Every finding on record at Trend Health & Rehab of Carthage LLC

Based on observation, staff interviews, record review, and facility policy review, the facility failed to ensure medications were properly labeled, dated, and stored for one (1) of two (2) medication rooms (South Hall) and one (1) of two (2) medication carts reviewed (North Hall). Findings include:A record review of the facility policy titled Medication Storage in the Facility, undated, revealed, .m. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, without labels, or have damaged labels are immediately removed from stock and disposed of according to facility procedures .During an observation of the North Hall long medication cart with Licensed Practical Nurse (LPN) #3 on [DATE] at 3:03 PM, one opened Lantus insulin pen prescribed for Resident #33 was available for use without a label identifying the date it was opened.During an interview on [DATE] at 3:03 PM, LPN #3 confirmed the Lantus insulin pen was open and in use but did not contain an opening date. LPN #3 acknowledged staff could not determine whether the insulin remained within the manufacturer's recommended use period without knowing when it was opened.During an observation of the South Hall medication room refrigerator with LPN #4 on [DATE] at 3:20 PM, one unopened vial of Levemir insulin prescribed for Resident #16 was available for use after the manufacturer's expiration date of [DATE]. Three floor-stock syringes of Spikevax 2025-2026 COVID-19 vaccine were also available for use after the manufacturer's expiration date of [DATE].During an interview on [DATE] at 3:20 PM, LPN #4 confirmed the Levemir insulin and three COVID-19 vaccine syringes remained available for use beyond their expiration dates. LPN #4 stated expired insulin could lose potency and fail to control a resident's blood glucose effectively. She stated expired vaccines could lose potency and fail to provide the intended protection against disease.During an interview on [DATE] at 3:35 PM, the Director of Nursing (DON) stated expired insulin and vaccines should be removed from use, and nurses were responsible for monitoring expiration dates. The DON confirmed medications should be labeled with the opening date when first opened and nurses were responsible for ensuring medications were appropriately dated and removed from use when expired. The DON acknowledged that without an opening date, staff could not determine whether the medications remained safe for administration. The DON acknowledged expired insulin and vaccines may lose effectiveness and could cause a resident to become ill.

Based on record review, staff interviews, and facility policy review, the facility failed to ensure residents' advance directives were maintained in their medical records and readily accessible to staff for two (2) of 20 sampled residents. Resident #5 and Resident #46. Staff interviews confirmed that advance directives for some residents were maintained in admission packets in the business office rather than in the medical record, limiting staff access. Findings include: A record of the facility policy, Residents' Rights Regarding Treatment and Advance Directives, dated 9/25, reveals, Policy: It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive .Policy Explanation and Compliance Guidelines .3.Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff .On 7/8/26 at 9:11 AM, in an interview with Registered Nurse #3, she reveals the resident charts have the code status form listed as the advance directive. Adding that this form informs staff only whether the resident is a full code or do not resuscitate (DNR). On 7/8/26 at 9:33 AM, during an interview with the Regional Consultant, she explained that the Advance Directives for some of the residents are located in their admission packets in the business office. She acknowledged that these documents should also be included in the residents' charts to ensure they are readily accessible at all times. At 9:44 AM on 7/9/26 in an interview with the Director of Nursing (DON), she points out that some of the Advance Directives are not readily accessible on the chart but is filed away in the business office adding that they should be readily available to staff at all times.A record review of Resident #5's admission Record revealed the facility admitted the resident on 8/1/16 with diagnoses that included Expressive Language Disorder and Cognitive Communication Deficit.A record review of Resident #5's Minimum Data Set (MDS), with an Assessment Reference Date of 5/28/26, revealed a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment.A record review of Resident #5's electronic health record revealed no advance directive. A Code Status Form was located in the resident's paper medical record under the tab labeled Advance Directive.A record review of Resident #46's admission Record revealed the facility admitted the resident on 10/10/25 with diagnoses that included Chronic Obstructive Pulmonary Disease and Depression.A record review of Resident #46's MDS, with an Assessment Reference Date of 6/15/26, revealed a BIMS score of 14, indicating intact cognition.A record review of Resident #46's electronic health record revealed no advance directive. A Code Status Form was located in the resident's paper medical record under the tab labeled Advance Directive.

Based on record review, resident interviews, staff interviews, and facility policy review, the facility failed to ensure residents' right to privacy in receiving mail by opening packages addressed to two (2) of 2 residents reviewed for mail privacy (Residents #29 and #72) without the residents' permission or presence, and failed to protect residents' right to receive personal mail unopened, as evidenced by concerns voiced during Resident Council that staff opened residents' mail prior to delivery. This had the potential to affect all residents who received mail at the facility.Findings include:A record review of the facility policy titled Resident Rights, updated 4/4/2025, revealed, 1. Federal and state laws guarantee certain basic rights to all residents fo this facility. These rights include the resident's right to .h. Privacy in sending and receiving mail.2. Residents are entitled to exercise their rights and privileges to the fullest extent possible. 3. Our facility will make every effort to assist each resident in exercising his/her rights.On 7/8/2026 at 2:56 PM, during a Resident Council meeting and a group interview with nine residents, including the Resident Council President, two residents (Residents #29 and #72) reported that facility staff had opened their mail before delivering it to them. The residents stated staff told them the mail was opened to check for contraband. The residents expressed concern that facility staff opened their personal mail without their knowledge or permission.During an interview on 7/9/2026 at 9:06 AM, the Activities Director stated the Administrator or Business Office Manager retrieved residents' mail and packages from the facility mailbox. The Activities Director stated the mail and packages were then provided to the Activities Department or Social Services for distribution to the residents. The Activities Director confirmed residents had the right to receive and open their mail and packages privately. The Activities Director stated the Administrator had opened packages addressed to two residents before the packages were given to them because of concerns that the packages contained prohibited substances.During an interview on 7/9/2026 at 11:30 AM, the Administrator stated the Administrator or Business Office Manager retrieved mail from the facility mailbox, and the Activities Director or Social Services staff distributed residents' mail and packages. The Administrator stated that approximately six months earlier, Resident #29 received contraband in a package, ingested the substance, and indicated an intent to share it with other residents. The Administrator stated Resident #72 had ordered a similar product that was prohibited by facility policy.The Administrator confirmed that when packages subsequently arrived for Residents #29 and #72, the Administrator opened the packages before taking them to the residents. The Administrator acknowledged that residents had the right to receive and open their mail privately and could refuse to have a witness present. The Administrator stated the packages were opened based on suspicion and prior experiences to determine what the residents were receiving and to prevent prohibited items from being hidden in their rooms.A record review of the facility Administrator's statement on letterhead signed and dated 7/9/2026 by the Administrator confirmed that the Administrator opened packages addressed to Residents #29 and #72 before delivering the packages to them. The document revealed the Administrator opened the packages based on suspicion and prior experiences. The document did not indicate that the residents gave permission for the Administrator to open their packages or that the residents were present when the packages were opened.Record review of the admission Record for Resident #29 revealed he was admitted to the facility on [DATE] with diagnoses including crebral infarction and other stimulant abuse.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/17/26 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #29 was cognitively intact.Record review of the admission Record for Resident #72 revealed he was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and generalized anxiety disorder.Record review of the MDS with an ARD of 4/21/26 revealed a BIMS score of 15 indicating Resident # 72 was cognitively intact.

Based on observation, interview, record review, and facility policy review, the facility failed to provide food at palatable temperatures for two (2) of three (3) days of survey with the potential to affect all residents who receive meals from the dietary department. Findings include:Record review of the facility policy Monitoring Temperatures of Cooked Foods dated 2013 revealed, .Procedure: TCS (Time/Temperature Control) cooked foods, after being cooked to the required minimum internal temperature, will be held on hot holding equipment that will keep the food at a minimum 135 degrees Fahrenheit (F) or higher . On 7/7/2026 at 3:25 PM, in an interview, Resident #29 stated that the food is cold and they're tired of rice and mixed vegetables. He noted that breakfast is the worst. He stated that breakfast is almost always cold.An interview on 7/7/2026 at 3:35 PM with Resident 59 revealed he had no complaints about anything except the food at the facility. He agreed with his roommate (Resident #29) and stated, The food is cold, especially at breakfast. The resident stated he has tried eating in his room and switching to dining in the dining room and either way it's always cold. He stated that it is not a time delay issue, because the Certified Nursing Assistants (CNAs) get the trays from the cart right away and bring it into the room. He stated that he has asked staff to heat up his food, and they tell him they aren't allowed to. Resident #59 stated that it's worse on the weekends. The State Agency (SA) asked the resident if he has brought it up in resident council, and he stated Oh yes, many times. They always say they are going to fix it, but they never do.On 7/8/26 at 11:14 AM, a food temperature test was conducted, and it was noted that pureed meats were observed and recorded at 120 degrees F. At this time, other foods tested and temperature checked included: pureed tomatoes which reached 120 degrees F, pureed tomatoes at 105 degrees F, rice 140 degrees F, stewed whole tomatoes at 140 degrees F and fried steak which was noted at 122 degrees F and peas which were recorded at 145 degrees F along with chopped meat that was temped at 115 degrees F.On 07/08/2026 at 2:56 PM, a Resident Council meeting was conducted with nine facility residents in attendance, including the Resident Council President. During the meeting residents voiced concerns regarding food service. Multiple residents stated that meals were frequently served cold and that coffee was often cold by the time it was received.On 7/9/26 at 7:35 AM a test tray temperature reading with the Dietary Manager revealed the following readings of a test breakfast tray: Eggs at 102 degrees F, Biscuit at 100 degrees F, Sausage at 99 degrees F, and Grits at 120 degrees F. Upon a test taste performed by the SA along with the Dietary Manager, the grits were noted to be warm, however, the sausage and eggs were both noted to be cold and not warm to the pallet. On 7/9/26 at 7:39 AM, the Dietary Manager tested the contents on the tray alongside SA. He noted that the contents of the tray included a piece of sausage, scrambled eggs, grits, and a biscuit. He noted that the biscuit should be at room temperature, however every other item including grits, sausage and eggs should be at a range of between 135 to 140 degrees F, and confirmed that the sausage, eggs nor grits did not meet this temperature recommendation. He noted that when he tried these foods that the grits were warm but not hot, while also noting that the eggs and sausage were not warm nor hot noting that the sausage was at room temperature. He also confirmed that he had received several complaints in the past, about three months ago, about cold food but noted that none of the facility's equipment for heating had changed, including a heating plate and burner table in the kitchen, so nothing was changed to address it. However, he had observed differences in the amounts of steam rising off some items being heated on the burners in the kitchen while others do not produce steam on the side, he noted that during temperature testing items on the side burners were not producing as much steam or reaching temperatures quite as high as the those on the larger main burners. He insisted that the facility checks the burners daily to be in working condition and stated that he asks residents daily about food temperatures but did not believe that residents may not eat their food if it is cold or could experience weight loss from such issues.An interview with the Administrator at 9:51 AM on 7/9/26 revealed that hot foods should be served at 135 degrees F, and he expects his staff to be professional, clean and sanitary and to serve hot foods at proper temperatures. He also stated that issues with food not meeting adequate temperatures include a lack of palatability leading to possible nutritional problems such as weight loss.A record review of Resident #29's admission Record revealed the facility admitted the resident on 10/9/25 with diagnoses that included Cerebral Infarction and Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting the Left Nondominant Side.A record review of Resident #29's Order Summary Report with active orders as of 7/9/26 revealed orders dated 5/5/26 for: Mechanical soft diet, Regular texture, Regular liquids consistency. An additional order dated 10/9/25 revealed Offer snack at bedtime.A record review of Resident #29's quarterly Minimum Data Set (MDS), with an Assessment Reference Date of 6/17/26, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition.A record review of Resident #59's admission Record revealed the facility admitted the resident on 4/8/25 with diagnoses that included Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting the Left Nondominant Side.A record review of Resident #59's Order Summary Report revealed orders for: LCS (Low Concentrated Sweets) diet, regular texture, regular liquids consistency dated 7/16/25.A record review of Resident #59's quarterly MDS, with an Assessment Reference Date of 6/11/26, revealed a BIMS score of 15, indicating intact cognition.

Based on interview, record review and facility policy review, the facility failed to provide reasonable accommodation of Residents' needs by not ensuring that necessary supports were consistently accessible and available to assist Residents in communicating their needs for one (1) of twenty (20) sample Residents. Resident #5.Findings include:A record review of the facility policy, Promoting/Maintaining Resident Self Determination, revised 9/25, revealed It is the practice of this facility to protect and promote resident rights by promoting and facilitating the resident self-determination through support of resident choice.Policy Explanation and Compliance Guidelines .1. All staff members involved in providing care to residents will promote and facilitate resident self-determination.On 7/7/26 at 11:21 AM, Resident #5 stated during an interview with the State Agency (SA) that she had difficulty being understood. She said she previously used a communication board but had not seen it in quite some time. She stated that she wanted to communicate freely with others and that having the board available at all times would help her express her needs.On 7/8/26 at 1:41 PM, during an interview, Licensed Practical Nurse (LPN)#1 reported she had worked with Resident #5 for several years and did not recall the Resident ever having access to a communication board. LPN #1 stated the board had been found and was on its charger, adding it had not been in the resident's room.On 7/9/26 at 8:04 AM, the Director of Nursing (DON) confirmed the resident has a communication board but said it was kept in a drawer rather than accessible at bedside. She acknowledged the resident is difficult to understand and that the board would assist her in communicating her needs.At 10:05 AM on 7/9/26, the Speech Therapist stated the resident has an electronic communication board and a whiteboard. She reported she placed the electronic board in the bottom nightstand drawer and that the resident must use the call light for staff to retrieve it because she cannot access it independently.At 10:27 AM on 7/9/26, in the presence of both the SA and the Speech Therapist, Resident #5 re stated her desire to have her communication boards accessible at all times and kept within reach despite occasional frustration.A record review of Resident #5's admission Record revealed the facility admitted the resident on 8/1/16 with diagnoses that included Expressive Language Disorder and Cognitive Communication Deficit.A record review of Resident #5's Minimum Data Set (MDS), with an Assessment Reference Date of 5/28/26, revealed a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment.

Based on observation, staff interview, record review and facility policy review, the facility failed to ensure Activities of Daily Living (ADLs) were provided in accordance with physician orders for one (1) of two (2) residents reviewed for ADLs. Resident #54.Findings include:Record review of the facility policy ADL Care Policy dated 8-23 revealed, It is the policy of this facility to provide appropriate treatment and services in relation to ADL care to resident to ensure all ADL needs are met on a daily basis, while attaining or maintain the residence of highest, practicable, physical, mental and social well-begin.Record review of the facility policy Nail Care Policy dated 2-26 revealed, .3. Routing cleaning and inspection of nails will be provided during ADL care on an ongoing basis.Observations on 7/7/2026 at 12:05 PM revealed Resident #54 lying in bed receiving continuous Percutaneous Endoscopic Gastrostomy (PEG) tube feeding. Observation revealed fingernails on both hands were jagged and extended approximately one-quarter (1/4) inch beyond the fingertips with a black substance present beneath the nails. The resident had a long beard with flaking skin present. A very strong, musty, unpleasant body odor was noted from the PEG tube. A strong unpleasant odor was also noted from the resident's mouth.Follow-up observations on 7/8/2026 at 12:00 PM revealed the resident's fingernails remained long, jagged, and unclean. A very strong, musty body odor continued to be present.An additional observation on 7/8/2026 at 1:35 PM continued to reveal a strong unpleasant odor from the resident's mouth.During an interview on 7/8/2026 at 1:40 PM, Registered Nurse (RN) #1 the resident's bathing schedule consisted of bed baths on Mondays, Tuesdays, Thursdays, and weekends, with showers on Wednesdays and Fridays. RN #1 further stated that Certified Nursing Assistants (CNAs) gently filed and cleaned the resident's nails on Mondays and that an RN performed diabetic nail care on Thursdays.During an interview on 7/8/2026 at 3:40 PM, the Director of Nursing (DON) was informed of the observations of long, jagged fingernails with black debris underneath, the strong musty body odor, and the strong oral odor. The DON stated it was her expectation that residents' personal hygiene be maintained and that CNAs and nurses provide bathing, mouth care, and nail care as ordered. The DON stated she would address the concerns with staff and provide in-service education.Record review of the admission Record revealed the facility admitted the resident on 10/4/22 with the diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side and Chronic Obstructive Pulmonary Disease.A record review of Resident #54's quarterly Minimum Data Set (MDS), with an Assessment Reference Date of 4/8/26, revealed the resident had severe cognitive impairment and required staff assistance with all activities of daily living.Record review of the Resident #54's Order Summary Report with active orders as of 7/9/26 revealed an order dated 12/18/2023 for Mouth care every shift; brush teeth every shift. An order dated 5/15/2024 for Gently smooth nails with an emery board and clean nails with a denture brush using soap and water once weekly on Mondays.

Based on record review, interview, and facility policy review, the facility failed to ensure that resident grievances voiced through the Resident Council were thoroughly investigated, addressed, and resolved for three (3) of three (3) residents reviewed for grievances (Residents #1, #2, and #3). Findings Included:Record review of the facility policy Resident and Family Grievances/Complaints revealed Policy: It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal.12. The facility will make prompt efforts to resolved grievances .A record review of Resident Council Minutes, dated 11/20/25, revealed that residents complained that food on the weekend has gotten bad. There was no documentation that the complaint had been addressed by the facility.A record review of Resident Council Minutes, dated 12/22/25, revealed that residents complained that food is cold once it comes down the hallway.A record review of the Resident Council Department Response Form, dated 12/22/25, revealed that the Dietary Manager reported that food was placed in containers to hold temperature until it reached the residents and that an in-service was conducted for dietary staff on 1/9/26 to improve food service. There was no further documentation to indicate that follow-up or monitoring was conducted to ensure the concern was resolved.A record review of Resident Council Minutes, dated 1/15/26, revealed that residents continued to complain that the food on the weekend was not good and tasted sweet, the water and tea do not have enough ice, breakfast biscuits and toast are hard and the grits are cold.A record review of the Resident Council Department Response Form, dated 1/15/26, revealed that the Dietary Manager (DM) indicated a meeting would be held with weekend staff to address the issue. There was no further documentation to indicate that the concern was investigated or resolved.A record review of Resident Council Minutes, dated 2/19/26, revealed that residents continued to complain that the food was cold.A record review of the Resident Council Department Response Form, dated 2/19/26, revealed that the Dietary Manager reported that food was being sent out faster and that staff were instructed to pass trays promptly. There was no further documentation to indicate that monitoring, follow-up, or evaluation of effectiveness was completed.An interview with Resident #1 on 3/23/26 at 2:00 PM, revealed that the food was still not good and was always cold. She stated that it was not about seasoning, but that the food overall did not taste good.An interview with Resident #2 on 3/23/26 at 2:15 PM, revealed that the food was still cold when served and did not taste good, although alternate meals were available.An interview with Resident #3 on 3/23/26 at 2:20 PM, revealed that the food tasted bad and was always cold. He stated that staff would heat the food if requested; however, the food was consistently served cold.An interview with the Dietary Manager on 3/23/26 at 3:00 PM, revealed that he was aware of the residents' complaints regarding food from Resident Council meetings. He stated that he had spoken with weekend staff and made changes such as replacing tray carts and providing guidance on food preparation; however, he acknowledged that there was no documentation of ongoing monitoring, follow-up, or additional interventions to ensure that the concerns were resolved.An interview with Social Services on 3/23/26 at 3:16 PM, she verified that she was aware of the Resident Council complaints about the food but had not followed up to determine what was done or if the issue was resolved.An interview with the Administrator on 3/23/26 at 3:30 PM, revealed that he was aware of the residents' complaints regarding food and acknowledged that additional follow-up and resolution efforts should have occurred to ensure that the grievances were resolved.Record review of the admission Record revealed that the facility admitted Resident #1 to the facility on 7/7/24 with a diagnosis of Type 2 Diabetes Mellitus.Record review of Section C of the Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 3/5/26 revealed Resident #1 has a Brief Interview for Mental Status (BIMS) score of 15, indicating that she is cognitively intact.Record review of the admission Record revealed that the facility admitted Resident #2 to the facility on [DATE] with a diagnosis of Polyneuropathy.Record review of Section C of the MDS with an ARD of 2/14/26 revealed Resident #2 has a BIMS score of 13, indicating that she is cognitively intact.Record review of the admission Record revealed that the facility admitted Resident #3 to the facility on [DATE] with a diagnosis of Quadriplegia.Record review of Section C of the MDS with an ARD of 2/14/26 revealed Resident #3 has a BIMS score of 15, indicating that he is cognitively intact.

Based on interviews and record review, the facility failed to ensure Resident #1 received necessary care and services in accordance with physician orders when staff did not obtain and implement a nephrologist's order to increase Lasix. This was identified for one (1) of three (3) residents reviewed for quality of care (Resident #1). Findings include: A phone interview with the complainant on 9/23/25 at 4:00 PM revealed Resident #1 attended a nephrology appointment in April 2025, where the nephrologist ordered Lasix to be increased to 40 milligrams (mg) twice daily. The complainant stated she returned the consultation paperwork to the facility nurse after the appointment. She reported that in May the resident began experiencing worsening leg swelling and weakness, and therapy was discontinued. She later learned the increased Lasix order had not been implemented. The complainant stated she believed the resident's hospitalization was a direct result of the missed medication orders. Record review of the April 2025 appointment calendar revealed Resident #1 had a nephrology appointment on 4/21/25. Record review of the nephrology consultation report dated 4/21/25 revealed: “Plan: Increase Lasix to 40 mg in the morning and 40 mg at noon.” Record review of the Order Summary Report revealed Lasix was not increased to 40 mg twice daily until 5/8/25, seventeen days after the consultation. During an interview with the Director of Nursing (DON) on 9/24/25 at 9:00 AM, she confirmed the consultation paperwork was not in the record and the Lasix order was not implemented on 4/21/25. She acknowledged the family had discussed the medication changes with the previous DON, but orders were not entered until 5/8/25. She confirmed failure to obtain the consultation form and follow-through with medication changes could result in resident decline. During an interview with the Medical Records staff on 9/24/25 at 10:30 AM, she stated consultation forms are given to the unit managers, who are responsible for ensuring orders are transcribed. She confirmed that if forms are missing, staff should follow up with the provider, but no follow-up occurred in this case. During an interview with the Unit Manager on 9/24/25 at 10:35 AM, she acknowledged the form may have been misplaced but confirmed staff should have followed up with the DON or Assistant Director of Nursing (ADON) to obtain the orders. During a continued interview with the DON on 9/24/25 at 10:40 AM, she confirmed that Resident #1 experienced worsening edema requiring hospital transfer on 5/12/25. An interview with the Administrator on 9/24/25 at 11:04 AM confirmed he was not aware that Resident #1's Lasix had not been increased as ordered or that the consultation sheet was missing from the record. He stated it was his expectation that if staff did not receive the forms, they should have followed up to obtain the information. An interview with the ADON on 9/24/25 at 11:10 AM revealed she obtained orders to transfer Resident #1 to the hospital on 5/12/25 due to increased edema and fever. Record review of the Emergency Department notes dated 5/12/25 revealed Resident #1 was admitted with edema and urinary tract infection. Review of the “admission Record” revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, pulmonary hypertension, diastolic heart failure, and chronic kidney disease. Record review of the Minimum Data Set with an Assessment Reference Date (ARD) of 4/3/25 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 04, which indicated Resident #1 is severely cognitively impaired.

Based on record review, observations, interviews, and facility policy review, the facility failed to ensure a resident's right to be free from abuse and neglect as evidenced by: 1) the facility failed to prevent verbal and physical abuse by a Certified Nursing Assistant (CNA) of Resident #2, and 2) failed to prevent neglect of a resident who required transfer via a mechanical lift (Resident #1), for two (2) of three (3) residents reviewed for abuse. Findings Include: Review of the facility policy titled, Abuse Policy and Procedure, dated 04/02/24 and signed by CNA #6, revealed, Each resident of this facility has the right to be free from verbal, sexual, physical and mental abuse .neglect . Review of the facility policy and procedure titled Code of Conduct dated 04/02/24 and signed by CNA #6 revealed, All employees must accept certain responsibilities, adhere to acceptable business practices in matters of conduct and behavior, and exhibit a high degree of personal integrity at all times. Review of the facility policy and procedure titled Reporting Requirements of the Vulnerable Adult Act, dated 04/02/24 and signed by CNA #6 revealed. Who is responsible for reporting? Any person who is employed at a care facility or is a health care professional working in connection with the facility who has knowledge or reasonable cause to believe that a resident of that care facility was the victim of abuse, neglect, or exploitation. Resident #2 Interview on 10/22/24 at 2:05 PM with CNA #5 she stated that she knew who CNA # 6 was but she had not really worked directly with her and didn't really know her, but when she saw her in the facility that she had an attitude. CNA #5 stated that about a month ago she was assisting Resident #3 with his bath when he confided in her that CNA #6 had been mean to his roommate (Resident #2). He stated that the privacy curtain had only been pulled halfway and he could see Resident #2 in his bed and he could see CNA #6 attempting to deliver care to the resident. CNA #6 was talking mean to Resident #2 and saying things like Get your hands down and stop moving as she slapped his hands and slapped the side of his face. Resident #3 stated that she mistreated Resident #2 and talked in a mean threatening voice to him. CNA #5 stated that she went to her Unit Manager Registered Nurse (RN) #1 and to the unit nurse Licensed Practical Nurse (LPN) #1 and reported the incidents of verbal and physical abuse. CNA #5 stated that Resident #3 was cognitive and gave good reliable statements to staff and verbalized reliable information and had good consistent memory recall. CNA #5 stated that Resident #3 had never varied with information when recalling the events of the incident of abuse by CNA #6 to his roommate Resident #2. CNA #5 stated that Resident #2 was looked after by the other residents and that he had been living at the facility for a long while and that he was Hispanic and did not speak English but could understand English language. CNA #5 stated that Resident #2 could answer questions by making physical gestures and nodding his head Yes or No. CNA #5 stated that the sister and family of Resident #2 visited him often and he would speak Spanish to his family and didn't really speak to anyone else. CNA #5 stated that they had reported the abuse to the Director of Nursing (DON) and that she had requested that CNA #5 and RN#1 go together and talk to Resident #2 and Resident #3. CNA #5 stated that Resident #3 never changed his recall of the events of verbal and physical abuse of his roommate at the hands of CNA #6. Resident #3 stated that CNA #6 had slapped Resident #2 on the face and on his hands and had talked very rudely and mean to Resident #2. Interview on 10/22/24 at 2:25 PM, with the facility Administrator (ADM) revealed that she had been contacted by someone from outside the facility that CNA #6 had worked at another facility and that she had been terminated from that facility for the same type of abuse to residents. ADM stated that she pulled the employment application of CNA #6 to see if she had documented her employment at the other facility. The application did not contain the other facility as a place of employment, but CNA #6 had admitted during the investigation that she had been terminated at another facility, prior to current employment, for the very same thing. ADM stated that the incident occurred on 09/19/24 and CNA #6 was sent home on suspension on 09/19/24 and was terminated on 09/23/24 for substantiated abuse of Resident #2. ADM stated that the facility staff believed what Resident #3 had reported and that he witnessed abuse of his roommate. Interview on 10/22/23 at 2:45 PM, with the Ombudsman confirmed that she had been given reports of verbal and physical abuse by CNA #6 at another facility prior to this report. Ombudsman stated that when she heard that CNA #6 had a second report of abuse at a second facility, she contacted her supervisor and her supervisor contacted the facility ADM. Ombudsman stated that she had many times spoken with Resident #3 and he was a very reliable witness. Interview on 10/22/24 at 12:05 PM, with CNA #1 stated that Resident #3 was cognitive, and he gave reliable information and he was not confused or demented. Interview on 10/22/24 at 5:19 PM, with RN #1 revealed that she had been instructed to go with CNA #5 and talk to Resident #3 and to Resident #2. RN #1 stated that Resident #3 told them that CNA #6 had verbally and physically abused Resident #2. Resident #3 stated that he saw CNA #6 slap the resident on the side of his face and on his hands. Resident #3 stated that he witnessed CNA #6 be mean and talk mean to Resident #2. RN #1 stated that they completed a physical assessment and did not find any injury to Resident #2. Resident #2 did not speak English, but he responded by demonstrating a slap to the side of his face. Resident #2 understands English but does not speak English. His sister came to the facility and Resident #2 told the sister that he had been slapped on the face and hands by CNA #6. RN #1 stated that she believed the reports of verbal and physical abuse given by Resident #2 and Resident #3. RN #1 confirmed that to her knowledge CNA #6 had been terminated from the facility for abuse of Resident #2. Interview on 10/22/24 at 5:50 PM, with CNA #6 via telephone revealed that Yes she had been terminated from the facility on 9/23/24 as a result of an alleged event of abuse toward Resident #2. CNA #6 denied the allegations of abuse and stated that she had worked at another facility and that she had left the other facility as a result of not passing the CNA exam in the time frame allotted by the facility. CNA stated that she received her training at another facility, and she obtained her certification after she was terminated from that facility. CNA confirmed that she was placed on suspension on 09/19/24 and was terminated on 09/23/24 and stated that she was terminated for allegedly abusing Resident #2. Observation and interview on 10/22/24 at 6:00 PM, with Resident #3 confirmed that he had told CNA #5 that he witnessed CNA #6 verbally and physically abusing his roommate Resident #2. Resident #3 stated that the situation was now over and that CNA #6 was no longer working at the facility and he did not want to talk about it any more. Resident #3 stated that he had told CNA #6 to her face that she knew she had abused (Resident #2) and it wasn't right. Resident #3 stated that he felt safe at the facility and he was not afraid or felt unsafe. Resident #3 stated that if he could have gotten up and walked over to his roommates bed during the time CNA #6 was abusing him that he would have taken care of things and she wouldn't do that any more. Resident #3 stated that his roommate was in such bad shape and was unable to defend himself. It was observed to be approximately six (6) to eight (8) feet of distance between the bed of Resident #3 and the bed of Resident #2. Observation and interview with Resident #2 on 10/22/24 at 6:20 PM, revealed that he was sitting alone in the day room in a wheelchair sleeping. Resident #2 quickly opened his eyes when his name was called. The Resident did not attempt to verbalize but followed with his eyes as he was spoken to. He nodded his head yes and no. He nodded no that he was not afraid, and he nodded yes that he was happy at the facility. Record review of a typed statement signed by the Psychiatric Mental Health Nurse Practitioner and dated 09/19/2024 revealed, (Resident #2) sister asked him if someone had hit or slapped him, he indicated with a nod yes and rubbed his check with his hands. His sister asked him if he felt safe, he indicated with a nod no. His sister asked him if anyone had been mean to him he indicted with a nod yes. I spoke with (Resident #3) and he stated that he witnessed (CNA #6) physically hit (Resident #2) on the hand several times, push him over in the bed, and pull on him forcefully almost pulling him out of the bed and he says these types of behaviors have happened several times, however he could not give an approximate number. (Resident #3) states he told her don't be doing him like that and (CNA #6) response was you shut up. Record review of a hand written statement signed by (CNA #5) dated 9/19/24 read: On 9/19/2024 I (CNA #5) had gave (Resident #3) a shower. After his shower I was making up his bed he told me that his aid was super mean to him. So I asked him who he said the girl and the hallway they call her (name of CNA #6). So he was still telling me that she don't never do anything for him when he ask. Then he got talking about his roommate (Resident #2). He told me that she be hitting and slapping him when giving him a bath and the curtain be open so he see everything. He also said she almost snatched him out of bed one day and also pops his hand. So after leaving out the room I asked (LPN #1) the nursing what to do and (RN#1) was walking down the hall so I talk to both of them. Record review of the hand written statement of Resident #3 written by RN #1 and witnessed by CNA #5 dated 9/19/24 read: (Resident #3) stated The curtain was pulled half way but I could see. She was being rude and telling (Resident #2) , Take your hands off me, don't touch me. (Resident #3) demonstrated to nurse (RN #1) and CNA (CNA #5) how CNA (CNA #6) slapped resident's hand. (Resident #3) stated, she almost jerked him out of the damn bed and I told her not to jerk on him like that and she told me, oh just shut up. She was slapping him on the hip telling (Resident #2) to turn over. If I could have gotten up and walked, I would of gotten a hold of her. Written statement read back to (Resident #3) and he signed the statement that it was correct and his words. The statement was signed and witnessed by CNA #5 and RN#1 on 9/19/24. Record review of the facility's form titled: NOTICE OF TERMINATION documented that (CNA #6) date of hire 04/02/24 Position CNA Effective 9/23/2024 revealed that (CNA #6) had an involuntary termination from the facility for Rule Violation. Supervisor's Comments: In light of the results of investigation into complaint/Grievance r/t (related to) Abuse of (Resident #2) and eyewitness account by his roommate Suspension 9/19/24 Termination 9/23/24 signed by ADM and DON and dated 9/23/24. Rehire NO. Record review of the Minimum Data Set (MDS) for Resident #3 dated 9/5/2024 revealed that he had a Brief Interview of Mental Status (BIMS) score of 14 indicating that he was cognitively intact. The record review of Resident #2's MDS dated [DATE] contained a BIMS score of 3 which indicated that Resident #2 was severely cognitively impaired. Resident #1 Cross reference F610, F656, F689 Record review of the Director of Nursing's (DON) investigation report dated October 2, 2024 and signed by the facility DON, stated, Please find attached the investigation of the Right Intertrochanteric femoral fracture identified by CT with contrast on 10/02/24 at (Local Hospital) emergency room (ER). 10/02/24 this resident presented with black vomiting while at the nursing home. In light of the fall and head injury on 10/01/24 the Nurse Practitioner (NP) ordered transfer to (Local Hospital) ER via emergency medical services (EMS) for further evaluation. On 10/02/24 .the DON was notified of a possible Hip fracture noted on the initial abdominal x-ray. A second test, CT without contrast, was done .identifying an acute comminuted and moderately displaced right hip fracture. The DON reported that on 10/02/24, after evaluation at the local ER, Resident #1 was then transferred to (Another Hospital). The DON's investigation report also documented on 10/01/24 this resident, (Resident #1) had a fall from the lift sling during transfer bed to wheelchair in the resident's room at the nursing home. In attendance were 3 CNAs (CNA #4) (CNA #3) and (CNA #2) and a medication LPN, (LPN #1). As per the statements of the nurse and CNAs when they moved the lift to transfer to wheelchair the resident slid out of one side hitting head on the front of the wheelchair causing a skin tear on the forehead, the lift was lowered to the floor, resident was assessed, repositioned and lifted by the total lift back into the bed. The NP and Resident Representative were notified. An order was received to transfer resident to the (Local Hospital) ER for evaluation. (Resident #1) was received back in the facility at 2220. The ER identified only the forehead skin tear. Interview on 10/22/24 at 11:50 AM with Certified Nursing Assistant (CNA) #1 revealed that she trained all the CNA's on the use of all mechanical lifts. She stated that the facility required two (2) person's to assist with the mechanical lifting of all residents. CNA #1 stated that Especially because of the resident's size there would be a necessity to use at least two (2) staff, and maybe more, while using the mechanical lift. CNA #1 confirmed that two staff must assist hands-on when using a mechanical lift for all facility residents. CNA #1 stated that both of the two assisting staff should be holding on to the lift and/or holding on to the resident during the entire mechanical lifting process. She stated that two staff should assist with placing the sling under the resident and two staff were required to hook the sling to the lift and check the accurate attachment of the sling to the lift; and two staff are required to be holding on to the resident and making sure the transfer was steady; by holding on to the resident from the time of sling placement, until the resident is safely and securely transferred would provide safety and assurance of a mechanical lift transfer. CNA #1 stated that never during the mechanical lift process of a resident should there be one (1) staff transferring a resident with a mechanical lift. CNA #1 stated that the use of one (1) staff using a mechanical lift was not in accordance with the facility policy and procedure. Interview on 10/22/24 at 12:20 PM with Licensed Practical Nurse (LPN) #1 via (by) telephone revealed that she was called to the room of Resident #1 to watch CNA #2 to operate the mechanical lift and transfer Resident #1 from the bed to the wheelchair. LPN #1 stated that she was called there to spot CNA #2 as she used the lift to transfer Resident #1. LPN #1 stated that spot meant to watch her use the mechanical lift, that she did not assist CNA #2 with the operation of the lift for Resident #1 and that she did not have her hands on the lift or her hands on Resident #1 during the transfer with the mechanical lift. LPN #1 stated that when she entered the room she saw CNA #2 operating the mechanical lift and that Resident #1 was up in the air in the sling when the mechanical lift tilted and Resident #1 fell to the floor. LPN #1 stated that CNA #4 was standing behind her near the door of Resident #1's room. LPN #1 stated that there was another CNA assisting CNA #2 with the mechanical lift but she did not know her name and she was unable to recall who the third CNA was that was there to assist. LPN #1 stated that Resident #1 fell from the lift and hit her head and received a skin tear. LPN #1 stated that she assessed Resident #1 while she was on the floor. Three (3) CNA's and LPN #1 assisted to lift Resident #1 back to the bed and LPN #1 stated that she assessed Resident #1 again while she was in the bed. LPN #1 stated that Resident #1 was bleeding from the injury to her forehead and she placed a compression bandage to the bleeding area of Resident #1's head. LPN #1 obtained orders to send Resident #1 to the ER for evaluation. Resident #1 left the facility via ambulance at approximately 9:00 AM on 10/01/24 and was returned to the facility at approximately 3:00 P.M. on 10/01/24 at change of shift. Resident #1 returned from the ER with a diagnosis of a skin tear to her forehead. LPN #1 stated that there was no misuse of the mechanical lift and that there were two (2) CNA's assisting with the mechanical lift of Resident #1. LPN #1 was not able to recall or describe who the second CNA was that assisted CNA #2 to operate the mechanical lift. Interview via telephone on 10/22/24 at 12:30 PM, with CNA #4 revealed that she was asked by LPN #1 to come with her to Resident #1's room. CNA #4 stated that when she entered the room of Resident #1, she saw the resident up in the air in the sling then she turned around to close the room door behind her and when she turned back around Resident #1 had fallen to the floor from the sling. CNA #4 stated that she did not see Resident #1 fall and she does not know who the other CNA was assisting CNA #2 with the mechanical lift, did not know her name and did not pay attention to what she looked like because she was concentrating on the resident. CNA #4 stated that she assisted the LPN #1 and the other two (2) CNAs to lift Resident #1 back to her bed after the fall. CNA #4 stated that Resident #1 obtained a skin tear to her head and was bleeding at her forehead. CNA #4 stated that LPN #1 assessed Resident #1 and placed a bandage on her bleeding head. CNA #4 stated that she did not assist with the operation of the mechanical lift, and she did not have her hands on the lift or on Resident #1 during the bed to wheelchair transfer. CNA #4 stated that she was in the room when Resident #1 fell but she did not see her fall because she was closing the door to the room behind her. She stated that she does not know how the incident occurred. Interview on 10/22/24 at 12:36 PM, with CNA #2 revealed that she had given Resident #1 a bed bath on the morning of 10/01/24 at approximately 8:30 AM just after the breakfast meal. CNA #2 stated that she was very nervous to give an interview and would probably get things confused because she was so nervous. CNA #2 was tearful and shaky during the entire interview. CNA #2 verbalized that she loved the residents and needed her job and that she would not intentionally do anything to hurt a resident. She repeatedly verbalized it's on me, I should not have started doing the lift before CNA #3 entered the room to help me. CNA #2 stated that she had solely given Resident #1 a bed bath and placed the sling under Resident #1 and had independently attached the sling to the lift and had lifted Resident #1 up above the bed prior to CNA #3 entering the room. CNA #2 stated that CNA #3 did come into the room after she had lifted Resident #1 up above the bed in the mechanical lift. CNA #2 stated she sees now that she should have waited until CNA #3 was present in the room before she started operating the mechanical lift. CNA #2 stated that CNA #3 was standing behind the wheelchair as she was lifting Resident #1. CNA #1 stated that she was driving the lift and when she had Resident #1 up in the air the mechanical lift tilted, and Resident #1 fell out and hit her head. She stated that LPN #1 and CNA #4 were also in the room watching her lift Resident #1. CNA #2 confirmed that there was no staff holding on to Resident #1 while she was lifting Resident #1 from the bed to the wheelchair. CNA #2 stated that Resident #1 fell out of the lift and hit her head and she began to bleed. She stated that LPN #1 told CNA #2 to continue to lower Resident #1 to the floor so they could assess her and treat her bleeding head. LPN #1 assessed Resident #1 while she was on the floor and then all four (4) of the staff (CNA #2, CNA #3, CNA #4 and LPN #1) assisted to transfer Resident #1 from the floor back into the bed, where LPN #1 re-assessed Resident #1 while she was in the bed. Resident #1 was transported to the hospital with a head injury on 10/01/24 at approximately 9:00 A.M. Interview on 10/22/24 at 1:30 PM, with CNA #3 revealed that she was not in the room with CNA #2 when she used the mechanical lift to transfer Resident #1. CNA #3 stated that she was with another resident assisting with her breakfast when (CNA #2) came and got her to help with Resident #1. CNA #2 stated that upon entering Resident #1's room there were no other staff present and Resident #1 was on the floor bleeding from the forehead. CNA #3 stated that CNA #2 had used the mechanical lift alone without a second staff and Resident #1 had fallen and received a head injury. They called LPN #1 and CNA #4 came along with LPN #1 to help get Resident #1 up off of the floor and back into the bed. The four (4) staff together assisted Resident #1 back to her bed where the LPN #1 assessed the resident. CNA #3 confirmed that she had provided a handwritten statement to the facility Director of Nursing (DON) confirming that she was not in the room when Resident #1 fell from the lift. CNA #3 reviewed her handwritten statement with the State Agency (SA) and confirmed that was her statement that was given to the DON. CNA #3 verbalized that Resident #1 was a large lady and that she required at least two (2) persons to assist with her care and to steady the mechanical lift. CNA #3 stated that Resident #1 never moved and was unable to move or wiggle because she was physically disabled. CNA #3 again confirmed that she was not in the room when CNA #2 was utilizing the lift and that she had told the DON that in her statement. Interview on 10/22/24 at 2:25 PM, with the facility Assistant Director of Nursing (ADON) and the ADM revealed that all mechanical lifts required two (2) persons to assist with the operation of the lift and the resident. Both the ADON and the ADM confirmed that they were not aware that CNA #2 had transferred Resident #1 with the lift by herself. Both the ADON and the ADM expressed that they were under the impression that the DON had thoroughly investigated the incident and had determined that there were three (3) staff assisting CNA #2 with the mechanical lift. Not until today were we made aware that the incident happened another way, stated the ADM. The ADM stated that on 10/02/24 Resident #1 was sent from the local ER for a hip fracture and had never returned to the facility and had been discharged from the facility. The ADM stated that she would talk to the DON when she returned to the facility from medical leave. The ADM confirmed that the incident should have been thoroughly investigated and that she should have known because she is ultimately the one who signs off on allegations of abuse or neglect, but she was unaware. Record review of the hand written statement that was provided to the DON on 10/03/24 by CNA #3 stated, On October 1, 2024 I was walking to feed a resident, as I was alerted to come in (Resident #1's) room. Once I walked into the room she was already laying on the floor. The nurse examined her. Then me, nurse, and another aide proceeded to help get her up off the floor and put back into the bed. The hand written statement was signed by CNA #3 and dated 10/3/2024. Record review of the hand written statement that was provided to the DON on 10/1/24 and signed by (CNA #4) stated, As me, (CNA #3), and (LPN#1) was walking in the room she began to lifted (Resident #1) as she was lifting she slipped out the sling hitted her head on the wheel of the wheel chair the rooms are so cluttered where you can't move around without hitted things in the room. Record review of the hand written statement that was provided to the DON on 10/3/24 by CNA #2 stated, I (CNA #2) gave (Resident #1) a bedbath for shower Day; got her fully dressed to get up. I made sure she was pulled up in bed before stepping out. Went to shower room and grab the total lift and brought into room, had her chair by bed being prepared to get her up. I went to door to ask someone to spot me with lift So (LPN #1) (the nurse) and two CNA came behind her as I was proceeding to transfer her to put in chair. The total lift tilted over and (Resident #1) fell and Hit her head on the edge of her chair leg. The hand written statement was signed by CNA #2 and dated 10/3/24. Record review of the undated hand written statement provided to the DON by LPN #1 stated, I was asked to step in the room to assist with a total transfer, along with 2 other staff. Once I stepped into the room. Staff began to lift her off the bed. Once lifted she steered the lift to get her over the wheelchair. As she began to steer the lift, resident slipped out of sling hitting her head on the front of wheelchair. Record review of After Visit Summary, dated 10/01/24, from the hospital stated, Tylenol only for pain. Monitor wound for any development of infection. Return for vomiting, weakness, lethargy. Reason for visit: Fall .Laceration of forehead . Record review of Hospital ER report dated 10/02/24 and titled, CT Abdomen Pelvis with contrast, revealed Reason for visit n/v (nausea and vomiting) Results: Acute appearing right femoral intertrochanteric fracture. The record review of the investigation completed by the facility's DON was not consistent with the handwritten statements of the CNAs nor the LPN's handwritten statement. On 10/25/24, after the SA had exited the survey, the facility's ADON notified via email and confirmed that they had re-interviewed and the CNA's and LPN involved with the incident of Resident #1's fall from the mechanical lift and that CNA #2 CNA #4 and LPN #1 confessed that they had not been truthful and had lied on their original statements that they gave to the DON on 10/1/24-10/3/24. CNA #2 confessed that she used the mechanical lift alone and improperly and that the other three (3) CNA's were not in the room when the fall of Resident #1 occurred. LPN #1 and CNA #4 both gave new statements that they were not present in the room with CNA #2 when Resident #1 fell and received serious injury and that they had falsified their statements and had not been truthful during the investigation of the suspected neglect. The record review of the Admission Record of Resident #1 revealed that she was admitted to the facility on [DATE] with diagnosis of Cerebral Infarction Due to Embolism of left middle cerebral artery; among many other diagnoses. Record review of the Section C of the Minimum Data Set (MDS) dated [DATE] for Resident #1 revealed she was severely cognitively impaired.

Based on observation, interviews, record reviews, and facility policy and procedures review the facility failed to avoid a preventable accident when Resident #1 was transferred with a mechanical lift without the required two (2) person transfer assistance. This resulted in Resident #1 sustaining an injury to her forehead and a right intertrochanteric femoral fracture requiring surgery. Resident #1 was transported to the hospital emergency room (ER) two times related to the accident. This was for one (1) of three (3) residents reviewed. Resident #1 Findings Included: Review of the facility policy, undated, titled: Modified Lifting Policy read: PROCEDURE: 1. Use of a mechanical lift requires two (2) nursing assistants to perform the procedure each time that it is used. 2. Staff will follow the documented lifting protocol deemed appropriate for each resident. This information is documented in the resident's chart and via a sticker system in a designated area of the facility for reference to each resident. This information should be referred to prior to lifting/transferring or assisting each resident. This documentation will also include type of lift and sling determined to be appropriate for each resident . The facility provided a notice that was posted in the facility that read: WARNING! Nursing Staff Never Use a Lift Alone! It is ABUSE! THE FACILITY POLICY IN REGARDS TO LIFTING WITH A MECHANICAL LIFT IS 1. Two Person Assist Every Time a Lift is Used 2. Properly apply the Sling 3. Always Assure you are using the correct lift. Record review of the DON's investigation report dated October 2, 2024 and signed by the facility DON, stated, Please find attached the investigation of the Right Intertrochanteric femoral fracture identified by CT with contrast on 10/02/24 at (Local Hospital) ER. 10/02/24 this resident presented with black vomiting while at the nursing home. In light of the fall and head injury on 10/01/24 the Nurse Practitioner (NP) ordered transfer to (Local Hospital) ER via EMS for further evaluation. On 10/02/24 .the DON was notified of a possible Hip fracture noted on the initial abdominal x-ray. A second test, CT without contrast, was done .identifying an acute comminuted and moderately displaced right hip fracture. The DON reported that on 10/02/24, after evaluation at the local ER, Resident #1 was then transferred to (Another Hospital). The DON's investigation report also documented on 10/01/24 this resident, (Resident #1) had a fall from the lift sling during transfer bed to wheelchair in the resident's room at the nursing home. In attendance were 3 CNAs (CNA #4) (CNA #3) and (CNA #2) and a medication LPN, (Licensed Practical Nurse #1). As per the statements of the nurse and CNAs when they moved the lift to transfer to wheelchair the resident slid out of one side hitting head on the front of the wheelchair causing a skin tear on the forehead, the lift was lowered to the floor, resident was assessed, repositioned and lifted by the total lift back into the bed. The NP and Resident Representative were notified. An order was received to transfer resident to the (Local Hospital) ER for evaluation. (Resident #1) was received back in the facility at 2220. The ER identified only the forehead skin tear. On 10/22/24 at 11:50 AM, in an interview with Certified Nursing Assistant (CNA) #1 revealed that she trained all the CNA's on the use of all mechanical lifts. She stated that the facility required two (2) person's to assist with the mechanical lifting of all residents. CNA #1 stated that the only way that a resident could possibly fall from a mechanical lift would be due to improper use of the lift or by placing the wrong size sling to the lift to move a resident. CNA #1 stated that she did not witness the fall of Resident #1, but stated that she had in past times assisted with the transfer of the resident and that she never moved about while in the lift because of her severely compromised physical and mental condition and was incapable of movement. CNA #1 stated that Resident #1 was non verbal and was dependent upon staff for all of her needs. CNA #1 stated that Especially because of the resident's size there would be a necessity to use at least two (2) staff, and maybe more, while using the mechanical lift. CNA #1 confirmed that two staff must assist hands-on when using a mechanical lift for all facility residents. CNA #1 stated that never during the mechanical lift process of a resident should there be one (1) staff transferring a resident with a mechanical lift. CNA #1 stated that the use of one (1) staff using a mechanical lift was not in accordance with the facility policy and procedure. On 10/22/24 at 12:20 PM, interview with Licensed Practical Nurse (LPN) #1 via (by) telephone revealed that she was called to the room of Resident #1 to watch CNA #2 to operate the mechanical lift and transfer Resident #1 from the bed to the wheelchair. LPN #1 stated that she was called there to spot CNA #2 as she used the lift to transfer Resident #1. LPN #1 stated that spot meant to watch her use the mechanical lift, that she did not assist CNA #2 with the operation of the lift for Resident #1 and that she did not have her hands on the lift or her hands on Resident #1 during the transfer with the mechanical lift. LPN #1 stated that when she entered the room she saw CNA #2 operating the mechanical lift and that Resident #1 was up in the air in the sling when the mechanical lift tilted and Resident #1 fell to the floor. LPN #1 stated that CNA #4 was standing behind her near the door of Resident #1's room. LPN #1 stated that there was another CNA assisting CNA #2 with the mechanical lift but she did not know her name and she was unable to recall who the third CNA was that was there to assist. LPN #1 stated that Resident #1 fell from the lift and hit her head and received a skin tear. LPN #1 stated that she assessed Resident #1 while she was on the floor. Three (3) CNA's and LPN #1 assisted to lift Resident #1 back to the bed. LPN #1 stated that she assessed Resident #1 again while she was in the bed. LPN #1 stated that Resident #1 was bleeding from the injury to her forehead and she placed a compression bandage to the bleeding area of Resident #1's head. LPN #1 obtained orders to send Resident #1 to the ER for evaluation. Resident #1 returned from the ER with a diagnosis of a skin tear to her forehead. LPN #1 stated that there was no misuse of the mechanical lift and that there were two (2) CNA's assisting with the mechanical lift of Resident #1. LPN #1 was not able to recall or describe who the second CNA was that assisted CNA #2 to operate the mechanical lift. On 10/22/24 at 12:30 PM, during a telephone interview with CNA #4 revealed that she was asked by LPN #1 to come with her to Resident #1's room. CNA #4 stated that when she entered the room of Resident #1 she saw the resident up in the air in the sling then she turned around to close the room door behind her and when she turned back around Resident #1 had fallen to the floor from the sling. CNA #4 stated that she did not see Resident #1 fall. CNA #4 stated that she did not know the name of the CNA that was assisting CNA #2 and did not pay attention to what she looked like because she was concentrating on the resident. CNA #4 stated that she assisted LPN #1 and the other two (2) CNA's to lift Resident #1 back to her bed after the fall. CNA #4 stated that Resident #1 obtained a skin tear to her head and was bleeding at her forehead. CNA #4 stated that LPN #1 assessed Resident #1 and placed a bandage on her bleeding head. She stated that she does not know how the incident occurred. On 10/22/24 at 12:36 PM, during an interview with CNA #2 revealed that she had given Resident #1 a bed bath on the morning of 10/01/24. CNA #2 stated that she was very nervous to give an interview and would probably get things confused because she was so nervous. CNA #2 was tearful and shaky during the entire interview. CNA #2 verbalized that she loved the residents and needed her job and that she would not intentionally do anything to hurt a resident. She repeatedly verbalized numerous times it's on me, I should not have started doing the lift before CNA #3 entered the room to help me. CNA #2 stated that she had solely given Resident #1 a bed bath and had placed the sling under Resident #1 and had independently attached the sling to the lift and had lifted Resident up above the bed prior to CNA #3 entering the room. CNA #2 stated she sees now that she should have waited until CNA #3 was present in the room before she started operating the mechanical lift. CNA #2 stated that CNA #3 was standing behind the wheelchair as she was lifting Resident #1. CNA #1 stated that she was driving the lift and when she had Resident #1 up in the air the mechanical lift tilted and Resident #1 fell out and hit her head. She stated that LPN #1 and CNA #4 were also in the room watching her lift Resident #1. CNA #2 confirmed that there was no staff holding on to Resident #1 while she was lifting Resident #1 from the bed to the wheelchair. CNA #2 stated that Resident #1 fell out of the lift and hit her head and she began to bleed. She stated that LPN #1 told CNA #2 to continue to lower Resident #1 to the floor so they could assess her and treat her bleeding head. LPN #1 assessed Resident #1 while she was on the floor and then all four (4) of the staff (CNA #2, CNA #3, CNA #4 and LPN #1) assisted to transfer Resident #1 from the floor back into the bed, where LPN #1 re-assessed Resident #1 while she was in the bed. Resident #1 was transported to the hospital with a head injury on 10/01/24 at approximately 9:00 A.M. On 10/22/24 at 1:30 PM, during an interview with CNA #3 revealed that she was not in the room with CNA #2 when she used the mechanical lift to transfer Resident #1. CNA #3 stated that she was with another resident assisting with her breakfast when (CNA #2) came and got her to help with Resident #1. CNA #2 stated that upon entering Resident #1's room there were no other staff present and Resident #1 was on the floor bleeding from the forehead. CNA #3 stated that CNA #2 had used the mechanical lift alone without a second staff and Resident #1 had fallen and received a head injury. They called LPN #1 and CNA #4 came along with LPN #1 to help get Resident #1 up off of the floor and back into the bed. The four (4) staff together assisted Resident #1 back to her bed where LPN #1 assessed the resident. CNA #3 confirmed that she had provided a hand written statement to the facility Director of Nursing (DON) confirming that she was not in the room when Resident #1 fell from the lift. CNA #3 reviewed her hand written statement with the State Agency (SA) and confirmed that was her statement that was given to the DON. CNA #3 stated that she had in past times assisted with the transfer of Resident #1 with a mechanical lift and there had never been any issues with Resident #1 resisting care or moving about while in the sling of the mechanical lift. CNA #3 verbalized that Resident #1 was a large lady and that she required at least two (2) persons to assist with her care and to steady the mechanical lift. CNA #3 stated that Resident #1 never moved and was unable to move or wiggle. CNA #3 again confirmed that she was not in the room when CNA #2 was utilizing the lift and that she had told the DON that in her statement. On 10/22/24 at 2:25 PM, an interview with the Assistant Director of Nursing (ADON) and the Administrator (ADM) confirmed that the two (2) person assist method required that two (2) staff would both assist with the operation of the lift and with the proper attachment of the sling. Both the ADON and the ADM confirmed that they were not aware that CNA #2 had transferred Resident #1 with the lift by herself. Both the ADON and the ADM expressed that they were under the impression that the DON had thoroughly investigated the incident and had determined that there was three (3) staff assisting CNA #2 with the mechanical lift. Not until today were we made aware that the incident happened another way, stated the ADM. The ADM stated that on 10/02/24 Resident #1 was sent from the local ER for a hip fracture and had never returned to the facility and had been discharged from the facility. The ADM stated that she would talk to the DON when she returned to the facility from medical leave. The record review of the investigation completed by the facility's DON was not consistent with the hand written statements of the CNAs nor the LPN's hand written statement. The DON did not investigate the incident in accordance with the facility's policies and procedures for the operation and use of mechanical lifts and for Abuse and Neglect. On 10/25/24, after the SA had exited the survey, the facility's ADON notified via email and confirmed that they had re-interviewed and the CNAs and LPN involved with the incident of Resident #1's fall from the mechanical lift and that CNA #2, CNA #4 and LPN #1 confessed that they had not been truthful and had lied on their original statements that they gave to the DON on 10/1/24-10/3/24. CNA #2 confessed that she used the mechanical lift alone and improperly and that the other CNAs were not in the room when the fall of Resident #1 occurred. LPN #1 and CNA #4 both gave new statements that they were not present in the room with CNA #2 when Resident #1 fell and received serious injury and that they had falsified their statements and had not been truthful during the investigation. Record review of the hand written statement that was provided to the DON on 10/03/24 by CNA #3 revealed, On October 1, 2024 I was walking to feed a resident, as I was alerted to come in (Resident #1's) room. Once I walked into the room she was already laying on the floor. The nurse examined her. Then me, nurse, and another aide proceeded to help get her up off the floor and put back into the bed. The hand written statement was signed by CNA #3 and dated 10/3/2024. Record review of the hand written statement that was provided to the DON on 10/1/24 and signed by (CNA #4) revealed, As me, (CNA #3), and (LPN#1) was walking in the room she began to lifted (Resident #1) as she was lifting she slipped out the sling hitted her head on the wheel of the wheel chair . Record review of the hand written statement that was provided to the DON on 10/3/24 by CNA #2 revealed, I (CNA #2) gave (Resident #1) a bedbath for shower Day; got her fully dressed to get up. I made sure she was pulled up in bed before stepping out. Went to shower room and grab the total lift and brought into room, had her chair by bed being prepared to get her up. I went to door to ask someone to spot me with lift So (LPN #1) (the nurse) and two CNA came behind her as I was proceeding to transfer her to put in chair. The total lift tilted over and (Resident #1) fell and Hit her head on the edge of her chair leg. The hand written statement was signed by CNA #2 and dated 10/3/24. Record review of the undated hand written statement provided to the DON by LPN #1 stated, I was asked to step in the room to assist with a total transfer, along with 2 other staff. Once I stepped into the room. Staff began to lift her off the bed. Once lifted she steered the lift to get her over the wheelchair. As she began to steer the lift, resident slipped out of sling hitting her head on the front of wheelchair. Record review of After Visit Summary, dated 10/01/24, from the hospital stated, Tylenol only for pain. Monitor wound for any development of infection. Return for vomiting, weakness, lethargy. Reason for visit: Fall. Record review of Hospital ER report dated 10/02/24 and titled, CT Abdomen Pelvis with contrast, revealed Reason for visit n/v (nausea and vomiting) Results: Acute appearing right femoral intertrochanteric fracture. Record review of the Section C of the Minimum Data Set (MDS) dated [DATE] for Resident #1 revealed she was severely cognitively impaired. The record review of the Admission Record of Resident #1 revealed that she was admitted to the facility on [DATE] with diagnosis of Cerebral Infarction Due to Embolism of left middle cerebral artery; among many other diagnoses.

Based on interviews, record reviews, and facility policy and procedure reviews, the facility failed to implement the care plan for transfer with a mechanical lift. During the transfer, Resident #1 fell from the lift and sustained a head injury and hip fracture requiring surgical repair. Resident #1 was one (1) of three (3) residents reviewed for care plans. Findings Included: Review of the facility policy titled Following the Care Plan Policy dated 2011, revealed, It is the Policy of this facility to follow a written and approved care plan for each resident. All employee will be trained upon hire and be required to follow the care plan. All employees will follow the written care plan that is developed in order to assure the residents needs are met . Review of the facility policy dated revised 6/13 titled Nurse Aide Information Policy revealed: It is the policy of this facility to initiate and maintain an individualized Nurse Aide Information (electronic health record) Kardex upon admission and complete within 7 (seven) days of the residents stay . 4. CNA's (Certified Nursing Assistant) will review their assigned residents Kardex per the kiosk electronic health record at the beginning of their shift and as needed throughout their shift . Record review of the Care Plan for Resident #1, date initiated 11/22/2022, revealed, I require assistance with ADL's (Activities of Daily Living) related to self-care impairment due to cerebrovascular accident (CVA) with intervention: Use total lift for transfers times two (2) person assist. Record review of the Care Plan contained in the CNA's Kiosk read: Monitor resident for side effects of oversedation, increased confusion, dizziness, blurred vision, or nausea. Safety: Provide assistance as needed for transfers. Use total mechanical lift x 2 person assist. CNA #1 revealed during an interview on 10/22/24 at 11:50 AM, that she trained all the CNAs on the use of all mechanical lifts. She stated that the facility required two (2) person's to assist with the mechanical lifting of all residents. CNA #2 revealed in an interview on 10/22/24 at 12:36 PM, that she had given Resident #1 a bed bath on the morning of 10/01/24 at approximately 8:30 AM. CNA #2 stated that she was very nervous to give an interview and would probably get things confused because she was so nervous. She was tearful and shaky during the entire interview. She repeatedly verbalized it's on me, I should not have started doing the lift before CNA #3 entered the room to help me. CNA #2 stated that she had placed the sling under Resident #1 and had independently attached the sling to the lift and had lifted the resident above the bed. CNA #1 stated that she was driving the lift when she had Resident #1 up in the air the mechanical lift tilted and Resident #1 fell out and hit her head. The CNA confirmed that Resident #1 was transported to the hospital with a head injury on 10/01/24 at approximately 9:00 AM. CNA #3 revealed in an interview on 10/22/24 at 1:30 PM, that she was not in the room with CNA #2 when she used the mechanical lift to transfer Resident #1. CNA #3 stated that she was with another resident assisting with her breakfast when (CNA #2) came and got her to help with Resident #1. CNA #3 stated that upon entering Resident #1's room there were no other staff present and Resident #1 was on the floor bleeding from the forehead. CNA #3 stated that CNA #2 had used the mechanical lift alone without a second staff and Resident #1 had fallen and received a head injury. They called Licensed Practical Nurse (LPN) #1 and CNA #4 came along with LPN #1 to help get Resident #1 up off of the floor and back into the bed. The four (4) staff together assisted Resident #1 back to her bed where the LPN #1 assessed the resident. CNA #3 confirmed that she had provided a hand written statement to the facility Director of Nursing (DON) confirming that she was not in the room when Resident #1 fell from the lift. The facility Assistant Director of Nursing (ADON) and the Administrator (ADM) revealed during an interview on 10/22/24 at 2:25 PM, that the CNA's used the care plan guides located in the CNA's kiosk on the units prior to each shift for reference on how to care for the residents that they are assigned to care for that shift. Both the ADON and the ADM confirmed that the mechanical lift's were care planned on each resident that required a mechanical lift and that all mechanical lifts required two (2) persons to assist with the operation of the lift and the resident. Both the ADM and the ADON confirmed that Resident #1 was care planned as a two (2) person assist with a total body mechanical lift. Both the ADM and the ADON confirmed that the two (2) person assist method required that two (2) staff would both assist with the operation of the lift and with the proper attachment of the proper size sling. Both the ADON and the ADM confirmed that they were not aware that CNA #2 had transferred Resident #1 with the lift by herself. Both the ADON and the ADM expressed that they were under the impression that the DON had thoroughly investigated the incident and had determined that there was three (3) staff assisting CNA #2 with the mechanical lift. Not until today were we made aware that the incident happened another way, stated the ADM. The ADM stated that on 10/02/24 Resident #1 was sent from the local ER for a hip fracture and had never returned to the facility and had been discharged from the facility. The ADM stated that she would talk to the DON when she returned to the facility from medical leave. Record review of the DON's investigation report dated October 2, 2024 and signed by the facility DON, stated, Please find attached the investigation of the Right Intertrochanteric femoral fracture identified by Computer Tomography (CT) with contrast on 10/02/24 at (Local Hospital) ER. 10/02/24 this resident presented with black vomiting while at the nursing home. In light of the fall and head injury on 10/01/24 the Nurse Practitioner (NP) ordered transfer to (Local Hospital) ER via EMS (emergency medical services) for further evaluation. The DON reported that on 10/02/24, after evaluation at the local ER, Resident #1 was then transferred to (Another Hospital). The DON's investigation report also documented on 10/01/24 this resident, (Resident #1) had a fall from the lift sling during transfer bed to wheelchair in the resident's room at the nursing home. In attendance were 3 CNAs (CNA #4) (CNA #3) and (CNA #2) and a medication LPN, (LPN #1). As per the statements of the nurse and CNAs when they moved the lift to transfer to wheelchair the resident slid out of one side hitting head on the front of the wheelchair causing a skin tear on the forehead, the lift was lowered to the floor, resident was assessed, repositioned and lifted by the total lift back into the bed. The NP and Resident Representative were notified. An order was received to transfer resident to the (Local Hospital) ER for evaluation. (Resident #1) was received back in the facility at 2220. The ER identified only the forehead skin tear. Record review of the hand written statement that was provided to the DON on 10/03/24 by CNA #3 stated, On October 1, 2024 I was walking to feed a resident, as I was alerted to come in (Resident #1's) room. Once I walked into the room she was already laying on the floor. The nurse examined her. Then me, nurse, and another aide proceeded to help get her up off the floor and put back into the bed. The hand written statement was signed by CNA #3 and dated 10/3/2024. Record review of After Visit Summary, dated 10/01/24, from the hospital stated, Tylenol only for pain. Monitor wound for any development of infection. Return for vomiting, weakness, lethargy. Reason for visit: Fall. Record review of Hospital ER report dated 10/02/24 and titled, CT Abdomen Pelvis with contrast, revealed Reason for visit N/V (nausea and vomiting) Results: Acute appearing right femoral intertrochanteric fracture. The record review of the Admission Record of Resident #1 revealed that she was admitted to the facility on [DATE] with diagnosis of Cerebral Infarction Due to Embolism of left middle cerebral artery; among many other diagnoses. Record review of the Section C of the Minimum Data Set (MDS) dated [DATE] for Resident #1 revealed she was severely cognitively impaired. On 10/25/24, three (3) days after the State Agency (SA) had exited the survey, the facility's ADON notified via email and confirmed that they had re-interviewed the CNA's and Licensed Practical Nurse (LPN) involved with the incident of Resident #1's fall from the mechanical lift, and CNA #2, CNA #4 and LPN #1 confessed that they had not been truthful and had lied in their original statements that they gave to the DON on 10/1/24-10/3/24. CNA #2 confessed that she used the mechanical lift alone and improperly and that the other three (3) CNA's were not in the room when the fall of Resident #1 occurred. LPN #1 and CNA #4 both gave new statements that they were not present in the room with CNA #2 when Resident #1 fell and received serious injury.

Based on interviews, record reviews, and facility policy and procedure reviews, the facility failed to thoroughly investigate the incident of a fall from a mechanical lift for Resident #1 who sustained an injury to her forehead and a fracture requiring surgical repair for one (1) of three (3) residents reviewed. Cross reference F600, F656, F689 Findings Include: The facility's undated policy titled Abuse Policy Responsibility stated, The facility will identify and INVESTIGATE all suspicious or allegations of abuse (such as suspicious bruising of residents, neglect or misappropriation of resident property). The facility will review the occurrence, pattern, and trend that may constitute abuse. The facility will thoroughly INVESTIGATE all alleged violations under the direct supervision of the Administrator. The facility will take all necessary steps to prevent further potential abuse while the investigation is in progress. Any employee of the facility suspected of abuse or neglect will be suspended pending investigation until the facility investigation is complete. Record review of the DON's investigation report dated October 2, 2024 and signed by the facility Director of Nursing (DON), stated, Please find attached the investigation of the Right Intertrochanteric femoral fracture identified by Computed Tomography (CT) with contrast on 10/02/24 at (Local Hospital) emergency room (ER). 10/02/24 this resident presented with black vomiting while at the nursing home. In light of the fall and head injury on 10/01/24 the NP ordered transfer to (Local Hospital) ER via EMS for further evaluation. The DON reported that on 10/02/24, after evaluation at the local ER, Resident #1 was then transferred to (Another Hospital). The DON's investigation report also documented on 10/01/24 this resident, (Resident #1) had a fall from the lift sling during transfer bed to wheelchair in the resident's room at the nursing home. In attendance were three (3) Certified Nursing Assistants (CNA) #4, CNA #3, and CNA #2 and a medication Licensed Practical Nurse (LPN) #1. As per the statements of the nurse and CNAs when they moved the lift to transfer to wheelchair the resident slid out of one side hitting head on the front of the wheelchair causing a skin tear on the forehead, the lift was lowered to the floor, resident was assessed, repositioned and lifted by the total lift back into the bed. The NP and Resident Representative were notified. An order was received to transfer resident to the (Local Hospital) ER for evaluation. (Resident #1) was received back in the facility at 2220. The ER identified only the forehead skin tear (on 10/1/24). Record review of Hospital ER report dated 10/02/24 and titled, CT Abdomen Pelvis with contrast, revealed Reason for visit n/v (nausea and vomiting) Results: Acute appearing right femoral Intertrochanteric fracture. During an nterview on 10/22/24 at 12:20 PM with Licensed Practical Nurse (LPN) #1 via (by) telephone revealed that she was called to the room of Resident #1 to watch CNA #2 to operate the mechanical lift and transfer Resident #1 from the bed to the wheelchair. LPN #1 stated that she was called there to spot CNA #2 as she used the lift to transfer Resident #1. LPN #1 stated that spot meant to watch her use the mechanical lift, that she did not assist CNA #2 with the operation of the lift for Resident #1 and that she did not have her hands on the lift or her hands on Resident #1 during the transfer with the mechanical lift. LPN #1 stated that when she entered the room she saw CNA #2 operating the mechanical lift and that Resident #1 was up in the air in the sling when the mechanical lift tilted and Resident #1 fell to the floor. LPN #1 stated that there was another CNA assisting CNA #2 with the mechanical lift but she did not know her name and she was unable to recall who the third CNA was that was there to assist. LPN #1 stated that Resident #1 fell from the lift and hit her head and received a skin tear. During an interview via telephone on 10/22/24 at 12:30 PM with CNA #4 revealed that she was asked by LPN #1 to come with her to Resident #1's room. CNA #4 stated that when she entered the room of Resident #1 she saw the resident up in the air in the sling then she turned around to close the room door behind her and when she turned back around Resident #1 had fallen to the floor from the sling. CNA #4 stated that she did not see Resident #1 fall and she does not know who the other CNA was assisting CNA #2 with the mechanical lift. CNA #4 was unable to describe or to recall the name of the CNA that was assisting CNA #2 with the mechanical lift of Resident #1, and stated that she does not know how the incident occurred. During an interview on 10/22/24 at 12:36 PM with CNA #2 revealed that she had given Resident #1 a bed bath on the morning of 10/01/24 at approximately 8:30 AM. CNA #2 stated that she was very nervous to give an interview and would probably get things confused because she was so nervous. CNA #2 was tearful and shaky during the entire interview. CNA #2 verbalized that she loved the residents and needed her job and that she would not intentionally do anything to hurt a resident. She repeatedly verbalized it's on me, I should not have started doing the lift before CNA #3 entered the room to help me. CNA #2 stated that she had solely given Resident #1 a bed bath and had placed the sling under Resident #1 and had independently attached the sling to the lift and had lifted Resident up above the bed prior to CNA #3 entering the room. CNA #2 stated that CNA #3 did come into the room after she had lifted Resident #1 up above the bed in the mechanical lift. CNA #2 stated she sees now that she should have waited until CNA #3 was present in the room before she started operating the mechanical lift. CNA #2 repeated numerous times It's on me, I don't want to get anyone in trouble it's on me. CNA #2 stated that CNA #3 was standing behind the wheelchair as she was lifting Resident #1. CNA #2 stated that there was not enough room at the beside to have CNA #3 holding on to the lift and holding on to Resident #1. CNA #1 stated that she was driving the lift and when she had Resident #1 up in the air the mechanical lift tilted and Resident #1 fell out and hit her head. She stated that LPN #1 and CNA #4 were also in the room watching her lift Resident #1. During an interview on 10/22/24 at 1:30 PM with CNA #3 revealed that she was not in the room with CNA #2 when she used the mechanical lift to transfer Resident #1. CNA #3 stated that she was with another resident assisting with her breakfast when (CNA #2) came and got her to help with Resident #1. CNA #2 stated that upon entering Resident #1's room there were no other staff present and Resident #1 was on the floor bleeding from the forehead. CNA #3 stated that CNA #2 had used the mechanical lift alone without a second staff and Resident #1 had fallen and received a head injury. They called LPN #1 and CNA #4 came along with LPN #1 to help get Resident #1 up off of the floor and back into the bed. The four (4) staff together assisted Resident #1 back to her bed where the LPN #1 assessed the resident. CNA #3 confirmed that she had provided a hand written statement to the facility Director of Nursing (DON) confirming that she was not in the room when Resident #1 fell from the lift. CNA #3 reviewed her hand written statement with the State Agency (SA) and confirmed that was her statement that was given to the DON. CNA #3 again confirmed that she was not in the room when CNA #2 was utilizing the lift and that she had told the DON that in her statement. Record review of the hand written statement that was provided to the DON on 10/03/24 by CNA #3 stated, On October 1, 2024 I was walking to feed a resident, as I was alerted to come in (Resident #1's) room. Once I walked into the room she was already laying on the floor. The nurse examined her. Then me, nurse, and another aide proceeded to help get her up off the floor and put back into the bed. The hand written statement was signed by CNA #3 and dated 10/3/2024. During an interview on 10/22/24 at 2:25 PM, with the facility Assistant Director of Nursing (ADON) and the Administrator (ADM) both the confirmed that they were not aware that CNA #2 had transferred Resident #1 with the lift by herself. Both the ADON and the ADM expressed that they were under the impression that the DON had thoroughly investigated the incident and had determined that there was three (3) staff assisting CNA #2 with the mechanical lift. Not until today were we made aware that the incident happened another way, stated the ADM. The ADM stated that on 10/02/24 Resident #1 was sent from the local ER for a hip fracture and had never returned to the facility and had been discharged from the facility. The ADM confirmed that the incident should have been thoroughly investigated and that she should have known because she is ultimately the one who signs off on allegations of abuse or neglect, but she was unaware. The ADM stated that she would talk to the DON when she returned to the facility from medical leave. The record review of the investigation completed by the facility's DON was not consistent with the hand written statements of the CNAs nor the LPN's hand written statement. The DON did not investigate the incident in accordance with the facility's policies and procedures for the operation and use of mechanical lifts and for Abuse. The facility did not suspend the staff during the investigation that were involved with the mechanical lift incident of Resident #1, as outlined in the facility's policy and procedure. On 10/25/24, after the SA had exited the survey, the facility's ADON notified via email and confirmed that they had re-interviewed and the CNAs and LPN involved with the incident of Resident #1's fall from the mechanical lift and that CNA #2 CNA #4 and LPN #1 confessed that they had not been truthful with their original statements that they gave to the DON on 10/1/24-10/3/24. CNA #2 confessed that she used the mechanical lift alone and improperly and that the other CNAs were not in the room when the fall of Resident #1 occurred. LPN #1 and CNA #4 both gave new statements that they were not present in the room with CNA #2 when Resident #1 fell and received serious injury. Record review of the hand written statement that was provided to the DON on 10/1/24 and signed by (CNA #4) stated, As me, (CNA #3), and (LPN#1) was walking in the room she began to lifted (Resident #1) as she was lifting she slipped out the sling hitted her head on the wheel of the wheel chair the rooms are so cluttered where you can't move around without hitted things in the room. Record review of the hand written statement that was provided to the DON on 10/3/24 by CNA #2 stated, I (CNA #2) gave (Resident #1) a bedbath for shower Day; got her fully dressed to get up. I made sure she was pulled up in bed before stepping out. Went to shower room and grab the total lift and brought into room, had her chair by bed being prepared to get her up. I went to door to ask someone to spot me with lift So (LPN #1) (the nurse) and two CNA came behind her as I was proceeding to transfer her to put in chair. The total lift tilted over and (Resident #1) fell and Hit her head on the edge of her chair leg. The hand written statement was signed by CNA #2 and dated 10/3/24. Record review of the undated hand written statement provided to the DON by LPN #1 stated, I was asked to step in the room to assist with a total transfer, along with 2 other staff. Once I stepped into the room. Staff began to lift her off the bed. Once lifted she steered the lift to get her over the wheelchair. As she began to steer the lift, resident slipped out of sling hitting her head of the front of w/c. Record review of the Section C of the Minimum Data Set (MDS) dated [DATE] for Resident #1 revealed she was severely cognitively impaired. The record review of the Admission Record of Resident #1 revealed that she was admitted to the facility on [DATE] with diagnosis of Cerebral Infarction Due to Embolism of left middle cerebral artery; among many other diagnoses.

Based on observation, staff interview, record review, and facility policy review, the facility failed to implement a comprehensive care plan for a resident requiring mouth care for one (1) of 16 care plans reviewed. Resident #47 Findings Include: Review of the facility policy titled Following the Care Plan Policy undated, revealed Policy: It is the Policy of this facility to follow a written and approved care plan for each resident. All employees will be trained upon hire and be required to follow the care plan . Record review of the Care Plan for Resident #47 revealed Focus: I require assistance with ADL's (activities of daily living) r/t (related to) self-care impairment due to Left-sided hemiplegia following a CVA (Cerebral Vascular Accident) Interventions . Provide mouth care/brush teeth every shift . An observation of Resident #47, on 5/13/2024 at 11:51 AM and 2:20 PM, and again on 5/14/2024 at 8:20 AM, revealed his upper and lower lips were cracked and dry with a crusty yellowish scaling of the skin. An observation and interview with the Director of Nursing (DON) on 5/14/2024 at 10:12 AM, described Resident #47's lips as dry and chapped. She confirmed oral hygiene had not been performed. An interview with the Director of Nursing (DON) on 5/15/2024 at 9:04 AM, revealed the purpose of the care plan was to lay out the framework for resident care that staff should provide. She revealed her expectation was for the staff to follow Resident #47's care plan for oral hygiene, and confirmed it was not followed.

Based on observation, staff interview, record review, and facility policy review, the facility failed to provide oral care for a resident receiving enteral nutrition as evidenced by dry, crusty areas of skin on the upper and lower lips for one (1) of five (5) residents receiving enteral feedings. Resident #47 Findings Include: Review of the facility policy titled Mouth Care Policy with a revision date of January 2002, revealed Policy: It is the policy to provide oral care assistance each am (morning) and HS (bedtime) for all residents and PRN (as needed) . An observation of Resident #47, on 5/13/2024 at 11:51 AM, and again at 2:20 PM, revealed his upper and lower lips were cracked and dry with a crusty yellowish scaling of the skin. Record review of the Order Summary Report with active orders as of 4/25/24, for Resident #47 revealed an order dated 5/17/2023, Strict NPO (nothing by mouth) Status and an order dated 12/18/2023, Mouth care done every shift, brush teeth r/t (related to) mouth care every shift. An observation of Resident #47 on 5/14/2024 at 8:20 AM, revealed him lying in bed with his eyes closed. His upper and lower lips were cracked and dry, with yellow scaly patches of skin. An observation and interview with Certified Nurse Aide (CNA) #2 on 5/14/2024 at 10:05 AM, revealed she was assigned to care for Resident #47 today, and he was unable to eat or drink by mouth. She described the residents' lips as dry and confirmed she had not done oral hygiene on the resident today. She revealed she came in earlier, and the resident was getting a bed bath, so she left and had not returned to check on the resident. CNA #2 confirmed that oral care should have been provided with the resident's bath this morning. An observation and interview with the Director of Nursing (DON) on 5/14/2024 at 10:12 AM, described Resident #47's lips as dry and chapped. She confirmed oral hygiene had not been performed and revealed oral care should be performed every shift by the aides. The DON revealed the resident needed a moisturizer applied to his lips for hydration and confirmed the dry crusty patches would be discomforting for the resident. Record review of the Admission Record revealed the facility admitted Resident #47 on 5/17/23 with medical diagnoses that included Dysphagia following Cerebral Infarction, Gastrostomy status, and Unspecified Dementia.

Based on staff interviews, record review, and facility policy review the facility failed to accurately complete section H of the Minimum Data Set (MDS) assessment for a Resident, as evidenced by incorrectly coding Indwelling catheter usage during the 7-day observation look-back period for one (1) of three (3) residents with indwelling catheters. Resident #57 Findings include: Review of the facility policy titled, MDS Correction Policy dated October 2019 revealed, Several processes have been put into place to assure that the MDS data are accurate both at the provider and in the QIES (Quality Improvement Evaluation System) ASAP (Assessment Submission and Processing)system: . Clinical corrections must also be undertaken as necessary to assure that the resident is accurately assessed, the care plan is accurate, and the resident is receiving the necessary care . An interview on 5/14/24 at 11:21 AM, the Director of Nurses (DON) revealed, Resident #57 does not have a catheter at this time. The DON stated, It was removed about six (6) weeks ago. During an interview on 5/14/24 at 2:30 PM, the MDS Nurse confirmed during the seven-day look-back period from April 9 through April 15, that Resident #57 did not have an indwelling catheter. She confirmed the indwelling catheter was discontinued on 2/19/24 and the MDS assessment was coded in error and did not portray an accurate assessment for the resident during the April 2024 quarterly assessment. She revealed I should have caught that error before submitting it. Record review of the MDS with an Assessment Reference Date (ARD) of April 15, 2024, revealed under section H- Bladder and Bowel that Resident #57 was coded for having an Indwelling catheter. Record review of the Electronic Treatment Administration Record (eTAR) for February 2024, revealed Foley Catheter . Start Date 2/9/24 D/C Date 2/19/24. Record review of the Admission Record for Resident #57 revealed she was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus and Hemiplegia and Hemiparesis.

Based on resident interview, staff interviews, record review, and facility policy review, the facility failed to provide resident centered activities for one (1) of five (5) residents reviewed for activities. Resident #1 Findings include: Review of the facility policy titled, Individual Activities and Room Visit Program, dated 1/24/2022, revealed Policy Statement: Individual activities will be provided for those residents . who do not wish to attend group activities. Policy Interpretation and Implementation: 1. Individual activities are provided for individuals who have conditions or situations that prevent them from participating in group activities, or who do not wish to do so . The activities offered are reflective of the resident's individual activity interests . Review of the facility policy, with no title, dated 9/2023, revealed (Formal Name of Facility) It is the policy of this facility that residents will not be allowed to sit outside the front of the facility for safety reasons due to heavy traffic, emergency services required at times and no barrier between traffic flow and front walkway. An observation on 10/4/23 at 10:30 AM, of the front porch of the nursing facility revealed an L shaped front porch attached to the nursing facility immediately beside the breeze way in front of the building. The breeze way and the porch were divided by an approximately 17-inch square in diameter pole and an approximately six (6) inch round and approximately three and a half (3 1/2) tall iron pole to the left front on the porch. The brick wall of the building was observed to the left side of the porch. The observation also revealed a brick wall in front of the porch that was approximately four and a half (4 1/2) feet tall with approximately 12 inch in diameter brick columns attached on top of to the 4 1/2 foot wall that extended to the top of the building. This wall was observed to extend around to the right side of the building. The front porch area was observed to be visible through the window of the nursing facility's activities room. An interview on 10/4/23 at 03:00 PM with Resident #1 revealed he did not understand why he was not allowed to do his most important daily activity. He revealed he was not interested in the activities that were scheduled and only played bingo every now and then. He revealed he told the staff when he was first admitted to the facility that being outside, off to himself, was therapy for him. He noted he was outside most of the day, would come in to get care, would come in to eat a meal or get a snack, and would go back out and stay outside until the evening. He further noted he followed the rules, had never been told he placed himself in danger for sitting out beyond the wall near the breeze way, had been sitting there since he was admitted to the building almost 2 years ago, and did not feel it was fair that his activity was stopped because another resident tried to run away. He also noted no one had come to him and offered or asked him about an alternative plan about sitting on the front porch or alternative of activities. He shared that he told the Administrator and the Director of Nursing (DON) that the activity he liked was taken away. He revealed he was not aware of the front porch sitting activity that was added to the activities calendar in September 2023 and he had not been offered the option to return to the front porch since that other resident tried to run away. Resident #1 noted he did not like sitting out back not being able to see life moving, did not want to be in a crowd with the other residents, and did not have adequate space to himself to enjoy his activity. He revealed he was not able to clear his mind and enjoy his activity if he was sitting around a lot of people and did not really relate to the older crowd. An interview on 10/4/23 at 02:00 PM, with the Activities Director, revealed she was informed by the Administrator that the residents were no longer to be allowed out on the front porch, that it needed to be scheduled as an activity on the activities calendar, and the Activities Coordinator would be the one out on the porch with them. She noted the activity of front porch sitting was not scheduled often on the activities calendar because the Administrator informed her that the same activities could not be scheduled to happen daily. She shared that the activities calendar would change if an activity had to be replaced and the residents were given the activity to sit on the front porch two (2) times in September. A follow up interview on 10/4/23 at 04:15 PM, with the Activities Coordinator confirmed she did not talk with Resident #1 regarding alternate activities to sitting on the front porch daily and had not informed him of it being scheduled on the activities calendar. She noted she watched Resident #1 and was aware that being off to himself out on the front porch appeared to be very important to him. She also noted he did not participate in the other scheduled activities. She revealed she did fill out section F of Resident #1's annual Minimum Data Set (MDS) Assessment and noted that being outside was very important to him. She also noted she was not aware she needed to go and assess a resident for alternative options of activities if their choice was no longer offered as an option by the nursing facility. She noted she was aware of there being different activity interests according to the age groups. An interview was held on 10/4/23 at 05:10 PM, with the DON and the Administrator. The DON revealed the residents were given the option of going out on the back patio if they wanted to go outside. The DON revealed the residents were sitting beyond the barrier on the front porch and were not safe. The Administrator provided the response of not knowing there was a corporate/owner rule that the residents could not sit outside on the front porch, and she had allowed them to do so. The Administrator noted Resident #1 had been informed of the corporate/owner rule of no residents being allowed to sit on the front porch, that the activity was now scheduled, and it was no longer available daily upon resident request. The DON nor the Administrator provided an answer when asked if Resident #1 had been assessed for an alternate activity to replace his front porch sitting activity. The DON responded that the facility activities are scheduled, and he can participate in any activities that are on the schedule. The Administrator noted Resident #1 refused to participate in the scheduled activities. The DON and the Administrator did not respond when asked if Resident #1 had the option to participate in the activities of his choice that met his requests and needs. The DON provided the response again that Resident #1 was told he could still go outside but had to go out on the back patio. The DON and the Administration did not confirm whether activities were offered that met the needs of Resident #1. Record review of the September and October 2023 Activities Calendars revealed, Front Porch Sitting was an activity scheduled for 9/13/23, 10/4/23, and 10/25/23. Record review of the book the Activities Coordinator noted she uses to add additional unscheduled activities revealed [DATE], Front Porch Sitting. The record review did not reveal that Resident #1 participated in the activity. Record review of the care plans for Resident #1 revealed Focus: I would like to participate in the recreational activities I currently enjoy .Interventions .Based on my interview of preferences for customary routine, please honor my daily preferences while I am in this facility . Record review of Section F of the Annual Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 09/13/2023, for Resident #1, revealed F0500 Interview for Activity Preferences that it was very important for the resident to do his favorite activities and to go outside to get fresh air. Record review of the Admission Record, for Resident #1, revealed an admitted [DATE]. Record review of Section C of the Annual Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 09/13/2323, for Resident #1, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #1 is cognitively intact.

Based on resident interview, staff interviews, and record review the facility failed to promote a residents right to make choices significant to the resident for one (1) of five (5) residents reviewed for Resident Rights. Resident #1. Findings include: Record review for a facility policy for Resident Rights related to Self Determination revealed there was no facility policy available. The Administrator provided documentation on the nursing facility's letterhead that revealed October 4, 2023, (Formal Name of Facility) does have a resident's rights policy and A Matter of Rights booklet that is given to each resident on admission, however there is not have a statement regarding self-determination of resident rights in the policy or the booklet. Review of the facility policy, with no title, date 9/2023, revealed (Formal Name of Facility) It is the policy of this facility that residents will not be allowed to sit outside the front of the facility for safety reasons due to heavy traffic, emergency services required at times and no barrier between traffic flow and front walkway. An interview on 10/4/23 at 03:00 PM, with Resident #1 revealed he did not understand why he was not being allowed to do the most important daily activity he chose. He revealed he told the staff when he first admitted that being outside, off to himself, was therapy for him. He noted he was outside most of the day, would stay outside until the evening, only coming in for care and meals. He further noted he followed the rules, had been sitting out on the front porch since he was admitted to the nursing facility almost two (2) years ago, everyone knew that this was the main activity he participated in and did not feel it was fair that his activity was stopped because another resident tried to run away. Resident #1 revealed he did not feel he was being able to make choices that fit his life and made him happy at the nursing facility. He also revealed he did not feel he was being allowed to exercise his rights of choosing what he wanted his activity to be. They said he could go out back but he did not enjoy it because there was always a lot of people, he is younger and preferred not to be around all the older people. He preferred to be out front where he could see life moving and could be more by himself. He shared that he felt no one at the nursing facility was honoring his choices. Record review of Section F of the Annual Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 09/13/2023, for Resident #1, revealed F0500 Interview for Activity Preferences that it was very important for the resident to do his favorite activities and to go outside to get fresh air. An interview on 10/4/23 at 04:15 PM, with the Activities Coordinator revealed she was aware that Resident #1 being off to himself out on the front porch appeared to be very important to him. She revealed she did fill out section F of Resident #1's annual Minimum Data Set (MDS) Assessment and noted that it was very important for Resident #1 to have his choice of activities. A telephone interview on 10/4/23 at 04:35 PM, with the Ombudsman revealed she did speak with the Administrator and the Director of Nursing (DON) regarding this situation for Resident #1 and was also informed it was a corporate/owner rule that residents are not to be allowed to sit on the front porch for safety reasons. She also revealed that Resident #1 informed her that he felt he was not being allowed to make choices that affected him daily and that his Resident Rights were being violated. An interview was held on 10/4/23 at 05:10 PM, with the DON and the Administrator. The DON revealed that Resident #1 was given the option of going out on the back patio if he wanted to go outside. The DON revealed Resident #1 was sitting beyond the barrier of the front porch and was not safe. The Administrator provided the response of not knowing there was a corporate/owner rule that the residents could not sit outside on the front porch, and she had allowed them to do so. The Administrator and DON did not respond when asked by the surveyor if Resident #1 was assessed to not be safe to be outside, or if activities were offered to meet Resident #1's needs and wants. The DON and the Administrator did not confirm whether the nursing facility failed to honor the Resident Right of Self-Determination of choices for Resident #1. Record review of the Ombudsman's Complaint Form dated 9/19/23 revealed the facility Administrator notified the Ombudsman that Resident #1 stated that the facility is violating his rights by not allowing the residents to sit outside on the front porch .(Administrator's name removed) stated that before she became the administrator, the residents weren't allow to sit on the front porch because of safety building rules in place by the owner. (Administrator's name removed) stated that she didn't know about the rule, so she has been allowing the residents to sit outside on the front porch until she found out about the safety building rule. (DON's name removed) stated that (Resident #1's name removed) was upset and stated he was going to file a complaint with (State agency's name removed) complaint hot line. 9-28-23 I spoke with (Resident #1's name removed) and he stated that he made a complaint with (State agency name removed) because he feels like it violates his rights. Record review of the care plans for Resident #1 revealed Focus: I would like to participate in the recreational activities I currently enjoy .Interventions .Based on my interview of preferences for customary routine, pleas honor my daily preferences while I am in this facility . Record review of the Admission Record, for Resident #1, revealed an admitted [DATE]. Record review of Section C of the Annual Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 09/13/2323, for Resident #1, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #1 is cognitively intact.

Based on observation, staff interview, record review and facility policy review, the facility failed to perform physician ordered weekly body audits as evidenced by two (2) high risk residents developing an avoidable facility acquired pressure ulcer for two (2) of 10 residents with pressure ulcers reviewed. Resident #32 and Resident #67. Findings include: Record review of the facility policy titled, Instructions For Pressure Wound Documentation and Photographing Procedure for Wounds Via PCC (Point Click Care) Skin/Wound APP with a revision date of 09/07/22 revealed .8. Review body audits daily to ensure they are completed as scheduled. This can be completed as you review your dashboard daily. Resident #32 An observation on 1/3/23 at 11:05 AM, revealed Resident #32 lying in bed, Heel protectors to bilateral feet. An interview on 1/4/23 at 11:00 AM, with the Treatment Nurse confirmed that Resident #32 had a facility-acquired pressure ulcer to her left heel that was discovered on 12/9/22. She confirmed that it was a suspected deep-tissue injury. The Treatment Nurse revealed she had already done the treatment for today but did show the pressure ulcer to the SA. SA observed a dry, blackened area with no opened areas to left heel. An interview on 1/4/23 at 12:25 PM, with Licensed Practical Nurse (LPN) #1 confirmed that weekly body audits are to be completed on all residents. She revealed that the body audit for Resident #32 was to be completed by the day shift nurse. She confirmed that there were no body audits completed for Resident #32 since 9/5/22 and Resident #32 has a deep tissue injury to her left foot. An interview on 1/04/23 at 2:50 PM, with Certified Nurse Assistant (CNA) #1 revealed that she has been assigned Resident #32. She stated if we notice any skin issues with our residents, we are to notify the nurse. When I put her back in bed today, I put her heel protectors on, but I don't think she has any sores on her feet. An interview on 1/4/23 at 3:17 PM, with the Director of Nurses (DON) confirmed that each resident is to have a weekly body audit and that Resident #32 had not had a body audit since 9/5/22. The DON confirmed the suspected deep tissue injury was facility acquired and if the weekly body audits were being completed as they should have been, this wound could have possibly been prevented. An interview on 1/5/23 at 03:40 PM, with Registered Nurse (RN) #1 revealed the resident had a stroke in 2019 and was readmitted to the facility. She revealed that the Skin at Risk score was 14, and the resident was at high risk for skin breakdown. Registered Nurse #1 confirmed the only order in place at that time was for the resident to be turned every two hours. A record review of the last weekly body audit completed dated 9/5/2022 revealed there were no skin issues or wounds present. Preventative interventions .Turn every two hours. A record review of the Skin & Wound Evaluation effective date 12/9/22 revealed the type of wound was Pressure, the stage was Deep Tissue Injury: Persistent nonblanchable deep red, maroon or purple discoloration. Location, Left Heel. In-house acquired. Wound measurements Area 11.8 centimeters (cm), Length 4.3 cm, Width 3.7 cm. A record review of Resident #32's Admission Record revealed the resident was readmitted to the facility on [DATE] with diagnoses of Cerebral infarction, Hemiplegia, and Hemiparesis affecting left non-dominant side, Type 2 Diabetes Mellitus and Hypertensive heart disease. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/6/22 revealed Resident #32 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident was moderately impaired. Resident #67 An observation on 01/03/23 at 11:52 AM, revealed Resident #67 sitting up in her reclining wheelchair in the day room. An observation on 01/04/23 at 4:02 PM, with the Treatment Nurse revealed a Stage 3 pressure ulcer to Resident #67's left heel with scar tissue and no drainage noted. An interview on 01/04/23 at 3:33 PM, with Licensed Practical Nurse (LPN) #3 confirmed that the LPN's are assigned the weekly body audits on the residents. She revealed it is triggered on the Electronic Treatment Administration Record (ETAR) and there is also an electronic form that has to be completed. She does not recall whether she ever was assigned Resident #67, but when she does a body audit, she takes the resident's clothes off and checks from head to toe for any skin issues. An interview on 01/04/23 at 4:15 PM, with the Treatment Nurse confirmed that Resident #67 currently has a facility acquired Stage 3 pressure ulcer to her left heel that was discovered on 07/22/22 as a Stage 2. She revealed that it is the responsibility of the LPN on the hall to do the resident's body audit's weekly. She stated the only preventative measure the resident had in place prior to the development of this pressure ulcer was turning and repositioning every two hours. She reported that in hindsight preventative measures being put into place prior to the development of this pressure ulcer might have prevented the development of it. She revealed that if the body audits would have been done weekly like they are supposed to then the pressure ulcer could have been discovered at an earlier stage. An interview on 01/04/23 at 4:30 PM, with the DON confirmed that Resident #67 has a facility acquired pressure ulcer to her left heel and a right leg amputation. She revealed that weekly body audits are supposed to be performed by the LPN's assigned to that resident. She revealed that this resident was in the hospital from around the first of May and returned to the facility on [DATE]. She revealed that the re-admission body audit did not show any issues with the resident's left foot or heel. She confirmed the resident did not get a weekly body audit after her re-admission to the facility on [DATE] but received one on 7/22/22 and that was when the pressure ulcer to her left heel was discovered. She confirmed that the resident did not have any preventative measures in place besides being turned or repositioned every two hours prior to the development of the pressure ulcer. She revealed that the resident only had one foot and should have had preventative measures in place to protect the left foot prior to the development of the current pressure ulcer. She confirmed that if the resident would have had her weekly body audits, then the pressure ulcer might have been discovered earlier. An interview on 01/05/23 at 2:30 PM, with LPN #2 confirmed that weekly body audits are supposed to be completed on all residents to make sure they have no skin issues and different nurses, and different shifts are assigned the body audits. She revealed that the body audits are documented as complete on the ETAR and a form titled Weekly Body Audit is completed on the computer and would be under miscellaneous on the resident's electronic record. During this interview, LPN #2 reviewed Resident #67's miscellaneous section in the resident's electronic record and confirmed that no weekly body audits were documented on Resident #67 from 6/4/22 until 7/21/22. She revealed she has no idea why this resident would not have had a weekly body audit completed, but should have. An interview on 01/05/23 at 5:00 PM, with the Treatment Nurse revealed she had not been made aware of the MDS skin assessments that indicated that Resident #67 was at high risk for pressure ulcers. Record review of Resident #67's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Type II Diabetes and Acquired absence of the right leg below the knee. Record review of Resident #67's Order Summary Report revealed the following orders: 02/11/22 Weekly body audits per assigned nurse on Fridays, in the morning every Friday. This review revealed there were no pressure ulcer preventative orders noted. Record review of Resident #67's electronic record for 06/22 and 07/22 revealed there were no Weekly Body Audits documented between 06/4/22 and 07/21/22, and from 07/25/22 to 12/7/22. This review revealed that the Left heel pressure ulcer measurements on 7/25/22 were 4.0 cm x 5.0 cm x 0.0 cm indicating it was a Stage 2 and the measurements on the Weekly Wound Observation Report dated 12/7/22 were 5.0 cm x 6.5 cm x 0.1 cm indicating it was a Stage 3. Record review of Resident #67's Minimum Data Set (MDS) assessments revealed an assessment on 9/8/22 that indicated the resident had a Stage 2 pressure ulcer with no measurements noted and on the 9/14/22 MDS assessment it indicated the resident had a Stage 3 with no measurements noted. Record review of Resident #67's Progress Notes revealed the resident was readmitted to the facility on [DATE] after a stay in the hospital. This review revealed that the resident did not have any issues related to the left heel on re-admission. Record review of Resident #67's Weekly Body Audits (V3.1-V4) revealed an audit dated 07/22/22 that indicated the resident had a Stage II pressure ulcer to her left heel. Record review of Resident #67's Skin and Wound Evaluation (V5.0) audits included the following measurements: 07/22/22 4.0 cm x 5.0 cm x 0.0 cm no drainage Stage II. Record review of Resident #67's Minimum Data Set with an Assessment Reference Date of 10/18/22 revealed in Section C a Brief Interview for Mental Status of 05, which indicates the resident is severely cognitively impaired and Section M revealed the resident has an unhealed Stage 3 pressure ulcer. 46013

Based on staff interviews, record review and facility policy review, the facility failed to implement comprehensive care plans for four (4) of twenty residents care plans reviewed. Resident #11, Resident #32, Resident #61 and Resident #67. Findings Include: A review of the facility's Following the Care Plan Policy, dated 3/21/22, revealed, it is the policy of this facility to follow a written and approved care plan for each resident .All employees will follow the written care plan that is developed in order to assure the resident's needs are met. Resident #11 Record review of Resident #11's care plans revealed the following care plan; printed date 1/4/23 revealed, Focus: I have a physical function deficit related to: self-care impairment, mobility impairment, Range of Motion (ROM) limitations related to dx (diagnosis) of Cerebrovascular Accident (CVA) with left sided hemiplegia and Left extremity (LE) contracture. I need assistance with my Activities of Daily Living (ADL's) .Interventions . Nail care PRN (as needed). On 01/03/23 at 11:40 AM, observation revealed Resident #11 sitting up in his wheelchair in front of the television. This observation revealed the resident is non-verbal but acknowledges when he was spoken to and held up his right hand and showed his thumb nail and then used his other fingers on his right hand to rub his long thumb nail. The resident then held up his left thumb and showed his left thumb nail. The residents thumb nails were uncut, long, and the resident's right ring finger and pinky finger revealed fingernails that were uncut, long and jagged. On 01/04/23 at 11:00 AM, observation revealed Resident #11 lying in bed with nails uncut, long and jagged to hands bilaterally. On 01/04/23 at 11:10 AM, during an observation and interview with Licensed Practical Nurse (LPN) #2 revealed it is the responsibility of the 3 PM-11 PM shift Certified Nursing Assistants (CNAs) to do the nail care. An observation of the resident at this time revealed LPN #2 confirmed that the resident's nails were long and jagged and needed to be trimmed. She revealed the purpose for keeping the resident's nails trimmed were to prevent an injury to his skin. On 01/04/23 at 11:45 AM, in an interview with the Director of Nurses (DON) confirmed that it is the responsibility of the 3 PM-11 PM shift CNAs to do nail care unless the resident is a diabetic or they are having a challenge getting the nails clipped. She revealed if the resident is a diabetic or the CNA is having a challenge then they are to notify their nurse. She revealed that nail care is not documented anywhere but is expected to be done with baths and the trimming should be addressed at least once per week. She revealed the reason that nails need to be trimmed is to prevent injury. Record review of Resident #11's Admission Record revealed the resident was admitted to the facility on [DATE] and medical diagnoses that include Hemiplegia and Hemiparesis following Cerebral infarction affecting left non-dominant side. Resident #32 Record review of Resident #32's comprehensive care plan with a print date of 1/4/23, revealed, Focus: I am at risk for pressure ulcer formation r/t (related to) decreased mobility, assistance required with bed mobility, and incontinence of bowel and bladder . Interventions . Weekly skin and body audit per assigned nurse with +/- (positive/negative) impairments documented. On 1/4/23 at 11:00 AM, an interview with the Treatment Nurse confirmed that Resident #32 had a deep tissue injury that was facility-acquired to her left heel that was discovered on 12/9/22. During an interview on 1/4/23 at 12:25 PM with Licensed Practical Nurse (LPN) #1 confirmed that weekly body audits are to be completed on all residents. She revealed that the body audit for Resident #32 was to be completed by the day shift nurse. She confirmed that there were no body audits completed for Resident #32 from 9/5/22 until 12/09/22 when it was discovered that Resident #32 had a deep tissue injury to her left foot. On 1/4/23 at 3:17 PM, interview with the DON confirmed that each resident is to have a weekly body audit and that Resident #32 had not had a body audit from 9/5/22 until 12/09/22. The DON confirmed the suspected deep tissue injury was facility acquired and if the weekly body audits were being completed as they should have been, this wound could have possibly been prevented. An interview on 01/05/23 at 9:33 AM, with the Minimum Data Set (MDS) nurse revealed she is one of the MDS nurses responsible for implementing the care plan. She revealed when a resident is admitted we do a baseline care plan within 48 hours. If there are any changes, they will be updated in the chart under the temporary care plan list. She revealed the MDS nurses will update the comprehensive care plan when there is a significant change and at least quarterly. She confirmed that the plan of care was not being followed and that Resident #32 was to have weekly skin audits, but they were not being done. A record review of Resident #32's Admission Record revealed the resident was readmitted to the facility on [DATE] with diagnoses of Cerebral infarction, Hemiplegia, and Hemiparesis affecting left non-dominant side, Type 2 Diabetes Mellitus, and Hypertensive heart disease. Resident #61 Record review of Resident #61's Care Plans with a print date 1/4/23 revealed Focus: I require assistance with ADL's r/t (related to) self-care impairment due to Guillain-Barre, limited ROM to upper and lower extremities, obesity, and poor cognition .Goal- My needs will be met every shift & as needed with assist of staff thru the next 90 days .Interventions .Nail care as needed or scheduled . An observation on 01/03/23 at 12:50 PM, revealed Resident #61 lying in bed with hands drawn inward bilaterally and long, uncut fingernails were observed. An observation on 01/04/23 at 8:53 AM, revealed Resident #61 lying in bed with hands in splints and long, uncut fingernails. On 01/04/23 at 11:05 AM, during an interview and observation with CNA #3 revealed it is the responsibility of the 3 PM-11 PM shift CNAs to complete nail care. She confirmed that Resident #61's nails were too long and needed to be trimmed. She revealed she started working on the North end of the hallway yesterday and noticed that the resident's nails were long, but she did not trim them or say anything to her nurse. On 01/04/23 at 11:25 AM, in an observation and interview with LPN #3 revealed she is Resident #61's nurse and confirmed that the resident's nails were too long and needed to be trimmed because she has contractures, and the nails could dig into her skin and cause an injury. Record review of Resident #61's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Need for assistance with personal care. Resident #67 Record review of Resident #67's care plan printed 1/4/23 revealed Focus: I am at risk for pressure ulcer formation r/t decreased mobility, assistance required with bed mobility, and frequent incontinence of bowel and bladder .Goal . I will have no pressure ulcer formation through the review date . Interventions .Weekly skin and body audit per assigned nurse with +/- impairments documented and CNA to check skin daily during care and report all red areas to assigned nurse . On 01/04/23 at 4:15 PM, during an interview with the Treatment Nurse confirmed that Resident #67 had a facility acquired pressure ulcer to her left heel that was discovered on 07/22/22. She revealed that it is the responsibility of the LPN on the hall to do the resident's body audit's weekly. She revealed that if the body audits would have been done weekly like they are supposed to then the pressure ulcer could have been discovered at an earlier stage. On 01/04/23 at 4:30 PM, during an interview with the Director of Nurses (DON) confirmed that Resident #67 has a facility acquired pressure ulcer to her left heel and a right leg amputation. She revealed that weekly body audits are supposed to be performed by the LPN's assigned to that resident. She confirmed the resident received a body audit on re-admission to the facility on [DATE] but did not receive weekly body audits after that date until 7/22/22 when the pressure ulcer to the left heel was first discovered. On 01/05/23 at 2:30 PM, in an interview, LPN #2 reviewed Resident #67's miscellaneous section in the resident's electronic record and confirmed that no weekly body audits were documented on Resident #67 after the initial body audit was completed on re-admission on 06/03/22 and that she could not find another body audit until 7/21/22. She revealed she has no idea why this resident would not have had a weekly body audit completed and confirmed that the facility failed to complete her weekly body audit. An interview on 01/05/23 at 2:54 PM, with RN #1 revealed she does the skin assessments for Minimum Data Set (MDS) assessments and makes recommendations for changes to the plan of care based on those assessments. She revealed that Resident #67 had a skin assessment completed prior to the development of the current pressure ulcer by MDS that revealed the resident was high risk for pressure ulcers. She revealed the resident's skin assessment resulted in a score of 14 on 05/09/22 which indicates the resident is at high risk for pressure ulcers. She revealed she does not recall making any changes to the resident's care plan or treatment suggestions. Record review of Resident #67's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Type II Diabetes and Acquired absence of the right leg below the knee. Record review of Resident #67's electronic record for June 2022 and July 2022 revealed there were no weekly body audits documented between 06/11/22 and 07/21/22. Record review of Resident #67's Weekly Body Audits revealed an audit dated 07/22/22 that indicated the resident had a Stage II pressure ulcer to her left heel 46013

Based on observation, staff interview, facility policy review, and record review the facility failed to prevent the possibility of food borne illness as evidenced by improper thawing of raw chicken, improper storage of two (2) bags of opened flour, and black substance on the inner door panel of the ice machine. This had the potential to affect 77 of 88 residents who receive food or ice from the kitchen. Findings include: Record review of Facility Policy dated for 02/11/2022 titled, Food Service Operational Standards For Purchasing, Receiving, Cooking and Storage of Food, revealed Policy: The facility receives, stores, prepares, distributes and serves food under sanitary conditions to prevent the spread of food borne illness and to reduce those practices that result in food contamination and compromised food safety .Procedure .3. Storage .b. Foods should be stored above the floor d. Keep foods in leak proof, non-absorbent, sanitary wrapping .4. Thawing .b. If time and space do not allow for refrigerator thawing, thaw frozen foods under potable (drinkable), running water at a temperature of 70 degrees or lower . Record review of Facility Policy, Ice Machine Maintenance and Cleaning dated 06/06/2022 revealed Policy: The facility ice machine will be deep cleaned and sanitized once every six months and cleaned with bleach solution weekly . On 01/03/23 at 10:35 AM, an observation during the initial kitchen tour revealed 14 raw chicken wings thawing in one side of the two (2) compartment sink. The chicken wings were submerged in a sink full of water and no water was running over the chicken to thaw it out. The observation also revealed 2 opened, twenty-five-pound bags of flour in the dry storage room. The top of each bag of flour was rolled down and was not sealed shut. One bag of flour with about five (5) pounds remaining inside, was located directly on the floor, and was not dated. The other bag of flour with approximately 20 pounds remaining, was dated, and was located on the bottom shelf about a foot off of the floor. On initial tour of the kitchen, the State Agency (SA) also observed a black substance, numerous spots about the size of a pencil eraser, scattered along the inner door panel of the ice machine and about eight (8) black spots located along the right inner gray side panel just inside the machine. On 01/03/23 at 10:40 AM, an interview with the Dietary Manager (DM) confirmed that raw chicken was not supposed to be thawed with water that was not running continuously. The DM revealed that the raw chicken was not being thawed correctly and could cause residents to get sick. The DM revealed that he had completed in-services with the employees on proper food handling, thawing, and storage of food. The DM also confirmed that the two sacks of self-rising flour should have had dates on them and should have been stored in a storage container with a lid to prevent exposure to possible contaminants. On 01/03/23 at 10:45 AM, an interview with the DM revealed that the black substance in the ice machine could be dirt or mold and that this could cause the residents to get sick. He also revealed that he cleaned the ice machine a week or two ago and that there was no certain person responsible for this task. The DM could not produce a cleaning schedule for the ice machine when asked for by the SA. On 01/03/23 at 10:50 AM, the SA observed the DM disposed of the bag of flour that was stored on the floor and the 14 chicken wings that were improperly thawing. On 01/05/23 at 11:00 AM, an interview with Administrator (ADM) revealed that he was the Supervisor who was directly over the DM. ADM also confirmed that the opened bags of flour could cause contamination which could make the residents sick. ADM stated that he would order a storage container with a lid to fix this issue. The ADM also confirmed that the black substance seen in the ice machine could have been mold which could cause the residents to get sick and their policy was to have the ice machine cleaned on a regular basis. On 01/05/23 at 11:40 AM, an interview with Dietary Aid #2, revealed that they received training on food handling, food thawing, and food storage when hired and that they were required to attend in-services monthly with DM. Dietary Aid #2 confirmed that the in-services were held in-person, topics were discussed verbally by DM and that the kitchen/dietary staff had to sign when completed. On 01/05/23 at 2:00 PM, an interview with Assistant Director of Nursing (ADON), revealed that there had been no recent facility outbreaks of food borne illness and no significant stomach issues. ADON confirmed that the brown substance in the ice machine could have been mold and that this could cause sickness throughout the residents in the facility. ADON also confirmed that the chicken wings thawing in the sink without running water could cause Salmonella or other illnesses to the residents and that this was unacceptable.

Based on observation, record review and staff interview, the facility failed to provide adequate supervision to ensure Residents did not elope from the facility for one (1) of eleven (11) residents reviewed, Resident #1. Resident #1, who was assessed and care planned as an elopement risk, was discovered on 12/31/2016, by Licensed Practical Nurse (LPN) #1, lying under his tipped over wheelchair in a ditch with running water, at approximately 5:35 PM, after Community Member #1 alerted LPN #1 to a man in a wheelchair in the street that runs in front of the facility. Staff interviews revealed they weren't sure how deep the water was in the ditch, but Resident #1's head was held up by staff to ensure water did not cause an injury or distress to the resident. The location of Resident #1, when found, was 0.1 miles from the facility front door. Resident #1 was taken to the local emergency room by Emergency Medical Services (EMS) and returned later that evening with a [DIAGNOSES REDACTED]. Based on statements in the facility investigation, Resident #1 was last seen inside the facility on 12/31/2016, at approximately 5:05 PM, by Dietary Assistant #1. This resulted in Resident #1 being out of the facility unsupervised, approximately 30 minutes until the resident was located by LPN #1 and Community Member #1 lying in the ditch. The lack of supervision for a resident with a history of wandering behaviors placed this and other residents at risk in a situation that was likely to cause serious harm, injury, impairment or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 12/31/16, when the resident eloped from the facility. The facility Administrator was notified on 1/11/2017 at 1:00 PM, of the Immediate Jeopardy and Substandard Quality of Care. An acceptable AOC was received on 1/12/17, in which the facility alleged the IJ was removed on 1/12/17. The State Agency (SA) determined the IJ was removed on 1/12/17, prior to exit, and the scope and severity for the IJ at 42 CFR 483.25 (d) F323, was lowered to a D level while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's undated Care System Guideline for Elopement revealed: Purpose: To establish a process that identified risk and establishes interventions to mitigate the occurrence of elopements. Residents are assessed for elopement risk on admission. If an elopement risk is determined a plan is established, interventions are documented on the elopement risk care plan and on the CNA care card. If after admission, a newly identified elopement risk resident is noted, a new risk assessment is completed and a plan is established. These interventions are put on the elopement risk care plan and on the CNA care card. If a bracelet alarm is chosen as an intervention there is a plan for daily monitoring of function. Review of the facility's written investigation, dated 1/5/17, revealed that on 12/31/16, at approximately 5:20 PM, a community member came into the facility and told LPN #1 a man in a wheelchair (determined to be Resident #1) was about 150 feet outside the front door. LPN #1 went outside and found Resident #1 beside his wheelchair. Resident #1 was assessed with [REDACTED]. Resident #1's statement was that he was going to see his doctor at the clinic next door. Upon return from the ER evaluation, Resident #1 did not remember the incident. The investigation included statements from staff that no alarms were heard other than when residents went out to smoke and a staff member was with them. The investigation included statements from staff that Resident #1 was last seen around 5:00 PM sitting in the hallway. The facility was unable to identify anyone who saw Resident #1 exit the facility or anyone who may have assisted the resident out of the facility. (The facility did not include in the written report that Resident #1 was found with his wheelchair tipped over on top of him with the wheels in the air. Resident #1 was also in a ditch with an undetermined depth of running water. Staff held the resident's head above the water in the ditch until EMS arrived to transport the resident to the ER). Review of an Incident report, dated 12/31/16, revealed that Resident #1 was off the premises and had fallen from his wheelchair. Resident voiced that he was going to the doctor. The incident report revealed that Resident #1's elopement alarm was still intact and functioning properly. Review of Progress Notes dated 12/21/16 at 5:40 PM, revealed Resident #1 exited the building, was assessed with [REDACTED]. Review of the Emergency Medical Technician (EMT) record, dated 12/31/16, revealed the incident for Resident #1 was reported to the ambulance service at 5:35 PM on 12/31/2016, and they were on scene by 5:38 PM. There was no Resident temperature documented on this report, however, the report noted Resident #1 was shaking from cold weather and was removed from the environment, dried and covered in dry blankets, and hot packs placed bilaterally in the axillary and in the groin area. Resident transported to local ER for evaluation. The report revealed a history: (Resident #1) escaped from the nursing home in wheelchair and began heading down the road. Patient was spotted by passerby and nursing home (NH) staff was alerted. NH staff began after the patient and the patient's wheelchair got too close to the shoulder of the road and slid into the ditch. First responders were there within minutes and removed the wheelchair but left the patient in the water and waited for EMS to arrive. Estimated time of patient in ditch is 7-8 minutes. Upon arrival, nursing home staff was holding the patients head out of the water and EMS immediately removed patient from water and got him out of the weather by wheeling him back to the nursing home via wheelchair to dry the patient and begin rewarming him. Patient was stripped of his wet clothes and was dried by EMS. Nursing home staff provided EMS with a gown for the patient. Patient denied any pain or discomfort and his only complaint was being really cold. Patient denied hitting his head or loss of consciousness. Review of the website, Accuweather.com, revealed that on 12/31/2016, the actual high temp that day was 63 degrees Fahrenheit and the low was 44 degrees Fahrenheit. The website, Weather.com, revealed that the temperatures were high 62 degrees Fahrenheit with a low of 43 degrees Fahrenheit with showers on 12/31/2016. Review of Assessments dated 10/10/16 and 1/1/17, revealed Resident #1 had a history of [REDACTED]. Review of Resident #1's physician's orders [REDACTED]. There was an order for [REDACTED]. Review of Resident #1's Care Plan, initiated 10/15/16, revealed the resident was at risk for elopement related to attempts to leave the facility. A goal was documented: I will have no incidence of elopement. Interview with Certified Nurse Aide (CNA) #2, on 1/13/2017 at 11:15 AM, revealed she took Resident #1 outside for supervised smoking at 4:30 PM, on 12/31/2016. When he finished at approximately 4:45 PM, she rolled him into the facility. She recalled the door alarm sounding because of his alarm bracelet activating it. She told him it was almost dinner time and to head to the dining room. Approximately five (5) minutes later, she saw Resident #1 inside the facility facing South Station. CNA #2 stated she had seen visitors in the past use the code to the front door, without staff assistance. Interview with Community Member (CM) #1, at 4:00 PM, and 4:25 PM, on 1/12/2017, revealed that on 12/31/2016, at approximately 5:28 PM to 5:30 PM, she drove past the Facility and saw a man in a wheelchair in the street. CM #1 stated that it was misty raining and getting dark. She turned her vehicle around, passed the man a second time and ran into the facility and spoke to woman at the nursing home. She stated when she went past the man the second time, he was still in the street. She told the woman in the facility, LPN #1, there was a man in a wheelchair in the street and asked if he belonged to the facility. CM #1 stated both of them ran to the end of the facility driveway. She stated it was approximately one (1) minute from seeing him the last time in the street until they saw Resident #1 lying in the ditch. Community Member #1 stated the ditch was not full enough for water to run over Resident #1's face. She remarked that before she could get her vehicle turned around and to the facility, two (2) more vehicles passed Resident #1 while he was in the street. She recalled seeing their brake lights as each vehicle got closer to the Resident. Interview with LPN #1 on 1/11/2017, at 11:15 AM, revealed on 12/31/2016 at approximately 5:30 PM, she was sitting in the facility front lobby when a Community Member (CM #1) came through the front door saying a man in a wheelchair was near the street and asked if he belonged to the facility. LPN #1 stated she and CM #1 ran to the end of the facility driveway, looked both ways down the street and did not see anyone. LPN #1 stated that the Community Member pointed to the left, indicating the last direction she observed the resident. LPN #1 stated at that time, a light reflected off of something and both she and CM #1 ran that direction. LPN #1 stated she found Resident #1 in a ditch on the left side of the street and the wheelchair was flipped over onto him. She stated there were unidentified community members stopping to assist after she and CM #1 got to the resident. LPN #1 stated she had one(1) person call 911, one(1) person shine a light onto the resident since it was dark, one (1) person to hold an umbrella over him since it was lightly raining and another person to call the facility. LPN #1 stated she held up the head of Resident #1 because there was water in the ditch. His face was not under water when I first got to him. She stated the Emergency Medical Technicians (EMTs) arrived and got Resident #1 out of the ditch and took him to the facility. LPN #1 stated Resident #1 did not look hurt and he wasn't complaining of any pain. LPN #1 stated she had seen Resident #1 push on the doors before but stated resident was confused so she couldn't say whether or not he was trying to push on the doors to get out. On 1/11/17 during the interview with LPN #1 at 11:15 AM, the surveyor walked with LPN #1 to the area where Resident #1 was located in the ditch, which was about a two (2) minute walk and 200 steps from the facility. LPN #1 stated she had been in the facility lobby about 10 minutes on the evening of 12/31/17 and didn't hear an alarm, and saw no one entering or leaving the facility during that time, prior to being summoned by CM #1. In an interview on 1/11/2017 at 11:45 AM, LPN #1 recalled telling staff to call the Administrator and Director of Nurses (DON) after she got back into the facility on [DATE]. LPN #1 stated There was water in the ditch, not sure of how deep. I got into the ditch with him and held up his head. His face was not under water when I first got to him. No water ever ran over his face. Observation at 11:45 AM on 1/11/2017, revealed the depth of the area where LPN #1 found Resident #1 measured 21 inches from the level of the street and 64 inches from the edge of the street. The street does not have a sidewalk and the edge of the street had crabgrass growing. The ditch was dry at the time of this observation. There was a culvert under a driveway that drains into this ditch and drains out from the next culvert. Community Member #1 also confirmed this location is where Resident #1 was lying in the ditch on 1/12/2017 at 4:25 PM. Interview with LPN #3, at 4:17 PM and 4:35 PM on 1/12/2017, revealed she had last seen Resident #1 around 4:30 PM (12/31/16). She stated after the EMT's brought Resident #1 inside the facility, he was assessed for injuries and his wet clothes were changed. She said there were no obvious injuries and he was not complaining of pain. She called the Medical Doctor and got orders to send Resident #1 to the emergency room (ER) for evaluation. She did not recall seeing his elopement band/bracelet but did recall the front doors alarming when Resident #1 was brought into the facility from the ditch. LPN #3 stated she did not recall hearing the door alarm sound when Resident #1 returned from the ER. She said that Resident #1 seemed to be more confused about a week prior to this, easily agitated, little things bothering him. LPN #3 stated Resident #1 was pleasantly confused 50 percent of the time, and knowing now that he had a UTI at the time of the incident made sense that he was more confused than usual, and resistive to care. She stated that North Unit nurses counted their Residents and she counted South Unit residents to ensure all the residents were in the facility the night of the event and all were accounted for. Interview with CNA #1 on 1/13/2017 at 10:40 AM, revealed he was Resident #1's CNA the shift that he eloped. CNA #1 did recall Resident #1 was wearing a jacket, t-shirt, jogging pants and shoes when the EMT's returned him to the facility right after he eloped. CNA #1 stated He didn't look hurt. He began to complain of pain between his right shoulder and neck. He stated that he recalled hearing the alarm sounding when CNA #2 took Resident #1 out to smoke at 4:30 PM, because he responded to that alarm and saw that it was Resident #1 going to smoke and was supervised by CNA #2. CNA #1 stated he helped change Resident #1's wet clothes and saw his alarm bracelet. CNA #1 stated he did not hear the alarm when they brought Resident #1 in from the elopement. Interview with LPN #2 on 1/13/2017 at 11:00 AM, revealed she was Resident #1's assigned nurse the shift he eloped. She last recalled seeing him at approximately 4:30 PM, propelling himself in his wheelchair for supervised smoking. She remembered when Resident #1 was brought back into the facility after the elopement that he was wearing a hat and a jacket because she assisted in removing those. She stated, I took his socks off and the elopement band was on his ankle. I was in such a hurry to get his clothes off, because they were wet, I didn't look to see if the bracelet was working. She stated, He was not hurt, only the small abrasion to his left knee. LPN #2 stated, He rubbed his neck when we got him to his room. LPN #2 also stated, It was raining outside, it was cool. He was shivering. He stopped shivering when we got him out of the wet clothes. Interview with the Maintenance Director on 1/12/2017 at 3:45 PM, revealed that he checks doors daily for locking and alarm function. He stated the Weekend Manager does the door check during the weekends. He stated, The Friday before this incident (12/30/16), I brought a resident to the front door, the door wasn't locking for some reason. I reset the system and it started working. The Maintenance Director stated, I did come in on 12/31/2016 when this happened to check all the doors. All the doors were alarming and locking like they should. I did the elopement drills every shift after also. He stated there were no noted problems. Elopement drills were done prior to this incident with no noted problems. He stated every exit door has an alarm and when the door is pushed open the alarm sounds and can't be silenced until the door is shut and the code is put in. He stated, Prior to this, the last time the (door alarm) code was changed was August 2016. Now we are going to do it one(1) time a month. Observation of Resident #1, on 1/10/2017 at 5:45 PM, revealed he had his elopement alarm band on his left ankle. Resident #1 was in the dining room feeding himself dinner. Resident #1 was oriented to person. Interview with Resident #1 on 1/11/2017 at 1:45 PM, revealed he did not recall ever leaving the facility, flipping his wheelchair over into a ditch or hurting himself. Observation of his Left Knee at this time revealed no scar or open area. The Function status of his elopement band revealed it is working. This is checked by observation of a red blinking light on the alarm and with a box, used by the Director of Nurses (DON), designed to check the alarm function. Review of the facility's investigation included an interview with Dietary Assistant #1. She recalled working the evening of 12/31/2016. She took meal carts out of the kitchen and saw Resident #1 at the first dining room door headed in the opposite direction. She turned him around and told him it was almost time for him to eat and to go to his table. She went back into the kitchen and doesn't recall seeing him again. She clocked in that day at 5:00 PM. Attempts X 2 that were made to contact Dietary Assistant #1 were unsuccessful prior to leaving the facility. Interview with Dietary Assistant (DA) #1 per return phone call on 1/19/17 at 5:15 PM, revealed she had seen Resident #1 after getting to work shortly after 5:00 PM (12/31/16). The DA stated Resident #1 said he needed to go see a man about his truck and go smoke. The DA stated she had told Resident #1 that his truck was not outside and no one was out smoking right then. The DA stated she told Resident #1 it was dinner time and turned his wheelchair around to go to the dining room. The DA stated the next time she saw Resident #1 is when the ambulance brought him back in. (There was no evidence that Resident #1's statement of wanting to go outside to see a man about his truck and go smoke was reported to nursing.) Interview with the Administrator on 1/10/17 at 5:30 PM, revealed there were alarms on all doors and all doors required a code for an Accutech bracelet to exit without alarming. She stated all doors required a code to be entered except the front door and the code for it is only entered from 8:00 PM until 8:00 AM, after the door is locked. She stated she could lock the front door now, but that would require a full time person at the front door to open it. The Administrator stated the door codes were changed after the incident with Resident #1's elopement. She stated Resident #1 was unable to say what happened and when asked, he stated he was going to his doctor's clinic. The Administrator stated Resident #1 had his alarm bracelet on prior and after the incident and was functional. The Administrator stated the only thing she could figure was that Resident #1 was sitting in the front lobby and the door would have automatically locked; unless a visitor was coming in or going out and used the code. The Administrator stated there was no way of knowing who that visitor would have been because there were no video cameras in the facility. The Administrator stated Resident #1 should not have been outside without supervision. Interview with the Director of Nurses (DON), on 1/11/17 at 10:30 AM, revealed she acknowledged Resident #1 left the facility unsupervised on 12/31/16. Statements from the DON included: There was a 100% head count done of all residents after Resident #1 eloped. Upon return from the ER, Resident #1 was monitored one on one (1:1) for 72 hours. He was still displaying wandering behaviors after the first 72 hours so the 1:1 was extended for another 72 hours. No further wandering behavior occurred; therefore the facility continued the every two (2) hour visual checks. Elopement bands were immediately checked on all 11 elopement risk residents on 12/31/2016. All 11 elopement risk residents were reassessed on 1/01/2017. The DON stated that 100% of the Residents were not reassessed for elopement risk until 1/10/17. The DON was not aware of how Resident #1 left the facility. During observation on 1/10/2017, by State Agency Surveyor, prior to entrance to the facility, at 5:20 PM to 5:30 PM, zero (0) vehicles passed the nursing home on the street. Two (2) vehicles did leave the facility parking lot during that 10 minute timeframe. Upon entrance to the facility on [DATE] at 5:30 PM, a sign was observed, by the surveyor, on the front doors for visitors to not assist residents out of the facility and to get a staff member if someone wants to go out. The front door was unlocked and opened freely with no code necessary for entrance and exit. Review of the medical record of Resident #1 revealed he was admitted on [DATE], with [DIAGNOSES REDACTED]. Medical Doctor orders revealed on 12/31/2016 that X-rays of his right hand and back of his neck were ordered due to pain. There were no negative outcomes. Ciprofloxacin 500 milligrams (mg) two (2) times a day for seven (7) days was ordered for a UTI. On 1/1/2017, Bacitracin 500units/gram to his left knee twice a day after cleaning with normal saline until healed. Treatment has been discontinued by 1/11/2017 due to healing. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/15/2016, revealed a Brief Interview for Mental Status (BIMS) score of 8, indicating Resident #1 was moderately impaired, made poor decisions and required cues/supervision. The facility Administrator was notified on 1/11/2017 at 1:00 PM of an Immediate Jeopardy and Substandard Quality of Care. The facility provided an Acceptable Allegation of Compliance (AOC) on 1/12/17 for the Immediate Jeopardy. Review of the facility's AOC revealed the facility took the following actions to remove the Immediate Jeopardy: 1. On 12/31/2016, at approximately 05:20/05:25 PM, License Practical Nurse (LPN) #1, who was sitting at the front entrance of the facility, was notified by Community Member #1, of a gentleman being off the property in his wheelchair. On 12/15/2016, Resident #1 had a Quarterly MDS with a BIMS score of 8, indicating Resident # 1 had moderately impaired cognition. Resident # 1 was last seen inside the facility by Dietary Assistant # 1 on 12/31/2016 at 05:05 pm. At approximately 05:30 PM, Resident #1 was found by Licensed Practical Nurse # 1 approximately 150 feet from the facility in the ditch. 911 was called by Community Member # 1 at 05:35 PM, and (Emergency Medical Services (EMS) arrived at 05:38 PM and assisted Resident # 1 from the ditch and returned him to the facility. Upon return back inside the facility, Resident #1 was assessed immediately by Licensed Practical Nurse #2 with a minor abrasion noted on his left knee and complaints of neck pain. During the assessment it was noted that Resident # 1's elopement band was on his left ankle and functioning by Licensed Practical Nurse # 2. Medical Doctor/Primary MD was notified at 05:40 PM of Resident #1 leaving the facility without staff knowledge, abrasion to knee and complaints of neck pain by Licensed Practical Nurse #3. New orders received to send Resident #1 to ER for evaluation. Resident #1's Responsible Party was notified by Director of Nursing of the incident at 06:30 PM . Resident # 1 returned to the facility at approximately 09:30 PM via EMS. No other issues reported. 2. On 12/31/2016 at 05:43 PM, Licensed Practical Nurse #3 notified the Director of Nursing of Resident # 1 being found outside the facility. The Director of Nursing directed Licensed Practical Nurse #3 to do a complete head count of all 90 residents to ensure everyone was in the facility. Licensed Practical Nurse #3 was also directed to check all eleven 11 elopement risk residents. The placement and functioning of all the Accutech alarm systems were checked. No negative findings. 3. On 12/31/2016 at 05:55 PM, the Administrator entered the facility and immediately began investigation. No functional issues identified with the Accutech system. The Administrator had concerns over the number of people who may have the exit door codes. No signage on the front door at this time. Resident # 1 was on stretcher in hallway at the south nursing station about to leave with EMS. Elopement band on Resident #1's left ankle at this time and function was observed by the Administrator. 4. On 12/31/2016 at 06:00 PM, the Director of Nursing initiated training for all facility staff on the elopement policy, including definition, prevention measures, assessment of risk, visual checks, door alarms, use of elopement bands, appropriate response to suspected elopement, sharing of codes with non- staff members or visitors. In-service also included abuse/neglect and accidents and incidents. No employees were allowed to work until they had completed this in-servicing. All in-servicing completed on 01/06/2017. 5. On 12/31/2017 at 06:15 PM, the Director of Nursing updated Resident #1's care plan related to the elopement. 6. On 12/31/2016 at 06:30 PM, the Administrator checked all facility exit doors. All found to be locking and alarming properly. 7. On 12/31/2016 at 06:30 PM, the Director of Nursing completed a second visual head count of all residents in the living center and confirmed that the head count matched the current census of 90. 8. On 12/31/2016 at 06:45 PM, the Director of Nursing checked all 11 residents assessed at risk for elopement to ensure elopement bands were in place and functioning. No negative findings identified. 9. On 12/31/2016 at 07:20 PM, the Director of Nursing completed an audit on physician orders/Medication Administration Records (MAR), care plans and care cards on all 11 identified at risk residents to ensure they were appropriately identified for elopement risk. All were appropriately identified. 10. On 12/31/2016 at 09:10 PM, the Administrator notified the MS Stated Department of Health via the complaint hotline of Resident #1 exiting the facility without staff knowledge on 12/31/2016 at 05:25 PM. 11. On 12/31/2016 at 09:29 PM, the Director of Nursing notified the Attorney General via their website of Resident # 1 exiting the facility without staff knowledge on 12/31/2016 at 05:25 PM. 12. On 12/31/2016 at 09:30 PM, Resident # 1 returned to facility from the ER. Resident #1 was placed into bed by EMS. The Administrator and Director of Nursing immediately assessed resident for elopement band placement and function. Elopement band was located on Resident # 1's left leg and was functioning. At approximately 09:35 PM, Certified Nursing Assistant (CNA) #1 and #2 assisted Resident #1 back into his wheel chair and he was brought to the front to check the bracelet against the front door system. The door locked appropriately. Resident #1 was returned to his room and placed to bed. 13. On 12/31/2016 at 09:30 PM, Resident # 1 was placed on 1:1 supervision by Director of Nursing. Staff monitoring of Resident # 1 for 72 hours with no negative outcome. 14. On 01/01/2017 at 08:00 AM, the Administrator reviewed the facility's elopement books to ensure all identified residents at risk pictures were present in the book. All 11 were identified in the books. 15. On 01/01/2017 at 08:30 AM, the Administrator placed signage on both sides of the front door asking visitors not to assist residents out of the facility. 16. On 01/01/2017 at 10:00 AM, all alarm bands were checked against the door system again by the Director of Nursing with the Administrator. No issues identified. 17. On 01/01/2017 at 10:45 AM, the Maintenance Director began elopement drills on all three (3) shifts. All drills completed by 01/03/2017. No issues identified. 18. On 01/01/2017 at 11:00 AM, all exit doors were rechecked by the Maintenance Director. No issues identified. 19. On 01/02/2017 at 08:00 AM, the Administrator increased the amount of checks completed on all exit doors. All exit door checks went from daily to twice a day. In addition to the daily door checks completed by the Maintenance Director, the Administrator is also checking the exit doors daily. The Administrator is now making audits of all the exit doors daily to ensure proper locking and alarming. 20. On 01/02/2017 at 08:00 AM, the Director of Nursing increased the amount of checks occurring on the elopement bands from weekly to daily. 21. On 01/02/2017 at 08:45 AM, a Quality Assessment and Performance Improvement meeting was held to discuss Resident # 1 exiting the facility without staff knowledge, Resident's location when found, and facility's actions to prevent re-occurrence. Attending this meeting included: Executive Director, Director of Nursing, Assistant Director of Nursing, Wound Care Nurse, Director of Clinical Education, South Unit Nurse Manager, North Unit Nurse Manager, Social Service Director, RNAC, Workforce Management Coordinator, Therapy Director, Housekeeping Supervisor, Dietary Manager and Medical Director. Elopement policy reviewed with no policy changes made. Items discussed included: call made to have code on front door changed, signage placed on front door, increased monitoring of exit doors and elopement bands, review of elopement books, reviewed physician orders/MAR, care plans and care cards, in-services on abuse/neglect, accident/incidents and elopement prevention and elopement drills. 22. On 01/03/2017 at 08:00 AM, the code to the front door was changed by a representative from the contracted alarm company. The Administrator will ensure the code is changed the first day of every month going forward. 23. On 01/10/2017 at 09:00 PM, the Director of Nursing and the Administrator did elopement risk assessment on all 93 residents in the facility. No new residents identified at risk for elopement. 24. On 01/11/2017 at 01:00 PM, the Administrator placed a staff member at the door to assist visitors in and out of the facility and to prevent the inadvertent exit of an elopement risk resident. A staff member will be on duty twenty four hours a day, seven days a week. 25. The facility alleges the immediate Jeopardy was removed 01/12/2017. On 1/13/17, The State Agency (SA) validated the facility had implemented the following measures to remove the IJ: 1. The SA validated the facility's incident of Resident #1's elopement on 12/31/2016, return to the facility on [DATE], emergency room (ER) evaluation and assessment and return to the facility again on 12/31/2016. The SA verified this by record review, interviews/written statements of staff, Emergency Medical Technicians (EMT) record, ER record and written reports to the SA. 2. The SA validated by staff interviews, review of the facility's investigation, review of written statements and Interdisciplinary Progress Notes that on 12/31/2016 all of the remaining 90 residents of the facility were accounted for. The placement and function of all Accutech alarm system bracelets worn by all 11 elopement risk residents were checked without negative findings. 3. The SA verified through record review, observation and interview with the Administrator that on 12/31/2016 no functional issues were identified with the Accutech System, the investigation began and that Resident #1 was noted with his elopement alarm bracelet and it was functioning. 4. The SA verified through interviews with staff and record review that in-services were initiated on 12/31/2016 and covered the elopement policy, definition of elopement, prevention measures, assessment of risk, visual checks, door alarms, use of elopement bands

Based on record review, policy review and staff interview, the facility failed to provide services and effectively monitor and meet the goals as outlined by the elopement risk care plan for one (1) of 11 residents reviewed, Resident #1, to ensure the resident did not leave the facility unsupervised. Resident #1 left the facility unattended and was located in a ditch with his overturned wheelchair approximately 0.1 miles from the facility and was returned to the facility, sent to the emergency room and returned with a [DIAGNOSES REDACTED]. The goal for the at risk for elopement care plan states I will have no incidence of elopement was not met when Resident #1 left the facility unattended. The intervention for evaluation of cognitive impairment of the resident's ability to understand changes in surroundings was not implemented when Resident #1 had increased confusion and agitation the prior week to Resident #1 leaving the facility. The facility's failure to effectively monitor and ensure Resident #1 did not leave the facility unsupervised, per care plan, caused a situation that was likely to cause serious injury, harm, impairment or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 12/31/16, when the resident eloped from the facility. The facility Administrator was notified on 1/11/17 at 1:00 PM of an Immediate Jeopardy and Substandard Quality of Care. An acceptable Allegation of Compliance (AOC) was received on 1/12/17 in which the facility alleged the IJ was removed on 1/12/17. The State Agency (SA) determined the IJ was removed on 1/12/17, prior to exit, and the scope and severity for IJ at 42 CFR 483.21 (b) (3) (F282), was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Interview with the Administrator on 1/11/17 at 1:10 PM, revealed the facility uses the CMS Resident Assessment Instrument (RAI) manual for a care plan policy/procedure. On 1/12/17, the Administrator provided copies of the RAI manual pages 2-41, 2-42 and 4-1 through 4-41 for the procedure used by the facility. Review of Chapter 4 of the RAI manual, dated October 2016, page 4-9 section for Identifying goal and objectives of care: revealed goals are to Clarify purpose of providing care and of specific interventions, and the criteria that will be used to determine whether the objectives are being met. Review of Resident #1's care plan for elopement risk revealed a focus: I am at risk for elopement related to: attempts to leave Living Center, dated 10/15/2016, and revised on 10/15/16. The Goal included I will have no incidence of elopement, initiated 10/15/2016, revised on 12/19/2016 and a target date of 3/31/2017. Interventions included: Ankle alarm to be worn at all times to alert personnel from leaving building. Check that unit is in place and properly functioning. Visual checks every two (2) hours, Assess for risk of elopement per living center policy, Evaluate effect of cognitive impairment upon resident's ability to understand changes in surroundings, Involve patient in preferred activities, Redirect patients from doors, Take picture of patient upon admission for identification for updating elopement book. This care plan was updated 12/31/16, for an actual elopement with interventions to Continue Plan of Care (POC). Keep in view of staff as much as possible. One on one (1:1) (with documented) every 15 minute checks, to ensure resident is in the facility X 72 hours. This care plan was updated on 1/3/16 for continued wandering with the intervention to continue 1:1 (with documented) every 15 minute checks X 72 hours. Review of a facility written report, dated 1/5/2017, revealed Resident #1 left the building unattended on 12/31/16. Resident #1 was last seen by a facility Dietary Assistant after she had clocked in to work at 5:00 PM, inside the facility. At approximately 5:20 PM, Community Member #1 came into the facility and told Licensed Practical Nurse (LPN) #1 there was a man in his wheelchair about 150 feet outside the front door. LPN #1 and Community Member #1 located Resident #1 outside on the ground. He was brought back inside by Emergency Medical Technicians (EMTs), assessed and taken to the local emergency room (ER) for further assessment and evaluation. Resident #1 was returned to the facility on the same date with a [DIAGNOSES REDACTED]. (The facility did not include in their report that Resident #1 was found in a ditch with his wheelchair turned over on top of him with water in the ditch and staff held Resident #1's head up out of the water until EMS arrived). Interview, and review of the care plan for Resident #1, with the Minimum Data Set (MDS) Nurse on 1/12/17 at 11:30 AM, revealed new orders are reviewed daily and the care plans are updated with new interventions. CNA Kardex's are called pocket guides and are updated by the Unit Managers. Pocket guides are updated when changes are made. The Unit Manager will communicate any changes in interventions to the CNA's and nurses. Care plans are started on admission and revised quarterly, unless, a significant change occurs before the quarterly. The MDS Nurse acknowledged the goal of the care plan was for Resident #1 not to be outside of the facility without supervision. Interview with LPN #3, at 4:17 PM and 4:35 PM on 1/12/2017, revealed she had last seen Resident #1 around 4:30 PM (12/31/16) prior to his exit from the facility. She stated after the EMT's brought Resident #1 inside the facility, the resident was assessed for injuries and his wet clothes were changed. She said there were no obvious injuries identified. She stated Resident #1 was sent to the emergency room (ER) for evaluation. She did not recall seeing his elopement band/bracelet prior to him going to the ER, but did recall the front doors alarming when Resident #1 was brought into the facility from the ditch. She said that Resident #1 seemed to be more confused about a week prior to this, easily agitated, little things bothering him. LPN #3 stated Resident #1 was pleasantly confused 50 percent of the time, and knowing now that he had a UTI at the time of the incident made sense that he was more confused than usual, and resistive to care. There was no evidence that the care plan was followed to evaluate the cognitive impairment of Resident #1 during the time he was observed to be more confused than usual. Interview with the Administrator on 1/10/17 at 6:20 PM, revealed she wasn't sure how Resident #1 got outside the facility, and stated the only thing she figured was a visitor may have used the door code while the resident was sitting in the lobby and he went out (prior to the door closing securely); the door wouldn't have alarmed then. The Administrator acknowledged the resident shouldn't have been outside without supervision, (per care plan goal). Review of the medical record revealed the facility admitted Resident #1 on 3/08/2014, with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/15/2016, revealed a Brief Interview for Mental Status (BIMS) score of 8, indicating Resident #1 is moderately impaired, makes poor decisions and requires cues/supervision. The facility provided an Acceptable Allegation of Compliance (AOC) on 1/12/17 for the Immediate Jeopardy. Review of the facility's AOC revealed the facility took the following actions to remove the Immediate Jeopardy: 1. On 12/31/2016, at approximately 05:20/05:25 PM, License Practical Nurse (LPN) #1, who was sitting at the front entrance of the facility, was notified by Community Member #1, of a gentleman being off the property in his wheelchair. On 12/15/2016, Resident #1 had a Quarterly MDS with a BIMS score of 8, indicating Resident # 1 had moderately impaired cognition. Resident # 1 was last seen inside the facility by Dietary Assistant # 1 on 12/31/2016 at 05:05 pm. At approximately 05:30 PM, Resident #1 was found by Licensed Practical Nurse # 1 approximately 150 feet from the facility in the ditch. 911 was called by Community Member # 1 at 05:35 PM, and (Emergency Medical Services (EMS) arrived at 05:38 PM and assisted Resident # 1 from the ditch and returned him to the facility. Upon return back inside the facility, Resident #1 was assessed immediately by Licensed Practical Nurse #2 with a minor abrasion noted on his left knee and complaints of neck pain. During the assessment it was noted that Resident # 1's elopement band was on his left ankle and functioning by Licensed Practical Nurse # 2. Medical Doctor/Primary MD was notified at 05:40 PM of Resident #1 leaving the facility without staff knowledge, abrasion to knee and complaints of neck pain by Licensed Practical Nurse #3. New orders received to send Resident #1 to ER for evaluation. Resident #1's Responsible Party was notified by Director of Nursing of the incident at 06:30 PM . Resident # 1 returned to the facility at approximately 09:30 PM via EMS. No other issues reported. 2. On 12/31/2016 at 05:43 PM, Licensed Practical Nurse #3 notified the Director of Nursing of Resident # 1 being found outside the facility. The Director of Nursing directed Licensed Practical Nurse #3 to do a complete head count of all 90 residents to ensure everyone was in the facility. Licensed Practical Nurse #3 was also directed to check all eleven 11 elopement risk residents. The placement and functioning of all the Accutech alarm systems were checked. No negative findings. 3. On 12/31/2016 at 05:55 PM, the Administrator entered the facility and immediately began investigation. No functional issues identified with the Accutech system. The Administrator had concerns over the number of people who may have the exit door codes. No signage on the front door at this time. Resident # 1 was on stretcher in hallway at the south nursing station about to leave with EMS. Elopement band on Resident #1's left ankle at this time and function was observed by the Administrator. 4. On 12/31/2016 at 06:00 PM, the Director of Nursing initiated training for all facility staff on the elopement policy, including definition, prevention measures, assessment of risk, visual checks, door alarms, use of elopement bands, appropriate response to suspected elopement, sharing of codes with non- staff members or visitors. In-service also included abuse/neglect and accidents and incidents. No employees were allowed to work until they had completed this in-servicing. All in-servicing completed on 01/06/2017. 5. On 12/31/2017 at 06:15 PM, the Director of Nursing updated Resident #1's care plan related to the elopement. 6. On 12/31/2016 at 06:30 PM, the Administrator checked all facility exit doors. All found to be locking and alarming properly. 7. On 12/31/2016 at 06:30 PM, the Director of Nursing completed a second visual head count of all residents in the living center and confirmed that the head count matched the current census of 90. 8. On 12/31/2016 at 06:45 PM, the Director of Nursing checked all 11 residents assessed at risk for elopement to ensure elopement bands were in place and functioning. No negative findings identified. 9. On 12/31/2016 at 07:20 PM, the Director of Nursing completed an audit on physician orders/Medication Administration Records (MAR), care plans and care cards on all 11 identified at risk residents to ensure they were appropriately identified for elopement risk. All were appropriately identified. 10. On 12/31/2016 at 09:10 PM, the Administrator notified the MS Stated Department of Health via the complaint hotline of Resident #1 exiting the facility without staff knowledge on 12/31/2016 at 05:25 PM. 11. On 12/31/2016 at 09:29 PM, the Director of Nursing notified the Attorney General via their website of Resident # 1 exiting the facility without staff knowledge on 12/31/2016 at 05:25 PM. 12. On 12/31/2016 at 09:30 PM, Resident # 1 returned to facility from the ER. Resident #1 was placed into bed by EMS. The Administrator and Director of Nursing immediately assessed resident for elopement band placement and function. Elopement band was located on Resident # 1's left leg and was functioning. At approximately 09:35 PM, Certified Nursing Assistant (CNA) #1 and #2 assisted Resident #1 back into his wheel chair and he was brought to the front to check the bracelet against the front door system. The door locked appropriately. Resident #1 was returned to his room and placed to bed. 13. On 12/31/2016 at 09:30 PM, Resident # 1 was placed on 1:1 supervision by Director of Nursing. Staff monitoring of Resident # 1 for 72 hours with no negative outcome. 14. On 01/01/2017 at 08:00 AM, the Administrator reviewed the facility's elopement books to ensure all identified residents at risk pictures were present in the book. All 11 were identified in the books. 15. On 01/01/2017 at 08:30 AM, the Administrator placed signage on both sides of the front door asking visitors not to assist residents out of the facility. 16. On 01/01/2017 at 10:00 AM, all alarm bands were checked against the door system again by the Director of Nursing with the Administrator. No issues identified. 17. On 01/01/2017 at 10:45 AM, the Maintenance Director began elopement drills on all three (3) shifts. All drills completed by 01/03/2017. No issues identified. 18. On 01/01/2017 at 11:00 AM, all exit doors were rechecked by the Maintenance Director. No issues identified. 19. On 01/02/2017 at 08:00 AM, the Administrator increased the amount of checks completed on all exit doors. All exit door checks went from daily to twice a day. In addition to the daily door checks completed by the Maintenance Director, the Administrator is also checking the exit doors daily. The Administrator is now making audits of all the exit doors daily to ensure proper locking and alarming. 20. On 01/02/2017 at 08:00 AM, the Director of Nursing increased the amount of checks occurring on the elopement bands from weekly to daily. 21. On 01/02/2017 at 08:45 AM, a Quality Assessment and Performance Improvement meeting was held to discuss Resident # 1 exiting the facility without staff knowledge, Resident's location when found, and facility's actions to prevent re-occurrence. Attending this meeting included: Executive Director, Director of Nursing, Assistant Director of Nursing, Wound Care Nurse, Director of Clinical Education, South Unit Nurse Manager, North Unit Nurse Manager, Social Service Director, RNAC, Workforce Management Coordinator, Therapy Director, Housekeeping Supervisor, Dietary Manager and Medical Director. Elopement policy reviewed with no policy changes made. Items discussed included: call made to have code on front door changed, signage placed on front door, increased monitoring of exit doors and elopement bands, review of elopement books, reviewed physician orders/MAR, care plans and care cards, in-services on abuse/neglect, accident/incidents and elopement prevention and elopement drills. 22. On 01/03/2017 at 08:00 AM, the code to the front door was changed by a representative from the contracted alarm company. The Administrator will ensure the code is changed the first day of every month going forward. 23. On 01/10/2017 at 09:00 PM, the Director of Nursing and the Administrator did elopement risk assessment on all 93 residents in the facility. No new residents identified at risk for elopement. 24. On 01/11/2017 at 01:00 PM, the Administrator placed a staff member at the door to assist visitors in and out of the facility and to prevent the inadvertent exit of an elopement risk resident. A staff member will be on duty twenty four hours a day, seven days a week. 25. The facility alleges the immediate Jeopardy was removed 01/12/2017. On 1/13/17, The State Agency (SA) validated the facility had implemented the following measures to remove the IJ: 1. The SA validated the facility's incident of Resident #1's elopement on 12/31/2016, return to the facility on [DATE], emergency room (ER) evaluation and assessment and return to the facility again on 12/31/2016. The SA verified this by record review, interviews/written statements of staff, Emergency Medical Technicians (EMT) record, ER record and written reports to the SA. 2. The SA validated by staff interviews, review of the facility's investigation, review of written statements and Interdisciplinary Progress Notes that on 12/31/2016 all of the remaining 90 residents of the facility were accounted for. The placement and function of all Accutech alarm system bracelets worn by all 11 elopement risk residents were checked without negative findings. 3. The SA verified through record review, observation and interview with the Administrator that on 12/31/2016 no functional issues were identified with the Accutech System, the investigation began and that Resident #1 was noted with his elopement alarm bracelet and it was functioning. 4. The SA verified through interviews with staff and record review that in-services were initiated on 12/31/2016 and covered the elopement policy, definition of elopement, prevention measures, assessment of risk, visual checks, door alarms, use of elopement bands, appropriate response to suspected elopement, sharing of codes with non-staff members or visitors, abuse/neglect and accidents and incidents. It was verified through record review and staff interviews that no employee was allowed to work until they were in-serviced. 5. The SA verified through staff interview and record review that on 12/31/2016 the Care Plan of Resident #1 was updated to reflect the elopement on 12/31/2016. 6. The SA verified through staff interview and record review that on 12/31/2016 the Administrator checked all facility doors and they were found to be locking and alarming properly. 7. The SA verified through record review and staff interview that on 12/31/2016, the Director of Nursing (DON) completed a second visual head count of all 90 residents and confirmed the head count matched the current census of 90. 8. The SA verified through record review and staff interview that on 12/31/2016, the DON checked the 11 elopement risk residents to ensure elopement bands/bracelets were in place and functioning with no negative findings identified. 9. The SA verified through staff interview and record review that on 12/31/2016, the DON conducted a complete audit of physician orders/Medication Administration Record [REDACTED]. 10. The SA verified through record review and staff interview that on 12/31/2016, the Administrator notified the Mississippi State Department of Health complaint hotline to verbally report the elopement of Resident #1 on 12/31/2016. 11. The SA verified through staff interview and record review that on 12/31/2016, the DON notified the Attorney General's office through their website to report the elopement of Resident #1 on 12/31/2016. 12. The SA verified through record review, staff interview, emergency room record, EMT record that Resident #1 returned to the facility on [DATE], Resident #1's elopement band/bracelet was assessed for placement, function and checked against the front door locking and alarm system with no negative findings. 13. The SA validated through record review and staff interview that on 12/31/2016 after return to the facility from the ER, Resident #1 was placed on one (1) on one (1) monitoring for the next 72 hours with no negative findings. 14. The SA validated through record review and interviews that on 1/01/2017, the Administrator reviewed the facility's elopement books to ensure all 11 elopement risk residents were identified by picture in the elopement books with no negative findings. 15. The SA verified through record review and interviews that on 1/01/2017, the Administrator placed signs on both sides of the front doors asking visitors to not assist residents out of the facility. Observation of signage on the front door on 1/10/17 and again on 1/13/17 validated the signage was in place on the front door. 16. The SA verified through interview and record review that on 1/01/2017, the DON and Administrator again checked all elopement alarm bands/bracelets against the door system with no issues identified. 17. The SA verified through staff interviews and record review that on 1/01/2017, elopement drills were conducted, by the Maintenance Director, on all shifts. 18. The SA verified through interview and record review that on 1/01/2017, the Maintenance Director rechecked all exit doors with no issues identified. 19. The SA validated through interviews and record review that beginning on 1/02/2017, the Maintenance Director and Administrator are each checking the facility exit doors daily. The exit door checks were increased 1/02/2017 from once daily to twice to ensure all are properly locking and alarming. 20. The SA verified through interview, observation and record review that beginning on 1/02/2017, the DON increased her weekly check of the elopement bands/bracelets to daily. 21. The SA validated through record review and staff interviews that on 1/02/2017, an emergency Quality Assurance (QA) meeting was conducted to discuss the elopement of Resident #1 on 12/31/2016, the location of where Resident #1 was found and the facility's actions to prevent further elopements. That QA meeting also reviewed the elopement policy with no changes made. The facility actions following the elopement were reviewed: a call made to alarm company to have alarm code changed, signs put on the front doors reminding visitors to not assist residents outside, the increased monitoring of the exit doors and the elopement alarm bands/bracelets, review of the elopement books, review of the MD orders/MARS, care plans and the care cards, in-services for the staff covering abuse/neglect, accident/incidents, elopement drills and elopement prevention. Those attending included the Administrator, Director of Nursing, Medical Director, South Unit Manager, Social Services and the Director of Clinical Education. 22. The SA verified through interview and record review that on 1/03/2017, the code to the front door was changed by the contracted alarm company representative. The Administrator will also ensure the code is changed the first day of each month going forward. 23. The SA validated through record review and staff interviews that on 1/10/2017, the Administrator and Director of Nurses completed an elopement risk assessment on all 93 residents in the facility and no new elopement risk residents were identified. 24. The SA verified through observation and staff interview that beginning 1/11/2017 at 1:00 PM, a staff member was assigned to the front doors 24 hour a day, 7 days a week, to assist visitors in and out of the facility and to prevent an elopement risk resident from exiting the facility without supervision.