10/24/18 revealed, .Why did it happen? Res continues to stand unassisted. Frequent urination. Unable to remember to call for assistance .NP to evaluate (increase) urge in urination. 11/18/18 at 6:34 PM - .Called to resident's room per CNA .Resident stated he was going to get his water pitcher and his knees went out on him, causing him to fall, knocking water pitcher off .offer resident a lighter weight pitcher . Review of the Manager Incident Review dated 11/19/18 revealed, Why did it happen? Res stood and knees weakened causing him to fall .What will decrease likelihood of reoccurrence? Lighter weight water pitcher . 11/28/18 at 12:05 PM - .Resident noted laying in floor on back .in front of sink .Intervention: Therapy to evaluate for correct way to use urinal and if grab bars needed at sink .Other Info (information) Resident stands at sink to use urinal with balance problem noted with standing and unable to stay balanced when trying to hold urinal and to position .correctly in urinal . Review of the Manager Incident Review undated revealed .Resident states he was trying to use urinal and fell . 12/4/18 at 10:00 AM - .LPN entered resident bathroom noted resident with both hands on grab bar, knees in bent position .Noted outer bathroom door alarm with low tone and inner bathroom door alarm was off wall .When LPN asked (resident) how alarm got in floor states, 'I tore that off' . Review of the Manager Incident Review dated 12/5/18 revealed .Res has poor safety awareness, has had TBI ([MEDICAL CONDITION]) .Replaced alarm on top of door frame. Observation of the nursing station, directly across from Resident #3's room, on 1/9/18 at 2:02 PM revealed 2 LPN's and 4 CNA's in the immediate area of the nursing station. Observation included the sounding of Resident #3's bathroom alarm for approximately 1-2 minutes before 1 (#1) of the 4 CNA's in the immediate area responded to the bathroom alarm. Observation of the resident and the resident's room on 1/9/18 at 2:05 PM revealed CNA #1 had transferred Resident #3 from the commode in the bathroom and was wheeling him back to bed. Observation revealed 2 alarms present at the top of the bathroom door casing, 1 on the inside of the door and 1 on the casing. Observation continued and revealed the first alarm placed on the door casing was not working. Observation of the alarm, after it was turned back on, revealed a soft chirping sound. Interview with CNA #1 on 1/9/18 at 2:07 PM, in the resident's room, revealed she stated the alarm had been turned off by her as the resident was being assisted. Interview with CNA #2 on 1/9/18 at 2:10 PM at the nursing station, revealed there was a louder sound alternative for the chirping alarm placed on the resident's bathroom door casing and stated, I put the alarm on the louder sound when I am working . Interview with the Rehabilitation (Rehab) Director on 1/9/18 at 2:15 PM, in the conference room, revealed Resident #3 was treated by P.T. and O.T. (Occupational Therapy) from admission in (MONTH) until 7/11/18. Continued interview confirmed the resident was treated by P.T. for a second period from 9/5/18-11/13/18. Further interview revealed the second treatment period focused on transfers and balance and the therapy department determined the resident was not safe for independent use of a hemi-walker. Further interview revealed the Rehab Director participated in the interdisciplinary meetings to address falls. Interview continued, with concurrent review of rehab screening tools provided, and confirmed the intervention of replacing the resident's water pitcher, developed on 11/19/18, did not address the circumstances of the 11/18/18 fall. Interview with the MDS Registered Nurse (RN) on 1/9/18 at 2:55 PM, in the conference room, included the question of whether providing the resident with a lighter water pitcher addressed the 11/18/18 fall, and the RN responded, It has gotten harder to come up with an intervention . Interview with the Administrator on 1/9/18 at 3:20 PM, in his office, confirmed the facility continued to have difficulty with battery checks and replacement when he arrived 3 weeks prior. Interview with the DON on 1/9/18 at 4:05 PM, in the conference room, revealed 7 of the investigations for the root cause of Resident #3's 11 falls concluded the root cause was due to the resident's cognition. Interview continued and the DON stated I will have to review them. In conclusion, 7 of the 11 falls Resident #3 had from 8/5/18-12/4/18 were not investigated for the immediate circumstances of each fall to aide in the development of an intervention to create a safer environment. Review revealed 7 intervention developed did not address the immediate circumstances of the resident's falls. In addition, the interventions related to the additional alarms, provided at the entry to the resident's bathroom, were not effective when the batteries were not functioning and when the softer alarm setting was not audible outside of the resident's room.

Based on facility policy review, Provider History Profile Review, medical record review, and interview the facility failed to provide an effective Quality Assurance Performance Improvement Program (QAPI) to ensure care plan interventions were effective, re-evaluate the effectiveness of care plan interventions after each resident fall, and consistently identify the root cause analysis of falls. The QAPI program failed to effectively evaluate, recognize, and monitor falls to ensure the QAPI program was effective in the prevention of repeat deficiencies at F-689 and F-865 (formerly at F-323 and F-520) affecting 1 resident (#3) of 4 residents reviewed for fall of 21 residents reviewed. The findings include: Review of the facility policy, Quality Assurance Performance Improvement, with a copyright date of 2014 revealed .Our Quality Assurance and Performance Improvement Program .represent our facility's commitment to continuous quality improvement .The program ensures a systematic performance evaluation, problem analysis and implementation of improvement strategies to achieve our performance goals .The QAPI committee's oversight responsibilities shall include, but not limited to the following .Utilize facility data to identify opportunities to improve systems and care. Data may include, but is not limited to .medical record review, fall log, incident and accident reports, quality measures, survey outcomes .The QAPI Committee will review the plan annually and make the necessary revisions, Revisions shall reflect the findings, discussions, meetings, surveys, interaction with executive leadership .of the previous year . Review of the Provider History Profile dated 12/2016 revealed the facility was cited at F-323 at a Harm level during the annual Recertification survey on 12/14/16 for failure to ensure a resident was free from accidents resulting in injury. Review of the Provider History Profile dated 11/2017 revealed the facility was cited at F-323 and F-520 at an E pattern level during the annual Recertification survey on 11/13/17 for failure to complete a thorough investigation of falls, failure to provide supervision for residents to prevent falls, and failure to implement interventions to prevent falls. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility record Incidents by Incident Type revealed Resident #3 had 11 falls from 8/3/18-12/4/18. Medical record review revealed the facility failed to consistently identify and investigate the root cause of Resident #3's falls. Further review revealed the facility failed to create effective interventions to prevent falls. Medical record review of the facility's documentation revealed 7 of the 11 falls Resident #3 had from 8/5/18-12/4/18 were not investigated for the immediate circumstances of each fall to aid in the development of an intervention for creating a safer environment. Review revealed 7 interventions developed had not addressed the immediate circumstances of the resident's falls. In addition, the interventions related to the additional alarms, provided at the entry to the resident's bathroom, were not effective when the batteries were not functioning and when the softer alarm setting was not audible outside of the resident's room. Interview with the Administrator on 01/9/19 at 3:44 PM, in the Administrator's office, confirmed the facility had a repeat deficiency of F-323 on 12/14/16 at a harm level during an annual recertification survey. Continued interview confirmed the facility had a repeat deficiencies of F-323 and F-520 on 11/13/17 during the annual recertification survey related to falls and QAPI. Further interview confirmed the QAPI Committee failed to conduct a thorough and consistent root cause analysis on the facility's resident falls and failed to effectively evaluate, recognize, and monitor their system for managing resident's falls to prevent repeat deficiencies. Further interview confirmed the facility's QAPI program failed to adhere to and follow their policy related to falls to prevent repeat deficiencies related to falls.

Based on the facility policy review, observation, and interview, the facility failed to properly air dry pans and maintain safe operating temperatures in 1 of 1 reach in refrigerators in the dietary department, potentially affecting 85 of 85 residents. The findings included: Review of the facility policy Cleaning Instructions: Food Preparation Appliances dated 2017 revealed, .wash and rinse according to manual guidelines for dishwashing .Allow to air dry . Review of the facility policy Refrigerator/Freezer Temperatures dated 2017 revealed, .ensure that all cold storage units are at 41 (degrees) or below for refrigeration .If the temperature of the unit is not in the desirable range, a corrective action is taken .management staff is notified . Observation with the Dietary Aide (DA) on 11/6/17 at 6:34 AM, in the kitchen, revealed 6 of 9 - 6.1 quart pans stored wet and available for use. Interview with the DA on 11/6/17 at 6:35 AM, in the kitchen, confirmed 6 of 9 - 6.1 quart pans were stored wet and should have been allowed to dry. Observation with the DA on 11/6/17 at 6:40 AM, in the kitchen revealed 2 internal thermometers located in the reach in refrigerator indicated the temperature of the refrigerator was 50 degrees. Review of the Reach-In Refrigerator/Freezer Temperature Log for the months of August through September 2017 revealed evening refrigerator temperatures were above 41 degrees for 46 of 99 days. Observation with the Dietary Manager (DM) on 11/6/17 at 7:30 AM, in the kitchen, revealed 2 trays with juice, nectar thick liquids and nectar thick milk, and 1 tray of pudding in the reach in refrigerator. Observation revealed temperatures were obtained and there was a temperature of 50 degrees for 1 glass of milk and 1 glass of apple juice. Interview with the DM on 11/6/17 at 7:35 AM, in the kitchen, confirmed the facility failed to maintain the reach in refrigerator at safe operating temperatures and failed to ensure refrigerated liquids were kept at safe temperatures.

Based on facility policy review, manufacturers instruction manual review, medical record review, review of facility investigation, and interview, the facility failed to follow the Plan of Care for 1 resident (#40) of 31 residents reviewed, resulting in harm to Resident #40. The findings included: Review of the facility policy Resident Rights undated, revealed .the facility must care .in a manner .that enhances or promotes your quality of life . Review of the manufacturers instruction manual, Slings User Guide, dated March 2005, revealed .a sling that is the wrong size or a bad fit for its patient .increases the risk of injury .it will be necessary for .a second attendant .Warning .it is essential .correct method of use before any attempt is made to lift a patient . Medical record review revealed Resident #40 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #40's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 14 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated the resident was cognitively intact. Continued review revealed the resident was independent with daily decision making, required extensive assist of 2 persons with bed mobility, transfers, toileting, and personal hygiene. Medical record review of the Plan of Care for Resident #40 dated 8/17/16 revealed .at risk for falls .interventions .2 person maxi lift .goal to have no fall related injuries while using the maxi lift . Medical record review of Resident #40's Kardex (job aid for daily care) dated 8/20/16 revealed .transfer .2 person maxie (maxi) lift blue (sling for specific resident weight) . Review of a facility investigation dated 8/25/16 revealed .unable to complete lift with sit to stand assisted to floor per CNA (Certified Nursing Assistant #6) .localized pain (right) shoulder .resident very weak CNA was using sit to stand to transfer . Medical record review of a physician's order dated 8/26/16 revealed .x-ray 2 views to right shoulder . Medical record review of a radiology report dated 8/27/16 revealed .fracture involving mid right clavicle .acute fracture . Medical record review of a physician's order dated 8/31/16 revealed .right arm sling on right arm every day x (times) 3 weeks for clavicle fracture . Interview with CNA #6 on 12/13/16 at 8:15 AM, in the conference room, revealed .(Resident #40) needed to be changed .I took her to her room .I was going to use the maxi lift but the pad slid out from under the resident .I could not get the pad hooked .I used the sit to stand lift .as I raised her up .she was about 5 inches above the seat of her wheelchair .she (resident) raised her arms straight up and slid out of the sling .landed on her bottom on the floor and fell to the side .when we use the sit to stand life or the maxi lift we are supposed to have 2 people in the room .I know I was supposed to use the maxi lift and have someone else to help .but I didn ' t . Interview with Physician #1 on 12/13/16 at 10:24 AM, in the conference room, revealed .the aide (CNA #6) was trying to get the resident up by herself with a lift and she (Resident #40) got tangled up in the sling and fell out of the lift .the resident was a 2 person assist with the maxi lift .the injury .was avoidable because the staff did not use the correct lift and did not have 2 person assist . Telephone interview with Licensed Practical Nurse (LPN) #2 on 12/13/16 at 2:42 PM revealed .(CNA #6) came to the nursing station and told me that (Resident #40) had slid out of the lift .when I walked into the room (CNA #6) had the wrong lift .(CNA #6) was using the lift by herself .they are supposed to use the sit to stand lift with (Resident #40) .because she (Resident #40) does not have muscle control . Interview with the Administrator and the Director of Nursing (DON) on 12/13/16 at 4:42 PM, in the conference room, confirmed the facility failed to follow Resident #40's plan of care resulting in harm to Resident #40.

Based on facility policy review, manufacturers instruction manual review, medical record review, review of facility investigation, observation, and interview, the facility failed to ensure 1 resident (#40) was free from injury of 4 residents reviewed for accidents of 31 residents reviewed, resulting in harm to Resident #40. The findings included: Review of the facility policy Resident Rights undated, revealed .the facility must care .in a manner .that enhances or promotes your quality of life . Review of the manufacturers instruction manual, Slings User Guide, dated March 2005, revealed .a sling that is the wrong size or a bad fit for its patient .increases the risk of injury .it will be necessary for .a second attendant .Warning .it is essential .correct method of use before any attempt is made to lift a patient . Medical record review revealed Resident #40 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #40's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 14 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated the resident was cognitively intact. Continued review revealed the resident was independent with daily decision making, required extensive assist of 2 persons with bed mobility, transfers, toileting, and personal hygiene. Medical record review of the Plan of Care for Resident #40 dated 8/17/16 revealed .at risk for falls .interventions .2 person maxi lift .goal to have no fall related injuries while using the maxi lift . Medical record review of Resident #40's Kardex (job aid for daily care) dated 8/20/16 revealed .transfer .2 person maxie (maxi) lift blue (sling for specific resident weight) . Review of a facility investigation dated 8/25/16 revealed .unable to complete lift with sit to stand assisted to floor per CNA (Certified Nursing Assistant #6) .localized pain (right) shoulder .resident very weak CNA was using sit to stand to transfer . Medical record review of a physician's order dated 8/26/16 revealed .x-ray 2 views to right shoulder . Medical record review of a radiology report dated 8/27/16 revealed .fracture involving mid right clavicle .acute fracture . Medical record review of a physician's order dated 8/31/16 revealed .right arm sling on right arm every day x (times) 3 weeks for clavicle fracture . Interview with CNA #6 on 12/13/16 at 8:15 AM, in the conference room, revealed .(Resident #40) needed to be changed .I took her to her room .I was going to use the maxi lift but the pad slid out from under the resident .I could not get the pad hooked .I used the sit to stand lift .as I raised her up .she was about 5 inches above the seat of her wheelchair .she (resident) raised her arms straight up and slid out of the sling .landed on her bottom on the floor and fell to the side .when we use the sit to stand life or the maxi lift we are supposed to have 2 people in the room .I know I was supposed to use the maxi lift and have someone else to help .but I didn ' t . Interview with Physician #1 on 12/13/16 at 10:24 AM, in the conference room, revealed .the aide (CNA #6) was trying to get the resident up by herself with a lift and she (Resident #40) got tangled up in the sling and fell out of the lift .the resident was a 2 person assist with the maxi lift .the injury .was avoidable because the staff did not use the correct lift and did not have 2 person assist . Telephone interview with Licensed Practical Nurse (LPN) #2 on 12/13/16 at 2:42 PM revealed .(CNA #6) came to the nursing station and told me that (Resident #40) had slid out of the lift .when I walked into the room (CNA #6) had the wrong lift .(CNA #6) was using the lift by herself .they are supposed to use the sit to stand lift with (Resident #40) .because she (Resident #40) does not have muscle control . Interview with the Administrator and the Director of Nursing (DON) on 12/13/16 at 4:42 PM, in the conference room, confirmed the facility failed to properly transfer Resident #40, resulting in injury to Resident #40.

Based on review of facility policy, medical record review, review of facility investigation, observation, and interview, the facility failed to develop a comprehensive Care Plan to prevent unsafe wandering and elopement from the facility for one Resident (#3) with a [DIAGNOSES REDACTED]. The facility's failure to develop a comprehensive Care Plan resulted in Resident #3 wandering into an area with the potential for access to unsecured chemicals and dangerous equipment and eloping from the facility resulting in lacerations, abrasions, and bruises, and placed Resident #3 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator (NHA) was informed of the Immediate Jeopardy on 6/16/2016 at 6:00 PM in the Conference Room. The findings included: Review of facility policy, Elopement Guidelines, (no date) revealed, .Documentation .Care plan that addresses potential to wander or exit living center and the measures taken to prevent wandering/elopement . Review of facility policy, Elopement Book and Documentation, creation date 5/5/2016, last review date 5/10/2016, effective date 5/10/2016, revealed, .It is (Facility's name) to maintain up to date and accurate 'Elopement Books at each nurse's station and in the business office .Documentation .Care plan that addresses potential to wander or exit living center and the measures taken to prevent wandering/elopement . Medical record review revealed Resident #3 was admitted to the facility 7/12/2010 with [DIAGNOSES REDACTED]. Medical record review of Resident #3's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had short and long term memory problems and cognition was moderately impaired (decisions poor; cues/supervision required). Continued review revealed Resident #3 required extensive assistance for most Activities of Daily Living (ADLs) and a wheelchair was used with limited assistance for mobility. Medical record review of the electronic Nurse's Notes dated 4/23/2015 at 9:12 PM revealed, .Res (Resident #3) was outside in parking lot and found lying face down on the ground with overturned wheelchair . Continued review of the Nurse's Notes at 9:25 PM revealed the Resident had egressed (exited) the facility through the 300 South Hall Door. Medical record review of Resident #3's Risk for Elopement Assessments dated 4/25/2015, 5/7/2015, 7/17/2015, 10/23/2015, 1/14/2016, and 4/25/2016 revealed the Resident was at risk for elopement from the facility. Medical record review of Resident #3's Care Plan revealed the Resident wandered and was at risk for elopement. Continued review revealed interventions were initiated on 5/8/2015. Further review of the interventions initiated revealed, .Check Wander guard placement function Q (every) Shift .Psych (Psychiatric) services to evaluate as ordered/ (or) indicated .Resident pictures placed in elopement books on north nursing station, south nursing station and front office .Wander guard departure bracelet applied as directed to inform staff members of attempts to exit the building . Medical record review of the Nurse's Notes revealed: 5/30/2015 at 9:00 PM, .propelled about the unit today looking for a way out . 6/5/2015 at 4:41 PM, .continues to exit seek . 6/12/2015 at 9:58 PM, .kicked the door .set off the alarm .resident responded I am getting out of here. 6/21/2015 at 11:32 PM, .Pushed on fire doors at beginning of shift . 8/14/2015 at 6:41 PM, .Exit seeking behavior .went to .door and kicked it open . 3/5/2016 at 5:32 PM, .Propelling self throughout the unit in .wheelchair . 4/28/2016 at 9:08 AM, .up in wheelchair, propelling self in hallways .confusion . 4/29/2016 at 9:40 AM, .poor judgement and decision making skills . 5/7/2016 at 1:45 PM, .confusion .Propels self about facility via wheelchair . 5/9/2016 (Late Entry) at 2:13 PM, .confused. Up in wheelchair wheeling self around facility . 5/10/2016 at 9:42 PM, .found resident lying on side in wheelchair across the parking lot .Abrasion and bruising noted on Rt (right) knee. Skin tear and bruising to left elbow. Scratches and abrasions noted around left eye, cheekbone, and temple . Review of a facility investigation dated 5/10/2016 revealed Resident #3 had eloped from the facility by wandering into the unsupervised Service Hall and a visitor exiting the building held the door open for the Resident to exit. Continued review revealed staff found the Resident lying on her side in a wheelchair in the parking lot. Further review revealed Resident #3 told staff I want to go home. Continued review revealed a 4 Point POC (Plan of Correction) was begun on 5/10/2016, but no individualized interventions for redirection to prevent unsafe wandering or attempts to exit the facility were included. Medical record review of Resident #3's current Care Plan for elopement revealed individualized interventions had not been developed and it remained unchanged from 5/8/2015. Observation of the surveillance video for 5/10/2016 confirmed Resident #3 had wandered onto the Service Hall at 3:22 PM in a wheelchair; staff was not present and the Resident was unsupervised. Continued observation confirmed a male visitor entered the Service Hall, walked past Resident #3 to the Service Hall egress doors, exited through the doors, and held the door open for Resident #3 to exit. Further observation confirmed the visitor exited the building and out of surveillance range. Continued observation confirmed Resident #3 exited the building, rolled onto the downward sloping parking lot, and toward a parked truck. Further observation of the video was not visually clear as Resident #3 neared the edge of the pavement to determine if the Resident flipped over in the wheelchair after dropping off of the pavement or if the Resident impacted with the truck and flipped over in the wheelchair. Observation of Resident #3 on 6/1/2016 at 11:00 AM revealed the Resident was in a wheelchair, wandering on the 300 South Hall (the Resident's room is located on the 200 South Hall) and the Resident was 15 feet from the fire door (where the initial elopement occurred on 4/23/2015). Continued observation confirmed no attempts were made by staff to redirect her. Observation of the facility's Service Hall on 6/1/2016 at 1:15 PM revealed the double doors provided access from inside the facility to the Service Hall and had no signage to instruct no entry for unauthorized persons (visitors, families alert residents with intact cognition); and had no monitoring or equipment to alert staff of unauthorized entry into an unsecured and unsafe area. Continued observation of the Service Hall revealed the laundry area was on the left side of the hallway and the entry door into the laundry area was not locked. Further observation revealed the unsecured laundry area contained 1 regular residential-size washing machine, 2 stainless steel commercial washing machines positioned on elevated platforms (with an uneven flooring surface), and 3 commercial soiled laundry bins (to hold soiled items to be washed). Further observation revealed the far right bin was one-third full of residents' soiled clothing and bed linens (soiled from urine and fecal incontinence; and food spillage). Continued observation revealed the regular washing machine had a shelf over it with an unsecured 12-ounce disposable clear plastic cup setting atop the shelf and was half-full with a blue liquid. Further observation revealed 11 buckets containing unsecured liquid chemicals were setting on the floor and each bucket held 5-gallons. Continued observation revealed 4 buckets contained bleach, 4 buckets contained fabric softener, and the remaining 3 buckets contained laundry detergent. Further observation of the unsecured laundry area revealed an unsecured room adjacent the soiled laundry area contained 3 commercial dryers for drying washed items. Observation of the exterior Service Hall egress area and parking lot on 6/1/2016 at 1:30 PM, in the presence of the Administrator (NHA), confirmed the NHA measured the area from where Resident #3 exited through the Service Hall egress to the point of impact, which measured 60 feet. Interview with Dietary Employee #1 on 6/1/2016 at 1:59 PM in the Conference Room, confirmed she was aware of Resident #3's risk for elopement. Continued interview revealed Dietary Employee #1 stated, (Resident #3) was on the ground off the parking lot (on 5/10/2016) .(Resident #3) is determined .we were all aware she tried frequently to get out (of the facility) .she has gotten into the Service Hall several times before getting out (on 5/10/2016) .she went into the Service Hall again that night (5/10/2016) .I .got the nurse .told her (Resident #3) is at it again, trying to get out . Interview with Dietary Employee #2 on 6/1/2016 at 2:19 PM, in the Conference Room, confirmed she was exiting the building on 5/10/2016 and found Resident #3 outside. Continued interview revealed Dietary Employee #2 stated, .(Resident #3) was on the ground .wheelchair was on its side .(Resident #3) was on (Resident's) left side off the pavement on gravel .(Resident) was beside a truck .fastened in her wheelchair with a lap belt. It looked like (Resident) hit the truck .flipped over and stopped (Resident) from going over the embankment behind the truck . (Resident) lifted her head up .looked at me .(Resident) didn't say anything .just looked at me .(Resident) has been in the Service Hall in the last two-to-three months at least two or three times trying to get out the doors .and sometimes .would come back to the Service Hall on the same night multiple times (prior to 5/10/2016 elopement and again after the elopement . Interview with Laundry Employee #1 on 6/2/2016 at 9:30 AM, in the Conference Room revealed Laundry Employee #1 stated, .During the past year, I have seen (Resident #3) in the Service Hall 10, maybe 15 times .I would take (Resident) to the main hall, nurses station, or to (Resident's) room .nurse's saw me bring her from the Service Hall many times, but they never did anything about it . Continued interview revealed Laundry Employee #1 stated, .There's three, 5-gallon buckets of (laundry detergent), four, 5-gallon buckets of bleach, and four, 5-gallon buckets of (fabric softener) in the laundry (soiled linen area) .The plastic disposable cup contains (laundry detergent) in it .from the 5-gallon bucket .there are chemicals back there they could get into .drink it .get it on their skin .in their eyes .it could cause their skin or eyes to get burned, such as the bleach .the two larger (commercial) washers (washing machines) get hot .190 degrees (Fahrenheit) .the (three) dryers .150-to-170 degrees (Fahrenheit) .hot enough to burn them .they could get hurt .electrical wires, too .this is dangerous and could kill somebody if they did the wrong thing or didn't know what they were doing .the door to the soiled area (from the Service Hall) is never locked . Interview with the Director of Laundry and Housekeeping on 6/2/2016 at 10:03 AM in the Conference Room revealed the Director stated, I'm aware (Resident #3) has been in the Service Hall .I would not want residents in the laundry area .soiled linens .clothes with urine, BM (feces), body fluids .make them very sick. There's chemicals .could kill them if they drank it .could get their hands caught in the washer or dryer doors .cause injury .washers and dryers get hot and could [MEDICAL CONDITION]. Continued interview with the Director of Laundry and Housekeeping confirmed the door from the Service Hall into the soiled linen area is never locked and chemicals were accessible. Interview with Licensed Practical Nurse (LPN) #1 on 6/2/2016 at 2:27 PM, in the Conference Room confirmed LPN #1 worked the 2:00 PM-10:00 PM shift on 5/10/2016 and was assigned to the 200 South Hall when Resident #3 was on the Service Hall and eloped. Continued interview revealed LPN #1 stated, .I was aware (Resident) was an elopement risk .When (Resident) got out (eloped), (Resident) was on the Service Hall unsupervised .rolled down the parking lot .When (Resident) wheelchair went off the pavement it probably threw (Resident) forward. When I got to her (Resident) was on mostly the gravel with (Resident) upper body . (Resident) knees were on the edge of the pavement. (Resident) was beside a white truck . (Resident) may or may not have hit the truck . (Resident) had abrasions on (Resident) face and forehead and knees. (Resident's) arms and knees were bruised .I assessed (Resident) to determine (Resident) was able to get into (Resident's) wheelchair, then to (Resident's) room for further assessment .Later that night, (Resident) was back on the Service Hall without supervision . (Resident) was brought back to the nurse's station (by Dietary Employee #1) and they let me know (Resident) was back on the Service Hall. I did not know (Resident) had gone back .we need to keep a closer eye on (Resident) .check on (Resident) every 15-to-30 minutes (after Resident had eloped on 5/10/2016) .This wasn't effective (keeping a closer eye on Resident by checking on Resident every 15-30 minutes) because (Resident) got back on the Service Hall the same night .All throughout the past year (Resident) has tried multiple times to get out .I felt like it was just a matter of time before (Resident) got out again (after the April 2015 elopement) . Interview with Certified Nursing Assistant (CNA) #1 on 6/14/2016 at 7:00 PM, in the Conference Room, revealed CNA #1 stated, .If they are trying to get out, I re-direct them to the TV (television) room to watch TV or keep a closer eye on them .when CNAs are assisting other residents .I don't know how to keep a closer eye on them honestly . Continued interview confirmed when asked about the Cardex (CNA Care Plan), CNA #1 stated, .It doesn't tell me what to do (for Resident #3's unsafe wandering or attempts to exit the facility) .they don't help us to keep her in here or her from trying to get out of here. Interview with CNA #2 on 6/14/2016 at 7:17 PM, in the Conference Room confirmed CNA #2 initially worked in the Dietary Department from December 2015 until April 2016 and transferred to the Nursing Department. Continued interview revealed CNA #2 stated, .I used to work in Dietary .I saw (Resident #3) back there (Service Hall) 10-to-15 times .(Resident's) Cardex doesn't tell us what to do to prevent wandering or to keep (Resident) from eloping .they are in a binder at the nurse's station .Cardex doesn't help with elopement or wandering . Interview with CNA #3 on 6/14/2016 at 7:45 PM in the Conference Room confirmed CNA #3 worked the 2:00 PM-10:00 PM shift on 5/10/2016 and was assigned to the 200 South Hall when Resident #3 was on the Service Hall and eloped. Continued interview revealed CNA #3 stated, .(Resident) wanders throughout the building and is free to wander. I've seen (Resident) wandering all over the building . Further interview with CNA #3 confirmed the Cardex for Resident #3 did not provide interventions to manage unsafe wandering or attempts to exit the facility and stated, They tell us (Resident) has a bracelet (wanderguard) .but it doesn't tell us how to stop (Resident) from going all over the building or .from trying to get out (elope) . Interview with CNA #4 on 6/14/2016 at 10:22 PM, in the Conference Room, confirmed CNA #4 worked the 2:00 PM-10:00 PM shift on 5/10/2016 and was assigned to the 200 South Hall when Resident #3 was on the Service Hall and eloped. Continued interview revealed CNA #4 stated, .On the day (Resident) eloped (5/10/2016), when I came in I went to get (Resident's) vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure) . (Resident) was saying (Resident) wanted to go home . (Resident) tried to get out .wanted to leave .I knew (Resident) was a wanderer . (Resident) was always trying to get out .I ran into (Resident's) daughter later and .daughter asked where (Resident) was .told her I just did (Resident's) vital signs .daughter said she didn't see (Resident) .I continued to assist my other residents .then I later heard them calling a code yellow (to alert staff a resident has eloped) .The Care Cards (Cardex) don't tell us what to do when (Resident) wanders or tries to get out . Interview with the Resident Nurse Assessment Coordinators (RNACs) #1 and #2 on 6/16/2016 at 7:30, PM in the Conference Room, confirmed RNACs #1 and #2 were responsible for the development of the Comprehensive Care Plans. Continued interview revealed RNAC #2 stated, That's (Resident #3's Elopement Care Plan) just a standard (not individualized) Care Plan . Further interview revealed RNAC #1 agreed with RNAC #2. Continued interview with RNACs #1 and #2 confirmed the facility failed to develop an individualized Comprehensive Care Plan for Resident #3 to provide interventions to prevent unsafe wandering and elopement. Interview with the NHA on 6/16/2016 at 9:30 PM, in the Conference Room, confirmed the NHA was aware Resident #3 was at risk for elopement and consistently wandered onto the Service Hall. Continued interview revealed the NHA reviewed Resident #3's Elopement Care Plan and Care Card (Cardex) and stated, . There are no interventions to re-direct (when wandering or attempting to exit the facility) .it doesn't identify what they (nursing staff) need to do for (Resident) . Continued interview with the NHA confirmed the facility failed to ensure an individualized Comprehensive Care Plan was developed for Resident #3 to prevent unsafe wandering and elopement. The Immediate Jeopardy was effective from 5/10/2016 through 6/17/2016. An Acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated through review of documents, observations, and staff interviews conducted onsite on 6/18/2016. The surveyor verified the allegation of compliance by: 1. Reviewing the facility's in-service records to validate the two RNACs responsible for the development of individualized Comprehensive Care Plans were in-serviced on 6/17/2016. This in-service also included the Nurse Educator and NHA, to ensure oversight and continuity. 2. Conducting interviews on 6/18/2016 at between 1:00 AM-1:45 AM with the two RNACs, Nurse Educator, and NHA to determine the level of comprehension gained through the in-service education conducted on 6/17/2016 regarding the development of an individualized Comprehensive Care Plan to ensure staff have developed individualized interventions and: A. Comprehend the difference between a standardized Comprehensive Care Plan versus an individualized Care Plan. B. The rational for an individualized Comprehensive Care Plan. C. A verbal explanation of (1) goal-directed wandering and (2) aimless wandering. How the difference is determined in the two types of wandering and viable interventions to address the occurrence of both types of wandering behaviors. 3. Reviewing the Comprehensive Care Plans of all Residents (Residents #2, #3, #5, and #6) assessed as at-risk for wandering and elopement developed on 6/17/2016. The review was to ensure the development of a Comprehensive Care Plan with individualized interventions to prevent unsafe wandering and elopement. 4. Observation of staff on 6/17/2016 between 6:45 PM-7:05 PM implementing individualized interventions for Resident #3 and #6's unsafe wandering behavior. Observation of Residents #2 and #5, who are at risk for elopement in addition to #3, revealed no wandering behaviors to require re-directive interventions (#2 was lying on the bed and #5 was in their room visiting with family). Noncompliance continues at a scope and severity of D for monitoring the effectiveness of corrective actions and evaluation of monitoring by the Quality Assurance (QA) Committee. The facility is required to submit a plan of correction. Refer to F-323 (J), Substandard Quality of Care.

Based on review of facility policy, review of Material Safety Data Sheets (MSDS), medical record review, review of facility investigation, observation, and interview, and review of facility forms, the facility failed to provide adequate supervision to prevent unsafe wandering and elopement from the facility for one Resident (#3) with a [DIAGNOSES REDACTED].#1); failed to ensure neurological assessments were completed with unwitnessed falls for two Residents (#1, #2); and failed to revise the Certified Nursing Assistant Care Cards for one Resident (#2) at-risk for falls of five residents reviewed for supervision of six residents reviewed. The facility's failure to provide supervision resulted in Resident #3 wandering into an area with access to unsecured chemicals and dangerous equipment and eloping from the facility, resulting in lacerations, abrasions, and bruises, and placed Resident #3 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator (NHA) was informed of the Immediate Jeopardy on 6/16/2016 at 6:00 PM in the Conference Room. F-323 resulted in Substandard Quality of Care. The findings included: Review of facility policy, Elopement Guidelines, (no date) revealed, Definition: Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for [REDACTED]. Review of facility policy, Elopement Book and Documentation, creation date 5/5/2016, last review date 5/10/2016, effective date 5/10/2016, revealed, .It is (Facility's name) to maintain up to date and accurate 'Elopement Books' at each nurse's station and in the business office. Each book shall contain pictures and face sheets of Resident's at risk for elopement . Review of Material Safety Data Sheets (MSDS) for bleach, fabric softener, and laundry detergent revealed, .Bleach .II Health Hazard Data-DANGER: CORROSIVE. May cause irritation or damage to eyes and skin .Harmful if swallowed .Medical conditions that may be aggravated by exposure .heart conditions .IV Special Protection and Precautions .wear safety glasses .avoid breathing vapors .avoid eye and skin contact and inhalation of vapor or mist . Continued review revealed, .Fabric Softener .Section II-Hazards .gastrointestinal irritation .eye irritant .skin irritant .Section VIII-Exposure Controls-Personal Protection .Eye and face protection: If a splash of solution is likely, chemical goggles may be needed. Skin Protection: Minimize skin contact with protective gloves . Further review revealed, .Laundry Detergent .Caution: Harmful if swallowed. Eye irritant: Avoid eye contact, which may cause mild to moderate transient irritation . Medical record review revealed Resident #3 was admitted to the facility 7/12/2010 with [DIAGNOSES REDACTED]. Medical record review of Resident #3's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident had short and long term memory problems and cognition was moderately impaired (decisions poor; cues/supervision required). Continued review revealed Resident #3 required extensive assistance of 2 or more staff for most Activities of Daily Living (ADLs). Further review revealed the Resident used a wheelchair with limited assistance for mobility. Medical record review of the electronic Nurse's Notes dated 4/23/2015 at 9:12 PM, revealed, .Res (Resident #3) was outside in parking lot and found lying face down on the ground with overturned wheelchair . Continued review of the Nurse's Notes at 9:25 PM revealed Resident #3 egressed (exited) the facility through the 300 South Hall Door. Review of a facility investigation dated 4/23/2015 revealed a Plan of Correction was initiated and included: 1. In-servicing on the Elopement Policy on 4/23/2015. 2. Red laminated Stop signage on all Fire and Egress doors implemented on 4/23/2015. 3. Small door alarms (purchased at local electronic shop) installed on all Fire Doors to alert when a door is opened (in addition to previously installed 15 second delay magnet (mag) locks with key code pads) placed on 4/23/2015. 4. Every 15 minute checks initiated on 4/25/2015. 5. Moved Resident #3 to the 200 South Hall where the hall's Fire Door egressed to a grassy area versus pavement. 6. Initiated installation of door screamer alarms (audible alarm will sound immediately upon opening the door and can be heard facility-wide) on all Fire Doors on 7/10/2015 and completed on 8/6/2015. 7. Every 15 minute checks discontinued on 8/6/2015. 8. Obtained State Life Safety approval for installation of metal fencing with gates for all Fire and Egress Doors on 8/5/2015. 9. Installation of fencing initiated on 10/1/2015 and completed on 10/15/2015. Medical record review of the Nurse's Notes revealed: 4/27/2015 at 2:24 AM, .confused . 4/28/2015 at 2:24 AM, .wanderguard (bracelet placed on the Resident and transmits a signal to an alarm attached to a door if egress (exit) is attempted) . 5/30/2015 at 9:00 PM, .Resident has propelled about the unit today looking for a way out . 6/5/2015 at 4:41 PM, .continues to exit seek . 6/12/2015 at 9:58 PM, .Resident .kicked the door hard enough to set off the alarm .resident responded 'I am getting out of here.' 6/21/2015 at 3:52 PM, .decreased safety awareness . and at 11:32 PM .Up in wheelchair. Pushed on fire doors at beginning of shift . 8/14/2015 at 6:41 PM, .Exit seeking behavior noted .went to .door and kicked it open but was stopped before exiting . 10/17/2015 at 11:54 AM, .Up and about in w/c propelling self ad lib (as much and as often as desired) . 11/12/2015 at 11:34 AM, .Redirected away from emergency doors many times this shift .Propelling self in hallways in w/c (wheelchair) at present . 4/28/2016 at 9:08 AM, .confusion. Oriented to self only . 5/3/2016 at 2:59 PM, .Has poor judgement and decision making skills . 5/7/2016 at 3:45 PM, .confusion .Propels self about facility via wheelchair . 5/9/2016 at 2:13 AM, .confused. Up in wheelchair wheeling self around facility . 5/10/2016 at 9:42 PM, .found resident lying on side in wheelchair across the parking lot .Abrasion and bruising noted on Rt (right) knee. Skin tear and bruising to left elbow. Scratches and abrasions noted around left eye, cheekbone, and temple . 5/12/2016 at 4:01 PM, .Propels self about facility via wheelchair . 5/14/2016 at 3:01 PM, .confusion noted to time, place, and events . 5/19/2016 at 3:40 PM, some confusion .Propels self about facility via wheelchair . Medical record review of Resident #3's Risk for Elopement Assessments dated 4/25/2015, 5/7/2015, 7/17/2015, 10/23/2015, 1/14/2016, and 4/25/2016 revealed the Resident was at risk for elopement from the facility. Review of a facility investigation dated 5/10/2016 revealed Resident #3 was found lying on her side in a wheelchair in the parking lot. Continued review revealed Resident #3 was interviewed and stated, I want to go home. Further review revealed the facility's investigation identified confusion and Dementia as contributing factors. Continued review revealed the outcome of the facility's investigative findings identified a visitor held door open for resident to go outside. Continued review revealed a 4 Point POC (Plan of Correction) was initiated on 5/10/2016: 1. Immediately in-service all available staff. Resident was immediately assessed for injury. Wonder Guard (wanderguard) was verified to be on resident and working. All doors were verified by maintenance to be in working order. All residents were verified to be in the building. 2. An audit was completed by the Director of Nursing (DON) to ensure all residents who are in the elopement book are up to date. Four residents were identified as having wandering behaviors. Their care plans and care cards were updated. No employees will be allowed to work until they have been in-serviced on elopement policy and procedures. 3. Signage placed on all exit doors stating please do not let residents out without checking with staff first. Executive Director (Administrator) sending out letter to all R.P.'s (Responsible Parties) asking them to use the main entrance (for entry and exit from the facility) and not let residents out (of) facility without checking with staff first. 4. Director of Maintenance to check all exterior exits daily to ensure wanderguard systems are in place and functioning properly. Director of Maintenance to bring findings to QAPI (Quality Assurance Performance Improvement) and Safety meeting for 3 months. Review of the facility Investigation Summary dated 5/13/2016 revealed Resident #3 was an elopement risk and exited the building through the back door on the facility's Service Hall. Observation and review of the Elopement Books on 6/1/2016 at 10:55 AM revealed an Elopement Book was located at the North and South Nurse's Stations and Business Office; and each book contained Resident #3's picture and identified the Resident as at risk for elopement. Observation of the surveillance video for 5/10/2016 revealed Resident #3 was on the Service Hall at 3:22 PM in a wheelchair, cradling a baby doll in her left arm; the Resident was alone and unsupervised. Continued observation revealed as Resident #3 propelled down the hallway toward the egress doors, a male visitor entered the Service Hall, walked past Resident #3 to the Service Hall egress doors, entered a code to unlock the doors, exited through the doors and held the door open for Resident #3 to exit. Further observation revealed the visitor exited the building and went into the parking lot, then out of surveillance range. Continued observation revealed Resident #3 exited the building and rolled onto the downward sloping parking lot, and the speed of rolling the wheelchair increased as the Resident continued to roll downward, without control, toward a parked truck. Further observation of the video was not visually clear as Resident #3 neared the edge of the pavement to determine if the Resident flipped over in the wheelchair after dropping off of the pavement, or if the Resident impacted with the truck and flipped over in the wheelchair. Observation of Resident #3 on 6/1/2016 at 11:00 AM, revealed the Resident was not in or near the Resident's room on the 200 South Hall. Continued observation revealed the Resident was in a wheelchair with a self-release lap belt in place and was wandering on the 300 South hallway 15 feet from the fire door (where the initial elopement occurred on 4/23/2015). Further observation confirmed staff made no attempts to redirect Resident #3. Observation of the facility's Service Hall on 6/1/2016 at 1:15 PM, revealed the double doors providing access from inside the facility to the Service Hall had no signage to instruct no entry for unauthorized persons (visitors, families, alert residents with intact cognition); and had no type of monitoring or equipment to alert staff of unauthorized entry into an unsecured area. Continued observation into the Service Hall revealed the laundry area was on the left side of the hallway and the entry door into the laundry area was not locked. Further observation revealed the unsecured laundry area consisted of two unsecured areas, with the first area being the soiled laundry area where soiled items were brought for holding and washing. Continued observation revealed the unsecured soiled laundry area contained 1 regular residential-size washing machine, 2 stainless steel commercial washing machines positioned on elevated platforms (with an uneven flooring surface), and 3 commercial soiled laundry bins (to hold soiled items to be washed) and measured 3 feet by 2 feet (side-to-side, front-to-back) by 2 feet deep (top-to-bottom). Further observation revealed the far right bin was one-third full of residents' soiled clothing and bed linens (soiled from urine and fecal incontinence; and food spillage). Continued observation revealed the regular washing machine had a shelf over it with an unsecured 12-ounce disposable clear plastic cup setting atop the shelf and was half-full with a blue liquid. Further observation revealed 11 buckets containing unsecured liquid chemicals were setting on the floor and each bucket held 5-gallons. Continued observation revealed 4 buckets contained bleach, 4 buckets contained fabric softener, and the remaining 3 buckets contained laundry detergent. Continued observation of the unsecured laundry area revealed the second area adjacent the soiled laundry area contained 3 commercial dryers for drying washed items. Observation of the Service Hall egress area and parking lot on 6/1/2016 at 1:30 PM, in the presence of the Administrator (NHA), confirmed the exterior of the Service Hall egress area was surrounded by a metal fence and gate with the fenced area measuring 88 inches (side-to-side) by 35 inches (front-to-back). Continued observation confirmed a 60-inch gate was positioned straight across from the egress doors and did not have any form of positive (non-locking) latch to close the gate; and the gate swung freely both inward and outward and did not close. Continued observation of the exterior Service Hall egress area and parking lot confirmed the NHA measured the area from where Resident #3 exited through the Service Hall egress to the point of her impact, which measured 60 feet. Interview with Dietary Employee #1 on 6/1/2016 at 1:59 PM in the Conference Room confirmed she was aware of Resident #3's risk for elopement and elopement from the facility in April 2015. Continued interview revealed Dietary Employee #1 stated, (Resident #3) was on the ground off the parking lot (off the pavement). I went in to call the nurse .(Resident #3) is determined .we were all aware she tried frequently to get out (of the facility) .since she got out last year, she has gotten into the Service Hall several times before getting out this last time (on 5/10/2016) .she went into the Service Hall again that night (5/10/2016) .I went and got the nurse and told her (Resident #3) is at it again, trying to get out .I can't remember the nurse's last name for sure, but I think it was (Licensed Practical Nurse #1) . Interview with Dietary Employee #2 on 6/1/2016 at 2:19 PM, in the Conference Room, confirmed she was exiting the building on 5/10/2016 and found Resident #3. Continued interview revealed Dietary Employee #2 stated, .(Resident #3) was on the ground .wheelchair was on its side and (Resident #3) was on (the Resident's) left side off the pavement on gravel .(Resident) was beside a truck and was fastened in the wheelchair with a lap belt. It looked like (the Resident) hit the truck; it flipped (the Resident) over and stopped (the Resident) from going over the embankment behind the truck. I went to (the Resident) .(the Resident) lifted (Resident's) head up and looked at me .(Resident) didn't say anything .just looked at me .(Resident #3) has been in the Service Hall in the last two-to-three months at least two or three times trying to get out the doors .(Resident) would be on the Service Hall, we'd take (Resident) back to the nurses station and sometimes (Resident) would come back to the Service Hall on the same night multiple times . Interview with Laundry Employee #1 on 6/2/2016 at 9:30 AM, in the Conference Room, revealed Laundry Employee #1 stated, .During the past year, I have seen (Resident #3) in the Service Hall 10, maybe 15 times .I would take (the Resident) to the main hall, nurses station, or to (Resident's) room .The nurses saw me bring (the Resident) from the Service Hall many times, but they never did anything about it . Continued interview revealed Laundry Employee #1 stated, .There's three, 5-gallon buckets of (laundry detergent), four, 5-gallon buckets of bleach, and four, 5-gallon buckets of (fabric softener) in the laundry (soiled linen area) .The plastic disposable cup contains (laundry detergent) in it .from the 5-gallon bucket .I would not want a resident in the laundry area, especially a confused resident .there are chemicals back there they could get into and drink it or get it on their skin or in their eyes .it's dangerous .it could cause their skin or eyes to get burned, such as the bleach .I guess it could even kill them .the two larger (commercial) washers (washing machines) get hot .190 degrees (Fahrenheit) and the (three) dryers do, too .150-to-170 degrees (Fahrenheit) .hot enough to burn them .they could get hurt .there are electrical wires, too .this is dangerous and could kill somebody if they did the wrong thing or didn't know what they were doing .the door to the soiled area (from the Service Hall) is never locked . Interview with the Director of Laundry and Housekeeping on 6/2/2016 at 10:03 AM, in the Conference Room, revealed the Director stated, I'm aware (Resident #3) has been in the Service Hall .I would not want residents in the laundry area .There's soiled linens and clothes with urine, BM (feces), body fluids .and they could get into that and make them very sick. There's chemicals and that could kill them if they drank it. They could get their hands caught in the washer or dryer doors and cause injury. Plus the washers and dryers get hot and could cause burns . Continued interview with the Director of Laundry and Housekeeping confirmed the door from the Service Hall into the soiled linen area is never locked and chemicals were accessible. Interview with Licensed Practical Nurse (LPN) #1 on 6/2/2016 at 2:27 PM, in the Conference Room, confirmed LPN #1 worked the 2:00 PM-10:00 PM shift on 5/10/2016 and was assigned to the 200 South Hall when Resident #3 was on the Service Hall and eloped. Continued interview revealed LPN #1 stated, .I was aware (Resident #3) was an elopement risk .When (Resident) got out (eloped), (Resident) was on the Service Hall unsupervised. A visitor let (the Resident) out. (The Resident) rolled down the parking lot to the edge of the pavement which drops off maybe about 5 or so inches. When the wheelchair went off the pavement it probably threw (Resident) forward. When I got to (the Resident), (Resident) was on mostly the gravel with (Resident's) upper body, and (Resident's) knees were on the edge of the pavement. (The Resident) was beside a white truck and may or may not have hit the truck .(The Resident) had abrasions on (Resident's) face and forehead and knees. (The Resident's) arms and knees were bruised .I assessed (the Resident) to determine if (Resident) was able to get into the wheelchair, then to (Resident's) room for further assessment .Later that night, (the Resident) was back on the Service Hall without supervision .(the Resident) was brought back to the nurses station (by Dietary Employee #1) and they let me know (Resident) was back on the Service Hall. I did not know (the Resident) had gone back .I had told the CNA (Certified Nursing Assistant) we need to keep a closer eye on her .check on her every 15-to-30 minutes .This wasn't effective (keeping a closer eye on the Resident by checking every 15-30 minutes) because (the Resident) got back on the Service Hall the same night .All throughout the past year (Resident #3) has tried multiple times to get out .I felt like it was just a matter of time before (the Resident) got out again (after the April 2015 elopement). Continued interview revealed LPN #1 stated, .The laundry room door is not locked .no residents should ever be back there .it's unsupervised and dangerous .they could fall or drink the chemicals and we wouldn't know it. It's dangerous and could kill a resident . Further interview with LPN #1 confirmed adequate supervision was not provided to prevent Resident #3 from wandering into unsafe areas (on the Service Hall and outside without supervision). Interview with CNA #2 on 6/14/2016 at 7:17, PM in the Conference Room, confirmed CNA #2 initially worked in the Dietary Department from December 2015 until April 2016, and transferred to the Nursing Department. Continued interview revealed CNA #2 stated, .I used to work in Dietary and there were plenty of times (Resident #3) was on the Service Hall without supervision .we've caught (Resident) back there alone and we would typically push (Resident) back off the Service Hall through the double doors .to the nurses station .I saw (Resident #3) back there (Service Hall) 10-to-15 times without supervision . Interview with CNA #3 on 6/14/2016 at 7:45 PM, in the Conference Room, confirmed CNA #3 worked the 2:00 PM-10:00 PM shift on 5/10/2016 and was assigned to the 200 South Hall when Resident #3 was on the Service Hall and eloped. Continued interview revealed CNA #3 stated, .(Resident #3) wanders throughout the building and is free to wander. I've seen (Resident) wandering all over the building. (Resident) was free to go down the Service Hall prior to 5/10/2016. If I had seen (Resident #3) go down the Service Hall I wouldn't have stopped (Resident) because I thought there was a wanderguard alarm on the door .If I know one of my residents is at risk for elopement, I check on them every two hours as I'm doing my rounds .looking back, the Service Hall is not safe for residents to be on .the chemicals could kill them. Interview with CNA #4 on 6/14/2016 at 10:22 PM, in the Conference Room, confirmed CNA #4 worked the 2:00 PM-10:00 PM shift on 5/10/2016 and was assigned to the 200 South Hall when Resident #3 was on the Service Hall and eloped. Continued interview revealed CNA #4 stated, .It was known (Resident) wandered onto the Service Hall and would try to kick doors open to get out. On the day (Resident) eloped last (5/10/2016), when I came in I went to get (Resident's) vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure) .(Resident #3) was saying (Resident) wanted to go home, this was not (Resident's) home .(Resident) tried to get out .wanted to leave .I knew (Resident #3) was a wanderer .was always trying to get out .I ran into (Resident's) daughter later and the daughter asked where (Resident) was .I told her I just did (Resident's) vital signs .daughter said she didn't see (Resident #3) .I continued to assist my other residents .then I later heard them calling a code yellow (to alert staff a resident has eloped) . Interview with the NHA on 6/16/2016 at 9:30 PM, in the Conference Room, revealed the NHA was aware Resident #3 was at risk for elopement and consistently wandered onto the Service Hall. Continued interview confirmed the NHA stated, .Yes, I knew (Resident #3) wandered onto the Service Hall .(Resident) has wandered onto the Service Hall ever since I've been here .I've been here three years this coming September (2016) .with the gate the way it is (no positive non-locking latch), it's not a deterrent to prevent elopement .We had the older version of the wanderguard alarm on the Service Hall (egress) door and if someone put the code in, then even if a resident had a wanderguard on, it wouldn't alarm because the code disabled the alarm, and they could go through the door with no alarm sounding .We do safety rounds monthly, but I just didn't think about the Service Hall being an unsupervised area .now, I realize it is .I never thought about a resident being able to go into the laundry . Continued interview with the NHA confirmed the facility failed to ensure adequate supervision for Resident #3 to prevent unsafe wandering on the Service Hall and elopement. Telephone interview with Resident #3's attending Physician (Medical Director) on 6/17/2016 at 2:09 PM, confirmed Resident #3's unsupervised wandering on the Service Hall with unsecured chemicals, contaminated laundry linens and clothing, and equipment placed her at risk to cause serious injury, harm, impairment or death. Medical Record review revealed Resident #1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of facility policy, Falls Management Guideline, dated 10/21/2015 revealed, .The licensed nurse assesses the resident for injuries (including neuro checks (assessment to detect abnormalities of the brain, spine, and the nerves that connect them) if indicated) and provides necessary treatment and initiates the Change in Condition Report-Post Fall/Trauma (Post Fall Analysis/Plan) .Appropriate interventions are implemented .Care plan is updated .The Interdisciplinary Team reviews the Change of Condition Report-Post Fall/Trauma and makes additional recommendations within 72 hours of the fall . Review of a facility policy, Neurological Checks, (undated) revealed, .Neurological checks (assessments) are to be performed whenever a resident strikes their head or face and for any un-witnessed fall . Review of facility policy, Care Cards (Cardex-CNA Care Plan), dated 5/10/2016 revealed, .It is (facility) policy to communicate .Resident specific information .Each Resident's Cardex is to be updated weekly and as needed .Cardex's are to be printed and distributed to the CNA's at the begging (beginning) of each shift . Review of instructions on a facility form, Post Fall Analysis/Plan, revealed, .(page 2 of 3) Specify Recommendations/Interventions taken to prevent reoccurrence .(page 3 of 3) Recommendations and Interventions Post Fall (Check all that apply) . Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #1's cognition was moderately impaired. Continued review revealed the Resident required limited assistance with bed mobility, transfers, ambulation, dressing, and personal hygiene. Medical record review of a Care Plan dated 12/11/2015 revealed Resident #1 was at risk for falls. Medical record review of a Nurse's Note dated 12/23/2015 at 1:00 AM, revealed, .SBAR (Situation, Background, Assessment, and Recommendation; a standardized communication tool)-Change of Condition .Res (Resident #1) fall from bedside to floor .found laying up against wall next to her bed .Cut to underside of left forearm (minor) . Medical record review revealed no new interventions were implemented to prevent further falls. Review of a facility investigation dated 1/6/2016 at 7:01 AM, revealed, .nurse was standing just inside the door with her back to the resident (#1) .When (Nurse) turned, resident was sitting in the floor at the foot of the bed with her knees drawn up to her chest .no injuries . Medical record review revealed no evidence a neurological assessment was completed for Resident #1's unwitnessed fall on 1/6/2016. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission MDS dated [DATE] revealed Resident #2's cognition was severely impaired. Continued review revealed the Resident required limited assistance with transfers and ambulation. Review of facility investigations for Resident #2 revealed the Resident had one unwitnessed fall while bending over to pick an object up from the floor on 4/1/2016 and a second unwitnessed fall from the bed on 4/28/2016. Continued review revealed no injuries from the falls. Medical record review revealed no evidence neurological assessments were completed for Resident #2's unwitnessed falls on 4/1/2016 and 4/28/2016. Medical record review of Resident #2's Care Plan dated 7/1/2015 revealed, .At risk for falls .4/1/16 Safety cues, and reminders. PT (Physical Therapy) to screen .4/28/16 Remind resident to lay in center of bed. Non-skid strips on floor . Medical record review of Resident #2's Cardex (CNA Care Plan) updated 6/2/2016 revealed . Wanderguard Bracelet .Additional Information . (Blank) . Interview with CNA #1 on 6/2/2016 at 3:15 PM, on the 200 South Hall, revealed, .(Resident #2) would have a star (symbol of a star) above (Resident's) bed if a fall risk .not sure if (Resident) is or not .nope not one there (star) .(Resident) walks with a cane and holds on the rail .can review Cardex to see what devices should be in place for the residents . Interview with LPN #2 on 6/2/2016 at 3:25 PM, at the South Wing Nurses Station, revealed, (Resident #2) slides .doesn't like to wear socks .so strips were placed at bedside .(Resident) has had a couple of falls .if (Resident) has anything special ordered it will be on his Care Plan .that's how we know .CNA's use the Cardex . Interview with the DON on 6/2/2016 at 6:40 PM, in the Conference Room, confirmed the facility failed to follow their policies to prevent falls, and to complete a Post Fall Analysis/Plan, and to develop new interventions on 12/23/2015 to prevent further falls for Resident #1. Continued interview with the DON confirmed the facility failed to follow their policies and revise the CNA Cardex to include new interventions developed on 4/1/2016 and 4/28/2016. Further interview with the DON confirmed the facility failed to follow their policies and complete neurological assessments after Resident #1's unwitnessed fall on 1/6/2016; and Resident #2's unwitnessed falls on 4/1/2016 and 4/28/2016. The Immediate Jeopardy was effective from 5/10/2016 through 6/17/2016. An Acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated through review of documents, observations, and staff interviews conducted onsite on 6/18/2016. The surveyor verified the allegation of compliance by: 1. Observing a door monitor posted at the interior Service Hall Doors on 6/1/2016 at 6:20 PM, to prevent residents from unsupervised wandering onto the Service Hall. 2. Observing a Commercial Door Company in the process of installing an alarm system on the interior Service Hall Doors to alert the facility of unauthorized entry from inside the facility into the Service Hall on 6/2/2016 at 5:00 PM (installation completed at 7:00 PM). Observing the normal and proper functioning of the alarm system on the interior Service Hall doors and the removal of the door monitor at 7:30 PM. 3. Observing all egress doors on 6/17/2016 for signage (Red Stop signage implemented on 4/23/2015); Notice to Visitors (not to let residents out of the facility without staff notification) implemented on 5/11/2016; and proper functioning of anti-elopement systems on the following doors: A. 100, 200, 300 North Hall Fire Doors B. 100, 200, 300 South Halls Fire Doors C. 200 South Alcove Fire Doors D. 200 North Alcove Egress Doors D. Dining Room Egress Doors E. Main Entry Egress Doors F. Service Hall Egress Doors G. Interior Service Hall Doors (leading into the Service Hall from inside the facility). All Egress Doors (excluding the interior Service Hall Doors) had (1) Red laminated Stop signage (implemented 4/23/2015); (2) signage to not let any resident out of the facility without nursing notification and consent to do so implemented on 5/10/2016; (3) a 15 second delayed mag lock with key code pad implemented prior to the elopements; and (4) a wanderguard alarm system (if a resident with a wanderguard bracelet attempts to exit the door locks, alarms sound, and the door will not open until the resident with the wanderguard is removed from the door area). The wanderguard alarm system in place did not have the upgraded version (tail gate feature) on the Service Hall Egre

Based on review of facility policy, medical record review, review of facility investigation, observation, review of Material Safety Data Sheets (MSDS), and interview, the facility failed to be administered in a manner to ensure the development of an individualized Comprehensive Care Plan for unsafe wandering and attempts to elope from the facility; to provide adequate supervision to prevent unsafe wandering and elopement from the facility for one Resident (#3) with a [DIAGNOSES REDACTED].#1); to revise the Certified Nursing Assistant Care Cards for one Resident (#2) at-risk for falls; and to ensure neurological assessments were completed with unwitnessed falls for two Residents (#1, #2) of six residents reviewed. The facility's administrative failure to develop an individualized Comprehensive Care Plan and failure to provide supervision resulted in Resident #3 wandering into an area with the potential for access to unsecured chemicals and dangerous equipment and eloping from the facility, resulting in lacerations, abrasions, and bruises, and placed Resident #3 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator (NHA) was informed of the Immediate Jeopardy on 6/16/2016 at 6:00 PM in the Conference Room. The findings included: Interview with the NHA on 6/16/2016 at 9:30 PM, in the Conference Room, confirmed the NHA was aware Resident #3 was at risk for elopement and had consistently wandered onto the unsupervised Service Hall since the NHA had worked at the facility (3 years effective September 2016). Continued interview confirmed the laundry area was unsecured and contained multiple and various hazardous chemicals; and was accessible from the Service Hall. Further interview confirmed the NHA installed fencing with gates (2015) around areas of egress as an elopement deterrent, but failed to ensure a positive non-locking latch to securely close the gates. Continued interview confirmed at one point in the past, the gates had a non-locking stop-plate to help secure the gates' position with the gate posts (to stabilize the gate and prevent it from swinging inward and outward); however, he had them removed due to employee injuries from bumping their arms on the plate during entry and egress through the gates. Further interview confirmed previous safety rounds were not effective in identifying unsafe, unsupervised, or hazardous or the potential for hazardous areas, specifically, the Service Hall and laundry area. Continued interview with the NHA confirmed the facility failed to be administered in a manner to prevent Resident #3 from unsafe and unsupervised wandering on the Service Hall and elopement. The Immediate Jeopardy was effective from 5/10/2016 through 6/17/2016. An Acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated through review of documents, observations, and staff interviews conducted onsite on 6/18/2016. The surveyor verified the allegation of compliance by: 1. Observing a door monitor posted at the interior Service Hall Doors on 6/1/2016 at 6:20 PM. 2. Observing the normal and proper functioning of the alarm system (completed on 6/2/2016 at 7:00 PM) on the interior Service Hall doors and removal of the door monitor at 7:30 PM. 3. Observing all egress doors on 6/17/2016 for Red Stop signage (implemented 4/23/2015); Notice to Visitors (not to let residents out of the facility without staff notification) implemented on 5/11/2016; and proper functioning of anti-elopement systems on the following doors: A. 100, 200, 300 North Hall Fire Doors B. 100, 200, 300 South Halls Fire Doors C. 200 South Alcove Fire Doors D. 200 North Alcove Egress Doors D. Dining Room Egress Doors E. Main Entry Egress Doors F. Service Hall Egress Doors G. Interior Service Hall Doors (leading into the Service Hall from inside the facility). All Egress Doors (excluding the interior Service Hall Doors) had (1) Red laminated Stop signage (implemented 4/23/2015); (2) signage to not let any resident out of the facility without nursing notification and consent to do so implemented on 5/10/2016; (3) a 15 second delayed mag lock with key code pad implemented prior to the elopements; and (4) a wanderguard alarm system (if a resident with a wanderguard bracelet attempts to exit the door locks, alarms sound, and the door will not open until the resident with the wanderguard is removed from the door area). The wanderguard alarm system in place did not have the upgraded version (tail gate feature) on the Service Hall Egress Doors and the 200 North Alcove Egress Doors. The Service Hall and 200 North Alcove Egress Doors were upgraded to include the tail gate feature. Installation of the upgraded wanderguard system was initiated on 5/13/2016 and completed on 5/14/2016. The interior Service Hall Doors had a key code pad and required a specific code to be entered by authorized facility personnel only for entry into the Service Hall from the inside of the facility. If the interior Service Hall Doors are opened without first entering the code, a bright strobe light will flash and an audible alarm will sound and can be heard facility-wide. Installation completed on 6/2/2016. All visual and audible door alarms placed on all Fire, Egress, and interior Service Hall Doors will continuously emit visually and/or audibly until staff respond to the specific alarm and manually deactivate. 2. Observing the exterior Fire and Egress areas with fencing and gates on 6/17/2016 to ensure the gates closed securely to a positive non-locking latch (installation competed on 6/7/2016) on the following: A. Fire Doors-200 and 300 North Fire Doors, totaling 3 gates B. Fire Doors-300 South, totaling 1 gate C. Egress Doors- Service Hall and Main Entry, totaling 3 gates 3. Observing the staff's response to the interior Service Hall alarms which were triggered by the surveyor on 6/17/2016 at 7:15 PM. 4. Interviewing 12 Responsible Parties of non-elopement risk residents and 3 Vendors on 6/16/2016 between 6:55 PM-9:00 PM, and 6/17/2016 between 9:20 AM-1:20 PM, to confirm receipt of written notice sent on 5/10/2016 and determine their level of comprehension regarding not letting resident(s) out of the facility without nursing notification, consent to do so, and signing the resident out. 5. Interviewing 5 visitors 6/16/2016 between 6:55 PM-9:00 PM, and 6/17/2016 between 9:20 AM-1:20 PM, to determine their level of comprehension regarding not letting resident(s) out of the facility without nursing notification, consent to do so, and signing the resident out. 6. Reviewing the facility's in-service records to validate facility staff were in-serviced on 6/17/2016 regarding the new alarm system on the interior Service Hall Entry Doors and the following facility policies: Elopement Elopement Book and Documentation Door Alarms and Access Codes 7. Reviewing in-service records to validate the NHA was in-serviced on 6/16/2016 by the Corporate Field Services Clinical Director regarding the completion of daily safety (environmental hazard) rounds, determining safe versus non-safe areas 8. Conducting interviews beginning on 6/17/2016 at 7:25 PM and ending on 6/18/2016 at 12:30 AM, with nursing staff to include the NHA, 6 Registered Nurses (including the Assistant Director of Nursing and Nurse Educator), 14 Licensed Practical Nurses, 10 Certified Nursing Assistants, 3 Nurse Aides, 4 Dietary Staff, 1 Business Office Staff, 1 Maintenance Staff, 4 Housekeeping and Laundry Staff for a total of 37 facility staff to determine the level of comprehension gained through in-service education conducted regarding the facility's policies; and changes to and implementation of the facility's policies, Elopement, Elopement Book and Documentation; and Door Alarms and Access Codes to ensure staff recognize and respond to the following: A. What constitutes a resident being At-Risk for elopement, how are At-Risk residents identified by facility staff. B. The rationale for preventative daily and monthly environmental hazard rounds (implemented 6/16/2016); what constitutes unsafe (hazardous) and unsupervised areas, what type of observations during rounds would require immediate intervention and follow-up, who is responsible for conducting the rounds, who oversees the rounds and ensures follow-up, location of facility's unsafe and unsupervised areas. Including, but not limited to any accessible unsupervised area with (1) means of egress, (2) unsecured chemicals, (3) equipment, or (4) objects with the potential to cause serious injury, harm, impairment, or death. C. A verbal explanation of what the Elopement Books are and their location, what constitutes a resident being placed in the Elopement Book, when and by whom are the Elopement Books updated, when and by whom the Elopement Books are used. D. The facility's policy and procedural requirement for the security of access codes for entry into the Service Hall from inside the facility; and all other access codes for entry and egress into and from the facility. Interviews included a verbal explanation to ensure (1) codes must not be posted or shared with unauthorized persons; (2) who are unauthorized persons; (3) facility areas which prohibit unauthorized persons (residents, families, visitors) from entering unsafe and unsupervised areas due to a potential risk of serious injury, harm, impairment, or death to a resident; and (4) why the response to all door alarms must be immediate. Noncompliance continues at a scope and severity of D level for monitoring the effectiveness of corrective actions and evaluation of monitoring by the Quality Assurance (QA) Committee. The facility is required to submit a plan of correction. Refer to F-279 (J) and F-323 (J), Substandard Quality of Care.

Based on review of facility policy, medical record review, review of facility investigation, observation, review of Material Safety Data Sheets (MSDS), and interview, the facility's Quality Assurance (QA) Committee failed to ensure the development of an individualized Comprehensive Care Plan for unsafe wandering and attempts to elope from the facility and failed to provide adequate supervision to prevent unsafe wandering and elopement from the facility for one Resident (#3) with a [DIAGNOSES REDACTED].#1); failed to revise the Certified Nursing Assistant Care Cards for one Resident (#2) at-risk for falls; and failed to ensure neurological assessments were completed with unwitnessed falls for two Residents (#1, #2) of six residents reviewed. The facility's failure to develop an individualized Comprehensive Care Plan, and failure to provide supervision, resulted in Resident #3 wandering into an area with the potential for access to unsecured chemicals and dangerous equipment and eloping from the facility, resulting in lacerations, abrasions, and bruises, and placed Resident #3 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator (NHA) was informed of the Immediate Jeopardy on 6/16/2016 at 6:00 PM in the Conference Room. The findings included: Interview with the NHA on 6/16/2016 at 9:30 PM, in the Conference Room, confirmed the NHA was aware Resident #3 was at risk for elopement, consistently wandered onto the Service Hall, and had wandered onto the Service Hall for almost three years (2.9 years). Continued interview confirmed the soiled laundry area was unsecure and contained multiple and various unsecured hazardous chemicals and equipment which had the potential to create serious harm or death with exposure and/or ingestion. Continued interview with the NHA confirmed previous safety rounds were done monthly, but the QA Committee failed to identify the Service Hall being an unsafe and unsupervised area. Telephone interview with the Medical Director on 6/17/2016 at 2:09 PM, confirmed the Medical Director was unaware Resident #3 was consistently wandering onto the Service Hall; and was unaware the laundry area was unsecured and contained unsecured hazardous chemicals and equipment. Continued interview with the Medical Director confirmed he was a member of the QA Committee. Further interview confirmed prior to the complaint survey initiated on 6/1/2016, the Medical Director was unaware of any surveillance rounds (Safety Rounds) being completed to identify risks and/or hazards, or potential risks and/or hazards brought to the QA Committee for evaluation, analysis, and implementation of corrective actions. The Immediate Jeopardy was effective from 5/10/2016 through 6/17/2016. An Acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated through review of documents, observations, and staff interviews conducted onsite on 6/18/2016. The surveyor verified the allegation of compliance by: 1. Observing a door monitor posted at the interior Service Hall Doors on 6/1/2016 at 6:20 PM, to prevent residents from unsupervised wandering onto the Service Hall. 2. Observing a Commercial Door Company in the process of installing an alarm system on the interior Service Hall Doors to alert the facility of unauthorized entry from inside the facility into the Service Hall on 6/2/2016 at 5:00 PM (installation completed at 7:00 PM). Observing the normal and proper functioning of the alarm system on the interior Service Hall doors and the removal of the door monitor at 7:30 PM. 3. Observing all egress doors on 6/17/2016 for signage (Red Stop signage implemented on 4/23/2015); Notice to Visitors (not to let residents out of the facility without staff notification) implemented on 5/11/2016; and proper functioning of anti-elopement systems on the following doors: A. 100, 200, 300 North Hall Fire Doors B. 100, 200, 300 South Halls Fire Doors C. 200 South Alcove Fire Doors D. 200 North Alcove Egress Doors D. Dining Room Egress Doors E. Main Entry Egress Doors F. Service Hall Egress Doors G. Interior Service Hall Doors (leading into the Service Hall from inside the facility). All Egress Doors (excluding the interior Service Hall Doors) had (1) Red laminated Stop signage (implemented 4/23/2015); (2) signage to not let any resident out of the facility without nursing notification and consent to do so implemented on 5/10/2016; (3) a 15 second delayed mag lock with key code pad implemented prior to the elopements; and (4) a wanderguard alarm system (if a resident with a wanderguard bracelet attempts to exit the door locks, alarms sound, and the door will not open until the resident with the wanderguard is removed from the door area). The wanderguard alarm system in place did not have the upgraded version (tail gate feature) on the Service Hall Egress Doors and the 200 North Alcove Egress Doors. The Service Hall and 200 North Alcove Egress Doors were upgraded to include the tail gate feature. Installation of the upgraded wanderguard system was initiated on 5/13/2016 and completed on 5/14/2016. The interior Service Hall Doors had a key code pad which required a specific code to be entered by authorized facility personnel only for entry into the Service Hall from the inside of the facility. If the interior Service Hall Doors are opened without first entering the code, a bright strobe light will flash and an audible alarm will sound and can be heard facility-wide. Installation completed on 6/2/2016. All visual and audible door alarms placed on all Fire, Egress, and interior Service Hall Doors will continuously emit visually and/or audibly until staff respond to the specific alarm and manually deactivate. 2. Observing the exterior Fire and Egress areas with fencing and gates on 6/17/2016 to ensure the gates closed securely to a positive non-locking latch on the following: A. Fire Doors-200 and 300 North Fire Doors, totaling 3 gates B. Fire Doors-300 South, totaling 1 gate C. Egress Doors- Service Hall and Main Entry, totaling 3 gates 3. Observing the staff's response to the interior Service Hall alarms which were triggered by the surveyor on 6/17/2016 at 7:15 PM. 4. Interviewing 12 Responsible Parties of non-elopement risk residents and 3 Vendors on 6/16/2016 between 6:55 PM-9:00 PM, and 6/17/2016 between 9:20 AM-1:20 PM, to confirm receipt of written notice sent on 5/10/2016 and determine their level of comprehension regarding not letting resident(s) out of the facility without nursing notification, consent to do so, and signing the resident out. 5. Interviewing 5 visitors 6/16/2016 between 6:55 PM-9:00 PM, and 6/17/2016 between 9:20 AM-1:20 PM, to determine their level of comprehension regarding not letting resident(s) out of the facility without nursing notification, consent to do so, and signing the resident out. 6. Reviewing the facility's in-service records to validate facility staff were in-serviced on 6/17/2016 regarding the new alarm system on the interior Service Hall Entry Doors and the following facility policies: Elopement Elopement Book and Documentation Door Alarms and Access Codes 7. Reviewing in-service records to validate the NHA was in-serviced on 6/16/2016 by the Corporate Field Services Clinical Director regarding the completion of daily safety (environmental hazard) rounds, determining safe versus non-safe areas 8. Conducting interviews beginning on 6/17/2016 at 7:25 PM and ending on 6/18/2016 at 12:30 AM, with nursing staff to include the NHA, 6 Registered Nurses (including the Assistant Director of Nursing and Nurse Educator), 14 Licensed Practical Nurses, 10 Certified Nursing Assistants, 3 Nurse Aides, 4 Dietary Staff, 1 Business Office Staff, 1 Maintenance Staff, 4 Housekeeping and Laundry Staff for a total of 37 facility staff to determine the level of comprehension gained through in-service education conducted regarding the facility's policies; and changes to and implementation of the facility's policies, Elopement, Elopement Book and Documentation; and Door Alarms and Access Codes to ensure staff recognize and respond to the following: A. What constitutes a resident being At-Risk for elopement, how are At-Risk residents identified by facility staff. B. The rationale for preventative daily and monthly environmental hazard rounds (implemented 6/16/2016); what constitutes unsafe (hazardous) and unsupervised areas, what type of observations during rounds would require immediate intervention and follow-up, who is responsible for conducting the rounds, who oversees the rounds and ensures follow-up, location of facility's unsafe and unsupervised areas. Including, but not limited to any accessible unsupervised area with (1) means of egress, (2) unsecured chemicals, (3) equipment, or (4) objects with the potential to cause serious injury, harm, impairment, or death. C. A verbal explanation of what the Elopement Books are and their location, what constitutes a resident being placed in the Elopement Book, when and by whom are the Elopement Books updated, when and by whom the Elopement Books are used. D. The facility's policy and procedural requirement for the security of access codes for entry into the Service Hall from inside the facility; and all other access codes for entry and egress into and from the facility. Interviews included a verbal explanation to ensure (1) codes must not be posted or shared with unauthorized persons; (2) who are unauthorized persons; (3) facility areas which prohibit unauthorized persons (residents, families, visitors) from entering unsafe and unsupervised areas due to a potential risk of serious injury, harm, impairment, or death to a resident; and (4) why the response to all door alarms must be immediate. Noncompliance continues at a scope and severity of D level for monitoring the effectiveness of corrective actions and evaluation of monitoring by the Quality Assurance (QA) Committee. The facility is required to submit a plan of correction. Refer to F-279 (J); and F-323 (J), Substandard Quality of Care; and F-490 (J).

Based on medical record review, review of staffing schedules, review of pharmacy records, review of facility policy, review of an employee memorandum, and interview, the facility failed to prevent a significant medication error for one resident (#21) of thirty-six residents reviewed. The facility's failure to have a system in place to prevent a significant medication error placed resident #21 in Immediate Jeopardy when the facility did not receive physician ordered medication. The facility had a systemic failure resulting in a medication not being clarified and transcribed to the Medication Administration Record, [REDACTED]. The Administrator, Director of Nursing, and Corporate Nurse Consultant were notified of the Immediate Jeopardy on November 2, 2010, at 11:15 a.m., in the admissions office. The Immediate Jeopardy at F-333 (substandard quality of care) was cited at a scope and severity of "J". The findings included: Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's order dated June 1, 2010 revealed "[MEDICATION NAME] (anticoagulant/blood thinner) (no dosage)...seek daily [MEDICATION NAME] orders..." Medical record review of a hospital discharge summary dated June 1, 2010 revealed "Hospital Course...had a lung scan showing high probability for [MEDICAL CONDITIONS] (blood clot in the lung)...started on [MEDICATION NAME] sensitive to it and developed a spontaneous hemorrhage in the right calf...In addition to hypersensitivity to [MEDICATION NAME] had hypersensitivity to [MEDICATION NAME] was tough to get this adjusted...also to be on [MEDICATION NAME] 2 mg (milligrams) a day...get a stat (immediately) Pro-time (monitors blood clotting time) 06/04/2010 and call..." Medical record review of the June 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Medical record review of the June 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s giving the medication would have initialed. Review of facility policy Medication Orders revealed "...Written transfer orders...implement a transfer order without further validation if it is signed and dated by the resident's current attending physician, unless the order is unclear or incomplete...complete documentation by clarifying orders as necessary..." Interview on November 1, 2010 at 3:30 p.m., with the Skilled Nursing Supervisor in the conference room confirmed the [MEDICATION NAME] written on the hospital physician's orders dated June 1, 2010 had not been clarified on admission. Interview on November 2, 2010 at 8:15 a.m., in the Admissions office with the DON (Director of Nursing) confirmed the x's on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Interview on November 2, 2010 at 8:40 a.m., in the Admissions office with the DON confirmed "...sometimes when we receive faxed orders and get the original orders something had been added, the orders are entered into the computer from the faxed orders, but the original orders are to be verified on admission." Interview on November 2, 2010 at 9:40 a.m., in the Admissions office with the Medical Director confirmed would have expected resident #21 to be on [MEDICATION NAME] based on resident #21's history of [MEDICAL CONDITION] Fibrillation and [MEDICAL CONDITIONS]. Interview on October 26, 2010 at 9:45 a.m., in the conference room with the DON confirmed the resident did not receive the [MEDICATION NAME] from June 1, 2010 through June 14, 2010. Interview on November 2, 2010 at 2:30 p.m. with the Administrator, Director of Nursing, and Assistant Director of Nursing, in the dining room, confirmed a New Admit Audit form was revised, adding Transcription of orders to "verify with original orders", this was done when the problem in was identified; the form is completed with every admission and reviewed daily in start up meeting. Review of the inservice records dated June 24, 2010, revealed, only nine nurses had signed the inservice record for "...compare-faxed orders with originals. (for changes or added info)...must always print...anticoagulant sheet..." Further review revealed the inservice was not completed until June 24, 2010 (10 days after the discovery of the medication error). Interview on November 2, 2010, at 1:00 p.m., by telephone, with RN (Registered Nurse) #5, confirmed was asked about resident #21's [MEDICATION NAME] dosage shortly after admission to the facility (admitted [DATE]) by a family member and told the family member the resident had no order for [MEDICATION NAME]. Medical record review of a physician's order dated June 15, 2010 revealed "[MEDICATION NAME] ([MEDICATION NAME] Sodium) 5 mg by mouth...daily...Administer 5 mg today and tomorrow..." Medical record review of a physician's order dated June 15, 2010 revealed "...PT ([MEDICATION NAME] Time) /INR (International Normalized Ratio) (monitors blood clotting time) in am (morning) call results to MD..." Medical record review of a physician's order dated June 15, 2010 revealed "...Hold [MEDICATION NAME] until results of PT/INR obtained..." Medical record review of the laboratory results dated [DATE] revealed "[MEDICATION NAME] Time 12.7...Reference Range 11.9-15.6...INR 0.9 Low-intensity Therapeutic Range 1.5-2.0..." Medical record review of a physician's order dated June 16, 2010 revealed "[MEDICATION NAME] 2 mg/d (day)..." Medical record review of a physician's order dated June 17, 2010 revealed "[MEDICAL TREATMENT] will do F/U (follow up) PT/INR blood work..." Medical record review of the [MEDICAL TREATMENT] Center Anticoagulation PT ([MEDICATION NAME] time) Therapy Report dated June 21, 2010 revealed "PT 15.4...INR 1.25." Medical record review of the laboratory report dated June 28, 2010 revealed "[MEDICATION NAME] Time 29.2...Reference Range...11.8-14.1...INR 2.75...Reference Range...0.89-1.11..." Medical record review of a physician's order dated June 30, 2010 revealed "[MEDICATION NAME]...2 mg by mouth once daily..." Review of the pharmacy delivery record revealed fifteen [MEDICATION NAME] Sodium ([MEDICATION NAME]) 2 mg tablets were delivered to the facility on [DATE] for resident #21. Medical record review of the July 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Interview on October 27, 2010 at 12:30 p.m, by telephone with the pharmacy director confirmed the order dated June 16, 2010 for the [MEDICATION NAME] 2 mg was not received until July 17, 2010. Review of the staffing schedule provided by the DON revealed RN (Registered Nurse) #3 worked on June 16, 2010, through June 21, 2010, June 23, 2010 through June 25, 2010, and June 28, 2010, through June 30, 2010. Interview on November 1, 2010 at 1:00 p.m., by telephone with RN #3 revealed RN #3 stated obtained the [MEDICATION NAME] from the "[MEDICATION NAME] supply of discharged meds..." to administer to resident #21 when worked from June 16, 2010 to June 30, 2010, "...but the residents names were unknown." Review of the pharmacy disposition records for May, June, and July 2010 revealed one (discharged ) resident with 2 mg of [MEDICATION NAME] (30) returned to the pharmacy on June 7, 2010 and documented as destroyed by pharmacy. Review of the inservice records dated June 24, 2010 revealed no inservice content related to physician's orders and the process to notify pharmacy, or the process for discontinued medications (return to Pharmacy for crediting to the specific residents account and/or destruction of the medications). Medical record review of the [MEDICAL TREATMENT] Anticoagulation PT Therapy Report dated July 7, 2010 revealed "PT 20.7 (11.8 - 14.1)...INR 1.00 (0.89 - 1.11)." Medical record review of the [MEDICAL TREATMENT] Anticoagulation PT Therapy Report dated July 19, 2010 revealed "PT 14.3 (11.8 - 14.1)...INR 1.14 (0.89 - 1.11)." Medical record review of a physician's order dated July 21, 2010 revealed "[MEDICATION NAME] 3 mg po (by mouth) on HD ([MEDICAL TREATMENT]) tx (treatment) days (PT 14.3 INR 1.14)[MEDICATION NAME] 2 mg po on non HD days..." Interview on October 26, 2010 at 11:40 a.m., with the DON in the DON's office confirmed when the physician telephoned a [MEDICATION NAME] dosage change July 21, 2010 that resulted in the facility discovery that resident #21 had not received any [MEDICATION NAME] and there was no [MEDICATION NAME] MAR indicated [REDACTED]. Review of the staffing schedule provided by the DON revealed RN #3 worked on July 1, 2010, July 3, 2010, through July 5, 2010, July 7, 2010, through July 9, 2010, July 14, 2010, and July 16, 2010, through July 19, 2010. Review of the staffing schedule provided by the DON revealed LPN #3 worked on July 2, 2010, July 6, 2010, and July 12, 2010. Review of the staffing schedule provided by the DON revealed RN #4 worked on July 20, 2010. Review of an Employee Memorandum of a statement from RN #3 dated July 23, 2010 revealed "...Gave medication from memory. When asked where June [MEDICATION NAME] came from (RN #3) stated...used from card of someone who had dc'd (discontinued) that strength..." Medical record review of a laboratory report dated July 26, 2010 revealed "[MEDICATION NAME] Time 15.6...INR 1.27..." Medical record review of a physician's order dated July 28, 2010 revealed "[MEDICATION NAME] 3 mg po (by mouth) daily..." Interview on October 26, 2010 at 3:45 p.m., in the conference room with the DON confirmed the DON was unable to say if resident #21 received the [MEDICATION NAME] from June 16 through July 20, 2010 from an unknown source or if resident #21 "even got it at all." Interview on October 27, 2010 at 10:00 a.m., in the conference room with the DON confirmed the facility was unable to determine if the July [MEDICATION NAME] MAR indicated [REDACTED] Interview on November 1, 2010 at 1:00 p.m., by telephone with RN #3 revealed obtained "...the [MEDICATION NAME] from discharged resident's..." to administer to resident #21 in July, but the residents names were unknown. Further interview confirmed no July MAR indicated [REDACTED]. Medical record review of the July 2010 MAR indicated [REDACTED]. Interview on November 1, 2010 at 2:00 p.m., in the conference room with LPN #3 revealed would not have given the [MEDICATION NAME] if the [MEDICATION NAME] MAR indicated [REDACTED] Medical record review of the July 2010 MAR indicated [REDACTED]. Interview on November 1, 2010 at 2:30 p.m. in the conference room with RN #4 revealed would give the [MEDICATION NAME] if the [MEDICATION NAME] MAR indicated [REDACTED]. Interview on November 1, 2010 at 2:45 p.m., in the conference room with the medical record staff #1, confirmed the [MEDICATION NAME] MARs are automatically printed when a [MEDICATION NAME] order is in the computer. Review of the inservice records dated July 23, 2010, revealed, only eleven nurses signed the inservice record for "...When running report (MAR) Must also run...anticoagulant..." Review of the inservice records dated August 15, 2010 revealed two nurses signed the inservice record for "...When running report (MAR) must also run...anticoagulant..." Review of the inservice records dated August 16, 2010 revealed one nurse signed the inservice record for "...When running report (MAR) Must also run...anticoagulant..." Interview on November 2, 2010 at 2:45 p.m., with the Director of Nursing, in the dining room, confirmed a "handful of nurses" were inserviced on the [MEDICATION NAME] MAR (medication administration record) Interview on November 2, 2010 at 2:30 p.m., with the Administrator, Director of Nursing, and Assistant Director of Nursing, in the dining room, confirmed an Anticoagulant Audit of residents (17) receiving Anticoagulant Therapy were completed on July 23, 2010. Interview on November 2, 2010 at 2:30 p.m., with the Administrator, Director of Nursing, and Assistant Director of Nursing, in the dining room, confirmed a monthly audit review of the recapitulation orders for anticoagulants was started on August 1, 2010. Interview on November 2, 2010 at 2:30 p.m., with the Administrator, Director of Nursing, and Assistant Director of Nursing, in the dining room confimed a monthly Chart/Cart/MAR audit was started August 3, 2010. Interview on November 2, 2010 at 3:00 p.m., with LPN #4, at the nursing station, confirmed does not remember having an inservice on verifying admission orders [REDACTED] Interview on November 2, 2010 at 3:05 p.m., with LPN #5, at the nursing station, confirmed did have an inservice a couple months ago on [MEDICATION NAME] MARS and verifying admission orders [REDACTED] Review of the inservice records dated September 10, 2010 revealed ten nurses signed the inservice record for End of Shift Checklist "...Review MAR/TAR for omissions in documentation of care administered during shift..." Review of the inservice records dated September 16, 2010 revealed seventeen nurses signed the inservice record for End of Shift Checklist "...Review MAR/TAR for omissions in documentation of care administered during shift..." Review of the inservice records revealed no inservices had been completed related to physician's orders being sent to the pharmacy or the availability of discharged medications. Review of the facility policy, Emergency Pharmacy Service and Emergency Kits revealed, "...Medications are not borrowed from other residents. The ordered medication is obtained either from the emergency kit or from the provider pharmacy...Upon removal of any medication or supply item from the emergency kit, the nurse documents the medication...on an emergency kit log. One copy of this information should be immediately faxed to the pharmacy with the original prescriber order or refill request form..." Interview on November 2, 2010 at 8:15 a.m., in the Admissions office, with the DON, confirmed no [MEDICATION NAME] had been charged from the emergency box in June or July 2010. Interview on November 2, 2010 at 12:50 p.m., by telephone with the pharmacy Director confirmed no order for [MEDICATION NAME] 2 mg dated June 30, 2010 had been received in the pharmacy. The Immediate Jeopardy at F-333 (substandard quality of care) was cited at a scope and severity of "J". C/O #

A revisit was completed at Golden Living Center Windwood on November 17, 2010, following acceptance of the Allegation of Compliance to remove the Immediate Jeopardy for F 333. The revisit revealed the corrective actions implemented on November 9, 2010, removed the Immediate Jeopardy at F 333, but noncompliance continues at a "D" level for F 333, as evidenced by the findings at tag F 333. Based on survey results dated November 2, 2010, the facility failed to prevent a significant medication error for one (#21) resident of thirty-six residents reviewed. The findings included: The facility provided an acceptable Credible Allegation of Compliance with a compliance date of November 9, 2010. An onsite visit was completed on November 17, 2010 to validate compliance. The credible allegation was validated on November 17, 2010, at 1:00 p.m. Validation of the Credible Allegation of Compliance was accomplished through medical record review and interview with licensed nurses. The facility provided evidence of inservice and training records for all nursing staff related to verification of admission orders [REDACTED]. Included in the validation process was review of facility tools used to document ongoing monitoring of verification of medication orders and medication administration. The facility remained out of compliance at a Scope and Severity level of "D" No actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility will remain out of compliance until it provides an acceptable plan of correction to include the continued monitoring to ensure the deficient practice does not recur and the facility's corrective measures could be reviewed and evaluated by the Quality Assurance Committee.

Based on medical record review, review of inservice records, and interview, the facility failed to ensure the Quality Assurance Committee inserviced all staff on all units related to verifying admission orders [REDACTED]. The findings included: The facility had a systemic failure resulting in a medication not being clarified and transcribed to the Medication Administration Record [REDACTED]. Review of inservice records dated June 24, 2010 through September 16, 2010 revealed 100% of licensed nurses were not inserviced for any of the presented inservice records. The facility failed to identify the concern of physician orders [REDACTED]. The facility failed to review the plan presented in the July 2010 meeting and make revisions to the action plan in August, September, and October 2010 and provide inservices to all Licensed Nurses. Interview on November 2, 2010 at 2:30 p.m., with the Administrator, Director of Nursing, and Assistant Director of Nursing, confirmed an admission audit form was revised after the June 2010 medication error was identified, an anticoagulant audit was completed, a review of the recapitulation orders for anticoagulants and a Chart/Cart/MAR audit was implemented after the July 2010 medication error was identified. Further interview confirmed the medication errors were discussed in the monthly Quality Assurance Meeting in July and August, 2010. The Administrator, Director of Nursing, and Corporate Nurse Consultant were notified of the Immediate Jeopardy on November 2, 2010, at 11:15 a.m., in the admissions office. Refer to F - 333 J SQC.

A revisit was completed at Golden Living Center Windwood on November 17, 2010, following acceptance of the Allegation of Compliance to remove the Immediate Jeopardy for F 520. The revisit revealed the corrective actions implemented on November 9, 2010, removed the Immediate Jeopardy at F 520, but noncompliance continues at a "D" level for F 520, as evidenced by the findings at tag F 520. Based on survey results dated November 2, 2010, the facility failed to ensure the Quality Assurance Committee inserviced all staff on all units related to verifying admission orders [REDACTED]'s orders not being sent to pharmacy. The findings included: The facility provided an acceptable Credible Allegation with a Compliance date of November 9, 2010. An onsite visit was completed on November 17, 2010, to validate compliance. Validation of the Credible Allegation of Compliance was accomplished through medical record review and interview with licensed nurses. The facility provided evidence of inservice and training records for all nursing staff related to verification of admission orders [REDACTED]. Included in the validation process was review of facility tools used to document ongoing monitoring of verification of medication orders and medication administration. The facility remained out of compliance at a Scope and Severity level of "D" No actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility will remain out of compliance until it provides an acceptable plan of correction to include the continued monitoring to ensure the deficient practice does not recur and the facility's corrective measures could be reviewed and evaluated by the Quality Assurance Committee.

Based on medical record review, review of facility investigations, review of the manufacturer's instructions, observation, and interview, the facility failed to ensure safety devices were in place and failed to implement new interventions to prevent falls for three residents (#9, #8, #11) resulting in harm for one resident (#9) of twenty-five residents reviewed. The findings included: Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short term memory problems only, moderately impaired cognitive skills for daily decision making, and required extensive assistance for transfers. Medical record review of a fall risk assessment dated [DATE] revealed the resident was at risk for falls. Medical record review of a physician's orders [REDACTED]." Review of a facility investigation dated March 14, 2010 revealed "...Objective/underlying illness/Dx (diagnosis): Hx (history) of falls; Impaired safety awareness/judgment...walking down hall-holding bed/chair alarm...intervention used prior to fall: Bed/chair alarm; pain assessment; Bed in low position; safety cues/reinforcement/reminder; call light w/in (within) reach...Recommendations and Interventions Post Fall: Bed/Chair alarm; pain assessment; Bed in low position; safety cues/reinforcement/reminder; Call light w/in reach; other use bed alarm when in bed..." Review of a facility investigation dated April 14, 2010 revealed "...Res. (resident) transferred self (without) assistance from bed-found on floor...one shoe on (and) one shoe off. Alarm intact beside...Continue present interventions...Intervention used prior to fall: Night light...change in footwear; Assistive device w/in reach...Recommendations and Interventions Post Fall...Change in footwear; Night light; Assistive device w/in reach..." Medical record review of a Change in Condition Report dated April 15, 2010 revealed "...Res. (resident) has Hx (history) of falls d/t (due to) impaired safety awareness, Bed was in low position, call light was in easy reach (res. did not use call light for assistance)...Res got (up) unassisted (with)...alarm monitor-was lying on the floor on...left side..." Medical record review of a hospital consultation report dated April 16, 2010 revealed "...Reason for Consultation: Right hip fracture or pain...Development of [DIAGNOSES REDACTED] of the hip with degenerative joint disease, but no acute fracture..." Review of a facility investigation dated August 4, 2010 revealed "...Return from one day surgery (at) 9:00 p.m. Had not had dinner. Sat resident in bed (with) (overbed) table and meal. Resident found in floor c/o (complaining of) R (right) hip pain. Call MD (Physician)...sent out for eval (evaluation)...Adm (admitted (with) (right) hip fx (fracture)...attempted to get OOB (out of bed) fell in floor, bed alarm was on-disconnected..." Medical record review of a x-ray report dated August 5, 2010 revealed "...Patient fell with pain...Impression: Comminuted right-sided intertrochanteric fracture...Deformity of the right femoral head, with a shallow acetabulum..." Observation on October 25, 2010 at 8:30 a.m., revealed the resident lying in the bed with the personal alarm clipped to the resident's shirt with the alarm box lying in the bed next to the resident. Observation on October 25, 2010 at 3:15 p.m., revealed the resident lying in the bed with the personal alarm clipped to the resident's shirt with the alarm box lying at the top of the bed. Observation on October 26, 2010 at 2:25 p.m., revealed the resident lying in the bed with the head of the bed elevated, the personal alarm clipped to the resident's sweater, and the alarm box lying on the bed under the pillow. Observation with RN (Registered Nurse) #1 on October 26, 2010 at 3:30 p.m., revealed the resident lying in the bed with the personal alarm clipped to the resident's shirt, and the alarm box lying on the bed under the pillow. Observation with the Staff Development Coordinator on October 27, 2010 at 8:15 a.m., revealed the resident lying in the bed with the personal alarm clipped to the resident's shirt, with the alarm box lying on the bed next to the resident. Review of the manufacturer's instructions for the personal monitor revealed "...Bed Use...mount the bed mounting holder to the side of the headboard facing the mattress...adjust the screw knobs so that the holder is secure...fasten the monitor to the holder, facing the patient..." Interview on October 27, 2010 at 8:15 a.m., with the Staff Development Coordinator in the resident's room confirmed the alarm box is not to be lying on the bed. Interview on October 27, 2010 at 8:30 a.m., with the Assistant Director of Nursing (ADON) in the conference room confirmed it was undertermined if the alarm was sounding at the time of the fall on April 14, 2010. Continued interview with the ADON confirmed no new interventions had been implemented after the fall on April 14, 2010 resulting in a fall with a fracture on August 4, 2010. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE] revealed the resident had long and short term memory problems and moderately impaired cognitive skills for daily decision making. Medical record review of the care plan updated August 25, 2009 revealed the resident had a history of [REDACTED]. Medical record review of a fall risk assessment dated [DATE] revealed the resident was at high risk for falls. Medical record review of a facility investigation dated July 17, 2010 revealed the resident fell without injury. Continued review of the facility investigation revealed the use of the soft belt at the time of the fall had not been addressed. Medical record review of a post fall investigation summary completed and signed by the Interdisciplinary Team dated July 19, 2010 revealed the resident "...attempted to get out of wheelchair sat in floor...make sure lap belt in place..." Observation on October 25, 2010 at 10:45 a.m., revealed the resident seated in a wheelchair with a soft belt in place. Interview with the Director of Nursing on October 25, 2010 in the conference room confirmed on July 17, 2010 the resident was to have a soft belt while in the wheelchair; the use of the soft belt at the time of the fall was not addressed in the investigation. Continued interview confirmed as per the post fall investigation the resident fell out of the wheelchair and the only Interdisciplinary Team recommendation was to ensure the soft belt was in place. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the care plan dated August 12, 2010 revealed the resident had a history of [REDACTED]. Review of a fall investigation dated September 25, 2010 revealed "...attempted to transfer self out of bed...slid into floor between bed and night stand...no apparent injury..." Continued review of the fall investigation revealed no documentation of what position the resident's bed was in at the time of the fall. Review of a post fall investigation summary completed and signed by the Interdisciplinary Team dated September 29, 2010 revealed "...keep bed low to floor when in bed." Interview with the Assistant Director of Nursing on October 27, 2010 at 10:30 a.m., in the conference room confirmed no new intervention was implemented after the fall on September 25, 2010.