Every finding on record at The Waters of Springfield LLC

Based on facility policy review, Administrator job description review, Director of Nursing (DON) job description review, Time and Date.com review, medical record review, facility investigation review, Emergency Medical Services (EMS) record review, hospital record review, observation, and interview, the facility failed to ensure a safe environment and provide adequate supervision to prevent an incident of elopement for 1 of 3 (Resident #2) sampled residents reviewed for wandering and behaviors. The facility's failure resulted in Immediate Jeopardy on 7/27/2026, when Resident #2, a vulnerable and cognitively impaired resident, with newly identified behaviors of wandering, eloped from the facility without staff knowledge or assistance in temperatures of 86 degrees Fahrenheit, and traveled approximately 366 feet through the parking lot, down the driveway, and toward a busy 2-lane road. Resident #2 self-propelled in his wheelchair through the parking lot and down the driveway toward a busy intersection. The facility was not aware Resident #2 was missing until approximately 8:00 PM, when staff observed Resident #2 self-propelling his wheelchair down the driveway approximately 255 feet from the facility exit door and headed toward a busy 2 lane road. Resident #2 veered off the driveway and fell approximately 2 feet into a ditch with large rocks. Resident #2 was transported to the hospital on 7/27/2026 at 8:41 PM. Xray results revealed Resident #2 sustained fractures to the eighth and ninth ribs on the left side. The facility's failure to provide adequate supervision placed all residents with wandering behaviors in Immediate Jeopardy (IJ) and resulted in Actual Harm to Resident #2. Immediate Jeopardy (IJ) is 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 former Administrator, the former Interim DON, Regional Nurse Consultant Z, and the Regional Director of Operations, were notified of the Immediate Jeopardy for F-689 on 8/4/2026 at 7:05 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-689. The facility was cited at F-689 at a scope and severity of J, which is Substandard Quality of Care. The IJ began on 7/27/2026 and continued through 8/12/2026. The IJ was removed on 8/13/2026. A partial extended survey was conducted from 8/4/2026 through 8/6/2026. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 8/10/2026 with an alleged removal date of 8/12/2026 and was validated on site by the surveyor on 8/12/2026 -8/13/2026 through medical record review, staff education review, staff interviews and audit review. The facility's noncompliance at F-689 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the undated facility's policy titled, .Missing Residents and Elopement, revealed .It is the policy of this facility that all residents are provided adequate supervision to meet each resident's nursing and personal care needs. All residents will be assessed for behaviors.that put them at risk of elopement.Residents that are at risk of elopement will be provided at least one of the following safety precautions.staff supervision of facility exits either directly or by video camera.door alarms on facility exits.a personal safety device that notifies facility staff when the resident attempts to or has left facility without supervision.At no time will any door alarm be deactivated without continual direct supervision of the exit(s).Staff training and education.All staff will be trained.regarding proper procedures in the event that a resident is found to be missing from the facility.Inservice training shall cover the environmental considerations to prevent elopement, the critical importance or responding to and investigating the reason of an alarm sounding, missing resident alarm code identification.All residents shall be assessed for behaviors that place them at risks of elopement. Review of the undated facility's policy titled, Guidelines for Notification of Change in Resident's Condition., revealed .It is the intent of the facility to ensure that the resident, their attending physician, and the resident's Responsible Party/POA [Power of Attorney] are notified of changes in the resident's condition, status, or treatment. This notification will be done promptly in order to obtain any new orders needed for appropriate treatment and/or monitoring related to the change, as well as to promote the Resident Right related to the right to make choices about treatment and care preferences.Nurses and other care staff are educated to identify changes in a resident's condition that require notification to the resident, their attending physician, and the resident's Responsible Party/POA.Requirement for notification of resident, their attending physician, and the resident Responsible Party/POA.A need to alter treatment significantly.A significant treatment alteration includes the need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment.The nurse will IMMEDIATELY notify resident, their physician, and/or the resident's Responsible Party/POA for the following: An accident involving the resident which results in injury.A significant change in the resident's physical, mental, or psychosocial status.Sudden decline in mental status.A change in behavior that places a resident in danger or potential to themselves or others. 2. Review of the Administrator job description dated 3/16/2026 and signed by the former Administrator, revealed .the Administrator leads and directs the overall operations of the facility in accordance with the resident needs, government regulations, and company policies as to maintain quality of care for the residents.Conduct regular rounds to ensure resident needs are being addressed.Ensure the building and grounds are properly maintained.and work areas are clean, safe and orderly.Ensure understanding of and compliance with all rules regarding resident rights.Create and maintain an atmosphere of warmth, care and support for residents. Review of the DON job description dated 7/20/2026 and signed by the former Interim DON, revealed .the Director of Nursing has the authority, responsibility, and accountability for the functions, activities, and training of the nursing services staff.In the absence of the Administrator, the DON assumes responsibility for the facility. The DON is responsible for the overall management of resident care 24 hours a day seven (7) days per week.Demonstrates the knowledge, skills and techniques necessary to care for residents with the following needs.neuro and dementia.infectious disease and wound care.Ensures that a sufficient number of qualified supervisory and supportive nursing personnel are assigned for each unit/shift to meet the resident's needs.Conducts periodic review to ensure all documentation is informative and descriptive of nursing care and of the resident's response to that care.Ensures that nursing documentation meets the following standards for Care Plans.Nursing Assistant Care Sheets.Treatment Sheets.Physician Orders. 3. Review of the Time and Date.com for 7/27/2026 at 7:53 PM, revealed the temperature for the county of occurrence was 86 degrees Fahrenheit and partly sunny, with 61 percent (%) humidity (the amount of water in the air making it harder to breathe). 4. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Diabetes Mellitus, Depression, Alzheimer's Disease, and Anxiety. Review of the Care Plan dated 1/21/2026, revealed .I may display behavioral symptoms related to psychosis [loss of contact with reality] such as delusional statements, paranoid ideations [unfounded thoughts and suspicions that others intend to cause harm], hallucinations [a false sensory perception of things that are not really there] and other behavioral symptoms related to diagnosis of psychotic disorder, Alzheimer's disease, dementia with mood disturbance and behaviors. Conduct an evaluation of my behavioral symptom(s) to determine what strengths or abilities & needs are communicated via [by means of] the behavior.Give psycho-active medication as ordered.Record behavioral symptoms.Intervene when any inappropriate behavior is observed.Use creative refocusing to alter behavioral patterns if I suffer from dementia.provide drawers, laundry basket for rummaging, tube sock with a knot to focus on my attention.Provide supportive group, 1:1 [one on one], or prn [as needed] intervention. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #2 scored a 7 on the Brief Interview for Mental Status (BIMS) assessment, which indicated he was severely cognitively impaired. Resident #2 required moderate to maximum assistance from staff to perform activities of daily living (ADLs) and required the use of a wheelchair for mobility. Review of the Nurse's Note for Resident #2 dated 7/27/2026 at 9:00 PM, revealed Resident exited the facility through the side entrance. The exit alarm sounded, and staff responded immediately. Resident was observed in the parking lot. While staff were approaching, the resident rolled from the parking lot into the adjacent ditch . Review of the Facility's Event Summary for Resident #2 dated 7/27/2026, revealed .On 7/27/2026 at approximately 8:10 PM, Resident.exited the facility through 100 hall exit and self-propelled into parking lot. While resident was self-propelling, resident rolled off driveway into grass and fell out of wheelchair into drainage area. Licensed Nurse and CNA [Certified Nursing Assistant] observed resident prior to fall, however, could not reach the resident to prevent fall .EMS [Emergency Medical Services] arrival. Resident.departed facility via ambulance at 8:41 PM. Review of the undated written statement by Registered Nurse (RN) F, revealed Nurse was sitting at nursing station; heard tech [Certified Nursing Assistant D] yell for help. Nurse ran down hall and tech said patient was outside. Nurse observed resident in ditch. 5. Review of the facility's investigation for Resident #2 dated 7/27/2026, revealed a facility head count was performed of all residents on 7/27/2026, one staff written statement, staff statements prepared by the Administrator, door alarms checked on all exit doors, and a side door reenactment performed by Administration staff on 7/28/2026 that revealed the 100 Hall door alarm had a faint beep sound that resembled a chair or bed alarm. 6. Review of the Call For Service (CFS) Report dated 7/27/2026, revealed Resident #2 was transported by EMS from the facility to the hospital on 7/27/2026 at 8:41 PM. 7. Review of the (Named Hospital) hospital note dated 7/27/2026, revealed Resident #2 sustained acute Fractures of the left anterolateral (front side) eighth and ninth ribs. The Resident's Assessment and Plan Diagnoses included: Cirrhosis (long term inflammation of the liver), Altered Mental Status, Ground-level fall, Left Pleural Effusion (accumulation of abnormal fluid in the area surrounding the lungs), Pulmonary insufficiency (incomplete closure of the pulmonary valve which allows blood to leak backwards into the right ventricle), and Left rib fractures. Review of the (Named Hospital) Discharge Instructions dated 7/31/2026, revealed .Discharge Disposition .Skilled Nursing Facility . During a telephone interview on 8/3/2026 at 2:09 PM, Certified Nursing Assistant (CNA) B was asked to recall the timeline of events related to Resident #2's elopement. CNA B stated, I was staying after my shift to finish my charting.Around 7:00 [PM], I assisted [Named CNA D] in putting a resident back to bed that was in isolation.He [Resident #2] wanted to follow us into the isolation resident's room.[Named CNA D] took him [Resident #2] back to the nurses' station.Approximately, 20 minutes later, we exited the isolation resident's room. CNA B was asked if the 100 Hall fire doors were closed. CNA B stated, Yes, they were closed. CNA B was asked if she recalled seeing Resident #2 at that time. CNA B stated, I am not sure where he [Resident #2] was at that time. CNA B stated, The next thing I know, I could barely hear the door alarm going off, and [Named CNA D] went to check the 100 Hall door and she [Named CNA D] yelled for [Named Licensed Practical Nurse (LPN) C] .I ran out as well, [Resident #2] was lying on his stomach in the ditch holding his head. CNA B was asked if Resident #2 had any injuries. CNA B stated, He had a cut on his face that was bleeding. LPN C dispatched EMS from my phone at 8:18 [PM]. CNA B was asked if she had ever noticed Resident #2 wandering or exhibiting exit seeking behaviors. CNA B stated, I don't think they had ever seen that behavior from him before. During an observation and Interview on 8/3/2026 at 2:39 PM, the former Administrator used a pedometer (that was zeroed out) and measured a distance of 355 feet from the 100 Hall exit door to the ditch, the location Resident #2 was found after falling. The former Administrator was asked the location of Resident #2 when staff initially saw him outside. The former Administrator stated, [Resident #2] got approximately 264 feet when staff saw him going down the drive towards the road. During an interview on 8/3/2026 at 3:34 PM, LPN C was asked to recall the elopement incident regarding Resident #2. LPN C stated, I was at the nurse's station on my computer. [Named CNA D] walked past [Resident #2] at the nurses' station and spoke to him as she walked past him, but she didn't stop and pay him attention. He looked at me angry and said what the h*** [expletive] did she say.I told him that I didn't hear her.[Named CNA B] and [Named CNA D] were in assisting a resident on the 100 Hall in isolation, and [Resident #2] was trying to get in the resident's room with them. [Named CNA D] called for my assistance with [Resident #2]. I was able to get [Resident #2] to follow me back to the nurse's station and I gave him a sandwich. After some time, the 2 CNAs called for me again because [Resident #2] was back down trying to enter the isolation resident's room.I got him to follow me back to the nurse's station, and I closed the double fire doors [to the 100 Hall]. LPN C was asked if she recalled the time the fired doors were closed. LPN C stated, It was before 8:00 PM, because I recall looking up again and he was back near the doors with his hand on the double door, and I had to redirect him .I asked why he wanted to go down that hall .He said he needed to talk with to those ladies.I thought we were good.When [Named CNA D] came out from the 100 Hall she spoke with him and he seemed fine and not angry anymore.I recall hearing [Named CNA D] say what door is that .I said what do you mean.Then, [Named CNA D] screamed. LPN C was asked where the resident was located when she got outside. LPN C stated, He was pretty far, he was booking it [going fast], we were yelling for him to stop, and he kept rolling and he fell into the ditch face forward. LPN C was asked if Resident had any injuries. LPN C stated, He had a laceration to his face, wrist, and scalp . LPN C was asked who called EMS. LPN C stated, I did not know what we were supposed to do.I called [the Administrator] and then EMS. During an interview on 8/3/2026 at 6:54 AM, CNA D was asked to recall the events of Resident #2's elopement. CNA D stated, He [Resident #2] was sitting close to the nurses' station in his wheelchair when I came in at 7:00 PM. CNA D was asked if she noticed any behavior out of his norm. CNA D stated, He was following us and we were going in to do patient care and we told him no .The other nurse closed the double doors and placed him in front of nurses' desk. CNA D was asked when was the last time she saw Resident #2 prior to the elopement. CNA D stated, When I got done with that isolation resident on the 100 Hall, [Resident #2] was still at the nurses' station when I walked past him on my way to the back hall to assist with a [named mechanical lift used for transfers] lift transfer .When I was coming back to the front, I heard an alarm and opened the side door at the end of the 100 Hall and saw him. CNA D was asked how far Resident #2 was from the exit door. CNA D stated, He was far towards the road. I yelled for him [to stop] but he kept going. I called for help. Before I could get to him, he fell in the ditch face down on the rocks. CNA D was asked if he had any injuries. CNA D stated, On the side of his face. CNA D was asked who called EMS. CNA D stated, [LPN C] called the Administrator, and then EMS. During an interview in the Resident's room on 8/3/2026 at 10:55 AM, Resident #2 was asked if he had been in the hospital recently. Resident #2 stated, Yes, I took a little stroll in my wheelchair and fell out of my chair, fractured 2 ribs. Resident #2 was asked were you by yourself. Resident stated, Yeah, at the time. Resident was asked where you were going. Resident stated, I don't know, just a stroll. During an interview on 8/4/2026 at 10:03 AM, the former Interim DON was asked what should staff do for elopements. The former Interim DON stated, Once they identify the resident is missing, they should implement a head count of all residents, check the premises, once the resident is located, they should assess the resident, notify the administrator if they didn't have injures, notify the physician, and family. The former Interim DON was asked what should staff do if the resident has injuries or suspected injuries. The former Interim DON stated, If there are injuries, I assume call 911 and then notify the administrator. We assess the resident when they fall, assess and stay with the resident to make sure the resident is safe until emergency arrives and takes over the scene.I would have called 911 first, and have someone else call the Administrator. The former Interim DON was asked if she assisted with the elopement investigation. The former Interim DON stated, [Named Administrator], [Named Regional Nurse Consultant], and myself performed staff interviews.The former Interim DON was asked did you assist with staff education. The former Interim DON stated, Yes, if they hear a [door] alarm to respond and to check the door immediately, circle the building to check for anyone and make sure every resident is accounted for. The former Interim DON was asked what do you think contributed to the resident getting out the facility. The former Interim DON stated, The volume of the alarm. The former Interim DON was asked do you think the double doors being closed contributed to the resident getting out of the building. The former Interim DON stated, Yes, I do. During a telephone interview on 8/4/2026 at 10:51 AM, Registered Nurse (RN) E was asked if Resident #2 had any recent behavior changes. RN E stated, Yes, recently he kept attempting to get up [out of his wheelchair] by himself and he had multiple falls. He is a high fall risk. He [Resident #2] mentioned that he wanted to go to Arizona because it was beautiful, and I reported to it to the Nurse Practitioner [NP] .The NP ordered a UA [Urinalysis] . During an interview on 8/4/2026 at 11:12 AM, the NP was asked if she was aware of Resident #2 having any increased confusion or behavior changes. NP stated, .He was saying he wanted to go back Florida .He had mentioned to staff that he wanted to go back to where he was from. He does have dementia. I gave an order for labs to be obtained on that Friday [7/24/2026]. The NP was asked if the UA was collected. The NP stated, I am not sure. I do not see any results for that. The NP was asked were you made aware the resident had gotten out of the facility. The NP stated, At 10:35 PM [on 7/27/2026], I was told that he had an elopement and was sent to the hospital. We do have other NP services that may have been contacted after hours. The NP was asked would you expect facility staff to know what to do if a resident were to get out of the facility. The NP stated, Yes, I would. During an interview on 8/4/2026 at 4:21 PM, the former Administrator was asked what interventions were put in place after the elopement incident with Resident #2. The former Administrator stated, We did not do anything until the next morning .The door alarm screechers were added around 9:30 AM on 7/28/2026. During a telephone interview on 8/18/2026 at 3:57 PM, the Medical Director (MD) was asked if staff are expected to identify a change in the resident's behavior and implement monitoring to prevent the risk of accidents or injury. The MD stated, Yes. The MD was asked do you expect staff to know what to do in the event of an elopement. The MD stated, Yeah, definitely. During an interview on 8/17/2026 at 10:16 AM, the Interim DON was asked should staff monitor residents with new behaviors of wandering and report it to the provider. The Interim DON stated, Yes, and they should document it in a progress note . The Interim DON was asked what should staff do when a door alarm is heard. The Interim DON stated, The minute it's heard they should check the door to see if someone exited the door or entered. If they cannot identify who entered, they should walk the perimeter [outside the building] to make sure no one exited. The Interim DON was asked do you expect staff to know what to do in the event of an elopement. The Interim DON stated, Absolutely. The Interim DON was asked who is responsible for the safety of the residents. The Interim DON stated, Everybody in the building. During an interview on 8/19/2026 at 12:12 PM, the Administrator was asked should staff identify a change in the resident's behavior and implement monitoring to prevent accidents or injury of the resident. The Administrator stated, Yes, and communicate those changes to the Physician or NP. The Administrator was asked would you expect staff to know what to do in the event of an elopement. The Administrator stated, Yes, ma'am. The Administrator was asked who is responsible for the safety of the residents. The Administrator stated, Everybody in the facility, that is our primary job. The facility's corrective actions for the removal plan were issued to the state surveyor on 8/12/2026. The corrective action plan included the following: Corrective Actions Implemented for Resident #2 on 7/27/2026 were: Partial skin and pain assessment completed by licensed nurse. Licensed Nurse called 911 and stayed with Resident #2 until EMS arrival. Resident #4 departed facility via ambulance at 8:41 PM. Family and Physician Notifications were made by a facility Licensed Nurse. Resident #2's Care Plan was updated to reflect changes made to the plan of care on 7/28/2026 by the facility MDS Coordinator. Care Plan reflects resident has been identified as elopement risk as of 7/27/2026 and was placed on 1:1 supervision upon readmission to facility on 7/31/2026. Elopement Assessment completed upon readmission to facility on 7/31/2026 by facility MDS Coordinator that determined resident is now high risk for elopement due to wandering behavioral change and history of elopement. Corrective Actions Implemented for Current Residents Beginning on 7/27/2026: a. On 7/27/2026 at 9:03 PM, a headcount of current residents was completed by the facility Administrator. All current residents were accounted for. b. On 7/27/2026 at 9:20 PM, all exterior door alarm and locking mechanisms were checked by the facility Administrator for correct functionality. No negative findings were identified. All door locking mechanisms locked and alarmed, per manufacturer standards. c. The elopement binders were updated at each nurses' station; identifying any potential elopement risks with photographs on 7/28/2026 by the Social Services Director. This was verified by the facility Administrator. d. On 7/28/2026, the Administrator and Housekeeping supervisor tested every exterior exit alarm under actual operating conditions, including from each staffed nurses' station with required corridor and fire doors closed. The facility verified that staff received an audible or visual notification (Audible means staff can hear the activated door alarm from the designated staffed area. Visual means staff receive a visual indicator from the system such as light color change) at each designated location. Any alarm or notification failure was corrected and retested before the facility alleged removal of immediate jeopardy, however none occurred. In addition, the facility added enhanced Screeching door alarms to increase the volume when a door is ajar. Administrator and Housekeeping Supervisor performed daily testing of door alarms beginning 7/28/2026. The facility tested each exterior exit under actual operating conditions with corridors/fire doors closed and verified staff received the required notification at each designated area. Enhanced screeching door alarms were also added to increase alarm volume. No notification failures occurred during testing. e. 100% (percent) of current staff will be educated by Administrator and DON on the Elopement Policy by 7/28/2026. Those who have not been educated will be educated prior to returning to work. f. Going forward, all new admissions will be reviewed upon admission for elopement risk by the admitting nurse and reviewed during daily clinical meeting by the DON and IDT (Interdisciplinary Team). g. An Elopement Drill was conducted by the Administrator on 7/28/2026 AM, 7/28/2026 PM, 7/29/2026 AM, 7/30/2026 PM, 8/1/2026 PM, 8/3/2026 PM, & 8/6/2026 PM with no concerns identified. Seven elopement drills have been completed with 2 occurring during dayshift and 5 occurring on night shift. h. 100% of current residents had an Elopement Risk Assessment completed on 7/28/2026 by MDS Coordinator to identify any residents with increased risk. No new concerns identified. An in-service was held for Current Facility Staff on 7/28/2026 by the Administrator. Current Facility Staff were educated on: Elopement Policy and Procedure Behavior Monitoring/Tracking to include exit seeking Facility's system to safeguard residents who are at risk for elopement What should you do as a staff member if you see the following: A resident going door to door trying to get outside A door alarm sounding An elderly person whom you do not know-asking for assistance to exit the facility? A door that does not appear to be engaging properly with the closure mechanism? An outside door that appears to have been propped open. Elopement Binders-What are they? Why have them? Where are they located Who updates them k. What should you do if you think a resident is missing l. What should you do if you see a non-staff member entering a door code. m. Why is it important to be certain that only residents who can have their needs met in the facility are admitted to the facility. n. Why is it critical that all residents have adequate supervision? The monitoring/audits by the Facility Leadership (includes the Administrator, Director of Nursing, MDS Coordinator, and the applicable department manager(s) responsible for the area being reviewed, such as Social Services, Housekeeping/Laundry, Maintenance, Rehabilitation, Dietary, or Activities) and any Regional Team member related to safety measures that are implemented for residents at risk of falls and wandering residents to prevent the recurrence of resident elopement will be presented at the Ad Hoc QAPI (Quality Assurance and Performance Improvement) Meeting, then monthly QAPI meetings. Any concerns will be addressed. However, any patterns will be identified. If needed, an Action Plan will be written by the QAPI committee. Any Action Plan will be monitored weekly by the Administrator until resolved. The Regional Team (includes the Regional Director of Operations, Regional Nurse Consultant, and Regional MDS Consultant as applicable) will assist with the development of any needed action plan and monitor weekly while in place. An Ad-Hoc (impromptu meeting) QAPI meeting was held on 7/28/26 and conducted by the Administrator to review and discuss the AOC (Allegation of Compliance) requirements. Elopement Drills will be completed by Maintenance Director or Administrator twice weekly, with one after 5pm each week x (times) 3 weeks, then monthly beginning 7/28/26. 100% audit of Elopement binders updated at each nurses' station identifying any potential elopement risks with photographs will be reviewed weekly x 4 weeks, biweekly x 4 weeks, then monthly and as needed by Director of Nursing &/or Regional Nurse. The Removal Plan was validated onsite by the surveyors on 8/12/2026 which included review of the facility education to show each step was completed, staff interviews to confirm completion, review of care plans, review of new hire orientation training, review of audit logs for completion, and review of door alarm checks for working order and staff response.

Based on policy review, American Heart Association (AHA) Adult Basic Life Support Algorithm for Healthcare Professionals dated 2025, Rules of the Tennessee Board of Nursing review, Tennessee Code Annotated (TCA) rules review, medical record review, 911 audio recording review, facility video footage review, facility investigation, Employee file review, Emergency Medical Services (EMS) record report review, County Emergency Communication and interviews, the facility failed to provide continuous Basic Life Support (BLS)/Cardiopulmonary Resuscitation (CPR) for 1 of 3 (Resident #1) sampled residents reviewed for CPR. Resident #1 was a vulnerable resident who was found on [DATE] at 6:07 AM, in the bathroom, on his knees slumped over the commode unresponsive. Resident #1 was a full code status (wanted all possible lifesaving, resuscitative measures taken) and CPR was not started when he was found unresponsive. The facility's failure to perform continuous CPR on Resident #1 resulted in Immediate Jeopardy and placed vulnerable and cognitively impaired residents with a full code status at risk. Immediate Jeopardy (IJ) is 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 was notified of the Immediate Jeopardy on [DATE] at 1:54 PM in the Administrator's Office. The facility was cited at F-678 at a scope and severity of J, which is Substandard Quality of Care. A partial extended survey was conducted on [DATE]. The IJ was effective from [DATE] through [DATE]. The IJ was removed on [DATE]. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on [DATE] at 12:15 PM. The corrective actions were validated by the surveyor on [DATE]. The facility's noncompliance at F-678 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the undated facility policy titled Cardiopulmonary Resuscitation, revealed .It is the intent of the facility to ensure that all residents suffering a cardiac or respiratory arrest will receive treatment of CPR unless the resident has a Do Not Resuscitate Order.Basic CPR is defined as artificial respiration accompanied by external cardiac compressions.CPR will be performed by licensed nursing or staff trained in CPR.Assess resident to determine Respirations have ceased/palpate or auscultate for absence of pulse/heartbeat.nurse will assess the resident for absence of heartbeat by using a stethoscope or palpate pulses and assess for absence of Respirations. Call for assistance.If a resident has a cessation of heartbeat or a cessation of respiration.delegate a person to page for assistance, call 911.All available licensed nurses and staff trained in CPR will respond promptly to the Code and assist as needed.Place the resident on firm surface.Initiate basic life support .Maintain basic life support until ambulance arrives for transfer to hospital.Notify physician and responsible party of the change in condition.Complete documentation in the Nurse's Notes. 2. Review of the AHA Adult Basic Life Support Algorithm for Healthcare Professionals revealed, Verify scene safety, check for responsiveness, check for responsiveness, shout for nearby help, activate emergency response system, send someone to get AED/defibrillator, look for no breathing or only gasping, and check pulse (simultaneously) .no breathing .pulse not felt start CPR .use AED/defibrillator as it is available .continue until ALS [advanced life support] professionals take over . 3. Review of Rules of the Tennessee Board of Nursing Regulations of Licensed Practical Nurses (LPNs), dated [DATE], revealed .The LPN scope of practice is a directed scope of practice and requires appropriate supervision. The LPN, practicing under the supervision of an RN, APRN [Advanced Practice Registered Nurse], licensed physician or dentist .Contributes to the nursing assessment by collecting, reporting, and recording objective and subjective data .Plans for patient care, including .Planning episodic nursing care for a patient whose condition is stable or predictable .Implements nursing interventions and prescribed medical regimens in a timely and safe manner .Collaborates and communicates relevant and timely patient information with patients and other health team members to ensure quality and continuity of care, including .Patient status .Assigns and delegates nursing activities appropriately .Delegate to another only those nursing measures for which that person has the necessary skills and competence to accomplish safely .Task does not require assessment, interpretation, or independent decision-making during its performance or at completion.Selected patient and circumstances of the delegation are such that delegation of the task poses minimal risk to the patient and the consequences of performing the task improperly are not life-threatening . 4. Review of Tennessee TCA 68-3-511 for a Registered Nurse (RN) determining and/or pronouncing death in a nursing home revealed under the following circumstances the RN may determine and pronounce a resident's death, The deceased was a resident of a nursing home; . Death was anticipated, and the attending physician or nursing home medical director has agreed in writing to sign the death certificate. The agreement by the attending physician or nursing home medical director must be present and with the deceased at the place of death; .The nurse is licensed by the state; and .The nurse is employed by the nursing home in which the deceased resided; . Review of Tennessee Code Annotated TCA 63-7-108 and standard 1000-02-.02 LICENSED PRACTICAL NURSE LIMITED, DIRECTED SCOPE OF PRACTICE revealed, (1) Licensed Practical Nurses have knowledge and preparation in nursing, but not to the extent required of Registered Nurses. Licensed Practical Nurses may only perform activities to the extent that the activity is included in the basic practical nurse curriculum .The LPN scope of practice is a directed scope of practice and requires appropriate supervision . 5. Review of medical record revealed Resident #1 was admitted to this facility on [DATE], with diagnoses including Thrombocytopenic disorder, Alcoholic Cirrhosis (advanced stage of chronic [NAME] scarring caused by long-term, heavy alcoholic use) and Hepatic Encephalopathy (serious, potentially reversible brain dysfunction caused by liver failure or cirrhosis, where the liver cannot filter toxins from the blood). Review of the Order Detail dated [DATE] at 7:29 PM, revealed an order for Zofran (medication to prevent nausea) Oral Tablet 4 Milligram (mg), give 1 tablet by mouth every 6 hours as needed for nausea/vomiting for 7 days. This was listed as a Physician's Standing Order. Review of the Care Pan dated [DATE], revealed Resident #1 had .elected/executed: FULL CODE status [[DATE]].impaired cognition/function or impaired thought process.require psychotropic medication to help manage and alleviate.hallucinations and/or delusions.risk for falls. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 10 which indicated Resident #1 was moderately cognitively impaired. Resident #1 required the use of a wheelchair and required partial to moderate assistance with toileting transfers and ambulation up to 10 feet. Review of the February 2026 Medication Administration Record (MAR) revealed Zofran 4 mg was administered to Resident #1 at 9:00 PM on [DATE]. There was no documentation of the effectiveness of the medication following the administration of Zofran for nausea. 6. Review of the 911 (emergency call center) audio recording on [DATE] beginning at 6:17:58 AM, revealed a call was made to 911 by LPN A requesting assistance for Resident #1. The LPN told the 911 operator that Resident #1 attempted to go to the bathroom, fell, hit his head and was now unresponsive. When asked by the 911 operator if Resident #1 was breathing, LPN A stated the resident was not breathing and alleged that CNAs were performing CPR. When asked if CPR was in process, LPN A responded, Yes. When asked if she was in the room with Resident #1, LPN A stated No, we, I got 2 techs [CNAs] in the room with him [Resident #1]. LPN A was asked if she was close to the CNAs and Resident and LPN A responded, No, I'm at the nurse's station calling. The 911 operator instructed the LPN to go to the Resident's room so she could answer questions about Resident #1. LPN A told the 911 operator she was unable to go to the room because the phone at the desk would not reach that far. LPN A provided general information, such as Resident #1's age, gender, weight, diagnoses (which was inaccurately provided as Hepatitis C due to a liver transplant), and room number to the 911 operator. LPN A requested that Emergency medical services (EMS) come though the side door of the facility. The 911 operator requested LPN A to go to Resident #1's room so CPR status could be provided to 911 operator. The 911 operator then asked LPN A to use her cell phone and go to the Resident's room and to call the 911 operator back once she got to the Resident's room. During the second 911 call at 6:19:13 AM, the 911 operator answered the call and LPN A stated, He's [Resident #1] gone.The 911 operator questioned for LPN A to repeat what she had said and LPN A stated, He's [Resident #1] definitely gone.they [CNAs] stopped CPR once they got him off the toilet.He's [Resident #1's] gone .Looks like he hit his head really hard. LPN A confirmed that CPR was not being done. The 911 operator asked .who's saying that 'yes he's gone' is it a nurse. LPN stated, He's cold. The 911 operator then asked again, Who is saying, 'he's gone'.are you a nurse. LPN A responded, I'm the nurse, yes, once they [CNA A and B] pull him off [positioned Resident #1 off of the toilet], you know, yeah he's gone. LPN A was asked if Resident #1 was cold to touch. LPN A responded, He [Resident #1], He is cold to touch, he's blue in the face. It look [looks] like his tongue is like in his mouth and he's blue, he's got blood, looks like he hit his head on the side. LPN A confirmed that Resident #1 was bleeding from his head and did not have a pulse. LPN A stated .I have nothing at all.He's cold, cold. The 911 operator stated that firefighters were on scene and for LPN A to make contact with them. 6. Review of facility video footage dated [DATE] revealed the following: At 3:49:58, CNA B entered Resident #1's room and exited at 3:50:12 AM. At 6:07:50 AM, CNA B entered Resident #1's room and exited at 6:08:24 AM. At 6:09:28 AM, LPN A, CNA B and CNA C entered Resident #1's room. They exited 11 seconds later. At 6:11 AM, CNA B entered Resident #1's room and exited approximately 12 seconds later. At 6:12 AM, CNA B and CNA C pushed a cart down the hallway and exited through the exit door with bags at 6:14 AM and remained outside for approximately a minute and a half before reentering the facility. At 6:16:01 AM CNA B re-entered Resident #1's room and exited the room at 6:16:16. At 6:20:26 AM, LPN A arrived outside of Resident #1's room with the crash cart and entered the resident's room leaving the crash cart in the hallway. At 6:22 AM, CNA C entered the room followed by CNA B. At approximately 6:23 AM, the local Fire Department entered Resident #1's room. At 6:26 AM, local EMS entered Resident #1's room and declared Resident #1 deceased at 6:30 AM. 7. Review of the facility investigation included the following timeline of events for Resident #1: a. [DATE] at 9:00 PM, LPN A administered Zofran for a complaint of nausea. b. [DATE] at approximately 4:00 AM, CNA B checked on Resident #1 because he was not feeling well and gave him a basin and bedside urinal and instructed him to call if he needed assistance. c. [DATE] at approximately 6:00 AM to 6:10 AM, CNA B answered the call light to Resident #1's room and the Resident's roommate reported Resident #1 went to the bathroom shortly before and had not come out. CNA B knocked on the restroom door and opened the door after receiving no response. Resident #1 was slumped over the toilet. CNA B did not touch the resident and went to get the nurse. (Named LPN A) immediately went to check on resident [#1]. d. [DATE] at 6:12 AM, LPN A notified the DON and verified Resident #1's Advance Directive. e. [DATE] at 6:14 AM, LPN A initiated emergency response, took the crash cart to (Resident #1's) room, called 911 from the facility phone at the nurses' station, and was told to hang up and call cell phone from resident [#1] room. f. [DATE] at 6:17 AM, LPN A called 911 and Resident #1 was assessed for signs of life by the 911 operator, Resident #1 laid on his back by LPN A to evaluate breathing status. Resident #1 was not breathing, was cold to touch and his face was blue in color. (According to the above video recording LPN A first went into Resident #1's room on [DATE] at 6:09 AM and re-entered at 6:20 AM, 11 minutes after originally discovering Resident #1). LPN A lay the Resident on his back to evaluate him. LPN A remained on the phone with 911 until the arrival of EMS. g. [DATE] at 6:23 AM, First responders arrived. h. [DATE] at 6:24 AM, Resident #1's roommate was relocated to another room. i. [DATE] at 6:25 AM, EMS arrived and no CPR was initiated due to signs of obvious death. j. [DATE] at 6:30 AM, Resident #1 was pronounced deceased by paramedics. 8. Review of Progress Notes dated [DATE] at 7:07 PM (late entry entered on [DATE] at 7:07 PM, 3 days after the incident with Resident #1 occurred), revealed LPN A documented .[Resident #1's] Roommate turned on call light, tech [CNA B] answered around 5:45 AM, and immediately reported resident (#1) down in bathroom. Nurse checked on resident, called DON, code blue, 911, NP [Nurse Practitioner] and rp [responsible party/representative]. Crash cart was pushed down, 911 on phone with nurse as she went to resident. Nurse notified 911 that resident was pulled off toilet, face was blue, no pulse, not alert & orient [oriented] and cold to touch. EMS/911 came in and took over . There were discrepancies observed in the facility's timeline, EMS documentation, interviews, and the observations obtained from the facility video footage. Review of facility's video footage from [DATE], revealed CNA B entered Resident #1's room at 6:07 AM. In addition, the facility's timeline stated LPN A initiated emergency response, took the crash cart to Resident #1's room, and called 911 from the nurses' station at 6:14 AM. The 911 call log revealed 911 was called at 6:17 AM. The facility video footage revealed LPN A took the crash cart to Resident #1's room at 6:20 AM. Interviews with staff revealed LPN A did not page a Code Blue and the LPN G (the other nurse working that night) was unaware there was an emergency situation in progress. 9. Review of the facility's undated investigation Conclusion statement of the events from [DATE], revealed the facility alleged CNA B found Resident #1 in the bathroom unresponsive and slumped over the toilet after she was alerted by his roommate that Resident #1 had been in the bathroom for a prolonged period of time. CNA B alerted LPN A of Resident #1's change in condition and when LPN A arrived in Resident #1's room, he remained slumped over toilet, cold to touch and unresponsive. LPN A called the Director of Nursing (DON) and then 911. LPN A made a second call to 911 from her cell phone and could not assess breathing status of Resident #1 due to his position. The 911 operator then instructed LPN A to reposition Resident #1 on his back and LPN A verified Resident #1 was not breathing and was blue in the face. It was relayed that Resident #1 had skin tears to the face caused by his face resting on the toilet seat. The nurse then allegedly left the room due to signs of obvious death and allegedly met with EMTs prior to their entry into Resident #1's room. After EMS assessed Resident #1, it was determined that he was deceased and was pronounced dead at 6:30 AM. 10. Review of the DON's written statement dated [DATE], revealed LPN A was educated regarding proper CPR policy and procedures as well as notifications. 11. Review of a Witness Statement by Resident #7 (Resident #1's roommate) dated [DATE], revealed Resident #7 was in bed and heard Resident #1 go into the bathroom and didn't hear anything else for about 20 minutes and alerted staff by using the call light. 12. Review of a hand-written Witness Statement by LPN A dated [DATE] and received over the telephone by the Administrator, revealed Resident #1 was observed with his knees bent, arms out, and horizontal over the toilet. While on the phone with 911 (operator) LPN A removed Resident #1 from the toilet and laid Resident #1 on the floor while on the phone with 911. Resident #1 had no pulse, was not responsive, was blue in the face and cold to touch. Review of a type-written Witness Statement by LPN A dated [DATE], revealed LPN A was notified by a CNA that Resident #1 was in the bathroom. LPN A checked on the Resident, notified the DON, called 911 and staff told of code blue. The crash cart was taken to Resident #1's room and Resident #1 was assessed while LPN A was on the phone with 911. Resident #1 was not alert, had no pulse, his face was blue and his skin was cold to the touch. 13. Review of a type-written Witness Statement by CNA B dated [DATE], revealed CNA B saw Resident #1 at approximately 4:00 AM. CNA B documented the Resident was alert and she had provided a basin and urinal to him and told him to call if he needed anything. At approximately 6:00 AM to 6:10 AM, Resident #1's roommate pushed his call button and notified staff that Resident #1 went to the bathroom shortly before and had not come out. CNA B knocked on the bathroom door and received no response. CNA B opened the door to the bathroom and observed Resident #1 slumped over the toilet. CNA B did not touch Resident #1 and immediately went to get the nurse. CNA B heard the nurse say code blue and the nurse took the crash cart to the room. CNA B and CNA C began closing resident room doors and clearing the hall. CNA B then observed Resident #1 had been placed on his back by the nurse. CNA B did not witness LPN A or EMS perform CPR. 14. Review of a type-written Witness Statement by CNA C dated [DATE], revealed CNA C entered Resident #1's room with LPN A and CNA B at approximately 6:00 AM to 6:10 AM after CNA B had observed Resident #1 in his bathroom slumped over the toilet unresponsive. LPN A called the DON and while at the nurses' station alerted staff to Code Blue. LPN A obtained the crash cart while she was on the phone. CNA C did not witness CPR being performed for Resident #1. 15. Review of the employee file for LPN G revealed a hire date of [DATE]. The file included a completed Orientation checklist which included competencies for nursing responsibilities during cardiac arrest, verbalize the policy for Do Not Resuscitate (DNR) orders/Advanced Directives, use of airways (a device used to administer oxygen and high-quality CPR), Ambu bags (handheld, manual device used to provide breaths to someone who cannot breathe adequately), checking the crash cart, and a valid CPR certification. Review of the schedule dated [DATE], revealed LPN G was the other LPN scheduled for 7:00 PM to 7:00 AM shift. Review of the employee file for LPN A (Resident #1's assigned nurse on the night of [DATE]) revealed a hire date of [DATE]. The file included a completed Orientation checklist which included competencies for nursing responsibilities during cardiac arrest, verbalize the policy for Do Not Resuscitate (DNR) orders/Advanced Directives, use of airways, Ambu bags, checking the crash cart, and a valid CPR certification. Review of the employee file for CNA B revealed a hire date of [DATE]. CNA B was not CPR certified. Review of the employee file for CNA C revealed a hire date of [DATE]. CNA C was not CPR certified. 16. Review of the (Named County) Emergency Medical Services report dated [DATE], revealed a 911 call was received on [DATE] at 6:17:58 AM and Resident #1 was noted to be dead without resuscitation efforts and was pronounced dead at 6:30 AM. Resident #1 had significant lividity in the head and neck core, extremities were cold to touch and the Resident's jaw had rigor mortis (temporary stiffening of the joints and muscles that usually begins in the face/jaw within 2 to 4 hours after death). Review of the County Emergency Communications dated [DATE], revealed a call was made at 6:17:58 by LPN A, EMS was assigned at 6:19:13 AM, and the Fire Station was assigned at 6:20:32 AM. The Fire Department arrived on scene at 6:24:06 AM, Medic arrived at 6:25:50 AM, EMS Battalion Chief arrived at 6:29:28 AM, and the police department arrived at 6:36:48. 17. Review of the QAPI Committee Meeting Minutes dated [DATE], revealed the Code Blue Policy, Allegations of Compliance (AOC), Performance Improvement Plan (PIP), Resident (#1's) Code Status and Process, Staff Education Inservice (begun [DATE]), and Mock Code Drills were discussed. The Quality Performance/Peer Review Facility Plan of Action/Continuous Quality Improvement revealed on [DATE] LPN A was educated and counseled on BLS Standards, CPR Policy, and Facility Expectations during Code Blue Response, on [DATE] a Mock Code Blue Scenario with Administrator and DON present was observed and an audit was conducted of employee files by Regional Human Resources of LPN and Certified Nurse Assistants who were certified with CPR. The facility failed to administer continuous CPR for a full-code resident who was found not breathing and without a pulse. 18. During an interview on [DATE] at 10:00 AM, the Nurse Practitioner was asked was she aware of the event that occurred involving Resident #1. When asked what she had been made aware of, she responded she was told that the facility had provided CPR. When asked what should be done when a resident with a Full-Code status was found without vital signs, she stated, .CPR should be performed . and verified the .resident should not be left alone by the staff after found . The NP was asked whether CPR should be discontinued once initiated prior to the arrival of EMS. The NP stated .EMS usually responds pretty quickly so staff has to do the best that they can until EMS arrives . During a telephone interview on [DATE] at 3:02 PM, Family Member (FM) D confirmed she was told by the facility that CPR was started and performed until EMS arrived at the facility. During an interview on [DATE] at 3:30 PM, FM D and FM E provided this surveyor with large files via airdrop (transfer of photos, videos, or documents between devices of a certain type). FM D and E stated Resident #1 had been treated for cirrhosis (advanced, irreversible liver scarring caused be chronic diseases such as hepatitis or alcohol abuse) for the past 2 years, had been placed on the transplant list, and had a Model for End-Stage Liver Disease (MELD) score of 13 (Numerical score used to assess the severity of chronic liver disease. Less than 15 indicates stable condition). FM D and FM E stated they had ordered an autopsy. During a phone interview on [DATE] at 8:15 PM CNA B said that she was Resident #1's CNA on the night of [DATE]. CNA B said she had made her 4 o'clock rounds and Resident #1 was lying in the bed and complained that he was not feeling well. She said that she gave him a basin in case he needed to vomit, his urinal and instructed him to call out if he needed any assistance. She said she went down to Resident #1's room when she noticed the call light was on and his roommate said that Resident #1 had been in the bathroom for a long time. The bathroom door was closed so she knocked on the door and there was no answer. When CNA B went into the bathroom, she noticed that Resident #1 was on his knees and did not respond. CNA B said she did not touch Resident #1 and went to get the nurse. She was asked whether she participated in CPR and she verified that she did not and did not see the nurse nor the emergency medical staff do CPR. CNA C was called four times requesting an interview, and she did not return any of the calls. During a telephone interview on [DATE] at 7:25 AM, LPN A was asked to explain what she saw once she entered Resident #1's room. LPN A stated, .He [Resident #1] was slumped over. He was in the bathroom.horizontal over the toilet . When asked to describe what she means by 'slumped over', LPN A stated he had .knees on the ground, slumped over.horizontally. LPN A was asked if he appeared like he was going to vomit. LPN A responded, .that's what it appeared but when we was [were] yelling his name and everything and then I looked at the floor and it [there] was blood down there.he was not responding and there was blood on the floor so I called 911.When I pulled him off of it [the toilet] though, he was blue.when I pulled him off to try to do CPR.he was blue.he was still of course not responding, and he was cold to touch. LPN A was asked when she went in Resident #1's room for the first time was Resident #1 breathing and did he have a pulse. LPN A responded, No. He wasn't, He wasn't responding when I first went in there and I seen [saw] the blood.and when I pulled him off.he still wasn't responding, he wasn't breathing, he still didn't have a pulse.when I seen [saw] him, his eye was bloodshot red . LPN A was asked the reason CPR was not done and she responded, he was already cold to touch and when I was on the phone with 911 to see if they still wanted me to initiate.they was like EMS was already in the building and just relay that to them.they were literally coming down the hallway. LPN A was asked if the facility has an Automated External Device (AED) and she said they did have a AED which was kept on the crash cart . LPN A was asked if she hooked the AED machine up to Resident #1. LPN A stated, .No, it wasn't no point to hook it up to him. LPN A was asked where the other nurse on the shift was located and whether she assisted with the code. LPN A responded, .it was just me and then two techs.I called a code blue and could not stop to try and locate the other nurse . During a phone interview on [DATE] at 2:59 PM, LPN G was asked whether she was aware of the Code Blue and she said she was not aware there was a Code Blue called at the facility. During an interview on [DATE] at 9:45 AM, the Regional Director of Operations and the [NAME] President of Clinical were asked when LPN A went into the room after she was notified of Resident #1 being unresponsive and how long she was in the room. The Regional Director of Operation said LPN A went in the room (Resident #1's room) immediately after she (LPN A) was made aware and stated, .she [LPN A] was in the room [Resident #1's room] approximately 11 seconds . When asked if that was enough time to do a proper assessment, the Regional Director of Operations agreed that 11 seconds were not long enough time to do a proper assessment, and the [NAME] President of Clinical nodded her head as if she agreed. During an interview on [DATE] at 12:20 PM, the DON was asked whether there should be documentation regarding the reason for as needed (PRN) medications and whether the effectiveness should be documented. The DON said the effectiveness should be documented in a progress note. The DON was asked the reason for the education of LPN A and the initiation of Mock Code Drills. The DON responded, .they were started because of the delay in CPR [on [DATE]].I was always taught that if a resident was a full code and did not have an Advanced Directive.CPR should automatically be initiated. The DON was asked which CPR policy did the facility follow. The DON confirmed she would need to follow up with the Administrator who later confirmed the facility utilized both the facility policy and the American Heart Association [AHA] guidelines. The facility policy has since been revised to reflect the AHA guidelines which allows CPR not to be performed on a resident with a full-code status if there are signs of irreversible death to include rigor mortis (temporary stiffening of muscles after death), dependent lividity (purple red discoloration of the skin cause by blood settling), decapitation (cutting off of the head), transection (cutting across a structure) and decomposition (break down of the body). During an interview on [DATE] at 4:00 PM, the Administrator said, he implemented Mock Code Drills due to the family dynamic that was displayed at the time of death. After review of the facility's plan of action, the Administrator was asked why he and the DON were educated. The Administrator responded, .corporate educated us [the Administrator and the DON] due to the changes in the policy related to Lividity.only a Registered Nurse [RN] can assess for lividity.based on the company's policy, state regulations and the American Heart Association. An acceptable Removal Plan which removed the immediacy of the Jeopardy was received on [DATE] at 12:15 PM and was validated onsite by the surveyor through medical record review, in-service sign-in log review, audit/monitoring tool review, and interviews. AOC #2 Facility: Waters of [NAME] Removal of Immediacy or IJ F-678 cited [DATE] As required by state and federal law, the facility, the Waters of [NAME], is respectively submitting the following removal of immediacy in order to request removal of the Immediate Jeopardy. Disclaimer Statement: The completion and submission of the credible allegation of compliance does not constitute an admission that the facility agrees with the allegation in the notification of Immediate Jeopardy. The facility is completing the removal of immediacy because it is required by state and federal law. The facility disagrees with and disputes the alleged deficiency as stated in the notification and disagrees with the accuracy of statements and other information relied upon in the support of the alleged deficiencies. This includes but is not limited to the alleged content/summary of interviews, the chronological training sequence of events and contact with healthcare professionals, and the description of the care and supervision provided to resident(s). The facility reserves its right to continue disputing, appealing and contesting this alleged deficiency and any action related to or arising therefrom in any other forum as needed. Allegation---F-678-Cardio-Pulmonary Resuscitation (CPR)-Basic Life Support The facility failed to provide continuous BLS (basic life support)/Cardiopulmonary Resuscitation (CPR) to a vulnerable resident, who was found on [DATE] at 6:07 AM, in the bathroom, on his knees slumped over the commode unresponsive. The facility failed to provide continuous CPR until local Emergency Medical services arrived, took over, and / or pronounced the resident deceased . Resident(s) Affected- As stated prior, Resident #1 expired. How other residents having the same potential to be affected by the same deficient practice will be identified, and what corrective action(s) will be taken- Residents who reside in the facility have the potential to be affected by this finding. Administrator and DON educated on BLS Standards, CPR Policy, and Facility Expectations during a Code Blue Response by the Regional Nurse on [DATE] to include: GUIDELINES FOR CARDIOPULMONARY RESUSCITATION-CPR Intent: It is the intent of the facility to ensure that it is able to-and does---provide emergency basic life support immediately when needed, including cardiopulmonary resuscitation (CPR), to any resident requiring such care prior to the arrival of emergency medical personnel in accordance with related physician orders, such as DNR (Do Not Resuscitate) as well as a resident's personal Advance D

Based on policy review, refrigerator temperature logs, observation, and interview, the facility failed to ensure food was stored, handled, prepared, and served under sanitary conditions, when food was found unlabeled and undated, baking pans contained carbon buildup, a grease trap under the stove was found with aluminum foil torn and with a large amount of food debris, and when the walk-in cooler temperatures were consistently above 41 degrees. The census was 37 with 34 of those residents receiving a meal tray from the kitchen. The findings include: 1. Review of the undated facility policy titled, Labeling and Dating, revealed .opened foods shall be clearly labeled .Food items to be labeled and dated include .items that are opened and stored for later use .Name of food item .Discard Date . Review of the undated facility policy titled, Cleaning Standards, revealed .Food contact surfaces, non-food contact surfaces, equipment, pans and utensils must be kept clean at all times. This includes but not limited to free of grease deposits, food residue, dust and other soil accumulation/debris . Review of the undated facility policy titled, Freezers and Refrigerators, revealed This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation .Acceptable temperatures should be 35 degrees to 41 degrees F (Fahrenheit) for refrigerators .Dietary staff must report unacceptable .refrigerator temperatures to the dietary manager immediately .The Dietary Manager will take immediate action if temperatures are out of range . 2. Review of the Refrigerator Temperature Log form dated 4/2025, revealed the walk-in cooler temperatures were documented as follows: a. 4/1/2025 PM: 46 degrees b. 4/9/2025 PM: 48 degrees c. 4/10/2025 PM: 46 degrees d. 4/14/2025 PM: 58 degrees e. 4/15/2025 PM: 51 degrees f. 4/16/2025 PM: 52 degrees g. 4/17/2025 PM: 48 degrees h. 4/18/2025 PM: 54 degrees i. 4/19/2025 AM: 42 degrees j. 4/19/2025 PM: 54 degrees k. 4/20/2025 AM: 44 degrees l. 4/21/2025 AM: 43 degrees m. 4/22/2025 AM: 45 degrees n. 4/23/2025 PM: 42 degrees o. 4/24/2025 PM: 44 degrees p. 4/27/2025 PM: 44 degrees q. 4/30/2025 PM: 42 degrees Review of the Refrigerator Temperature Log form dated 5/2025, revealed the walk-in cooler temperatures were documented as follows: a. 5/2/2025 PM: 44 degrees b. 5/3/2025 PM: 44 degrees c. 5/5/2025 PM: 44 degrees d. 5/7/2025 PM: 48 degrees e. 5/8/2025 AM: 49 degrees f. 5/9/2025 AM: 49 degrees g. 5/10/2025 AM: 45 degrees h. 5/10/2025 PM: 45 degrees i. 5/11/2025 AM: 44 degrees j. 5/11/2025 PM: 47 degrees k. 5/12/2025 AM: 43 degrees l. 5/12/2025 PM: 46 degrees m. 5/13/2025 AM: 45 degrees n. 5/13/2025 PM: 52 degrees o. 5/14/2025 AM: 48 degrees p. 5/14/2025 PM: 56 degrees q. 5/15/2025 AM: 54 degrees r. 5/15/2025 PM: 50 degrees s. 5/16/2025 AM: 55 degrees t. 5/16/2025 PM: 51 degrees u. 5/17/2025 PM: 44 degrees v. 5/18/2025 PM: 50 degrees 3. Observations of the walk-in cooler in the kitchen on 5/18/2025 at 10:30 AM and at 3:20 PM, revealed a thermometer reading of 52 degrees. Observations in the kitchen beginning on 5/18/2025 at 10:30 AM, 3:20 PM, and 5/19/2025 at 10:00 AM, revealed the following: a. An open large clear bag with white powder unlabeled and undated sitting on top of a flour bin container. b. 8 large rectangular baking pans with carbon build-up. c. A grease trap drawer under the stove with excessive tearing of aluminum foil with a black plastic lid and excessive food debris. During an interview on 5/19/2025 at 7:42 AM, the Regional Certified Dietary Manager (CDM) revealed the facility had purchased a new refrigerator and threw all of the food away that was in the cooler. During an interview on 5/19/2025 at 10:00 AM, the Regional CDM and the CDM confirmed the clear bag of white powder was thickening powder for drinks and should not been left on top of the flour bin unlabeled and undated. The Regional CDM confirmed the grease trap under the stove was filled with food debris and the plastic lid could have been a fire hazard. The Regional CDM and the CDM confirmed 8 large rectangular baking pans had carbon build-up and should not have been used. During an interview on 5/19/2025 at 11:10 AM, the Regional CDM confirmed that the food in the walk-in cooler should have been thrown away when the walk-in cooler temperatures were consistently above the appropriate temperatures. During an interview on 5/20/2025 at 11:38 AM, the Administrator confirmed he was told two times about the temperatures in the walk-in cooler being elevated. The Administrator was asked should these elevated walk-in cooler temperatures been reported to you. He stated, Yes .when they received the abnormal temperatures . The Administrator confirmed the entire dietary staff have been educated about refrigerator temperatures and he would have purchased a new one if he would have been informed sooner.

Based on facility policy review, observation, and interview, the facility failed to ensure measures to prevent the spread of infection were followed for 3 of 6 (Resident #2, #25, and #26) residents observed for medication administration when 3 of 3 (Registered Nurse (RN) B, Licensed Practical Nurse (LPN) C and LPN D failed to perform appropriate hand hygiene during medication administration. The findings include: 1. Review of the undated facility policy titled, Hand Hygiene Procedure, revealed .Hand hygiene should be performed if there has been any contact with a resident, resident's environment .before direct contact with residents, before application of gloves, and removing gloves . 2. Observation on the C hall on 5/19/2025 at 2:01 PM, revealed LPN C washed her hands, prepared medications, entered Resident #26's room, washed her hands, donned gloves, administered Brimonidine sol 0.2 percent [%] one drop to the left eye, removed her gloves, donned clean gloves, administered 1 drop to the right eye drop, placed eye drops into a plastic bag, removed her gloves, and washed her hands. LPN C exited the room, returned the bottle of eye drops to the medication cart, washed her hands, and signed out medication. LPN C failed to perform hand hygiene between glove changes during medication administration. 3. Observation on the B hall on 5/19/2025 at 2:12 PM, revealed RN B washed her hands, donned a pair of clean gloves, prepared medications for Resident #5, removed her gloves, entered Resident #5's room and administered the medications to the resident, exited the resident's room and returned to the medication cart. RN B failed to perform hand hygiene before and after administration of medications and removal of gloves. 4. Observation on the B hall on 5/20/2025 at 8:16 AM, revealed LPN D prepared Resident #2's medications, donned clean gloves, entered Resident #2's room, administered her medications, removed her gloves, administered Latanoprost Sol. 0.005% one drop to each eye, removed her gloves, donned a pair of clean gloves and administered Symbicort 160-4.5 inhaler. LPN D then removed her gloves, exited the room and returned to the medication cart. LPN D failed to perform hand hygiene before preparing medication, before and after glove exchange, and after administering medication. During an interview on 5/20/2025 at 4:42 PM, the Director of Nursing (DON) was asked if the nurse should have washed her hands prior to preparing medication for administration. The DON stated, Yes, they should or use hand sanitizer. The DON was asked should the nurse perform hand hygiene between glove exchange. The DON stated, Yes, they should.

Based on policy review, medical record review, observation, and interview, the facility failed to be present for supervision and assistance in the dining room for 2 of 7 (Resident #6 and #8) residents in the dining room during dining. The findings include: 1. Review of the facility policy titled, Resident Dining Services, dated 12/12/2006, revealed .process in place to ensure residents receive .appropriate assistance and supervision . 2. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Alzheimer's Disease, Anxiety, and Vascular Dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #6 was severely cognitively impaired for daily decision-making skills and required supervision with eating. 3. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including Stroke, Dementia, and Seizures. Review of the quarterly MDS dated [DATE], revealed a BIMs score of 11, which indicated Resident #8 was moderately cognitively impaired and required supervision with eating. Observation in the dining room on 5/19/2025 at 12:55 PM, revealed that Resident #6 and Resident #8 were feeding themselves and no staff members were present to supervise with dining. During an interview on 5/19/2025 at 3:35 PM, the Administer confirmed someone should be present and supervising residents during meals.

Based on policy review, observation, and interview, the facility failed to provide a private space that prevented interference for the resident group meeting (Resident #1, #9, #11, #25 and #33) for 1 of 1 (Resident Council) sampled group reviewed. The findings include: 1. Review of the facility policy titled, Resident Council Procedural Guide, dated 11/28/2017, revealed .facility supports the rights of residents to organize and participate in resident groups .The resident has a right to organize and participate in resident groups in the facility .The facility must provide a resident .private space .they must be provided privacy for meetings . 2. Observation in the Dining Room during the Resident Council Meeting on 5/19/2025 at 1:46 PM, revealed the Transportation Driver was sitting in the room while the meeting in progress. Observation in the Dining Room during the Resident Council Meeting on 5/19/2025 at 2:03 PM, revealed the Transportation Driver walked over to the entrance door a let a family member in the door and the family member came over and spoke with a resident who was in attendance at the meeting. Observation in the Dining Room during the Resident Council Meeting on 5/19/2025 at 2:25 PM, revealed a resident entered the dining room to go to the snack machine. 3. During an interview on 5/19/2025 at 3:06 PM, the Activity Supervisor was asked if the meetings were always interrupted. The Activity Supervisor stated, Yes, that is an issue . During an interview on 5/19/2025 at 3:43 PM, the Administrator confirmed Resident Council was supposed to be uninterrupted.

Based on observation, interview, and facility policy review, the facility failed to label and date food items in a walk-in refrigerator. This had the potential to affect all residents who received food from the kitchen. Findings included: 1. An undated facility policy titled, Food Safety, indicated, Food items that do not have a manufacturer's expiration date will be labeled and dated with a received and use by date. 2. During a tour of the kitchen on 07/22/2024 at 8:50 AM, with the Dietary Director (DD), the following was observed in the walk-in refrigerator: Six, undated bowls of salad; Four, small, undated bowls of pears; Four, small, undated and unlabeled bowls of yellow pudding; Two, undated and unlabeled pieces of meat, of which the DD identified as country fried steak; and Two, unlabeled and undated bowls of white sauce, of which the DD stated was tartar sauce. During an interview on 07/24/2024 at 4:02 PM, [NAME] #10 stated all foods had to be labeled and dated after being opened. [NAME] #10 stated leftover foods were wrapped, dated, and used within three days. During an interview on 07/25/2024 at 8:44 AM, [NAME] #11 stated all food items should be labeled and dated when opened. During an interview on 07/25/2024 at 9:27 AM, the DD stated it was her expectation for staff to date food items upon receipt. The DD stated it was her expectation for opened foods to be labeled with opened and use by dates. During an interview on 07/25/2024 at 9:36 AM, the Registered Dietician stated it was her expectation that all opened foods should be labeled and dated with an opened and use by date. During an interview on 07/25/2024 at 9:57 AM, the Director of Nursing stated all opened food items should be labeled and dated. During an interview on 07/25/2024 at 10:06 AM, the Administrator stated all food items should be dated and labeled.

Based on record review, facility document review, facility policy review, and interview, the facility failed to protect the residents' right to be free from physical abuse perpetrated by other residents for 3 (Residents #33, #198, and #48) of 9 residents reviewed for abuse. Specifically, on 03/17/2024, Resident #29 hit Resident #33 with a meal tray. On 11/29/2023, Resident #10 struck Resident #198 on the right forearm and grabbed and pulled the resident's hair. On 12/19/2023, Resident #15 struck Resident #48, which caused the resident to fall backwards out of their wheelchair. Findings included: 1. A facility policy titled, Abuse Prevention Program, updated 01/19/2017, revealed, It is the policy of this facility to prevent resident abuse, neglect, mistreatment and misappropriation of resident property. Each resident receives care and services in a person-centered environment in which all individuals are treated as human beings. 2. An Admission Record revealed the facility admitted Resident #33 on 09/15/2021. According to the Admission Record, the resident had a medical history that included diagnoses of anxiety disorder, cognitive communication deficit, mild dementia with mood disturbance, and depression. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/08/2024, revealed Resident #33 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. Resident #33's care plan revealed a focus area initiated 01/08/2024, that indicated the resident's comprehensive assessment indicated the resident had a history of suspected abuse, neglect exploitation, past trauma, and/or other factors that may increase susceptibility to abuse/neglect. An Admission Record revealed the facility readmitted Resident #29 on 11/09/2023. According to the Admission Record, the resident had a medical history that included diagnoses of Chronic Pain Syndrome, Major Depressive Disorder, Anxiety Disorder, and Vascular Dementia. A quarterly MDS, with an ARD of 04/03/2024, revealed Resident #29 had a BIMS score of 10, which indicated the resident had moderate cognitive impairment. Resident #29's care plan revealed a focus area initiated 10/03/2023, that indicated the resident may exhibit signs or symptoms of anxiety as evidenced by episodes of agitation, restlessness, tearfulness, and worried facial expressions related to the resident's diagnosis of Anxiety. Interventions indicated that the resident may be referred to mental health services, including psychiatric consultations and psychotherapy services (initiated 10/03/2023). Resident #29's Progress Notes dated 03/17/2024 at 7:38 PM, indicated it was reported that Resident #29 hit another resident with a meal tray. The note indicated the Administrator, Director of Nursing (DON), and a Nurse Practitioner were notified. The note indicated that an immediate intervention of one-to-one staff supervision was implemented and that the resident was going to be sent for a psychiatric evaluation. A facility investigation document, dated 03/17/2024, indicated that at around 6:30 PM, Registered Nurse (RN) #1 was alerted to a resident-to-resident event. The document indicated that Resident #29 attempted to take an uneaten meal tray when Resident #33 told Resident #29 not to. The document indicated Resident #29 proceeded to dump the tray and strike Resident #33 with the tray. The document indicated RN #1 separated the residents and called for assistance. Per the document, the Administrator was notified at 6:38 PM after RN #1 ensured the safety of the residents. The document indicated that Resident #33 was interviewed by the Administrator and stated that Resident #29 attempted to remove a meal tray with uneaten food when Resident #29 stated they should not do that. The document indicated Resident #33 stated that Resident #29 dumped the tray on the floor and hit them (Resident #33) in the head. The document indicated Resident #4, a witness to the incident, was interviewed and stated that when Resident #29 attempted to remove a meal tray with uneaten food, Resident #33 told them that they should not do that. The document indicated Resident #4 stated that Resident #29 dumped the tray and struck Resident #33 with the tray. The document indicated Resident #4 stated that staff immediately separated the two residents. During an interview on 07/24/2024 at 3:21 PM, Resident #4 stated they did remember the incident between the Resident #29 and Resident #33. Resident #4 stated Resident #29 was in the dining room and did not want the food they had been served, so Resident #29 took their tray to the cart and grabbed another tray that another resident had not eaten. Resident #4 stated Resident #33 just told Resident #29 to leave it alone, that they could not have it. Per Resident #4, Resident #29 got mad, threw the stuff off the tray and hit Resident #33 with it. Resident #4 stated that it was not a hard hit. Resident #4 stated it scared them when the incident occurred, but they currently felt safe. Resident #4 stated Resident #33 did not do anything, but just walked away. Resident #4 stated they left the room to go get staff to come in and help. Resident #4 stated the two residents were never in the dining room together following the incident. During a telephone interview on 07/24/2024 at 7:28 PM, RN #1 stated when she was notified of an incident between two residents, she first separated the residents and made sure they were both safe, then notified the Administrator and DON. She stated there was an incident several months ago where a resident came up to her and reported that there was an issue between Resident #29 and Resident #33. She stated the resident reported to her that Resident #29 picked up a tray and hit Resident #33 with it. RN #1 stated that was not behavior she had ever seen from Resident #29 before. She stated at the time, Resident #29's room was in the back and both residents ate in the same dining room. She stated she believed that one of the residents, she thought Resident #29, was sent out for an evaluation following the incident. She stated the resident who witnessed the incident told her that Resident #33 did not become aggressive and stated the resident was just sitting calmly in the dining room when she arrived. She stated, from what she could remember, Resident #29 was trying to get a sandwich and Resident #33 told the resident not to, that they were not supposed to have it. During a telephone interview on 7/25/2024 at 9:38 AM, RN #2 stated that she had not worked at the facility since 04/07/2024. She stated she did remember the incident between Resident #29 and Resident #33. She stated the incident was unexpected for Resident #29 to have done something like that. She stated the residents were separated immediately. She stated she remembered that staff moved Resident #29 soon after the incident, sent the resident to the hospital for an evaluation, and kept the resident on one-to-one staff supervision for a while. She stated that as far as she knew, Resident #29 had never done anything like that before. During an interview on 07/25/2024 at 10:35 AM, Resident #33 stated they did remember the incident with Resident #29. The resident stated Resident #29 got mad, tried to take food off of old food trays. The resident stated when they told Resident #29 to stop, Resident #29 grabbed the tray and hit them with it. The resident stated that it did not hurt, stating I've got a hard head. Resident #33 stated they felt safe in the facility and had not seen that resident since. During an interview on 07/25/2024 at 11:30 AM, the DON stated if there was an instance of resident-to-resident abuse, when staff either heard of it or witnessed one resident swing at another resident, the first thing they needed to do was separate them and provide safety, then notify the abuse coordinator, the Administrator. She stated that interviews should be conducted about the incident immediately of anyone who had information regarding the incident. The DON stated she vaguely remembered the incident between Resident #29 and Resident #33. She stated that from what she remembered, Resident #29 was going to the meal cart, opened it, and was getting something off the cart. She stated that Resident #33 told Resident #29 to not touch it or mess with it. Per the DON, Resident #29 got upset and got the meal tray and hit Resident #33 in the face with the tray. She stated that Resident #29 was sent out to the hospital for an evaluation immediately after the incident. She stated that staff monitored Resident #29 closely prior to being sent out. Per the DON, there was not any bruising or redness to Resident #33. During an interview on 07/25/2024 at 11:16 AM, the Administrator stated that if there was a resident-to-resident altercation, staff should separate the residents immediately and ensure they were not injured then immediately notify him. He stated that if staff could not reach him, they should reach out to the DON. He stated that once notified, they started an investigation into the incident and put interventions in place. The Administrator stated that when they completed their investigation into the incident between Resident #29 and Resident #33, they found that it did happen, but they did not know what caused it. He stated that it was not normal behavior for Resident #29, who was usually a very quiet person. He stated that they did their best to prevent abuse. The Administrator stated that they discussed abuse monthly at their staff meetings, posted policies in the bathrooms, and had skills survey every year. PAST NON-COMPLIANCE VERIFICATION The facility implemented the following corrective actions: Resident #29's Psychological Diagnostic Interview, dated 03/18/2024 indicated that the resident medication regimen was reviewed and indicated that a depression screening was completed and was positive. The record indicated a plan for psychiatric services. Resident #29's Progress Notes dated 03/19/2024 at 11:00 AM, indicated the resident remained on one-to-one staff supervision while out of bed and every 15 minute checks when in bed. Resident #29's Progress Notes dated 03/20/2024 at 7:03 AM, indicated the resident remained on one-to-one staff supervision while out of bed and every 15 minute checks when in bed. Resident #29's Psychiatric Evaluation, dated 03/19/2024, indicated an evaluation was completed on that day. The record indicated a recommendation of an increase in an antidepressant medication and to discontinue one-to-one staff supervision. Resident #29's Psychiatric Evaluation, dated 03/26/2024, indicated the resident had a follow-up evaluation and indicated no changes in recommendations. An untitled facility document, dated 03/18/2024, indicated staff documented they provided one-to-one staff supervision for Resident #29 from 1:30 AM to 7:00 AM. Resident #33's Weekly Skin Check, dated 03/17/2024 at 7:54 PM, indicated the resident had no loss of skin integrity. Resident #33's Psychiatric Evaluation, dated 03/19/2024, indicated the resident was seen following a physical altercation with another resident and indicated that Resident #33 was not the instigator. The record indicated to continue with the current plan. 3. An Admission Record revealed the facility admitted Resident #10 on 08/10/2023. According to the Admission Record, the resident had a medical history that included diagnoses of Anxiety, Dementia, and Paranoid Schizophrenia. An annual MDS, with an ARD of 07/01/2024, revealed Resident #10 had a BIMS score of 10, which indicated the resident had moderate cognitive impairment. Resident #10's care plan revealed a focus area initiated 08/25/2023, that indicated Resident #10 was at risk for alteration in behaviors as evidenced by mood alterations with schizophrenia, personal history of verbal outburst, and wandering. An Admission Record revealed the facility admitted Resident #198 on 08/03/2023. According to the Admission Record, the resident had a medical history that included diagnoses of Vascular Dementia with Anxiety. A quarterly MDS, with an ARD of 03/28/2024, revealed Resident #198 was had a BIMS score of 0, which indicated severe cognitive impairment. Resident #10's Progress Notes dated 11/29/2023 at 7:02 PM, revealed the MDS Coordinator observed Resident #10 in their bedroom grabbing onto another resident's right forearm with one hand and handful of Resident #198's hair in their other hand. The note indicated the residents were separated. A typed facility investigation, dated 11/29/2023, signed by the Administrator, indicated on 11/29/2023 at around 1:35 PM, Resident #10 struck Resident #198 on the right forearm and grabbed and pulled Resident #198's hair. The document indicated staff separated the residents and Resident #10 was placed on one-to-one staff supervision. The document indicated Resident #198 was interviewed and stated they tried to get into their room when Resident #10 struck their arm and pulled their hair. The document indicated Resident #198 stated that a nurse separated them. The document indicated Resident #41, Resident #198's and Resident #10's roommate, was interviewed and stated that Resident #10 struck Resident #198's arm, then pulled Resident #198's hair. The document indicated the facility concluded that the resident to resident event did occur. During an interview on 07/24/2024 at 2:55 PM, Resident #41 stated they were sitting with Resident #198 when Resident #10 approached them and started playing with Resident #198's hair. Resident #41 stated that Resident #10, without warning, started pulling out Resident #198's hair. Resident #41 stated that a nurse came and separated the two residents. During an interview on 07/25/2024 at 8:28 AM, Certified Nurse Aide (CNA) #27 stated that Resident #198 completed their lunch meal and was trying to get back into their room to lie down but crossed paths with Resident #10. CNA #27 stated that Resident #41 informed her that Resident #10 grabbed Resident #198 by the back of their head and pulled the resident out of their wheelchair. CNA #27 stated that by the time she arrived, the residents had already been separated. CNA #27 stated that she had not seen Resident #10 act like that before. She stated staff moved Resident #10 to the end of the hall so they could not have contact with Resident #198. During an interview on 07/25/2024 at 8:56 AM, the MDS Coordinator confirmed she was at the nursing station at the time that Resident #10 and Resident #198 had an altercation. The MDS Coordinator stated Resident #198 was in the way of Resident #10 and Resident #10 grabbed Resident #198's arm and pulled out their hair. She stated that she notified the Administrator, physicians, and family. She stated Resident #10 was sent out for a psychiatric evaluation. During an interview on 07/25/2024 at 9:57 AM, the DON stated that in the event of an abuse allegation it was her expectation of staff to ensure all parties were safe, notify the nurse on the floor and for the nurse to immediately notify the abuse coordinator, the Administrator. During an interview on 07/25/2024 at 10:06 AM, the Administer stated it was reported to him that Resident #10 pulled Resident #198's hair. He stated the residents were separated, and the incident was reported to the state survey agency and the policy. He stated the management team then conducted an investigation and Resident #10 was sent out for a psychiatric evaluation. PAST NON-COMPLIANCE VERIFICATION The facility implemented the following corrective actions: The facility's Investigation Timeline indicated on 12/29/2023 at approximately 2:30 PM, emergency medical services (EMS) arrived at the facility and at 2:41 PM, Resident #10 was taken by EMS. A facility document titled Every 15 minute checks, dated 11/29/2023, indicated staff documented that one-to-one staff supervision was provided to Resident #10 until EMS to the facility to take the resident to the hospital. Documentation revealed staff documented from 1:30 PM to 2:30 PM. Resident #10's Progress Notes dated 11/29/2023, indicated the resident was sent to the emergency room for evaluation. A note dated 12/14/2023 indicated the resident returned to the facility on that day. Resident #198's Pain Review, dated 11/29/2023 at 4:13 PM, indicated the resident had throbbing pain to the back of their head and scalp and indicated that it Hurts a Little Bit. A facility document titled, Training Log/Sign In Sheet, dated 11/29/2023, indicated staff received training on the facility's abuse policy, reporting abuse, types of abuse, and the grievance process. 4. An Admission Record revealed the facility admitted Resident #15 on 02/14/2022. According to the Admission Record, the resident had a medical history that included diagnoses of Dementia, Depressive episodes, Restlessness and Agitation. A quarterly MDS, with an ARD of 06/06/2024, revealed Resident #15 had a BIMS score of 5, which indicated the resident had severe cognitive impairment. Resident #15's care plan included a focus area initiated 08/01/2022, that indicated the resident had an alteration in behaviors as evidenced by being resistant to care and indicated that the resident was verbally aggressive to staff and combative with care. An Admission Record revealed the facility admitted Resident #48 on 06/21/2022. According to the Admission Record, the resident had a medical history that included diagnoses of Dementia, Cerebral Infarction (a stroke) without residual deficits, Anxiety Disorder, and Traumatic Amputation at level between right hip and knee. A significant change in status MDS, with an ARD of 05/29/2024, revealed Resident #48 had a BIMS score of 7, which indicated the resident had severe cognitive impairment. Resident #48's Progress Notes dated 12/19/2023 at 10:45 AM, revealed staff requested assistance because two residents had an altercation. The note indicated Resident #15 was on the ground and their wheelchair was flipped over. The note indicated the resident was helped back up and the two residents were separated. Resident #15's Progress Notes dated 12/19/2023 at 10:45 AM, indicated the resident had been in an altercation with another resident (Resident #48) and was separated from the other resident. A typed facility investigation, dated 12/19/2023, indicated Resident #15 and Resident #48 were outside for a smoke break. The document indicated Resident #15 attempted to take a lighter and when a staff member attempted to redirect the resident, Resident #15 made a rude remark to the staff member. The document indicated Resident #48 then made a comment to Resident #15, at which time Resident #15 stood up and began to approach Resident #48. The document indicated Housekeeping Aide (HA) #21 attempted to stand between the two residents but Resident #15 struck Resident #48, causing the resident to fall backwards. The document indicated HA #21 alerted other staff members and both residents were separated, and Resident #15 was placed on one-to-one staff supervision. The document indicated Resident #48 was assessed and denied pain and had no physical injuries. The document indicated Resident #15 was sent to the emergency room for a psychiatric evaluation. Per the document, the facility's investigation found that the incident did occur and staff acted in the best interest of the residents, attempting to prevent the incident and seeking immediate assistance after the event. During an interview on 07/24/2024 at 12:59 PM, HA #21 stated she was monitoring residents in the designated smoking area when Resident #15 and Resident #48 got into an altercation. HA #21 stated Resident #15 grabbed a cigarette lighter, and she told the resident that they had to wait for staff to light their cigarette. She stated Resident #15 indicated that they were an adult, then Resident #48 told Resident #15 to have respect for HA #21. She stated that Resident #15 started cussing at Resident #48, then Resident #15 stood up and hit Resident #48 in the face, knocking the resident out of the wheelchair. HA #21 stated that they then yelled for help and Physical Therapist (PT) #28, along with two other staff, including the Administrator, arrived and assisted Resident #48 back into their wheelchair. During an interview on 07/24/2024 at 1:31 PM, Resident #35 stated they were sitting in the smoking area at the time of the incident between Resident #15 and Resident #48. Resident #35 stated that Resident #15 and Resident #48 were both talking to each other when Resident #48 started cursing at Resident #15. Resident #35 stated Resident #15 then hit Resident #48 in the face, knocking the resident over. Resident #35 stated staff then came and separated the two of them and helped Resident #48 off the ground. During an interview on 07/24/2024 at 1:46 PM, PT #28 stated he heard a staff member yelling for help and when he got to the smoking area, Resident #48 was on their back. He stated that he was told that Resident #15 came over on top of Resident #48 and they were fighting. He stated that the residents were separated. During an interview on 07/24/2024 at 4:09 PM, Resident #32 stated they was sitting on the smoking deck at the time of the incident. The resident stated Resident #48 was antagonizing Resident #15. Per Resident #32, Resident #15 told Resident #48 to stop antagonizing Resident #15 or they would hit them. The resident stated that Resident #48 did not stop, and Resident #15 punched Resident #48, knocking them out of their chair. During an interview on 07/25/2024 at 9:57 AM, the Director of Nursing (DON) stated she was not employed at the time of the incident. The DON stated that in the event of an abuse allegation it was her expectation of staff to ensure all parties were safe, notify the nurse on the floor and for the nurse to immediately notify the abuse coordinator, the Administrator. During an interview on 07/25/2024 at 10:06 AM, the Administrator stated that by the time he arrived at the smoking area, staff had already separated Resident #15 and Resident #48. He stated he reported the incident to his boss, the police, and the state survey agency. The Administrator stated it was his expectation to be contacted immediately for physical abuse allegations. PAST NON-COMPLIANCE VERIFICATION The facility implemented the following corrective actions: A facility document indicated staff document one-to-one supervision was provided to Resident #15 until EMS transported the resident on 12/19/2023. Documentation revealed staff documented the supervision from 10:45 AM to 12:00 PM. Resident #48's skin assessment dated [DATE] revealed No issues noted. Resident #15's Progress Notes revealed the following notes: A note dated 12/19/2023 at 12:01 PM indicated Resident #15 was sent to the emergency room for an evaluation and treatment following an altercation with Resident #48. A note dated 12/19/2023 at 10:45 PM indicated that Resident #15 returned to the facility from the emergency room . A note dated 12/20/2023 at 6:25 PM indicated that Resident #15 struck a nurse and was sent back to the emergency room . A note dated 12/20/2023 at 11:12 PM indicated that Resident #15 returned to the facility from the hospital. A note dated 12/20/2023 indicated that Resident #15 was to stay on one-to-one supervision to prevent future altercations until the resident was transferred to another facility. A note dated 12/22/2023 at 3:42 PM indicated that Resident #15 was transferred to a psychiatric hospital. Facility documents titled, Training Log/Sign In Sheet, dated 12/20/2023, indicated staff received training on reporting change in behaviors to a charge nurse immediately, and if there is a verbal or physical altercation involving a resident, never leave the resident, call for help. The facility has continued to supervise these residents' behaviors without recurrence.

Based on interview, record review, and facility policy review, the facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) for 1 (Resident #24) of 2 sampled residents reviewed for beneficiary notification. Findings included: 1. A facility policy titled, Advanced Beneficiary Notices, dated 11/2018, revealed, Policy: It is the policy of the facility to follow the Medicare requirements for issuing Advanced Beneficiary Notices and Notices of Non-Coverage of services as defined in the Medicare Claim Processing Manual, Chapter 30. Revision 4001, March 16th, 2018. Types of Notices: 1. Financial Liability: a. SNFABN - Traditional Medicare Part A only. The policy revealed, Overview of Financial Liability Notices - Medicare Beneficiaries have rights and protections related to their financial liability under Traditional Medicare. Advanced Beneficiary Notices (ABN) is to inform a Medicare Beneficiary, before he or she receives specified items or services that Medicare probably will not pay for them. Per the policy, 6. The SNFABN must be issued Prior to receiving the non-covered care (Upon admission or before) or (upon Termination of Medicare covered Skilled Care Needs - on or before the last covered day). 2. The Beneficiary Notice-Residents discharged within the Last Six Months form, completed by the facility indicated Resident #24 was discharged on [DATE] and remained in the facility. Resident #24's SNF Beneficiary Notification Review, completed by the facility, revealed the resident's start date of Medicare Part A Skilled Services was 06/07/2024 and the last covered day of Medicare Part A Skilled Services was 07/17/2024. The review indicated the facility initiated the discharge from Medicare Part A services when benefit days were not exhausted. The review indicated the facility did not provide the SNFABN, Form CMS-10055, to the resident because the resident discharged from the facility and did not receive non-covered services. During an interview on 07/23/2024 at 1:10 PM, the Business Office Manager (BOM) stated she thought the SNFABN needed to be given, but she was told by their corporate Minimum Data Set (MDS) staff that, since Resident #24 remained in the facility, they did not have to provide the SNFABN CMS-10055 to the resident. During an interview on 07/23/2024 at 1:15 PM, the Social Services Director (SSD) stated she was told by her MDS corporate office that the SNFABN did not have to be given if a resident remained in the facility. During an interview on 07/23/2024 at 1:30 PM, the MDS Coordinator stated she was not sure when the SNFABN needed to be provided. The MDS Coordinator stated she thought the facility cheat sheet showed that, since Resident #24 had skilled days remaining and remained in the facility and also went from Medicare to Medicaid, they would not need to give that notice. During an interview on 07/24/2024 at 3:52 PM, the Administrator and BOM stated they did not have an official beneficiary notice policy. During an interview on 07/25/2024 at 11:16 AM, the Administrator stated he did not know what the different notices were or what was required to be given to whom or when. The Administrator stated he expected they gave the notices in a timely manner to residents or their responsible parties and that they were given the appropriate notices. During an interview on 07/25/2024 at 11:30 AM, the Director of Nursing (DON) stated that she thought the form or discharge notice had to be issued within 24 hours before discharge. The DON stated she was not familiar with the CMS-10055 and that form was usually completed by the financial office. The DON stated she expected staff should be giving whatever notices were required by the regulations.

Based on record review, interview, document review, and facility policy review, the facility failed to report an allegation of abuse to the State Survey Agency (SSA) for 1 (Resident #36) of 7 sampled residents reviewed for abuse. Findings included: 1. A facility policy titled, Abuse Prevention Program, updated 01/19/2017, indicated, It is the policy of this facility to prevent resident abuse, neglect, mistreatment and misappropriation of resident property. Each resident receives care and services in a person-centered environment in which all individuals are treated as human beings. The following Procedures shall be implemented when an employee or agent becomes aware of abuse or neglect of a resident, or of an allegation of suspected abuse or neglect of a resident by a 3rd party. The policy further indicated, When an alleged or suspected case of abuse or neglect is reported to the Administrator, the Administrator, or person in charge of the facility, will notify the following persons or agencies of such incident immediately. State Licensing and Certification Agency (i.e. [id est, that is] TDH [Tennessee Department of Health (SSA)]). 2. An Admission Record revealed the facility admitted Resident #36 on 08/10/2023. According to the Admission Record, the resident had a medical history that included diagnoses of Mood Disorder due to known physiological condition with Major Depressive-like episode and Malignant Neoplasm of the right breast. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date of 05/16/2024, revealed Resident #36 had a Brief Interview for Mental Status score of 10, which indicated the resident had moderate cognitive impairment. Resident #36's care plan included a focus area initiated 08/21/2023, that indicated the resident had a self-care deficit. Interventions indicated the resident required extensive assistance from two staff with bed mobility and transfers (initiated 08/21/2023), and required extensive assistance from one staff with toileting, eating, bathing, dressing, and mobility on the unit (initiated 08/21/2023). A typed facility investigation document, dated 05/22/2024, indicated Family Member (FM) #23, a family member of Resident #36, approached Registered Nurse (RN) #12 and Certified Nurse Aide (CNA) #30 on 05/22/2024 and asked to speak with the man who had been going in their family member's room, touching and trying to kiss the resident. The document indicated that the staff told FM #23 they did not know what man they were referring to, but FM #23 could speak to the Administrator or the Director of Nursing (DON). The document indicated FM #23 left the building and staff immediately notified the Administrator of the concern. The document indicated that the Administrator and DON contacted FM #23 who stated that Resident #36 told them that a couple weeks ago, a man came into their room, told them they had beautiful body parts and began to touch Resident #36. The document indicated that Resident #36 was interviewed and indicated that a man came into their room in the past couple of days and told them they had beautiful body parts and began touching them. The document indicated that Resident #36 told the person to stop at which time, the person stopped and left the room. The facility investigation documents revealed no indication the allegation of sexual abuse had been reported to the state survey agency. During an interview on 07/24/2024 at 12:07 PM, the Administrator stated FM #23 reported an allegation of sexual abuse to facility staff, and he was contacted immediately. The Administrator stated it had been determined within two hours of the initial reporting of the allegation to the facility staff that the alleged incident had not occurred and therefore, the allegation was not reported to the TDH (SSA). During an interview on 07/24/2024 at 1:27 PM, the DON stated the incident was not reported to the TDH (SSA) because Resident #36 recanted the allegation within a two-hour period after initially reporting the allegation to the staff. During an interview on 07/25/2024 at 11:20 AM, the DON stated she was now aware any allegation of abuse, neglect, or misappropriation must be reported to the proper authorities per the facility's policy. During an interview on 07/25/24 at 12:21 PM, the Administrator stated he understood all allegations of abuse must be reported to appropriate state agencies.

Based on observation, interview, record review, and facility policy review, the facility failed to arrange a follow-up appointment with an ophthalmologist based on a recommendation made by the optometrist for 1 (Resident #25) of 2 sampled residents reviewed for vision services. Findings included: 1. A facility policy titled, Vision Service, dated 05/14/2023 revealed, Policy: It is the policy of the facility to provide medically related social services to attain or maintain the highest practicable physical, mental and psychological well-being of each resident. This includes meeting any need for vision care to include routine as well as emergency indicated services. The policy indicated, 6) SSD [Social Services Director] will work with the resident, family, physician, optometrist and/or ophthalmologist to coordinate timely care. Per the policy, Note: Negative findings will be immediately addressed. The attending physician will be notified as well as the facility's visual provider. The DON [Director of Nursing], MDS [Minimum Data Set] Coordinator and SSD will also be notified as well as the resident of their responsible party. 2. An Admission Record revealed Resident #25 admitted to the facility on [DATE]. According to the Admission Record, the resident had a medical history that included diagnoses of Type 2 Diabetes Mellitus, Hypertension, and Dry Eye Syndrome. Resident #25's care plan included a focus area, initiated 02/07/2023, that indicated the resident had dry eye syndrome. Interventions directed staff to observe for changes in visual status and to have ophthalmology or optometry appointments as indicated. Resident #25's optometrist's Eye Care Chart Note, dated 03/07/2024, revealed Resident #25 presented as a new patient for an evaluation of the right and left eye due to Diabetes Mellitus and Systemic Hypertension, which occurred daily and affected both eyes. The note revealed an assessment plan that indicated a cataract of the left eye and specified, Cataracts are visually significant; Please schedule for cataract evaluation with Ophthalmologist of facility choice. A quarterly MDS, with an Assessment Reference Date (ARD) of 04/28/2024, revealed Resident #25 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS indicated the resident had moderately impaired vision and needed corrective lenses. During a concurrent observation and interview on 07/22/2024 at 1:25 PM, the surveyor noted Resident #25's right eye was significantly smaller than the left eye. Resident #25 stated they were blind in their right eye and had cataracts in their left eye. Resident #25 stated they needed surgery but were unsure where the facility was with scheduling it. Resident #25's Progress Notes, dated 01/01/2024 through 07/24/2024, revealed no evidence to indicate the resident was evaluated by an ophthalmologist. Resident #25's Order Summary Report, with active orders as of 07/24/2024, revealed an order dated 07/15/2022, that specified the resident may receive services of eye care, audiologist, podiatrist, dental, psychiatrist, cardiologist, physiatrist, nurse practitioner, wound physician and any other specialist as deemed necessary. During a concurrent record review and interview on 07/24/2024 at 10:23 AM, the SSD reviewed Resident #25's electronic medical record and stated she did not see any notes recently from the vision provider for the resident or any records of appointments with the vision provider. The SSD stated she did not know anything about Resident #25 needing a follow-up appointment. During an interview on 07/24/2024 at 2:56 PM, the SSD stated she had to call the vision provider to obtain the records from Resident #25's most recent eye appointment, and she had not seen the report. The SSD stated she was not aware that the optometrist had written that the resident needed to have cataract surgery, and, if she had, it would have already been scheduled and completed. During an interview on 07/25/2024 at 9:25 AM, the SSD stated she understood they missed Resident #25's appointment for an evaluation for cataract surgery. The SSD stated the vision provider was supposed to let the facility know if there were follow-up appointments that needed to be made. The SSD stated since she was not working at the facility in March 2022, when Resident #25 was seen by the optometrist, she did not know what happened. The SSD stated that, as far as she could tell, there had not been communication between the vision provider and the facility to let them know if a resident needed further evaluation. During an interview on 07/25/2024 at 11:16 AM, the Administrator stated he thought the vision provider came to the facility quarterly, and after a resident was seen by the vision provider their documentation was emailed to the SSD. The Administrator stated, even though the SSD had only been in that role since March 2024, the emails would have been assumed by the person taking that role, and the current SSD should have had access to all the emails sent by the vision provider. The Administrator stated, if nursing was aware of the resident's need for an appointment and the resident had not been seen in a timely manner, nursing would bring it up in their morning meeting. The Administrator stated he did not recall that anyone spoke about Resident #25 needing to be seen by an ophthalmologist for cataract surgery, and he was not aware that Resident #25 needed that surgery. The Administrator stated he expected residents' vision, dental, and hearing needs to be met timely and appointments with outside providers to be scheduled timely. During an interview on 07/25/2024 at 11:30 AM, the DON stated she was not aware prior to 07/24/2024 that Resident #25 needed to have cataract surgery. The DON stated there were some issues with the previous social worker not getting the residents the appointments they needed timely.

Based on policy review, medical record review, document review, timeanddate.com, and interview, the facility failed to ensure all residents received supervision to ensure a safe environment that was free of accident hazards for 1 (Resident #20) of 3 sampled residents reviewed for accident hazards/supervision. On 08/06/2022 at approximately 9:00 PM, an agency nurse entered the code on the door keypad and let Resident #20 out of the facility. Approximately 30 minutes later, the facility was notified Resident #20 was found in the parking lot of another facility, less than half a mile from the facility. The failure placed Resident #20 in at risk for harm, serious injuries, or death, resulting in Immediate Jeopardy. Immediate Jeopardy (IJ) (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 IJ at F689 scope/severity of J began on 08/06/2022 when the resident eloped from the facility, unsupervised and without staff knowledge. The Administrator was notified of the IJ and was provided a copy of the IJ template on 09/24/2023 at 5:10 PM. The IJ began on 08/06/2022 through 08/07/2022, at which time the facility implemented corrective actions to correct the identified deficient practice and prevent recurrence; and the IJ at F689 was cited as a Past Non-Compliance. The facility was cited for past noncompliance for F-689 and is not required to submit a Plan of Correction (PoC) for F689. The facility is required to submit a PoC for all other deficiencies. Findings included: 1. Review of the undated facility Policy and Procedure Regarding Missing Residents and Elopement, indicated, It is the policy of this facility that all residents are provided adequate supervision to meet each resident's nursing and personal care needs. All residents will be assessed for behaviors or conditions that put them at risk of elopement. 2. Medical record review of the Admission Record revealed Resident #20 was admitted to the facility on [DATE] with diagnoses that included Dementia, Other Abnormalities of Gait and Mobility, History of falling, Muscle wasting and atrophy, need for assistance with personal care, and lack of coordination. The Admission Record indicated the resident's primary diagnosis was a Displaced Intertrochanteric Fracture of the Left Femur, subsequent encounter for closed fracture with routine healing, with an onset date of 06/21/2022. A review of Resident #20's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/23/2022, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The MDS further indicated the resident did not exhibit wandering behavior during the seven-day assessment period. According to the MDS, the resident required extensive assistance of two or more people with transfer and bed mobility and required limited assistance of one person for locomotion on the unit. The MDS indicated locomotion off the unit did not occur during the assessment period. Additionally, the MDS revealed the resident used a wheelchair for mobility. A review of Resident #20's Care Plan initiated on 06/23/2022 indicated the resident required assistance with activities of daily living (ADL) function and mobility. A Care Plan initiated on 07/07/2022 indicated the resident was at risk for falls related to assistance required for transfers and mobility related tasks. A review of Resident #20's Nursing Progress Note, dated 08/06/2022 10:00 PM, indicated at 9:00 PM, a nurse went to the front area of the facility and the resident stated they wanted to stay in the front day area. Per the Nursing Progress Note, the resident had on seasonal attire. The Nursing Progress Note revealed at 9:30 PM, another facility called and informed the staff that Resident #20 was at their facility. A staff nurse went to the other facility and assisted Resident #20 into their personal car. Upon return to the facility, an immediate skin audit was completed and revealed the resident had no skin issues, no pain, or other complaints. The resident was placed on 1:1 supervision, a departure alert system bracelet (wander guard) was placed, and the resident's spouse was notified. A review of the facility's incident report dated 08/09/2022, indicated on 08/06/2022 at 10:30 PM, Resident #20 was found in the parking lot of another facility. Per the incident report, the resident was in a wheelchair and dressed appropriately for the mild and calm weather. The incident report revealed the resident was easily redirected to a vehicle and was returned to the facility. According to the incident report, the resident was assessed for injuries, and none were found. A departure alert system bracelet was placed on the resident, with 1:1 monitoring, and the resident's spouse and physician were notified. Per the incident report, Resident #20 did not have a history of exit-seeking behavior and was not at risk for elopement. The incident report indicated the resident was away from the facility for approximately 45 minutes and traveled three tenths of a mile in their wheelchair. Per the incident report, the facility determined a staff member entered the code in the door keypad and let the resident out of the facility. A review of www.timeanddate.com, revealed the outside temperature on 08/06/2022 at 9:00 PM was 80 degrees Fahrenheit. During an interview on 09/19/2023 at 1:23 PM, the Director of Nursing (DON) stated there had been no other elopements since the incident in August 2022. During an interview on 09/21/2023 at 8:29 PM, the Administrator stated Resident #20 was let out of the facility by an agency nurse. Per the Administrator, after the incident, the agency nurse no longer worked at the facility. In a telephone interview on 09/21/2023 at 11:16 AM, Registered Nurse (RN) #12 confirmed she was the agency nurse who let Resident #20 out of the facility. RN #12 stated at the time of the incident, Resident #20 was sitting up in the lobby with other visitors. She said Resident #20 was fully dressed in jeans, a shirt and jacket, and did not have a wander guard [departure alert system] on, so she did not think anything about letting the resident out of the building. She said the resident told her they were waiting for their spouse, and she thought if the resident was cognitively intact, did not have a history of wandering and was not wearing a wander guard that it was okay to let the resident outside. During a telephone interview on 09/21/2023 at 5:59 PM, Licensed Practical Nurse (LPN) #13, stated she was assigned to care for Resident #20 when the resident eloped on 08/06/2022. LPN #13 stated she had just checked on the resident about thirty minutes earlier. Per LPN #13, she had no concerns about the resident wandering. According to LPN #13, approximately thirty minutes later, another facility called to inform the staff that Resident #20 was at their facility. LPN #13 stated she was unaware how the resident got out of the facility, but the DON told her an agency nurse (RN #12) was seen on video entering the code on the door and allowing the resident out of the facility. LPN #13 reported another nurse (LPN #9) went to the other facility and retrieved the resident. LPN #13 stated when Resident #20 returned to the facility, she completed an assessment of the resident and placed the resident on one-on-one monitoring the rest of the night. In a telephone interview on 09/21/2023 at 6:26 PM, LPN #9 stated he answered the telephone call when the staff at another facility called the facility to inform Resident #20 was at their facility. LPN #9 stated the other facility was located less than half a mile and he went to get the resident around 9:30 PM/9:45 PM. Per LPN #9, Resident #20 was able to exit the facility because an agency nurse let the resident out. During an interview on 09/23/2023 at 8:05 AM, the resident's spouse stated Resident #20 had gotten out of the facility and was wandering outside looking for his/her spouse. The family member stated with Resident #20's health issues, the resident should have had staff with him/her. According to the family member, Resident #20 was recovering from a fractured hip at the time of the elopement and would not have been safe outside by himself/herself. During an interview on 09/23/2023 at 11:05 AM, the Maintenance Director stated it would not be safe for a resident in a wheelchair to be in the parking lot or to cross the road at any time of day, especially at night because, this is a highway state route and could be busy no matter what time of day it is. During an interview on 09/23/2023 at 2:00 PM, LPN #8 stated she does not think the facility is located in an unsafe area, but that Resident #20 would not be safe to travel across the road to the other facility where the resident was found. Observation on the night of 09/23/2023 revealed traffic on the road the resident crossed to get to the other facility was steady. The facility parking lot was lighted, but crossing the road to get to the other facility required travel through a dark area. Review of the facility's Quality Performance/Peer Review Facility Plan of Action/Continuous Quality Improvement form, dated 08/16/2022, revealed the facility initiated corrective actions on 08/06/2022 to remove the immediate jeopardy and correct the failed practices as follows: 1. What corrective action(s) will be accomplished for those residents affected by the deficient practice - Affected Resident A. Immediately conduct head to toe skin assessment of resident who eloped and incident report completed. Date completed 08/06/2022. Person Responsible: DON/ADON. B. Immediately reassess resident for elopement and update care plan. Date completed 08/06/2022. Person responsible: DON/ADON. C. Add resident to elopement risk book. Date completed 08/07/2022. Person responsible: DON/ADON. D. Educate staff regarding elopement risk. Date completed: Ongoing. Person responsible: All Managers. E. Place on 1:1 for 24 hours and reassess at that point. Secure MD [Medical Doctor] order for 1:1. Date completed 08/07/2022. Person responsible: SSD [Social Services Director]/DON. F. Complete family conference to discuss safety and any arrangements needed for placement. Date completed 08/07/2022. Person responsible: SSD/DON. G. Create timeline for event. Date completed 08/07/2022. Person responsible: DON/ADON. 100% check of all residents to ensure all are present and accounted for. Date completed 08/06/2022. Person responsible: DON/ADON. 100% elopement assessment for all residents to ensure proper identification of residents at risk for elopement to ensure the following: A. Updated and accurate elopement assessments completed. Date completed 08/07/2022. Person responsible: DON/ADON. B. Resident photo and identifiers list present in elopement binders. Date completed 08/07/2022. Person responsible: SSD. C. Updated elopement care plan in record. Date completed 08/07/2022. Person responsible: MDS. D. Notify MD and family for any residents who are at risk for elopement. Date completed 08/07/2022. Person responsible DON/SSD. Door checks immediately and daily for function, proper closure and safety. Date completed 08/07/2022. Person responsible: Maintenance. Door codes changed immediately with staff education. Door codes to be changed at least monthly. Date completed 08/07/2022. Person responsible: Maintenance. II. How will you identify other residents that may have the potential to be affected by this Immediate Jeopardy practice and what corrective actions will you take for those residents. A. An elopement / wandering assessment will be completed upon admission and then quarterly and PRN [as needed]. Date completed: Ongoing. Person responsible: DON/ADON. B. Communication to staff concerning those residents who are at risk for elopement with the elopement risk binder. Date completed: Ongoing. Person responsible: Clinical Team. C. IDT [Interdisciplinary Team] to monitor orders, MARS [Medication Administration Records] and care plans during daily CQI [continuous quality improvement] meeting. Date completed: Ongoing. Person responsible: CQI Team. D. Any resident displaying significant wandering behavior will be assessed for elopement/wandering risk and care planned appropriately. Date completed: Ongoing. Person responsible: Behavioral Team. E. Staff education 100% including agency, PRN, FMLA [Family Medical Leave Act], etc. [et cetera] on Elopement Drill, Policy and all staff completed passing grade on post test [sic]. Nobody works without getting the education and testing first before resident care or assignment. Date completed: Ongoing. Person responsible: All managers. III. What systemic changes will be made to ensure corrective action and how the corrective action(s) will be monitored to ensure the deficient practice will not recur. A. Care plans & [and] individualized behavior plans will address wandering as a specific problem. Approaches will be formulated, patterns identified, and root cause determined and addressed. Date completed: Ongoing. Person responsible: MDS. B. Preventative measures: 1. Preventative measures noted in the behavioral plan. Date completed: Ongoing. Person responsible: MDS. 2. Utilization of an individualized identification system for at risk residents (pictures, elopement risk binder, wander guards). Date completed: Ongoing. Person responsible: DON/ADON. 3. Monitoring the environment by use of visual checks, door alarms, key pads [sic] at doors that are tested daily. Date completed: Ongoing. Person responsible: Maintenance, Clinical Team. 4. Use of psych services for those exhibiting behaviors. Date completed: Ongoing. Person responsible: Behavioral Team. Date completed: Ongoing. Person responsible: Behavioral Team. C. A wandering/elopement notebook containing pictures & pertinent demographic information will be maintained by Social Services and kept at each nurses [sic] station. Date completed: Ongoing. Person responsible: SSD. IV. What Quality Assurance Program will be put into place including who will monitor and how often. A. All facility staff educated and post tests completed on Elopement Drills, Elopement prevention, Missing Person P&P [policy and procedure]. Date completed: Ongoing. Person responsible: HR [Human Resources], All Managers. B. Missing person/elopement drill during new hire orientation and every 3 months ongoing. Date completed: Ongoing. Person responsible: All Managers. C. 100% audit/review daily (M-F) [Monday through Friday] in CQI meeting of all residents assessed at risk for elopement. Date completed: Ongoing. Person responsible: QAPI [Quality Assurance Performance Improvement] Team. D. Present audit findings to QAPI monthly for review and recommendations. Date completed: Ongoing. Person responsible: QAPI Team. After review and verification of the facility's corrective actions, to include review of the facility's investigation, monitoring tools, and staff education, and interviews with numerous facility staff regarding the education provided, the survey team determined the facility implemented the above corrective actions beginning on 08/06/2022 and conducted ongoing education and monitoring; therefore, immediate jeopardy past noncompliance was cited. The facility was cited for past noncompliance for F-689 and is not required to submit a Plan of Correction (PoC) for F689. The facility is required to submit a PoC for all other deficiencies.

Based on interviews, record review, and facility policy review, the facility failed to report allegations of abuse and misappropriation of resident report that involved 3 (Residents #1, #2, and #17) of 7 sampled residents reviewed for abuse and misappropriation of resident property. Findings included: 1. A review of the facility's policy titled, Abuse Prevention Program, revised on 03/01/2021, indicated, Any alleged violations involving mistreated, abuse, neglect, exploitation, misappropriation of resident property, any injuries of an unknown origin, or reasonable suspicion of a crime against a resident MUST be reported to the Administrator or Director of Nursing. The policy specified, This report shall be made immediately, but not later than two hours after the allegation is made. If the events that case [sic] the allegation involve abuse or resulted in serious bodily injury, or not less than 24 hours if the events that cause the allegation do not involve abuse and did not result in serious bodily injury. The policy further specified, When an alleged or suspected case of abuse, neglect, exploitation, or crime against a resident is reported to the facility Administrator, the Administrator, or DON [Director of Nursing] in the Administrator's absence, will notify the following persons or agencies of such incident immediately. Any incident that involves crimes or a significant injury to a resident will be reported within 2 hours of the incident. 2. A review of Resident #1's Admission Record indicated the facility admitted the resident on 11/03/2022 with a diagnosis to include dementia. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/17/2023, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. A review of Resident #1's undated care plan indicated the resident had altered cognition. A review of Resident #2's Admission Record indicated the facility admitted Resident #2 on 08/18/2023 with a diagnosis to include dementia. A review of an admission MDS, with an ARD of 08/25/2023, revealed Resident #2 had a BIMS score of 9, which indicated the resident had moderate cognitive impairment. A review of Resident #2's care plan with an initiation date of 08/29/2023, indicated the resident was at risk for alteration in mood state such as verbal expressions of distress. Review of a document titled, Incident Reporting System indicated on 09/05/2023 at 1:50 PM, the Administrator was notified that at approximately 1:45 PM on 09/05/2023, Resident #2 threw a plastic cup at Resident #1 while the residents sat across from each other in the dining room. Per the document, the residents were immediately separated and examined for injuries. The document indicated the facility the report to the state agency of the abuse allegation on 09/05/2023 at 4:46 PM. During an interview on 09/19/2023 at 12:44 PM, the Administrator said he realized the incident on 09/05/2023 was submitted late. 3. A review of Resident #17's Admission Record indicated the facility admitted Resident #17 on 09/27/2022 with diagnoses that included low back pain, anxiety disorder, and essential hypertension. A review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 06/21/2023, indicated Resident #17 had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. A review of Resident #17's undated care plan, revealed the resident was alert, oriented, and able to express their needs, desires, and opinions. A review of the facility's initial report to the state agency, indicated Resident #17 reported on 08/11/2023 they loaned $320.00 to a facility housekeeper approximately five months ago and the facility housekeeper had not paid the resident back. Per the initial report, the employee denied the allegation made by resident and was suspended pending the outcome of the investigation. The initial report indicated the facility notified the state agency of the allegation on 08/14/2023 at 8:15 PM. In an interview on 09/24/2023 at 5:30 PM, the Administrator stated it was his fault the initial report for the misappropriation of Resident #17's money was not sent to the state agency for three days.

Based on medical record review, document review and interview, the facility failed to implement a quality assurance plan when concerns were identified related to misappropriation of resident funds and controlled medications for 2 of 7 (Resident #6 and Resident #17) sampled residents reviewed for misappropriation. The findings included: A facility policy for the Quality Assurance/Performance Improvement (QAPI) committee was requested from the Administrator on 09/24/2023 at 5:30 PM but was not received prior to exiting the facility. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses that included Cerebral Infarction, Chronic Obstructive Pulmonary Disease, and Chronic Respiratory Failure with Hypoxia. Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/29/2022, indicated Resident #6 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS indicated Resident #6 received as needed pain medications. Review of the care plan with an initiation date of 05/26/2022, indicated the resident was at increased risk for alteration in pain/discomfort related to joint pain, back pain, and neuropathy. Interventions directed the staff to provide analgesic medications as ordered per plan of care. Review of a facility report dated 08/05/2022, indicated there was a possible drug diversion. Per the facility report, Resident #6 was sent to the emergency roiagnom on [DATE] and when management went to remove the resident's narcotics from the medication cart, the narcotics had not been logged in on the narcotic count sheet or in the medication cart. According to the facility report, Licensed Practical Nurse (LPN) #10 did not come to the facility as requested for a drug screen or to complete a statement. The facility report indicated the outcome of the investigation was incomplete as LPN #10 had not cooperated with the investigation. Per the facility report, the facility would reimburse the resident for the medication. During an interview on 9/24/2023 at 5:30 PM, the Administrator stated, .did not take the identified problem of missing hydrocodone to the QAPI committee .I plead ignorance . 2. Review of the medical record revealed Resident #17 was admitted to the facility on [DATE] with diagnoses that included Low Back Pain, Anxiety Disorder, and Hypertension. Review of a quarterly MDS with an ARD date of 06/21/2023, indicated Resident #17 had a BIMS of 14, indicating the resident was cognitively intact. Review of the undated care plan revealed the resident was alert, oriented, and able to express their needs, desires, and opinions. Review of the facility's initial report to the state agency dated 08/11/2023, revealed Resident #17 reported on 08/11/2023 they loaned $320.00 to a facility housekeeper approximately five months ago and the facility housekeeper had not paid the resident back. Per the initial report, the employee denied the allegation made by resident and was suspended pending the outcome of the investigation. Review of the facility's Follow-up Summary, dated 08/19/2023, indicated the $320.00 loan was returned to Resident #17 and the facility terminated the employment of Housekeeper #29. Per the Follow-up Summary, the resident was pleased with the outcome of the investigation. A review of the facility's Quality Performance/Peer Review/Facility Plan of Action/Continuous Quality Improvement plan, dated 8/11/2023, revealed no interventions related to the event involving Resident #17. During an interview on 9/24/2023 at 5:30 PM, the Administrator reviewed the QAPI plan in relation to the incident with Resident #17 and agreed there was nothing specific about misappropriation of resident property in the plan, but about abuse in general. The Administrator stated the identified issue regarding misappropriation of resident property was not taken to QAPI for discussion or follow up.

Based on facility policy, medical record review, observations and interview, the facility failed to maintain a medication error rate of less than 5%. There were two (2) medication errors in 27 opportunities for a medication error rate of 7.4%. This deficient practice affected 2 of 2 (Resident #23 and Resident #24) sampled residents reviewed for medication administration. The findings include: 1. Review of the undated facility's policy titled, Physician Orders- (Following Physician Orders), revealed, .It is the policy of the facility to follow the orders of the physician . 2. Review of the medical record revealed Resident # 23 was admitted to the facility on [DATE] with diagnoses that included Orthopedic Aftercare, Muscle Wasting and Atrophy, and Anemia. Review of an admission MDS, with an ARD of 07/18/2023, revealed Resident #24 had a BIMS score of 14, which indicated the resident was cognitively intact Review of the care plan with a start date of 07/13/2023, revealed Resident #24 was at risk for alteration in nutritional status related to anemia. The interventions directed staff to give medications according to the physician's orders. Review of Resident #23's Order Summary Report revealed a physician's order dated 07/12/2023 for a multiple vitamin tablet with directions to give one tablet by mouth per day as a supplement. During an observation on 9/20/2023 at 8:45 AM, RN #4 administered medications to Resident #23, to include one multivitamin with mineral tablet. During an interview on 9/20/2023 at 8:55 AM, RN #4 stated, . I did looked at the bottle closely and had not seen the minerals listed on the multivitamin bottle an order from the physician was required to substitute medications . During an interview on 9/20/2023 at 11:25 AM, The Director of Nursing (DON) stated, . multivitamins and multivitamins with minerals are two different medications, and if one was given instead of the other, it was a medication error . 3. Review of the medical record revealed Resident #24 was admitted to the facility on [DATE] with diagnoses that included Aftercare following Joint Replacement Surgery, Congestive Heart Failure, and Atherosclerotic Heart Disease. Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/13/2023, revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. Review of the care plan with a revision date of 08/07/2023, revealed, Resident #24 was at risk for decreased cardiac output related to hypertension, coronary artery disease, and hyperlipidemia. An intervention directed staff to administer the resident's medication according to the physician's orders. Review of Resident #24's Order Summary Report revealed a physician's order dated 8/03/2023 for aspirin oral tablet with directions to give 81 milligrams (mg) by mouth once daily as a preventative measure. During an observation on 9/19/2023 at 8:14 AM, Registered Nurse (RN) #2 prepared medications for Resident #24. RN #2 removed the medications from the containers and placed the medications in a cup. RN #2 stated, . [Resident #24's] medications were crushed and mixed with applesauce RN #2 placed the enteric coated aspirin tablet, 81 mgs, in a plastic sleeve to be crushed and was stopped by the surveyor. When the nurse reviewed the September Medication Administration Record (MAR) that included the transcribed physician's orders, she realized the aspirin that had been ordered for Resident #24 was not enteric coated. RN #2 stated .when she placed the enteric coated aspirin into the sleeve to crush the medication instead of the aspirin that was ordered, I had made a medication error .

Based on policy review, medical record review, observation and interview, the facility failed to follow guidelines and wear the proper personal protective equipment (PPE) when care was provided for 1 of 3 (Resident #11) residents observed who required enhanced barrier precautions. The findings include: 1. Review of the facility's policy titled, Clinical Standard & Guideline Enhanced Barrier Precautions, with a revision date of 12/19/2022, revealed .It is the policy of the facility to ensure that additional and appropriate PPE is utilized, when indicated, to prevent the spread of Multidrug-resident Organisms also known as MDROs. Further review of the policy revealed, These precautions are generally in place for the duration of the resident's stay, or until there is resolution of the wound or discontinuation of the device that placed the resident at 'higher risk. Who is at 'High Risk' for acquiring or spreading a MDRO .Residents with wounds regardless of MDRO status . 2. Review of medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses that included Hemiplegia and Hemiparesis following a Cerebral Infarction affecting the Right Dominant side. Review of the annual Minimum Data Set (MDS), with an Assessment Reference Date of 06/16/2023, indicated Resident #11 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The MDS indicated Resident #11 had a Stage 4 pressure ulcer that was present on admission. Review of Resident #11's care plan with a revision date of 07/12/2023, revealed alteration in skin integrity, the interventions included staff to perform wound care according to physician's orders and follow contact precautions per facility policy. Observations in the hallway outside Resident #11's room on 9/21/2023 at 10:45 AM revealed, an enhanced barrier precautions (EBP) sign on the door instructing those who provided care to wear a gown, gloves, and other PPE, if needed. Licensed Practical Nurse (LPN) #8 set up supplies to complete Resident #11's treatment on an overbed table and applied gloves. LPN #8 then proceeded into the resident's room with the overbed table and completed the treatment to the resident's sacral wound as ordered. LPN#8 did not wear a gown while providing wound care for Resident #11. During an interview on 9/21/2023 at 10:55 AM, LPN #8 stated, .I realized as soon as I left the room that I should have worn a gown .due to the EBP . I was rushed and had not thought about putting on a gown . During an interview on 9/21/2023 at 11:39 AM, The Director of Nursing (DON) stated, .a resident placed on EBP .the nurse who provides care should wear a gown . During an interview on 9/24/2023 at 12:16 PM, the Administrator stated, .I expect the directions on the EBP sign posted to be followed when care is provided for a resident who required EBP .

Based on interviews, record reviews, document reviews, and facility policy review, the facility failed to ensure narcotic medication was not diverted for 1 (Resident #6) of 7 sampled residents reviewed for abuse. The facility further failed to ensure money that belonged to 1 (Resident #17) of 7 sampled residents reviewed for abuse was not misappropriated by the staff. Findings included: 1. A review of a facility policy titled, Abuse Prevention Program, revised on 03/01/2021, indicated, It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility. The policy specified, 7. Misappropriation of resident property is the deliberate misplacement, exploitation, or wrongful, temporary, or permanent, use of a resident's belongings or money without the resident's consent. 2. A review of Resident #6's Admission Record indicated the facility admitted the resident on 03/25/2022 with diagnoses that included cerebral infarction, chronic obstructive pulmonary disease, and chronic respiratory failure with hypoxia. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/29/2022, indicated Resident #6 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS indicated Resident #6 received as needed pain medications. A review of Resident #6's Care Plan, with an initiation date of 05/26/2022, indicated the resident was at increased risk for alteration in pain/discomfort related to joint pain, back pain, and neuropathy. Interventions directed the staff to provide analgesic medications as ordered per plan of care. A review of Resident #6's Medication Administration Record, for July 2022, revealed an order dated 07/27/2022, that instructed the staff to give one tablet of hydrocodone-acetaminophen 5-325 mg to the resident every six hours as needed for pain. A review of a pharmacy Packing Slip indicated the pharmacy sent 30 hydrocodone/acetaminophen 5-325 milligram tablets to the facility on [DATE] for Resident #6. Licensed Practical Nurse (LPN) #9 signed the packing slip at 10:47 PM, indicating receipt of the medication. A review of a facility report dated 08/05/2022, indicated there was a possible drug diversion. Per the facility report, Resident #6 was sent to the emergency roiagnom on [DATE] and when management went to remove the resident's narcotics from the medication cart, the narcotics had not been logged in on the narcotic count sheet or in the medication cart. According to the facility report, Licensed Practical Nurse (LPN) #10, who was assigned to care for the resident when the medications were received into the facility, did not come to the facility as requested for a drug screen or to complete a statement. The facility report indicated the outcome of the investigation was incomplete as LPN #10 had not cooperated with the investigation. Per the facility report, the facility would reimburse the resident for the medication. A review of an undated handwritten statement signed by LPN #9 revealed LPN #9 signed in the medication for the building on 07/28/2022 and distributed the medication to each nurse on duty, to include LPN #10. Per the statement, LPN #9 was notified on 08/01/2022 that Resident #6's pain medication was not logged into the narcotic book and was missing. LPN #9 denied knowledge regarding what happened to the medication after it was given to LPN #10 and denied taking the resident's medication. A telephone interview was held with the pharmacy manager on 09/22/2023 at 1:22 PM. The pharmacy manager reviewed pharmacy records and verified that on 07/28/2022, 30 tablets of hydrocodone were sent to the facility for Resident #6 and signed by a staff member as delivered to the facility. In an interview on 09/23/2023 at 3:25 PM, the Administrator stated Resident #6 had not missed any medications when the narcotics were taken. 3. A review of Resident #17's Admission Record indicated the facility admitted Resident #17 on 09/27/2022 with diagnoses that included low back pain, anxiety disorder, and essential hypertension. A review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 06/21/2023, indicated Resident #17 had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. A review of Resident #17's undated care plan, revealed the resident was alert, oriented, and able to express their needs, desires, and opinions. A review of the facility's initial report to the state agency dated 08/11/2023, indicated Resident #17 reported on 08/11/2023 they loaned $320.00 to a facility housekeeper approximately five months ago and the facility housekeeper had not paid the resident back. Per the initial report, the employee denied the allegation made by resident and was suspended pending the outcome of the investigation. A review of the facility's Follow-up Summary, dated 08/19/2023, indicated the $320.00 loan was returned to Resident #17 and the facility terminated the employment of Housekeeper #29. Per the Follow-up Summary, the resident was pleased with the outcome of the investigation. An interview was held with Resident #17 on 09/20/2023 at 10:30 AM. Resident #17 stated about five months ago they loaned money to a staff member (Housekeeper #29). The resident stated the staff member made them promise not to tell anyone about the loan. Resident #17 stated the staff member came into their room crying and carrying on and stated they did not know if something had happened to their spouse, so the resident gave the staff member the money so the staff member could buy a cell phone. Resident #17 stated it got to the point where the staff member avoided them and would not speak to them, so Resident #17 reported the incident to the Administrator. According to Resident #17, the Administrator paid the resident their money back. Resident #17 stated no other staff had borrowed money from them. In an interview on 09/24/2023 at 5:30 PM, the Administrator stated he terminated the employment of the staff member that borrowed money from Resident #17.

Based on policy review, medical record review, observation, and interview, the facility failed to failed to serve meals in accordance with the prescribed diet for 1 of 4 sampled residents (Resident #5) reviewed for prescribed diets. The findings include: Review of the facility's .Dietary Policy and Procedure Manual, dated 2017, revealed .Meals will be served at the appropriate texture and consistency per each Resident's individual plan of care .All residents shall have a tray card on file indicating food preferences and dietary needs .Resident tray cards will be used during meal times to ensure that proper diets and preferences are served and that individual care planned items are offered and encouraged . Review of a Physician's Order dated 1/21/2022, revealed .General diet Dysphagia texture, Thin liquids consistency, small bites . Review of a Nutritional assessment dated [DATE], revealed Resident #5 required a mechanical soft diet with thin liquids. Review of a Speech Therapy Note dated 2/14/2022, revealed .Current Functional Status .Current Diet .Mechanical soft . Review of the lunch meal ticket dated 2/15/2022, revealed .[Named Resident #5] .General Mech [mechanical] soft .GROUND CHICKEN TENDERS WITH BROTH .BUTTERED MASHED POTATOES . Observation in the resident's room on 2/15/2022 at 11:49 AM, revealed Certified Nursing Assistant (CNA) #1 delivered and set up Resident 5's lunch tray, then exited the room. Resident #5's tray contained a regular diet of chicken tenders, french fries, carrots, and mixed fruit. The lunch tray did not contain a mechanical soft diet as ordered. Resident #5 picked up her fork and began to eat the chicken tenders, and no staff members were present. During an interview on 2/15/2022 at 11:55 AM, the Speech Language Pathologist (SLP) confirmed that Resident #5 was prescribed a mechanical soft diet. The SLP confirmed that the resident's lunch tray did not contain a mechanical soft diet. During an interview on 2/15/2022 at 5:44 PM, the Director of Nursing (DON) confirmed that residents should receive the diet that was prescribed by the Physician.

Based on policy review, medical record review, and interview, the facility failed to ensure residents' personal property was maintained for 2 of 2 sampled residents (Resident #10 and #22) reviewed for personal property. The findings include: Review of the facility's undated policy titled, Resident Personal Clothing and Belongings Handling, revealed .Personal Belongings are to be listed on the belongings List in the Resident's chart. New items brought to the facility other than during the admission process, should also be added to this list . Review of medical record, revealed Resident #10 had diagnoses of Diabetes, Hypertension, Anxiety Disorder, Depressive Episodes, [CONDITION(S)], [CONDITION(S)] Disorder, and Dysphagia. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #10 was cognitively intact. Review of Resident #10's Personal Inventory sheet revealed a blank sheet with no inventory of Resident #10's personal belongings. Resident #10's inventory sheet was not signed by the staff member, family member, or the resident. Resident #10 was missing a black velvet robe. Review of medical record, revealed Resident #22 had diagnoses of [CONDITION(S)], [CONDITION(S)], Chronic Kidney Disease, [CONDITION(S)], Anxiety Disorder, Hypertension, and Adult Failure to Thrive. Review of the quarterly MDS dated [DATE], revealed that Resident #22 was cognitively impaired. Review of Resident #22's Personal Inventory sheet revealed the following items listed on the inventory sheet were right and left hearing aides, glasses, upper dentures, a gold watch and wedding ring. The following missing items not listed on the inventory sheet were 2 pair of khaki pants, 4 t-shirts, a pull over jacket, and 3 pair of shoes. Resident #22's inventory sheet was not signed by the staff member, family member, or the resident. During an interview on 7/7/2021 at 2:15 PM, the Activity Director confirmed that she purchased a black velvet robe for Resident #10 in 5/2021. The Activity Director confirmed that she did not update or add the robe to the Resident #10's inventory list. The Activity Director confirmed that she was informed that Resident #10's robe was missing two weeks ago. The Activity Director confirmed that she should have placed the resident's robe on her inventory list. During an interview on 7/8/2021 at 8:09 AM, the Assistant Director of Nursing (ADON) confirmed that the inventory sheets should be completed on admission and when new items are brought into the facility. The ADON confirmed that the inventory sheet should be signed by the staff member, family, or the resident. The ADON confirmed that the staff members should update the inventory list with each new item. During an interview on 7/8/2021 at 11:32 AM, the Director of Nursing (DON) confirmed that the inventory list should be completed on admission and when new items are brought into the facility. The DON confirmed that the inventory list should be signed by the staff, family member, or the resident.

Based on policy review, medical record review, and interview, the facility failed to provide a comprehensive Care Plan related to anticoagulants and diuretics for 2 of 5 sampled residents (Resident #10 and #25) reviewed for unnecessary mediations. The findings include: Review of the facility's policy titled, Baseline Care Plan Assessment/Comprehensive Care Plans, dated 11/25/2017, revealed .Within 72 hours following the admission of the resident, the Baseline Care Plan Assessment will be reviewed/discussed and revised as needed .The Comprehensive Care Plan will be finalized within 7 days of completion of the full comprehensive MDS [Minimum Data Set] Assessments . Review of medical record, revealed Resident #10 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #10 was cognitively intact and was coded for receiving an anticoagulant in the last 7 days. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] Tablet [an anticoagulant] 5 MG [milligram] Give 1 tablet by mouth two times a day for blood thinner . The facility failed to provide a comprehensive Care Plan related to Resident #10's anticoagulant. During an interview on 7/8/2021 at 7:12 PM, the MDS Coordinator confirmed that the Care Plans are created on admission, quarterly, with significant changes and with each physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 7/8/2021 at 7:32 PM, the Assistant Director of Nursing (ADON) confirmed that Resident #10 should have been care planned for the anticoagulant. Review of medical record, revealed Resident #25 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] Tablet [a diuretic] 20 MG Give 1 tablet by mouth one time a day for [CONDITION(S)] related to Essential (Primary) Hypertension . The quarterly MDS dated [DATE], revealed Resident #25 was cognitively intact and was coded for receiving a diuretic in the last 7 days. The facility failed to provide a comprehensive Care Plan related to Resident #25's diuretic. During an interview on 7/8/2021 at 4:09 PM, Licensed Practical Nurse (LPN) #1 confirmed that Resident #25 was on a diuretic. During an interview on 7/8/2021 at 7:15 PM, the MDS Coordinator confirmed that Resident #25 was on a diuretic. The MDS Coordinator confirmed that Resident #25 should have been care planned for the diuretic. During an interview on 7/8/2021 at 7:32 PM, the ADON confirmed that Resident #25 should have been care planned for the diuretic.