Every finding on record at Tucker Park Crossing of Journey LLC

Based on observations, staff and resident interviews, record review, and review of the facility's policies titled, Infection Prevention and Control Program F880, F880 Multidrug-Resistant Organisms (MDRO) and Enhanced Barrier Precautions (EBP), and Wound Care Guidelines the facility failed to provide a Legionella water program, use aseptic technique during wound care, ensure proper use of Personal Protective Equipment (PPE) for residents who were under enhanced barrier precautions (EBP) during medication administration, identify and prevent the spread of C-Diff (clostridium difficile) colitis, and to clean and maintain respiratory equipment properly. This deficient practice had the potential to cause widespread infection, food-borne illness, and widespread C-Diff colitis and could affect all 129 residents who resided at the facility.Findings include: Review of the facility policy titled, F 880 Multidrug-Resistant Organisms (MDRO) and Enhanced Barrier Precautions (EBP) revised April 2025 revealed the facility's expectation Appropriate precautions will be taken when caring for individuals . requiring Enhanced Barrier Precautions. Further review of section Definition: Enhanced Barrier Precautions revealed that Nursing home residents with . indwelling medical devices are at especially high risk.The use of gown and gloves for high-contact resident care activities is indicated. Item 3. Indwelling Medical Devices are defined as (but not limited to): . c. Feeding tubes . Item 5. Application During Daily Life: . g. Indwelling medical device care (device care or use). Review of the facility policy titled, Wound Care Guidelines revised May 2021 revealed in section Steps in the Procedure . item 2. Establish a clean field on resident's overbed table ., . Item 5. Place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites. Item 9. Use no-touch technique. Item 16. Be certain all clean items are on clean field. Item 21. Use disinfectant wipe to clean overbed table. Item 23. Wipe reuseable supplies with alcohol as indicated (i.e. outsides of containers that were touched by unclean hands .) Review of the facility's policy titled Infection Prevention and Control Program F800 revised January 2024, revealed there is no verbiage concerning Legionella testing or prevention. 1. Interview with the Maintenance Director on 01/30/2026 at 10:38 AM revealed when the water management program was requested from the Maintenance Director, he brought back an empty clipboard. He stated he had no idea what the water management program was, he had never heard of it. An interview on 01/30/2026 with the Director of Nursing (DON) revealed she had no idea that there was no water infection prevention program for the facility. An interview with the Administrator revealed that he had just become aware that there was no water infection program in place. He provided a report containing water testing from 2/13/2024, testing for Legionella, and none was detected. 2. Observation made on 01/28/2026 at 1:11 PM of medication administration by Registered Nurse (RN) CC to R50 revealed the medication observed was alprazolam tablet 1 mg (milligram) (controlled substance), ordered to be administered via gastrostomy tube (G-tube) three times daily for anxiety disorder. During the administration of the medication via the resident's G-tube (an indwelling medical device), RN CC donned (put on) gloves but did not don a gown prior to performing the high-contact resident care activity involving the indwelling medical device. Interview on 01/28/2026 at 1:39 PM with RN CC acknowledged that she should have worn appropriate PPE, including a gown, when providing care to R50. When asked about the EBP signage posted on the resident's door, RN CC stated she was not aware that PPE, including a gown, was required when administering medications via the resident's G-tube. Observation made on 01/30/2026 at 11:50 AM revealed Licensed Practical Nurse (LPN) Wound Skin Ostomy Care (WSOC) performing wound care for R6 with a Stage IV sacral wound. The LPN WSOC did not disinfect the treatment cart prior to placing paper barriers and wound care supplies on the surface. Clean supplies were placed on the resident's bedside table without sanitizing the table, and were later transferred to the resident's bare mattress, which was not disinfected. During wound cleansing, the LPN wiped the wound bed with gauze using gloved hands and did not remove gloves or perform hand hygiene prior to opening and applying CollaSorb powder and calcium alginate dressing. The same gloves used to cleanse the wound were used to handle clean supplies and apply treatment products. Following completion of the dressing, the LPN washed the wound cleanser bottle with soap and water while wearing gloves and later returned the bottle to the treatment cart. 3. Review of the electronic medical record (EMR) revealed R6 was admitted to the facility with pertinent diagnoses including but were not limited to Stage IV full-thickness sacral pressure wound, type 1 diabetes mellitus with neuropathy and other circulatory complications, chronic kidney disease stage 3A, cerebrovascular disease, and polyneuropathy. Review of R6's care plan dated 01/28/2026 indicated a problem of stage 4 sacral pressure wound and diabetic foot ulcers. Goals included, but not limited to, wound healing, preventing infection, and avoiding complications related to pressure and diabetes. Interventions included, but were not limited to, administering prescribed wound treatments and medications, monitoring and documenting wound size, depth, and condition, assessing for signs of infection, and reporting changes to the physician as needed. Review of the Physician's Orders for R6 included but was not limited to: Order dated 11/11/2025 for Treatment: Cleanse sacrum wound with wound cleanser or normal saline and blot dry. Apply collagen to wound bed and then calcium alginate. Skin prep periwound (around the wound). Apply a border gauze dressing. Change dressing 3x's (times per week) a week and prn (as needed). Interview on 01/30/2026 at 12:20 PM with LPN WSOC regarding the wound care procedure. The LPN reported no observed breaches in infection control during the procedure. She stated that she believed all her actions were appropriate and that, if she used disposable paper barriers, the procedure complied with infection-control standards. She further stated that hand hygiene was required only twice, after removing the old dressing and upon completion of wound care. Additionally, she reported that washing the wound cleanser bottle with soap and water was considered sufficient. Interview on 01/30/2026 at 3:10 PM with the Director of Nursing (DON) revealed that LPN WSOC reported directly to her. She stated that facility expectations for wound care included disinfecting the treatment cart prior to set-up and after completion of the procedure, disinfecting bedside tables and bed surfaces before placing supplies, changing gloves and performing hand hygiene after wound cleansing and prior to application of treatment products, and disinfecting reusable wound care bottles with alcohol or other approved disinfectant wipes. The DON confirmed that cleaning the wound cleanser bottle with soap and water alone did not meet facility infection-control standards. 3. During observation with R18 on 1/27/2026 at 1:06 PM, it was revealed that R18 was on 3 liters of oxygen (O2). The O2 machine had fuzzy, thick, and dry gray particles on the filter on the back of machine. R18 also stated that the tubing for the O2 machine got changed once a week and she hadn't seen a Respiratory Therapist (RT). Observation on 01/28/2026 at 1:24 PM revealed that R18 had just finished ADL (activities of daily living) care and was lying in bed with a night gown on. The air filter on the back of the O2 machine was covered with fuzzy, thick, and dry gray particles. Observation on 01/30/2026 at 8:19 AM revealed R18 was sitting up in bed eating breakfast and watching television. The air filter on the back of the O2 machine was covered with fuzzy, thick, and dry gray particles. Interview with Certified Nursing Assistant (CNA) NN on 01/27/2026 at 02:16 PM revealed that the nurses handled O2 machines. Interview with RN CC on 01/28/2026 at 2:24 PM revealed that tubing for O2 machines was replaced on the night shift and that she was not sure how often the tubes were replaced. RN CC also stated that RT was supposed to clean filters every day and was last here Monday, 01/26/2026 and Tuesday, 01/27/2026. Interview with Unit Manager AA on 01/30/2026 at 8:39 AM revealed she didn't know who was supposed to clean the O2 machine filters, ensure that a resident had a filter, or how often the filters were to be cleaned. Interview with DON on 01/30/2026 at 9:28 AM revealed that the RT was supposed to follow up on all residents that were on O2.

Based on observations and staff interviews, the facility failed to provide a safe, functional, sanitary environment for residents, staff, and the public by not cleaning the Packaged Terminal Air Conditioner (PTAC) filter in six rooms (Room D-16, Room D-12, Room D-15, Room E-52, Room D-15, and Room E41) on five of five halls sampled. This deficient practice had the potential to cause respiratory irritation and exacerbation of conditions in residents with chronic obstructive pulmonary disease and other related lung diseases.Findings include:Observation on 01/27/2026 at 11:45 AM in room D16 revealed that the PTAC unit had two filters, and both filters observed to have a grey fuzzy substance approximately 1/8 inch thick, covering the filter.Observation on 01/27/2026 at 12:00 PM of resident rooms D12 and D15 revealed that both PTAC units in these rooms had 2 filters, and both filters in each unit were covered with a grey fuzzy substance that made the filters opaque.Observation on 01/27/2026 at 12:17 PM of resident room E52 revealed that both filters in the PTAC unit were covered with a grey fuzzy substance that made the filters opaque.Observation on 01/27/2026 at 02:06 PM revealed that room D15's PTSC filters still had a fuzzy grey substance on the two filters.Observation on 01/27/2026 at 02:10 PM revealed the PTAC filters in room E41 had a grey fuzzy substance on both filters.Observation on 01/28/2026 at 02:24 PM revealed that the PTAC filters in rooms D16, D12, D15, and E41 had a grey fuzzy substance on them that made the filter opaque. Observation and interview on 01/28/2026 at 05:00 PM during a walk-through with the Maintenance Director revealed that all PTAC units in the building, including B, C, E, A, and D halls, required cleaning.

Based on observations, staff interviews, and review of the facility's policy titled, Exercise of Rights/Resident Rights F550 and Residents Rights, the facility failed to allow one resident (R) (38) to exercise their rights in the facility by making her own choices.Findings include:Review of the facility's policy titled Exercise of Rights/Resident Rights F550, revised November 2025, section titled Policy Statement documented, Our residents have the right to be treated with respect and dignity and care that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Our residents have the right to exercise their rights without interference, coercion, discrimination, or reprisal from the facility and will be supported by our community in the exercise of those rights. 13. C. Allowing residents unrestricted access to common areas open to the public, unless this poses a safety risk for the resident.Review of the policy titled Residents Rights revised November 2025, further review of Guidelines documented, . 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 to assure that the resident is always treated with respect, kindness, and dignity.Review of the electronic medical record (EMR) revealed R38 was admitted to the with pertinent diagnoses including but not limited to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety and repeated falls.Review of R38's annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8, which indicates moderate cognitive impairment. Section GG, Functional Status, revealed R38 required supervision/touching assistance with eating and mobility regarding wheeling 50 ft (feet) and two turns. Review of R38's care plan indicated a problem of R38 has a behavior problem r/t (related to) going in and out of other resident's rooms and removing their items, and then will say the items are hers. Goals included but not limited to R38 will have no evidence of behavior problems by review date. Interventions included but not limited to provide a program of activities that is of interest and accommodates residents status, anticipate and meet R38's needs, and monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes.Observation on 01/28/2026 at 1:27 PM in E Hall dining room during lunch revealed Licensed Practical Nurse (LPN) DD entering the dining room announcing they had trays for residents who had not yet eaten and other residents who had already eaten were asked to go to their room while the other residents ate so it didn't look as if the residents who did not have a tray in front of them had not been fed yet. LPN DD directly spoke with R38 making the statement to R38 to please leave the dining room so that the residents who had not been fed could eat since R38 had already eaten. R38 proceeded to wheel out of the E Hall dining room. R38 came back in the E Hall dining room at 1:35 PM. LPN DD redirected R38 back out of the E Hall dining room stating the other residents had not yet finished eating.Interview on 01/28/2026 at 1:42 pm with LPN DD revealed she did ask residents to leave the dining area so that it didn't look like a dignity issue. LPN DD revealed some families did not understand. She further stated she didn't feel that it infringed on the rights of R38 because the resident didn't know. LPN DD further revealed the resident had some dementia and memory issues but she would explore more to make sure it didn't infringe on the resident's rights.Interview on 01/30/2026 at 10:00 AM with the Director of Nursing (DON) revealed that it was not ok for staff to ask residents to leave a preferred space if that was where they wanted to be at the moment. If that was where they wanted to be, then they should be allowed to stay there. The DON further revealed she felt that it was a dignity issue for the resident to be asked to go to their room. She further stated it was R38's right to be there and it was an issue. The DON revealed R38 could have a negative effect of possibly isolating the resident in what was her home and it could be embarrassing to the point of where she would not come out of her room.Interview on 01/30/2026 at 5:47 PM with the Administrator revealed dignity and respect was all residents were treated with dignity and respect and if not treated with dignity and respect, people tended to respond more negatively if not treated that way.

Based on staff interviews, record review, and review of the facility's policy titled, Pre-admission Screening and Resident Review (PASARR) F644, F645, F646, the facility failed to assess and refer residents whose diagnosis qualified for PASARR II evaluation for one of three residents (R) (R68) reviewed for PASARR. This deficient practice had the potential to cause R68 not receive the appropriate treatment and placement for mental illness.Findings include:Review of the facility's policy titled Pre-admission Screening and Resident Review (PASARR), revised November 2016, revealed in Section 3: Residents with newly evident or possible serious mental disorders will be referred for appropriate services based upon their assessed needs.Review of the electronic medical record (EMR) revealed resident R68 was admitted to the facility on [DATE] with pertinent diagnoses, including but not limited to schizophrenia, bipolar disorder, hypertension, hypothyroidism, and muscle weakness.Review of R68's quarterly Minimum Data Set (MDS) assessment, dated 12/24/2025, revealed a Brief Interview for Mental Status (BIMS) score of 11, indicating that R68 had moderate cognitive impairment. Section GG, Functional Status, revealed R68 required setup or cleanup assistance for meals and oral hygiene; required supervision with toileting hygiene, dressing, bathing, and putting on and taking off footwear.Review of R68's care plan dated 1/6/2026 indicated a Focus of risk for altered nutritional/hydration status related to Schizophrenia and some confusion. Interventions included but were not limited to Encourage consumption of fluids provided. Honor food preferences and update PRN (as needed). Monitor and record meal intakes. Provide and serve the diet as ordered. Provide recommendations as needed. The focus for R68 was on psychotropic medications related to her schizophrenia diagnosis. Interventions include, but are not limited to Administer medications as ordered. Monitor and document for side effects and effectiveness. Monitor and record occurrences of target behavior symptoms, pacing, wandering, disrobing, inappropriate response to verbal communication, violence or aggression towards staff or others, and document per facility protocol.Review of the Physician's Orders for R68 included, but was not limited to:Risperdal intramuscular 25mg intramuscular as needed for behaviors.Review of the EMR for R68 revealed a PASARR I on the chart from a residential nursing facility. There was no PASARR II or application for a PASARR II.Observation and interview on 01/27/2026 at 11:12 AM with R68 revealed the resident sitting on her bed, dressed in street clothes. At this time, she was listening to music. Her thoughts were very disorganized and, in some cases, sounded dilutional.Interview with the Social Services Director on 1/29/2026 at 2:38 PM revealed that the PASARR I came from the hospital, and if it did not trigger a PASARR II, she did not fill out an application for a PASARR II. She also indicated that R68 has a diagnosis of dementia. When the EMR was opened, she was unable to find the diagnosis of dementia as a primary diagnosis.Interview with the Director of Nursing (DON) on 01/30/2026 at 2:46 PM revealed that she knew nothing about the PASARR process. She left it up to the admissions team.Interview with the Admissions Coordinator on 01/30/2026 at 1:45 PM revealed that they tried to get the hospital to fill out a PASARR I on all admissions, but sometimes they come from home, or there was not enough time to get it done.An interview with the Administrator on 01/30/2026 at 2:46 PM revealed that he knew nothing about what goes on with the PASARR process at this facility. He was the interim Administrator and has been here for five months. There is another company that has bought the home, and they are coming in on the first of February.

Based on observation, record review, staff interviews and review of the facility policies titled, Comprehensive Care Plans and Wandering, Unsafe Resident, the facility failed to develop a care plan regarding wandering and elopement risk for one residents (R) (R62) who had been assessed for wandering upon admission. The deficient practice had the potential for R62's needs not to be met. Findings include:Review of the policy titled Comprehensive Care Plans, revised March 2025, section; Policy revealed An individualized comprehensive person-centered care plan that includes measurable objectives and time frames to meet the residents medical, nursing, mental, cultural, and psychosocial needs is developed for each resident. Guidelines: . 2. The comprehensive care plan is based on a thorough assessment that includes but is not limited to, the MDS (Minimum Data Set) and physician orders. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change.Review of the policy titled Wandering, Unsafe Resident, revised October 2025, revealed under Policy Interpretation and Implementation, . 3. The resident care plan will indicate the resident is at risk for elopement and other safety issues. 4. Interventions to try to maintain safety will be included in the resident's care plan.Review of the electronic medical record (EMR) revealed resident R62 was admitted to the facility with pertinent diagnoses including but was not limited to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, restless legs syndrome, depression, unspecified.Review of the EMR revealed R62 had a care plan conference dated 12/2/2025 which documented, R62 has been having exit seeking behaviors and staff have been redirecting her very much.Review of the EMR revealed resident R62 had a Behavioral Health Evaluation dated 11/25/2025 which documented, wandering behaviors which occurred 1-3 days, Under 1. Prior Level of Function, Stressors or Trigger H: R62's daughter states behaviors are recent as of 18 months ago. 3. Successful interventions: Resident has been difficult to re-direct.Review of R62 care plan dated 12/4/2025 indicated a problem of R62 has a behavior problem r/t (related to) walking the halls with her belongings and refusing to take them to her room. Goals included but not limited to R62 will have fewer episodes of by review date. Interventions included but not limited to Administer medications as ordered. Monitor/document for side effects and effectiveness, Anticipate and meet R62's needs, Explain all procedures to R62 before starting and allow to adjust to changes.Review of R6's2 care plan dated 12/30/2025 indicated a problem of R62 is at moderate to high risk for an elopement and currently wanders. Packs belongings to go home, Stays near exit doors. Goals included but not limited to R62 will remain safe within the designated confines of the community through the next review period. Interventions included but not limited to Provide lodging on a secure unit; Utilize a wanderguard, check placement to right wrist each shift and function each day. Utilize per manufacturer recommendationsReview of the Physician's Orders for R62 included but was not limited to:Order dated 12/30/2025: Wanderguard placed to resident's right wrist.Order dated 12/30/2025: to Check Placement of Wander Guard each shift and document where it is placed. Right wrist ID# FOC969 expiration date 02/2029Interview on 01/30/2026 at 3:12 PM with the MDS Assistant revealed the elopement and the interventions were discussed that were being put in place. She further stated the care plan could be updated by anyone however, the EMR system did not give the option for them to put in a start date of the care plan. She stated the care plan was revised on 12/30/2025 from the elopement and she did not know how to make the system show the start date of the care plan. She further stated the elopement care plan was developed on the day R62 eloped since it did happen.Interview on 1/30/2026 at 2:38 pm with the Director of Nursing (DON) Stated the care plan was updated that same day to include a wanderguard. When asked how to tell when the care plan was last updated, the DON revealed she did not see the date when the care plan was updated. The DON stated she was not sure why the care plan was revised on 12/01/2025 to include the interventions of use of wanderguard. She further stated the MDS Coordinator was responsible for updating the care plan but did not know why it was stating a wanderguard because the resident did not have an elopement prior to 12/30/2026. The DON's expectation of the staff was to follow the care plan. If the care plan was not being followed, they were not getting the services they needed, and the facility was unable to evaluate to see if they were receiving the changes they needed to know what was working for them.Interview on 01/30/2026 at 5:47 PM with the Administrator revealed care plan updates and revisions expectations were for staff to follow the regulations. If it was not completed, then staff did not know what they should be doing or what they should not be doing. The Administrator further revealed he regularly told staff the care plan was a living breathing document.

Based on observations, staff and family interviews, record review, and review of the facility's policy titled, Change in a Resident's Condition or Status, the facility failed to assess and report changes in condition to the provider for one of 61 sampled residents (R) (R138). The deficient practice led to R138 being hospitalized .Findings include:Review of the facility's policy titled Change in a Resident's Condition or Status, revised November 2017, under Policy Interpretation and Implementation, section1revealed: The Nurse Supervisor/Charge Nurse will notify the resident's attending Physician or On-Call Physician, and consistent with the delegation, the resident's representative, when there has been: . b. A significant change in the resident's physical, mental, or psychosocial status, including a deterioration in health, mental, or psychosocial status, in either life-threatening conditions or clinical complications.Review of the electronic medical record (EMR) revealed R138 was admitted to the facility with pertinent diagnoses, including but not limited to systolic heart failure (CHF), kidney failure stage III, type 2 diabetes, syncope and collapse, morbid obesity, venous insufficiency, Thyrotoxicosis, and myocardial infarction.Review of R138's admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated R138 was cognitively intact. Section GG, Functional Status, revealed R138 required clean-up or set up assistance for meals and oral hygiene, R138 required maximum assistance for toileting hygiene, shower/bathing, upper and lower body dressing, and footwear. For bed mobility, R138 required substantial assistance. A review of R138's Care Plan dated 10/5/2025 revealed a Focus-R138 has a diagnosis of Congestive Heart Failure. Give cardiac medications as ordered. Monitor Lab work: Potassium (K+), Sodium (NA), blood urea nitrogen (BUN), and Creatinine. Monitor/document/report to MD PRN (as needed) any s/sx (signs/symptoms) of Congestive Heart Failure: dependent edema of legs and feet, periorbital (around the eye) edema, SOB (shortness of breath) upon exertion, cool skin, dry cough, distended neck veins, weakness, weight gain unrelated to intake, crackles and wheezes upon auscultation of the lungs, orthopnea (shortness of breath when lying on back), weakness and/or fatigue, increased heart rate (Tachycardia) lethargy and disorientation. Focus-R138 is incontinent of bowel. Interventions: Check the resident every two hours and assist with toileting as needed. Provide peri care after each incontinence episode.Review of the Physician's Orders for R138 included but was not limited to: Monitor and document bowel movements (BM) every shift. Record review revealed that the Medical Director saw R138 on 12/02/2025 (note written 12/10/2025) with no mention of diarrhea or signs and symptoms of low potassium. There was no mention of staff reporting any problems. Review of the November 2025 and December 2025 Certified Nursing Assistant (CNA) ADL (activities of daily living) documentation provided, including bowel movements. Large/medium/loose/diarrhea incontinent stools were documented on both day and night shift, starting on November 15, 2025, and continued until R138 left the faciity on [DATE]. Loose/Diarrhea stools were documented as follows:Interview on 01/30/2026 at 08:10 AM with the Infection Preventionist Licensed Practical Nurse (LPN) revealed that she was not made aware of R138 having diarrhea while she was in this facility. R138 resided in room [ROOM NUMBER] on C-hall, and there were two residents in rooms [ROOM NUMBERS] on C-hall who had C-Diff and were admitted in October 2025. She stated that she tried to monitor any residents who had loose stools.Interview with CNA KK on 01/30/2026 at 08:49 AM revealed that she did not usually work with room [ROOM NUMBER], only when filling in for the usual CNA, but she did remember R138 having diarrhea several times and assisting the other CNA with cleaning the resident. She would have reported the diarrhea to the charge nurse if she were her CNA. CNA KK stated she just thought the resident had taken a laxative.Interview on0 1/30/2026 at 8:54 AM with LPN EE, Unit Manager of C hall revealed that she was aware that R138 had a few loose stools, she was not compliant with therapy, and the family was bringing in food from home. In that case, we would have given her some Immodium, contacted the nurse practitioner, and, of course, drawn labs. LPN EE confirmed that there were no labs drawn on R138 since 11/11/2025, and a one-time order for Imodium was not on the physician's orders.Interview on 01/30/2026 at 09:32 AM with the Director of Nursing (DON revealed that her expectations for assessing residents every shift on the C hall were because it was the acute Medicare Hall, and the regulations state they should be assessed every shift. If the resident had a change in condition, such as diarrhea or refusing medications, her expectation was for the nurse to notify the physician who was on call. The outcome could be dehydration, and they should have labs drawn or possibly IV (intravenous) fluids. Interview on 01/30/2026 at 11:02 AM with LPN GG revealed that she remembers R138 refusing medication, but does not remember the loose stools or the CNAs reporting to her that the resident had any diarrhea. At one point, she had been constipated, and we had to give her laxatives. Around that time, she had stopped eating, drinking, and taking her medications. She also refused therapy, saying she was too weak.Interview on 01/30/2026 at 11:20 AM with the Medical Director revealed that he did not remember the resident, but if she was not able to talk and tell me her problems, I didn't know them. He stated that his expectations were for the nursing staff to keep him informed of any changes in the residents' condition.An interview on 01/30/2026 at 11:41 AM with the Nurse Practitioner (NP) revealed that she was unaware of R138's diarrhea, but she was out on leave the last week in November 2025, and it may have been reported to the on-call NP.Interview on 02/4/2026 at 10:50 AM with a family member of R138 revealed that she met R138 at a doctor's visit. R138 was unable to sit up in the wheelchair; it took 3 people to pull her up in the wheelchair. She was improperly dressed in some socks, no shoes, thin leggings, a blouse, and a thin blanket wrapped around her. The family member also confirmed that the UU RN and the Social Service Director both knew about R138's diarrhea because on 12/01/2025, the Social Service Director came to me, concerned about R138s strong smelling diarrhea and that she would get with the doctor about it. The family member stated that she had also spoken with Registered Nurse (RN) UU about diarrhea, and she seemed to be aware of it and told me the NP was aware of it.

Based on observations, staff and resident interviews, record review, and review of the facility policies titled, F 689 Accidents and F 689 Accidents-Elopement, the facility failed to ensure the environment remained free of accident hazards for three of 61 sampled residents (R) (R45, R78, R92) and failed to maintain a safe environment to prevent resident elopement for one of 14 R's (R62) reviewed for elopement risk. Specifically, the facility allowed over-the-counter (OTC) flu and cold medications and shaving razors to be present and accessible in resident rooms without appropriate supervision or safety controls, and failed to adequately secure and monitor exit doors, allowing a resident to leave the building unsupervised. This deficient practice had the potential to cause injury, medication misuse, adverse drug events, elopement, serious injury, or death.Findings include: Review of the facility policy titled F 689 Accidents revised August 2022, revealed under Policy, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Further review of section Guidelines – Facility-Oriented Approach to Safety revealed that Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes. and that When accident hazards are identified, the QAA (Quality Assessment and Assurance) /Safety Committee shall evaluate and analyze the cause(s) of the hazards and develop strategies to mitigate or remove the hazards to the extent possible. Review of section Resident-Oriented Approach to Safety revealed that Our resident-oriented approach to safety addresses safety and accident hazards for individual residents, and that Staff shall use various sources to identify risk factors for residents, including the information obtained from the medical history, physical exam, observation of the resident, and the MDS. Further review revealed that Implementing interventions to reduce accident risks and hazards shall include. ensuring that interventions are implemented; and documenting interventions, and that Monitoring the effectiveness of interventions shall include. ensuring that interventions are implemented correctly and consistently. Review of the facility policy titled Wandering, Unsafe Resident revised October 2025, under Policy revealed, The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. Wandering – random or repetitive locomotion. The movement may be goal directed (e.g. appears to be searching for an exit) or non-goal directed or aimless. Under Policy Interpretation and Implementation documented, . 2. The staff will assess at-risk individuals for potential correctable risk factors related to unsafe wandering. 3. The resident care plan will indicate the resident is at risk for elopement and other safety issues. 4. Interventions to try to maintain safety will be included in the resident's care plan. 6. Nursing staff will document circumstances related to unsafe actions, including wandering, by a resident. 1. Review of the electronic medical record (EMR) revealed R45 was admitted to the facility with pertinent diagnoses including but not limited to essential hypertension, unspecified convulsions, schizophrenia, and depression. Review of R45's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated R45 was cognitively intact. Section GG (Functional Status) revealed R45 was independent with all Activities of Daily Living (ADLs). Review of Section D (Mood) revealed R45 reported little interest or pleasure in doing things and feeling down, depressed, or hopeless nearly every day over the prior two weeks. Review of R45's care plan dated 12/9/2025 indicated a problem of risk for injury due to seizure disorder, need for staff assistance with ADLs, hypertension, anticoagulant therapy, mood/depression, schizophrenia, and potential for impaired judgment related to medication or self-care tasks. Goals included but were not limited to remaining free from injury and avoiding adverse effects from medications. Interventions included but were not limited to monitoring and documenting seizure activity and implementing seizure precautions, supervising medication administration and monitoring for adverse reactions. Review of the Physician Orders for R45 included but was not limited to: Order dated 08/22/2025 for Xarelto 20 mg (milligram), give 1 tablet by mouth daily for cardiovascular disease; monitor for bleeding due to anticoagulant therapy. Order dated 07/31/2025 for Furosemide 40 mg, give 1 tablet by mouth daily for edema; monitor for dizziness, hypotension, and fall risk. Order dated 07/31/2025 for Metoprolol Succinate ER (extended release) 100 mg, give 1 tablet by mouth daily for hypertension; hold for pulse < (under) 60 or systolic BP (blood pressure) <120; monitor for hypotension, dizziness, and fall risk. Order dated0 8/19/2025 for Levetiracetam 1000 mg, give 2 tablets by mouth twice daily for epilepsy; monitor and document seizure activity every shift. Order dated 07/30/2025 for Oxcarbazepine 600 mg, give 1 tablet by mouth twice daily for epilepsy; monitor and document seizure activity every shift. Order dated 01/21/2026 for Aripiprazole 15 mg, give 1 tablet at bedtime for schizophrenia; monitor for sedation, unsteady gait, or confusion. Observation on 01/27/2026 at 1:19 PM of R45 in room E41-2 revealed two bottles of Brand name Cold and Flu over-the-counter medication located on a shelf at the foot of the resident's bed. One bottle was nearly empty, and the second bottle was approximately half full, indicating prior use. The medications were unsecured and accessible. Interview on 01/28/2026 at 3:12 PM with R45 in his room revealed that he was upset about returning from his outing yesterday and discovering that his cough medication had been discarded. R45 stated that the reason he purchased his own was because the amount they give him at the facility was not enough for him, stated that he had a bad cough and taking more of the medication was what worked for him. Review of a Nursing Progress note dated 01/28/2026 revealed R45 had Brand name cold medication in his room without a physician's order and had been taking the medication at his discretion. The note indicated the medication was removed from the room, and the Nurse Practitioner (NP) and Responsible Party were notified. Review of the EMR revealed R78 was admitted to the facility with pertinent diagnoses including but not limited to unspecified sequelae of cerebral infarction, vascular dementia, visual loss-both eyes, difficulty in walking, muscle weakness, cognitive communication deficit. Review of R78's quarterly MDS assessment dated [DATE] revealed a BIMS score of 6, which indicated R78 was severely cognitively impaired. Section GG revealed R78 was dependent or required substantial assistance with most ADLs. R78 used a manual wheelchair and was dependent on staff for all wheelchair mobility. Review of Section D revealed R78 reported little interest or pleasure in doing things, feeling down, depressed, or hopeless, trouble falling or staying asleep, and feeling tired or having little energy nearly every day over the prior two weeks. R78 also reported trouble concentrating nearly every day. Review of R78's care plan dated 12/9/2025 indicated problems including risk for falls, visual impairment, muscle weakness, difficulty walking, vascular dementia, diabetes, hypertension, incontinence, pain, and potential for verbal/physical aggression. Goals included but were not limited to remaining free from injury and participating in ADLs. Interventions included but were not limited to assisting with ADLs and transfers, providing a safe environment, supporting mobility, and monitoring for behavioral changes. Review of the Physician Orders for R78 included but was not limited to: Order dated 01/14/2024 for Aspirin 81 mg chewable, give 1 tablet by mouth daily for blood thinner. Order dated 12/15/2025 for Losartan-HCTZ (hydrochlorothiazide) 50-12.5 mg, give 1 tablet by mouth daily for hypertension. Order dated 01/06/2026 for Hydralazine 100 mg, give 1 tablet by mouth three times daily for hypertension, hold if systolic BP ≤ (lower than or equal to)130. Order dated 01/13/2024 for Memantine 10 mg, give 1 tablet by mouth twice daily for dementia. Order dated 01/13/2024 for Insulin Lispro, inject per sliding scale subcutaneously before meals and at bedtime for type 2 diabetes. Observation on 01/27/2026 at 12:12 PM of R78 in room E51-1 revealed several shaving razors located inside a clear plastic bag placed on top of the bedside nightstand. The razors were unsecured and accessible. Interview on 01/27/2026 at 12:13 PM with R78 revealed that the shaving razors belonged to him, reported he uses the razors, and stated that was why the razors were present in his room, indicating they were his personal belongings. 2. Review of the EMR revealed R92 was admitted to the facility with pertinent diagnoses including but not limited to hemiplegia and hemiparesis following cerebral infarction (left non-dominant side), hemiplegia and hemiparesis following cerebrovascular disease (right non-dominant side), difficulty walking, contracture, left knee, stiffness of left hand, need for assistance with personal care, and essential hypertension. Review of R92's annual MDS assessment dated [DATE] revealed a BIMS score of 15, which indicated R92 was cognitively intact. Section GG revealed R92 required supervision, partial, or substantial/maximal assistance with most ADLs, including eating, personal hygiene, bathing, dressing, and transfers. Review of R92's care plan dated 12/31/2025 indicated a problems including left-sided hemiplegia/hemiparesis with contractures, risk for falls, fatigue, impaired balance, limited mobility, pain, hypertension, risk for infection, depression, and potential for verbal/physical aggression. Goals included but were not limited to maintaining safety, participating in ADLs to the highest practicable level, and remaining free from complications related to stroke or hemiplegia. Interventions included but were not limited to assisting with ADLs and transfers and providing pain management and medication monitoring. Review of the Physician Orders for R92 included but was not limited to: Order dated 12/10/2025 for clonidine transdermal patch 0.2 mg/24 hr weekly, apply every Wednesday for hypertension and noncompliance with oral medications. Order dated 03/19/2025 for lisinopril 40 mg tablet by mouth once daily for hypertension, hold if SBP (systolic blood pressure) <120 mmHg, DBP (diastolic blood pressure) <60 mmHg (millimeters of mercury), or HR <60 bpm (beats per minute). Order dated 06/13/2023 for resident to wear left hand splint daily 4–6 hours as tolerated for contracture management. Observation on 01/27/2026 at 12:24 PM of R92 in room E50-1 revealed a shaving razor located inside a cup placed on top of a dresser adjacent to the resident's bed. The razor was unsecured and accessible. Interview on 01/27/2026 at 12:25 pm with R92 revealed the resident stated he shaved independently, reported he did not require assistance from staff, and stated he also shaved his head. Interview on 01/27/2026 at 3:36 pm with Unit Manager Registered Nurse (RN) AA revealed that she confirmed the presence of shaving razors on top of the dresser in room E51-1 and removed them and discarded them into a sharps container. At 3:37 PM confirmed the presence of shaving razors on top of the dresser in room E-50-1, again removing and discarding from the room. At 3:38 PM confirmed the presence of Brand name Cold and Flu OTC medication, 2 bottles, on a shelf in room E41-2 and stated, No, how was this missed? Stated that these items were a safety concern. Specifically, the OTC medication may be easily abused and this would not be an approved medication for a resident to keep at bedside. Interview on 01/27/2026 at 3:49 PM with the Director of Nursing (DON) revealed that OTCs should not be accessible to residents at all, and the only exception would be an inhaler, and the resident would have to be assessed to keep this medication. The concern was that if a wondering resident came into contact with the medication they may take it, a child who is visiting, or the resident themselves not knowing how much to take. In regards to shaving razors, residents were assessed during admission for ability to use them, and they were allowed to keep them, however, these must be in an enclosed bag and out of reach, inside the night stand, and also care planned for their use. 2. Review of the EMR for R62 revealed admission to the facility with pertinent diagnoses including but was not limited to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, restless legs syndrome, depression, unspecified. Review of the EMR revealed R62 had a care plan conference dated 12/02/2025 which documented, R62 has been having exit seeking behaviors and staff have been redirecting her very much. Review of the EMR revealed resident R62 had a Behavioral Health Evaluation dated 11/25/2025 which documented, wandering behaviors which occurred 1-3 days, Under 1. Prior Level of Function, Stressors or Trigger H: R62's daughter states behaviors are recent as of 18 months ago. 3. Successful interventions: Resident has been difficult to re-direct. Review of R62 annual MDS assessment dated [DATE] revealed BIMS score of 14, which indicates R62 was cognitively intact. Section GG revealed R62 was independent in all areas with the exception of shower/bathe assistance (supervision or touching assistance) and eating (setup/clean up assistance). Review of R62's care plan dated 12/4/2025 indicated a problem of R62 has a behavior problem r/t (related to) walking the halls with her belongings and refusing to take them to her room. Goals included but not limited to R62 will have fewer episodes of by review date. Interventions included but not limited to Administer medications as ordered. Monitor/document for side effects and effectiveness, Anticipate and meet R62's needs, Explain all procedures to R62 before starting and allow to adjust to changes. Review of R62 care plan dated 12/30/2025 indicated a problem of R62 is at moderate to high risk for an elopement and currently wanders. Packs belongings to go home, Stays near exit doors. Goals included but not limited to R62 will remain safe within the designated confines of the community through the next review period. Interventions included but not limited to Provide lodging on a secure unit; Utilize a wanderguard (device to alert staff of wandering outside a preferred area), check placement to right wrist each shift and function each day. Utilize per manufacturer recommendations. Review of the Physician's Orders for R62 included but was not limited to: Order dated 12/30/2025 Wanderguard placed to resident's right wrist. Order dated 12/30/2025 to Check Placement of Wander Guard each shift and document where it is placed. Right wrist ID# FOC969 expiration date 02/2029. Observation on 01/29/2026 at 2:10 PM on D Hall, a locked unit, revealed all exits on first hall to the left led to the parking lot and the door was locked, first hall to the left exit led to the back of the building with a covered area which included ashtrays and a chair. The door was locked and there was a fenced in area beyond the exit. Observation 01/30/2026 12:45 PM on D hall, a locked unit, revealed R62 was in her room standing at her door. She spoke to me about her day. She stated she was having an alright day but was about to go soon. R62's bags were observed at the exit doors. Interview on 01/29/2026 at 2:22 PM with Licensed Practical Nurse (LPN) DD revealed that R62 went out the front exit during an electrical outage. She was dressed for the weather appropriately. Interview on 01/30/2026 at 12:54 PM with Certified Nursing Assistant (CNA) TT revealed he was walking by the exit door and felt a breeze and noticed the door was open. He ran to the gate directly outside of the door to see if he could see anyone. He stated there was a gate in front of the door but was not sure if she went out of that door since he was not able to open the gate. He further stated he could not open or figure out how to open the gate, which was the only way off of the porch. He further revealed he suspected she went out of an alternate door that was on the side by the activities area because it was easier and there was a ramp she could have gone down. He then ran to tell the RN he was going to the street to check for the resident. He ran to the street by the road while looking both ways and noticed R62. She was cross five lanes of traffic [and was continuing to walk] about 4 or 5 houses down from the house that you see when you look directly out of the door [from the facility]. Once he saw her, he ran down towards R62 to make sure she was safe. R62 was not willing to walk back so he stayed in place until assistance arrived. He was not able to look at the time. He revealed she was not upset but she was not wanting to come back to the facility. He stated she came back to the facility and was still attempting to get out again [later that day] which was normal. Stated the doors had not been locked when he made it back to the facility around 10:15-10:30 AM and was instructed to stand by the doors but could not remember who told him to do that but the Unit Manager and the DON were present on the hall. When asked about the resident, he stated she exit sought daily and constantly was going to the doors shaking on them. He further stated her bags were always packed and at the door. Interview on 01/30/2026 at 2:38 PM with the DON revealed the sprinkler system was being serviced and was not supposed to trip the electrical system [power]. Stated the care plan was updated that same day to include a wanderguard since R62 did not have an elopement prior to 12/30/2026. Interview on 01/30/2026 at 5:47 PM with the Administrator revealed he was not onsite from when he received the call of the elopement, the staff had already noticed that R62 was gone, and they had gone out and received the message they had located her outside. At that time, apparently the sprinkler guys were there, and all the doors were open and they [all staff] had started fire watch on the doors. The Maintenance Assistant was put on the line/phone and once the sprinkler technician realized the problem (when the facility called the code), another supervisor from the sprinkler company did the test wrong, which had never happened before.

Based on observations, record review, staff interviews, and review of the facility's policies titled, Administering Medications F 760, Administering Oral Medications, Medication Administration Schedule, and Insulin Administration, the facility failed to ensure accurate administration of medications to four residents (R ) (R47, R113, R114, and R50) for four of 25 medication opportunities observed, resulting in a medication error rate of 16% (percent). This deficient practice has the potential to negatively impact residents, leading to complications of current health status.Findings include:Review of the facility's policy titled, Administering Medications F 760 revised [DATE] revealed under Guidelines, step 3. Medications must be administered in accordance with the orders, including any required time frame. Step 7. The individual administering the medication must check the label THREE (3) times to verify the right medication, right dosage, right time and right method (route) of administration before giving the medication. Further review revealed step 22. Each nurse's station will have access to a current medication reference manual.Review of the facility's policy titled, Administering Oral Medications revised [DATE] revealed under Steps in the Procedure . step 6. Check the label on the medication and confirm the medication name and dose with the MAR (medication administration record). Further review under Reporting . step 2. Report other information in accordance with facility policy and professional standards of practice.Review of the facility's policy titled, Insulin Administration revised [DATE] revealed under Preparation . step 3. The type of insulin, dosage requirements, strength, and method of administration must be verified before administration, to assure that it corresponds with the order on the medication sheet and the physician's order. Further review of step 5. The nursing staff will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery system(s) prior to their use.Review of the facility's policy titled, Medication Administration Schedule revised [DATE] revealed under Policy Interpretation and Implementation . step 3. A physician's order for specific times supersedes any routine schedule.Review of the facility's reference guide by Omnicare pharmacy titled, Guidance for Using Insulin Products dated 2025 revealed Prime pen-like devices prior to each and every injection to minimize bubbles. Dial units as per below guidance and push until a drop of insulin is seen at the top of the needle. with the guidance for Other Insulin Pen Devices: 2 units. Further review revealed After injection, hold the needle in the skin in order to ensure complete delivery of the dose. Large doses may require the needle be left in the skin longer than the time given below. The time given for Lantus insulin is indicated as At least 10 seconds.Observation on [DATE] at 08:59 AM on A-hall with Licensed Practical Nurse (LPN) BB, it was observed that R47 had physician orders for Multiple Vitamins-Minerals Tablet Give 1 tablet by mouth one time a day for Supplement. During medication administration, the nurse administered a One-Daily Multivitamin without minerals, which did not match the ordered medication.Observation on [DATE] at 09:02 AM on A-hall with LPN BB, it was observed that R113 had physician orders for Lidoderm External Patch 5 % (Lidocaine) Apply to Lower Back topically every 12 hours for Back Pain and remove per schedule, however, the nurse did not administer due to lack of availability. There was no notification to the physician regarding the missed dose.Observation on [DATE] at 09:35 AM on the A-hall with LPN BB, it was observed that R114 had physician orders for Metoprolol Tartrate Oral Tablet 25 MG (milligram) (Metoprolol Tartrate) Give 1 tablet by mouth one time a day for HTN (hypertension) hold if HR 50 or lower, SBP systolic blood pressure) below 120. At the time of administration, R114's vital signs were BP 109/54 mmHg (millimeters of mercury) and HR (heart rate) 56. The nurse administered the medication despite the SBP being below the prescribed threshold, giving the medication outside the ordered parameters.Observation on [DATE] at 1:11 PM on the B-hall with RN CC, it was observed that R50 had physician orders for Insulin Glargine Solution (Lantus) 100 UNIT/ML (milliliter) Inject 26 unit subcutaneously every morning and at bedtime for diabetes. The insulin was administered outside the prescribed time, as the order specified morning administration, but it was given at 1:11 PM. Additionally, the nurse did not prime the insulin pen before use and did not hold the pen in place after injection, which was not consistent with proper administration technique.Interview on [DATE] at 9:18 AM with LPN BB revealed that the ordered Lidoderm (Lidocaine) patch was not administered due to unavailability. LPN BB checked the medication cart and then searched the medication room for available house stock, with none found. The automated medication system did not stock Lidoderm patches. LPN BB consulted another nurse on the unit, who searched her medication cart for house stock, and additionally contacted the nurse on C-Hall on the first floor; no patches were available. LPN BB stated that she would submit a reorder request to the pharmacy and expected delivery this evening.Interview on [DATE] at 10:15 AM with Registered Nurse (RN) CC who was administering medications on the A-hall, revealed her cart did not contain Lidocaine patches for R113.Interview on [DATE] at 10:20 AM with Unit Manager RN AA revealed she was unaware that R113's Lidocaine patches were unavailable. Review of the MAR indicated documentation that the patch was administered on [DATE] at 10:54 AM, [DATE] at 10:26 PM, and [DATE] at 10:13 AM, suggesting no doses were missed. The Unit Manager met with LPN BB to address documentation reflecting administration when no patch was available. LPN BB stated she did not know how the documentation occurred and was instructed to correct the entry. Follow-up interview on [DATE] at 11:24 AM revealed RN AA contacted the evening nurse who stated she administered the patch the previous evening but did not realize she clicked on that.Interview on [DATE] at 3:05 PM with R113 revealed that she did not receive her Lidocaine patch at all the previous day and had not received one yet on the day of the interview. She reported requesting Tylenol for pain management until her Lidocaine patch became available.Interview on [DATE] at 12:52 PM, via telephone with Name of company Pharmacy revealed that the pharmacy representative confirmed receipt of a new order that day for a Lidocaine 4% patch for R113. She stated the previous order had expired on [DATE], which prevented processing a refill.Interview on [DATE] at 1:11 PM with RN CC stated that she was unfamiliar with the procedure for priming an insulin pen or holding the pen in place after it reached zero/clicks. She indicated she had not received training or been made aware of any facility policy regarding insulin pen administration. RN CC further explained that she did not administer the resident's morning insulin as ordered because the resident was not in his room at the scheduled time. She believed that since the insulin was long-acting, the timing would not adversely affect the resident.Interview on [DATE] at 9:46 AM with LPN BB stated that when reviewing R114's metoprolol order, she only considered the heart rate parameter and did not account for the blood pressure. She acknowledged that administering the medication outside the prescribed parameters, particularly with a low blood pressure, could cause dizziness or confusion. The LPN stated she would monitor the resident's blood pressure and watch for side effects, and if the BP fell below 100 mmHg, she would contact the NP for possible intervention.Interview on [DATE] at 9:45 AM with the Director of Nursing (DON) revealed that nurses were required to verify the MAR at least three times to ensure accuracy and prevent medications errors. She further emphasized that the facility's expectation was a zero-error rate for all medication administration. Nurses must never document a medication as given if it was not available. If a medication was unavailable in the cart or automated medication system, the nurse was expected to contact the pharmacy to obtain the medication, notify the physician of the missed dose, inform the responsible party, and document all actions taken in the MAR. For insulin pens, nurses must prime with 2 units and hold the pen in place for five seconds to ensure proper delivery, as failing to do so may result in administering air and improper absorption. If a medication was given outside the physician's parameters, nurses were expected to assess the resident, monitor blood pressure, notify the physician, and document all actions, since deviations could result in the resident's blood pressure dropping dangerously low.

Based on observations, staff interviews, record review and review of the facility's policies titled, Storage of Medications F 761 and reference guide by Omnicare pharmacy titled, Guidance for Using Insulin Products, the facility failed to ensure medications were properly stored by failing to remove expired medications from one of three medication rooms, and failing to properly date and discard expired insulin pens in one of five medication carts. This deficient practice had the potential to result in residents receiving ineffective or expired medications, placing them at increased risk for adverse health outcomes.Findings include:Review of the facility's policy titled Storage of Medications F761, revised 10/2024, revealed under Guidelines step 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed per state regulation. Review of the facility's reference guide by Omnicare pharmacy titled, Guidance for Using Insulin Products dated 2025 revealed Upon opening, all vials/cartridges/pens should be dated.Observation and interview on 1/28/2026 at 1:50 pm during review of the medication room A/B/E-Hall, on the second floor, with Unit Manager Registered Nurse (RN) AA, revealed 5 floor stock of 50% Dextrose injection, usp 25G/50 mL, which were located inside a box under the counter, had expired on 07/2025. RN AA confirmed the expiration of the Dextrose injections, further stating that she was not aware that it was inside that box, and immediately removed them and discarded them. Observation and interview on 1/28/2026 at 2:15 pm during review of the B-Hall medication cart with Licensed Practical Nurse (LPN) BB revealed the following concerns: One insulin Aspart pen with an open date of 1/1/2026, and an expiration date of 1/31/2026, indicating the pen had been in use for more than 28 days and was expired as of 1/28/2026. One Lantus Solostar insulin pen with no documented open date or expiration date; the pen was observed open and in current use. One insulin Lispro (Humalog) KwikPen labeled with an open date of 1/28/2026 and an expiration date of 2/5/2026, reflecting a 7-day expiration rather than the manufacturer-recommended 28 days after opening.LPN BB confirmed the documented dates, or lack thereof, on the insulin pens and stated she did not open or label those pens, noting that multiple nurses utilize the medication carts as they are frequently reassigned. She stated that once insulin is removed from refrigeration, the expiration date should be calculated as 28 days from the date opened and clearly written on the pen or vial. She acknowledged that this process had not been followed for the identified insulin pens and stated that failure to properly date insulin could result in residents receiving ineffective medication. The expired and undated insulin pens were discarded at the time of observation. LPN BB further stated that nurses are expected to calculate the 28-day expiration timeframe; however, she was not aware of a specific written policy outlining this requirement. Interview on 1/30/2026 at 9:45 am with the Director of Nursing (DON) revealed that nurses are required to verify the Medication Administration Record (MAR) at least three times prior to medication administration to ensure that there are no errors before giving the medication. The DON stated that unit managers are responsible for conducting weekly checks of medication carts and daily checks of medication rooms to ensure all medications listed on the MAR are available and properly stored. Expired medications are to be identified and scanned back to the pharmacy promptly. Regarding insulin management, the DON stated that all insulin maintained in medication carts must be clearly labeled with the date opened and the calculated expiration date, which is 28 days from opening. The nurse who opens the insulin is responsible for labeling it appropriately. If an insulin vial or pen is found to be undated or expired, it must be discarded. The DON further stated that use of expired medications may be harmful to residents and potential side effects are unknown.

Based on staff and family interviews, record review, and review of the facility policies titled Baseline Care Plans and Comprehensive Care Plans, the facility failed to ensure that one R (R) (R7) out of eight reviewed for participation in care plan meetings, or R7's Power of Attorney (POA), were invited to participate in the care plan meetings to ensure that the care plan was individualized to meet R7's personal goals and preferences. Findings include: Review of facility policy titled Baseline Care Plan, revised 6/2025, revealed the Guidelines section included . 6. Within 48 hours, the summary of the baseline care plan should be presented to the resident and/or their representative in writing, in a manner and language they understand. 7. Document evidence of the summary given to the resident or their representative in the medical record. Review of facility policy titled Comprehensive Care Plans, revised 3/2025, revealed the Guidelines section included 1. The facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. 12. Provide the resident and their representative a copy of the current care plan or a summary.Review of the admission Record for R7 revealed he was admitted to the facility on [DATE] and diagnoses included, but were not limited to, asthma and end-stage renal disease.Record review of the Minimum Data Set (MDS) Quarterly assessment, dated 8/21/2024, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 11 (indicating moderate cognitive impairment).Review of R7's electronic medical record (EMR) attached under the Miscellaneous Documents a document titled Care Plan Conference Summary, dated 1/30/2025, revealed there was no indication that the resident or POA were invited to or attended the care plan meeting.Review of R7's EMR attached under the Miscellaneous Documents a document titled [Resident's name] Baseline Care Plan dated 5/29/2025 Section Q Signatures and Acknowledgement revealed no indication that R7 or the family of R7 attended, signed, or was given a copy of the resident's care plan. In a telephone interview on 7/2/2025 at 2:31 pm with R7's POA, who is a family member, stated that the family was concerned about the care and services R7 was receiving. The POA stated the family wanted to participate in R7's plan of care. The POA further stated he had placed calls to the facility and left messages, requesting that someone return the call so that a care plan meeting could be scheduled. The POA stated the facility never returned any of the calls. In an interview on 7/2/2025 at 3:27 pm, the Clinical Reimbursement Coordinator (CRC) CC stated that the residents were invited to the care plan meeting via a letter that was delivered to the resident. CRC CC stated there was no need to invite the POA/Family to the care plan meeting for R7. The CRC stated that R7 was his own responsible party, and families were only invited if the resident requested it.In an interview on 7/2/2025 at 4:30 pm, the Administrator stated that the resident, as well as the family/Responsible Party (RP)/POA, should be invited to the care plan meetings. The Administrator stated he educated the Interdisciplinary Team (IDT) by reviewing the federal guidelines related to inviting the resident/families/RP/POA to the care plan meetings.

Based on family and staff interviews, and record reviews, the facility failed to notify the Power of Attorney (POA)/family of a change in condition of one resident (R) (R7) of eight residents reviewed for notification of change. Findings include:Review of the admission Record for R7 revealed he was admitted to the facility on [DATE] and diagnoses included, but were not limited to, asthma and end-stage renal disease. Further review of the admission Record revealed one person was listed as R7's POA and two people were listed as emergency contacts.Record review of R7's Minimum Data Set (MDS) Quarterly assessment, dated 8/21/2024, revealed that a Brief Interview for Mental Status (BIMS) was assessed at eleven (indicating moderate cognitive impairment).Review of a Nursing Skilled Note, dated 6/26/2025, revealed R7 was observed vomiting {sic} coffee ground- like emesis, in house nurse practitioner notified and assessed resident. Recommended that the resident be sent out to the hospital for further management. Emergency Medical Service (EMS) was contacted, and the resident was transferred to the hospital at 10:15 am, accompanied by EMS personnel. Resident was stable at the time of transfer. Family was contacted, however there was no answer.In a telephone interview on 7/2/2025 at 2:31 pm with R7's family member, who is the POA, the family member stated they were unaware that R7 had been sent out to the hospital on 6/26/2025 and remained in the hospital. In an interview on 7/2/2025 at 3:23 pm, the Unit Manager DD stated the nurse should have made a follow-up call to the family. She stated that if the nurse could not contact the family, it should have been passed to the next shift. In an interview on 7/8/2025 at 10:36 am, the Social Service Director (SSD) stated that R7 remained in the hospital.

Based on staff interviews, record review, and review of the facility policies titled Grievance/Complaint Log and Lost and Found, the facility failed to make a prompt effort to file a grievance for two of eight sampled residents (R) (R7 and R8) who verbally reported grievances. This deficient practice had the potential to place residents at risk of not having their grievances resolved in a timely manner. Findings include:Review of the facility policy titled Grievance/Complaint Log, with a review date of 10/2024, revealed Policy Statement: The disposition of all resident grievances and/or complaints will be recorded on our facility's Resident Grievance/Complaint Log. Policy Interpretation and Implementation: 1. The disposition of all written grievances and/or complaints must be recorded on the Resident Grievance/Complaint Log.Review of the policy titled Lost and Found, with a review date of 10/2024, revealed Policy Statement: Our facility shall assist all personnel and residents in safeguarding their personal property. Policy Interpretation and Implementation: Resident or family complaints of missing items should be reported by such staff member to the Social Services Director or, in their absence, Manager on Duty. An investigation of such will begin, and the resident or responsible party will be informed of the outcome in 5 days.1. Review of the admission Record for R7 revealed he was admitted to the facility on [DATE], and diagnoses included, but were not limited to, asthma and end-stage renal disease.Record review of the Minimum Data Set (MDS) Quarterly assessment, dated 8/21/2024, revealed a Brief Interview for Mental Status (BIMS) assessed at 11 (indicating moderate cognitive impairment).Review of a Nursing Skilled Note, dated 2/28/2025, revealed R7 dropped his pouch with his cellphone and wallet in it at some point during or after dialysis. Dialysis, maintenance, and nursing staff all looked for the pouch. The nurse placed a call to the family. The family provided R7 cell phone number to the facility. The family was informed the facility will call the cell number to locate the phone.Review of the Grievance Log from 1/23/2025 to 6/26/2025 revealed no documented grievances filed for R7. The surveyor requested any facility reportable incident (FRI) filed by the facility for R7. No FRI was provided to the surveyor.In an interview on 7/2/2025 at 2:31 pm, R7's family, who is also the Power of Attorney (POA), stated he spoke with R7 at least twice a week. The POA stated the last time R7 called from the cell phone was on 2/25/2025. The POA stated a call was received from R7 in February 2025, and the resident (R7) called from the nurse's station. The POA stated the resident stated he was missing a wallet and cell phone. The POA stated he/she spoke with a staff member who confirmed that the wallet and phone were missing, and the facility was trying to locate the phone and wallet. The POA stated that the family sent R7 a new wallet that included fifty dollars in one-dollar bills and a cell phone. He stated that soon after, R7 called again and stated the wallet, money, and cell phone that were sent were missing. The POA stated he did make calls to the facility and left messages that were not returned.2. Review of the admission Record for R8 revealed she was admitted to the facility on [DATE] and diagnoses included, but were not limited to, essential (primary) hypertension and chronic kidney disease.Record review of the MDS Quarterly assessment, dated 6/29/2025, revealed a BIMS assessed at 15 (indicating little to no cognitive impairment).Review of the Grievance Log from 1/23/2025 to 6/26/2025 revealed R8 filed one grievance on 1/27/2025, regarding being bathed with an undesirable water temperature. There were no other documented grievances for R8.During an interview and observation on 7/2/2025 at 11:16 am, R8 was lying in bed with two blankets pulled up to her chin. The resident stated she was cold, and the room's air conditioner was always on high. R8 stated that she has made many complaints to anyone who will listen about the temperature of the room. She stated the staff would adjust the temperature, but if the roommate complained, the temperature would be readjusted. She stated she had also complained of the slow response to answering the call light. R8 stated she had also verbalized the complaints to the Unit Manager.In an interview on 7/3/2025 at 12:08 pm, Social Service Director (SSD) AA stated she was responsible for tracking the grievances on the Grievance Log form. The SSD revealed anyone can complete a Complaint/Grievance Report form. She stated a grievance can be filed verbally or in writing. After the Complaint/Grievance Report form is completed, a copy of the grievance is given to the appropriate department to investigate. The department will return the grievance form to the Social Service Department, indicating if it was resolved and if the person filing the grievance is satisfied with the outcome. The grievances must be resolved within 5 to 7 days. The SSD stated the Administrator was not required to sign off on the grievances. The SSD stated she was not aware that R7 was missing a phone and wallet. She further stated she was not aware that R8 was having problems with the room temperature or the slow response to answering call lights. The SSD stated that she will speak to R8 regarding her concerns. In an interview on 7/8/2025 at 11:51 pm, Unit Manager (UM) BB confirmed that R8 had complained about the temperature in the room being cold and staff not answering the call light in a timely manner. UM BB stated she did not think she needed to file a grievance on behalf of R8 if she could resolve the issue.

Based on staff interviews, record review, and review of the facility's policy titled, F 625 Bed Hold, the facility failed to ensure a bed-hold policy upon transfer to the hospital for one of two residents (R) (R27) reviewed for hospitalization s. Findings include: Review of the facility policy titled F 625 Bed Hold revised May 2023 revealed, 1. Upon admission and when a resident is transferred for a non-emergency hospitalization or for therapeutic leave, a representative of the business office will provide information concerning our bed-hold policy. 2. When emergency transfers are necessary, the facility will provide the resident and the resident representative with information concerning our bed-hold policy per state law as applicable. Review of R27 clinical records revealed, the resident admitted to the facility with diagnoses that included but not limited to chronic kidney disease, acute on chronic systolic (congestive) heart failure, chronic obstructive pulmonary disease, unspecified, acute respiratory failure, and diabetes mellitus. Review of R27's Physician orders revealed an order for torsemide oral tablet 40 milligrams (mg), ipratropium-albuterol inhalation solution 0.5-2.5 (3) (mg)/3 milliliter (ml), Trelegy Ellipta inhalation aerosol powder breath activated 200-62.5-25 micrograms/ante cibum (mcg/ac), and oxygen (O2) at 4 (four) liters per minute (L (liters)/min [minute]) via nasal cannula to maintain O2 at or above 92% continuously every shift. Review of R27's most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed, Section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident had little to no cognitive impairment. Interview on 10/31/2024 at 11:10 am with Licensed Practical Nurse (LPN) AA revealed, Registered Nurse (RN) GG was the night supervisor in charge, and she sent R27 to the hospital on 10/27/2024 due to edema. LPN AA confirmed that RN GG did not complete the proper paperwork for the Business Office Manager (BOM) to create a copy of the bed hold. Interview on 10/31/2024 at 11:20 am with the BOM revealed that a bed-hold policy was given upon admission in the admission packet. She indicated she was responsible for issuing the bed hold paperwork to the residents that were transferred to the hospital. She revealed normally the nurse put the transfer in a green folder at the nursing station for her to process the bed hold forms. She confirmed R27 did not receive any bed hold paperwork upon transfer to the hospital on 6/9/2024, 8/11/2024, and 10/27/2024. She stated, the main reason bed hold policies do not get issued to the residents was because it's a break in our process. Interview on 10/31/2024 at 11:30 am with the Administrator and Director of Nursing (DON) confirmed it was the responsibility of the nursing staff to get the information to the BOM in a timely matter to properly issue bed hold policy forms to all residents or their responsible party who were being transferred to the hospital. DON stated they also have an encrypted phone app that allows them to communicate over the weekends. Telephone Interview on 10/31/2024 at 1:30 pm with RN GG confirmed she did not give the bed hold paperwork to the BOM. She stated, I did not know to do a bed hold, and have not receive any training on the proper steps regarding bed holds. I only know about doing assessments and that is what I did for her.

Based on observations, interviews, record review and review of the facility's policy titled Goals and Objectives, Restorative Services and Rehabilitative Nursing Care the facility failed to provide a right-hand grip splint for up to 4.5 hours for one of one Residents (R19) reviewed for rehab and restorative. Findings include: Review of the facility's policy titled Goals and Objectives, Restorative Services last reviewed 10/2024 revealed the policy was specialized rehabilitative service goals and objectives shall be developed for problems identified through resident assessments. Under the Policy's Guidelines section revealed, Rehabilitative goals and objectives are developed for each resident and are outlined in his/her plan of care relative to therapy services. 2. (b) Assisting the resident in developing and strengthening his/her physiological and psychological resources. 2. (c) Encouraging the residents to maintain his/her independence and self-esteem. Review of the facility's policy titled Rehabilitative Nursing Care last revised 10/2024 under the Policy's Interpretation and Implementation revealed, 1. General rehabilitative nursing care is that which does not require the use of Qualified Professional Therapist to render such care. 2. Nursing personnel are trained in rehabilitative nursing care, and our facility has an active program of rehabilitative nursing which is developed and coordinated through the residents' care plan. 3. The facility's rehabilitative nursing care program is designed to assist each resident to achieve and maintain an optimal level of self-care and independence. Review of the Electronic Medical Record (EMR) revealed R19 was admitted to the facility on [DATE] with the diagnoses of but not limited to hemiplegia and hemiparesis following cerebrovascular disease affecting the right dominant side. Review of R19's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Section GG (Functional Abilities and Goals) impaired upper extremity mobility on one side, and lower extremity impairment on one side, mobility by way of wheelchair, Section O (Special Treatments, Procedures, and Programs),Speech Language Pathologist (SLP) start 4/4/24-7/5/2024, Occupational Therapist (O/T) 6/10/2024-9/6/2024, Physical Therapy (P/T) 4/4/2024-6/20/2024. Review of the document titled Occupational Therapy Discharge Summary dated 6/10/2024 - 9/6/2024 revealed a discharge summary that patient will wear grip splint on right hand for up to 4.5 hours with minimal signs/symptoms of redness, swelling, discomfort or pain. Review of the document titled [Name of Facility] Follow Up Question Report dated 10/23/2023-12/22/2023 Restorative Nursing revealed, Resident to tolerate Right grip splint 2 hours or better with minimal pain six/week for 12 weeks. There were no other weekly Restorative notes from the Restorative Certified Nursing Aide nor monthly notes from the Supervisors of Restorative Nursing Care. Review of the document titled Restorative Nursing Program Recommendations dated 9/29/2024 revealed OT recommendations for resident to tolerate right grip splint five hours to maintain current level of function (CLOF). Review of the document titled Plan of Care (POC) Response History dated 10/30/2024 revealed a mobility device task with all No responses checked from 10/17/2024- 10/30/2024. Observation on 10/27/2024 at 2:45 pm of R19 in the day area revealed, the resident's right hand was very contracted, and his fingernails were touching the inside of his hand. R19 was not wearing a splint on his right hand. Observation and Interview on 10/28/2024 at 4:56 pm with R19 revealed he did not have a splint on his right hand. R19 right hand was turned inward with his fingers touching his hand. When asked about his splint, R19 went to his drawer and opened it where the splint was observed inside his drawer. Observation on 10/29/2024 at 12:43 pm of R19 revealed, he was not wearing a splint on his right hand. Further observation revealed, the splint was in his drawer at bedside. Interview on 10/29/2024 at 1:15 pm with MDS, CC and MDS, DD revealed, they should document on the resident for 12 weeks six times per week. They said his order possibly fell off, and they stopped the documentation. They said they could ask PT/OT to pick him up or flag the order for restorative to do the task and document. When asked if there was any documentation to support the times that he wore the splint they said they would look through the system for it. During a follow up interview at 4:30 pm, they returned with documentation of the splint from 10/23/2023 to 12/4/2023 and confirmed there was no documentation for R19 wearing the splint this year. Interview on 10/30/2024 at 10:50 am with Licensed Practical Nurse (LPN), FF revealed that staff should apply the splint to the resident's hand if no restorative person was present to do it. She said sometimes he refused to have his splint applied. She went to ask the Certified Nursing Assistant (CNA) HH if she had applied the splint to the resident's right hand, and she returned and reported that the staff member had applied the splint. Interview on 10/30/2024 at 11:00 am with CNA, HH revealed she did apply the splint to the resident's right hand. She said she saw the splint lying on the resident's nightstand and applied it. Interview on 10/30/2024 at 11:10 am with LPN, Unit Manager (UM), II revealed she had educated the staff on yesterday 10/29/2024 regarding applying splints all shifts, on residents with orders. She said she informed them it was to be documented in the EMR under task, and document change of positions as well. She said she informed them that the task tab shows who gets it, where it was applied, and if they refuse it. She said they were to notify Therapy if it was applied or not, and if the resident refuses, it was to be documented. They should also document applying and removal times. Interview on 10/31/2024 at 10:35 am with the Director of Nursing (DON) revealed her expectations for the Supervisors overseeing the Restorative Team was to take care of the residents according to the orders, applying splints, walking, etc. She said she would follow through and make sure that each resident was receiving daily restorative care as ordered. She said she would ensure that information was gathered from Physical Therapy (PT) and is communicated with the Medical Doctor, Nurses and UMs. She said she expects the residents to receive the care that they deserve and ordered to receive. She said the MDS Nurse was over restorative, and each part of the nursing team was responsible for ensuring the resident on the unit receives restorative care even though there was a restorative team. She said they are to reach out and follow up if their residents have not received their restorative care. She said she expects the restorative Supervisors to communicate with PT to coordinate care of the residents receiving restorative care during therapy and at discharge to prevent omitting new orders.

Based on observations, staff and resident interviews, record review, and review of the facility's policy titled, Confidentiality and Privacy Information, the facility failed to ensure the privacy for one of 30 residents (R) (R98) was maintained by displaying a sign on the bedroom wall disclosing protected personal information. Findings include: A review of the facility's policy titled Confidentiality and Privacy Information, effective date of 10/2023 under the Policy Statement revealed, Our facility shall treat all resident information confidentially. The resident has a right to personal privacy and confidentiality of his or her personal medical record. Review of R98's quarterly Minimum Data Set (MDS) dated [DATE] revealed, for Section B (Hearing, Speech, Vision), indicated the resident's vision was highly impaired; Section C (Cognitive Patterns), a Brief Interview of Mental Status (BIMS) of 15 which indicated little to no cognitive impairment. Observation on 10/27/2024 at 5:24 pm in the room of R98 revealed, a sign above the bed stating visually impaired. Interview on 10/27/2024 at 5:24 pm with R98 revealed, he was unaware of the sign above the bed when asked about it. Interview on 10/30/2024 at 4:21 pm with Certified Nursing Assistant (CNA) BB revealed most of the time the nurses would let them know of any diagnoses and tell them how to care for residents. CNA BB revealed she would ask the nurse or the unit manager if she forgot what to do for the resident and had access to the resident's Plan of Care (POC) on the computer. Interview on 10/30/2024 at 3:49 pm with Licensed Practical Nurse (LPN) FF revealed, she had received trainings related to dignity, privacy and how to treat residents with respect. LPN, FF revealed, if she saw the sign, she would have removed it. She further revealed, if the resident was alert enough, she would speak to them to let them know why she removed it. Interview on 10/30/2024 at 5:38 pm with the Administrator revealed they did not know the sign was there and it was not their expectation for anything with private information to be posted on the resident's wall.

Based on observations, staff interviews, record review, and review of the facility's policy titled Oxygen Administration, the facility failed to administer oxygen (O2) as ordered for one of two residents (R) (R9) reviewed for respiratory care. Findings include: Review of the facility's policy titled Oxygen Administration with effective date of 4/2024 under the section titled, Purpose revealed, The purpose of this procedure is to provide guidelines for safe oxygen administration. Under the section Preparation revealed, 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Under the section, Documentation revealed, After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record:1. The date and time that the procedure was performed. 2. The name and title of the individual who performed the procedure. 3. The rate of oxygen flow, route, and rationale. Review of R9's Electronic Medical Records (EMR) revealed R9 had diagnoses that included but not limited to chronic systolic congested heart failure (CHF), pleural effusion, chronic obstructive pulmonary disease (COPD), and acute and chronic respiratory failure. Review of R9's Minimum Data Set (MDS) dated [DATE] revealed Section C - Cognitive Pattern-a Brief Interview of Mental Status (BIMS) score of 15, which indicated little to no cognitive impairment; Section I - Active Diagnoses -Anemia, Heart failure, Asthma (COPD) & Respiratory failure; and Section O - Special Treatments, Procedures, and Programs-Oxygen therapy. Review R9's physician orders dated 10/1/2024 revealed, O2 at 2 LPM (liters per minute) via nasal cannula. Observation on 10/27/2024 at 3:37 pm revealed, R9 oxygen was flowrate was set at 3 LPM via nasal cannula. Observation on 10/28/2024 at 1:40 pm revealed, R9 oxygen flow level was set at 3.5 LPM via nasal cannula. Interview on 10/28/2024 at 2:02 pm with License Practical Nurse (LPN) AA confirmed R9 oxygen orders were 2 LPM and the oxygen in R9 room was set at 3.5 LPM. Interview on 10/28/24 at 2:44 pm with Director of Nursing (DON) revealed her expectations of staff to follow orders recommended by the physician. DON stated if a resident the oxygen is set at a higher level there could be an adverse effect depending on the residents' medical condition.

Based on observation, resident and staff interview, record review, and review of the facility's policy titled, Administering Medication the facility failed to follow the physician's orders as recommended for one of 30 residents (R)(R23). Findings include: Review of the facility's policy titled, Administering Medication dated October 2024 documented Medications shall be administered in a safe and timely manner, and as prescribed. (3) Medications must be administered in accordance with the orders, including required time frame. R23 was admitted to the facility on [DATE] with a diagnosis that includes fracture of left lower leg sequela, and displaced trimalleolar fracture of unspecified lower leg, initial encounter for closed fracture. Review of the most recent quarterly MDS dated [DATE] documented R23 had a Brief Minimum Data Set (BIMS) score of 14 indicating little to no cognitive impairment. Further review revealed R23 had no behavior exhibited and requires a four-person mechanical lift, and assistance with activities of daily living (ADLs). Review of the care plan dated for 10/9/2024 revealed there is not care plan for opioid medication and management. Review of the Physicians order dated 10/15/2024 documented tramadol (narcotic) hydrochloric (HCL) Oral Tablet (tab) 50 milligrams (MG). Directions: Give tablet mouth every eight hours as needed for severe pain (pain level 7-10). Review of the Physicians order dated 10/15/2024 documented hydrocodone-acetaminophen (acet)(narcotic) 7.5-325 tab {100 each (ea)}. Directions: Give one ablet by mouth every four hours as needed for moderate pain (pain level 4-6). Review of the Physicians order dated 8/22/2024 documented FentaNYL (opioid) patch 72 hours 23 (micrograms) MCG /hour (hr). Directions: apply one patch topically every 72 hours. Interview and observation on 10/20/2024 at 1:24 pm with R23 revealed she is aware on the three medications she is taking along with the pain scale for each medication. She stated she request her pain medication and tells the nurses what narcotics she wants and along with the pain level she is having. She confirmed she asked for hydrocodone often even though it is not within the pain scale that is recommended per her physicians. Review of the Medication Administration Record (MAR) dated for October documented: Hydrrocodone-acet given October 1 with a pain level of 8. Hydrrocodone-acet given October 2 with a pain level of 7. Hydrrocodone-acet given October 3 with a pain level of 8 and 7. Hydrrocodone-acet given October 4 with a pain level of 8. Hydrrocodone-acet given October 5 with a pain level of 8 and 7. Hydrrocodone-acet given October 6 with a pain level of 8. Hydrrocodone-acet given October 7 with a pain level of 7. Hydrrocodone-acet given October 8 with a pain level of 9. Hydrrocodone-acet given October 9 with a pain level of 8. Hydrrocodone-acet given October 10 with a pain level of 8. Hydrrocodone-acet given October 13 with a pain level of 7. Hydrrocodone-acet given October 14 with a pain level of 8. Hydrrocodone-acet given October 15 with a pain level of 7. Hydrrocodone-acet given October 16 with a pain level of 7. Hydrrocodone-acet given October 18 with a pain level of 7. Hydrrocodone-acet given October 22 with a pain level of 7. Hydrrocodone-acet given October 24 with a pain level of 8. Tramadol given on October 4 with a pain level of 4 and 5. Tramadol given on October 12 with a pain level of 5. Tramadol given on October 13 with a pain level of 6. Tramadol given on October 22 with a pain level of 6. Tramadol given on October 26 with a pain level of 6. Tramadol given on October 27 with a pain level of 6. Interview on 10/30/2024 at 1:36 pm with Licensed Practical Nurse (LPN) AA stated because R23 is aware of her pain ans she'll usually lets the staff know the pain level she is having and the medication she would like to take. LPN AA continued to state she does ask for pain medication often but is not a seeker. She stated she contacts the nurse practitioner (NP) and physicians if she believes R23 needs an adjustment to her medication. Interview on 10/30/2024 at 1:50 pm with the Director of Nursing (DON) revealed the staff are supposed to operate according to the physician's order. If there are any changed that need to be made the staff are expected to call the physician for specific orders that need to take place. She continued to confirm the physician's orders, and the Medication Administer Record (MAR) should align. Interview on 10/30/2024 at 5:45 pm with the Administration confirmed all nurses should follow the medical doctor orders as prescribed.

Based on observations, resident and staff interviews, record review, and review of the facility's policy titled, Comprehensive Care Plan, the facility failed to develop a care plan specific to the recommendations per the physician's order related to the pain scale for one resident (R) (R23), failed to develop a care plan for dialysis for R64, and failed to to follow and update the care plan for refusals on restorative care for R19. The sample size was 30 residents. Findings include: Review of the facility's policy titled, Comprehensive Care Plan dated August 2024 revealed, An individualized comprehensive person-centered care plan that includes measurable objective and time frames to meet the resident's medical, nursing, mental, cultural and psychological needs is developed for each resident. Further review of the policy revealed, (1) The facility's Care Planning/Interdisciplinary Team (IDT), in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident maybe expected to attain. (2) The comprehensive care plan is based on a thorough assessment that includes but is not limited to Minimum Data Set (MDS) and physician's orders. Assessment of residents are ongoing, and care plans are revised as information about the resident and the resident's condition change. (3) The Care Planning/IDT is responsible for the periodic review and updating of care plans: (a) When there has been a significant change in the resident condition. 1. Review of clinical records revealed R23 was admitted to the facility on [DATE] with diagnoses that included fracture of left lower leg sequela, and displaced trimalleolar fracture of unspecified lower leg, initial encounter for closed fracture. Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed for Section C (Cognitive Patterns) R23 had a Brief Interview of Mental Status (BIMS) score of 14 indicating little to no cognitive impairment. Review of R23's care plan dated for 10/9/2024 revealed there was not a care plan for opioid medication and management. Review of the physician's order dated 10/15/2024 documented tramadol (narcotic) hydrochloric (HCL) oral tablet (tab) 50 milligrams (MG). Directions: Give tablet mouth every eight hours as needed for severe pain (pain level 7-10.) Review of the Physicians order dated 10/15/2024 documented hydrocodone-acetaminophen (acet)(narcotic) 7.5-325 tab {100 each (ea)} Directions: Give one ablet by mouth every four hours as needed for moderate pain (pain level 4-6). Review of the Physicians order dated 8/22/2024 documented Fentanyl (opioid) patch 72 hours 23 (micrograms) MCG /hour (hr) Directions: apply one patch topically every 72 hours. During an observation and interview on 10/30/2024 at 1:24 pm, with R23 revealed she was aware and involved in her care plan meetings. She stated that her care plans should address the medication she has ordered. Interview on 10/30/2024 at 1:36 pm with Licensed Practical Nurse (LPN) AA revealed care plans were done on all residents quarterly related to their medication and treatment. She further stated if there were any concerns that needed to be addressed the staff should report this to her and she would report the concerns to the Nurse Practitioner (NP). After the concerns were reported she would assess the resident herself and a change of condition should take place. Interview on 10/30/2024 at 4:08 pm with LPN FF revealed she was able to update the care plan herself. She revealed, the MDS staff were involved in addressing concerns for the residents and would have a team meeting to implement interventions if needed. She continued to state if there was something incorrect, she would go to the MDS team to be corrected. Interview on 10/30/2024 at 4:21 pm with MDS CC and MDS DD staff both revealed, they were responsible for updating the care plan. They stated the care plan meetings involve the nurses and the IDT team, and they record the information that was being obtained in the meetings. MDS CC stated the medical part of the care plan was completed by the nurses. Further interview with MDS DD revealed the staff collaborate on the MDS part and the IDT team can do the medication portion of the MDS. They further stated the nurses should let them know if things need to be updated or have changed. Lastly, MDS CC and MDS DD both confirmed they do not look at any assessment as they are putting together the residents care plans. Interview on 10/30/2024 at 5:48 pm with the Director of Nursing (DON) confirmed the MDS team handles completing and updating the care plans. She stated they headline the care plan, and the nurses were able to update as needed. She continued to confirm the MDS staff were the ones who can input specific information into the care plans. 44757 2. Record review of R64's Admission MDS assessment dated [DATE] revealed, for Section C (Cognitive Patterns), a BIMS of 12 which indicated little to no cognitive impairment, Section I (Active Diagnosis) revealed, dependence on renal dialysis, acute kidney failure, unspecified and disorder of kidney and ureter, unspecified. Review of the comprehensive care plans for R64 revealed she did not care have a care plan for receiving dialysis. Observation on 10/27/2024 at 5:04 pm of R64 revealed, she had a port in her chest. Interview on 10/27/2024 with R64 revealed she received dialysis and went to dialysis in house on Mondays, Wednesday and Fridays during the mornings. Interview on 10/30/2024 at 5:08 pm with MDS DD revealed both coordinators were responsible for updating the care plans, but the nurses were able to as well or anyone on the IDT can update. She confirmed that R64 had not been care planned for dialysis and that it was an oversight. Interview on 10/30/2024 at 5:34 pm with the DON revealed it was the expectation for MDS to handle the updates of the care plan. 3. Review of the Electronic Medical Record (EMR) revealed R19 was admitted to the facility on [DATE] with the diagnoses of but not limited to hemiplegia and hemiparesis following cerebrovascular disease affecting the right dominant side. Review of R19's quarterly MDS assessment dated [DATE] revealed for Section C (Cognitive Patterns) a BIMS score of 5 (five) indicating severe cognitive impairment, Section GG (Functional Abilities and Goals) impaired upper extremity mobility on one side, and lower extremity impairment on one side, mobility by way of wheelchair, Section O (Special Treatments, Procedures, and Programs),Speech Language Pathologist (SLP) start 4/4/24-7/5/2024, Occupational Therapist (O/T) 6/10/2024-9/6/2024, Physical Therapy (P/T) 4/4/2024-6/20/2024. Review of R19's care plan dated 9/22/2024 revealed a focus: ROM or improve resident range of motion (ROM). Contracture to Right arm and hand. Goal: Resident will maintain or improve mobility through next assessment period. Interventions: Put towel or roll in R19's right hand to maintain skin integrity. Provide R19 with an active range of motion per therapy or nursing assessment. OT to evaluate and treat per order. Further review of care plans revealed, there was no care plan written for the resident's refusal to wear his splint. Review of the document titled Occupational Therapy Discharge Summary dated 6/10/2024 - 9/6/2024 revealed a discharge summary that patient will wear grip splint on right hand for up to 4.5 hours with minimal signs/symptoms of redness, swelling, discomfort or pain. Interview on 10/30/2024 at 10:50 am with LPN FF revealed, stated should apply the splint to the resident's hand if no restorative person was present to do it. She said sometimes he refuses to have his splint applied. Interview on 10/30/2024 at 5:08 pm with MDS CC and MDS DD revealed they are both responsible for updating the residents MDS's, but the nurses and the IDT update the care plans at the meetings. She revealed, the MDS Nurse was responsible for the assessment, and the care plan conferences, but the staff could modify or resolve anything on the care plan. She revealed they assist the CNAs to find things they may need related to the care plan. She said the staff can see the interventions as well. She said the nurse should let them know if things are to be updated or have been updated. She confirmed they were responsible for keeping the care plans updated.

Based on staff interviews, record review, and review of the PBJ (Payroll Based Journal) [NAME] Report 1705D for the First Quarter (Q1) of Fiscal Year (FY) 2024, the facility triggered a One-Star staffing rating and triggered for Low Weekend Staffing. The facility census was 115 residents. Findings include: A review of the PBJ [NAME] Report for FY Q1 2024 (October 1 through December 31, 2023) revealed the facility reported data declaring one-star staffing ratings and triggered for Low Weekend Staffing. In an interview on 5/8/2024 at 7:27 pm, the Director of Nursing (DON) revealed the Administrator reviews and discusses the PBJ reports during the Quality Assurance and Performance Improvement (QAPI) meetings. She stated she was newly employed during the period of 10/1/2023 through 12/31/2023. She further stated the facility was not utilizing agency staff, only had one unit manager, and the nursing staff was 60-70 percent staffed and extremely understaffed during the period of 10/21/2023 through 12/31/2023.

Based on observations and staff interviews, the facility failed to provide a safe, clean, and comfortable homelike environment for 27 rooms on five halls. These rooms contained dirty bathroom ceiling vent grills, oversized bathroom doors, damaged and missing drawer handles and doors on bedside nightstands and clothing chests, dirty damaged Packaged Terminal Air Conditioner (PTAC) units, damaged wall handrail, brown ceiling tiles, damaged bathtub, and damaged, unpainted walls. 1. Initial screening observation on 5/5/2024 at 1:23 pm and observation on 5/6/2024 at 9:58 am revealed room D-5's shared bathroom ceiling vent grill was dirty with gray substance. Further observation revealed the bathroom door was oversized and unable to be closed. Initial screening observation on 5/5/2024 at 1:36 pm and observation on 5/6/2024 at 10:05 am revealed room D-7's bedside chest missing drawer handles. Further observations of clothes cabinet chest located underneath sink with broken and damaged front drawer doors. Initial screening observation on 5/5/2024 at 2:07 pm and observation on 5/6/2024 at 10:07 am revealed room D-8's bathtub wall strip loose, ceiling tiles with brown stains, wall with two holes and exposed caulking and sheetrock material. Initial screening observation on 5/5/2024 at 2:37 pm in Room C-22 revealed bathroom ceiling tiles with brown stains and leaking water. Initial screening observation on 5/5/2024 at 3:15 pm and observation on 5/6/2024 at 10:11 am revealed room D-8's clothes cabinet chest located underneath the sink with broken front wooden drawers and chipped with sharp edges. The PTAC unit was unattached to the wall. Initial screening observation on 5/5/2024 at 3:20 pm and observation on 5/6/2024 at 10:15 am revealed wall handrails outside of the sitting area with exposed, chipped wood and was unattached to the wall. 45811 2. During observation on 5/5/2024 at 1:15 pm in Room B-24 , it was revealed there was paint missing around the toilet paper holder in the bathroom. During observation on 5/5/2024 at 1:20 pm in Room B-30, the wall behind the bed had three holes in the sheet rock. 46579 3. Observation on 5/05/2024 at 1:07 pm in Room A-19 revealed a bath basin and a urinal that were unlabeled and unbagged. There was a large amount of spider webs with leaves on the outside part of the window. The wall behind the B bed had a large number of dark scuff marks. The base board in the corner of the bathroom was found coming off the wall. The personal refrigerator in the room was dirty. Observation on 5/5/2024 at 1:22pm in Room A-20 revealed scuff marks on the inside of the bathroom door and on the wall in front of B bed. There was also a hole in the wall plaster behind the towel rack in the bathroom. Observation on 5/5/2024 at 1:26 pm in Room E-51 revealed there were three bath basins on the floor under the sink in the bathroom. They were not labeled and not in a bag. There was paint chipped off on the bathroom wall, and there were spider webs with leaves on the outside of the window. Observation on 5/5/2024 at 1:36 pm in Room E-52 revealed the wall was dirty behind bed A. Observation on 5/5/2024 at 1:45 pm revealed E-50 the bathroom toilet had a rounded lid, and the tank was rectangular, and there was an emesis basin not labeled or bagged. There was missing paint and a hole noted in the bathroom, and dirt, spider webs, and leaves noted on the area between the window and the screen. Observation on 5/5/2024 at 1:58pm in Room E-45 revealed there was a bed pan and a urinal that were not labeled or bagged. The bathroom sink did not have any warm/hot water, and the sink was stopped up. A ceiling tile had a gap in it in the bathroom. Observation on 5/5/2024 at 3:22 pm in Room D-1 revealed a hole in the outside bathroom door. Observation on 5/5/2024 at 3:25 pm revealed the floor in the hallway between Rooms D-3 and D-1, D-2 and D-4 was noted to have chipped pieces from the floor tile. 49394 4. Observation on 5/5/2024 at 12:52 pm in Room B-35 revealed a gap in ceiling by the sprinkler head in the bathroom, and paint missing from the wall behind the bed on the right side. Observation on 5/5/2024 at 2:00 pm in Room E-42 revealed three bath basins, rusty caulk around the toilet, and wheelchair leg rests in the bathroom. Observation on 5/5/2024 at 2:07 pm in Room E-43 revealed water damage to ceiling tiles and a broken handle on the dresser. Observation on 5/5/2024 at 2:15 pm in Room E-44-1 revealed missing hooks on the privacy curtain and a hole in the wall behind the door. Observation on 5/6/2024 at 8:46 am in Room B-39 revealed no privacy curtain in front of the bed. Observation on 5/6/2024 at 8:59 am in Room E-40 revealed scraped paint on the wall behind the bed, the toilet was running and did not flush, a missing grate on the PTAC unit, an electrical outlet out of the wall, a foot board hanging from Bed 1, and damage to the wall behind the head of the bed. Observation on 5/6/2024 at 11:57 am in Room B-27 revealed damage to the wall behind the head of the bed, and water damage to ceiling tiles. Observation on 5/6/2024 at 4:50 pm in Room B-39 revealed the privacy curtain for bed A was missing, scraped wall paint at the head of the bed, and the privacy curtain was off track for Bed B. Observation on 5/6/2024 at 5:40 pm in Room E-44-2 revealed wheels were off the bed near the footboard on the left side, and a hole in the wall. Observation on 5/7/2024 at 11:06 am in Room B-27 revealed damage to the wall at the head of the bed. Interview during walking rounds on 5/8/2024 at 9:15 am with the Maintenance Director (MD) confirmed and stated the conditions of the rooms were unacceptable and needed attention of repairs and removal of damaged/stained unrepairable items. The MD mentioned he managed and tracked all facility maintenance work orders through the TELS computer system. He stated he will immediately correct and address the damaged items in each room. The MD stated he was not aware of any Maintenance policy in place. The Administrator confirmed the facility does not have an Environmental Maintenance policy but provided the Maintenance Work Orders Maintenance policy. Interview on 5/8/2024 at 2:19 pm with Licensed Practical Nurse (LPN) DD revealed they do not keep maintenance work order books at any of the nursing stations. She stated the staff are required to report work orders on a (computer maintenance system). She stated this was more of a manageable tracking system for the nursing staff to use. She stated they have had issues in the past when they had to write work orders down in the nurse station's service requests binder.

Based on record review, staff interviews, and review of the job description for the Administrator and the Director of Nursing, the facility administration failed to provide oversight and monitoring of the nursing staff to ensure medication orders were transcribed correctly to prevent the incidences of medication errors for three of 22 sampled residents (R) (R#1, R#2, R#3). On 3/20/2023 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator, Interim Director of Nursing, and Assistant Director of Nursing were informed of the Immediate Jeopardy (IJ) on 3/20/2023 at 3:09 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 2/3/2023. An Acceptable Removal Plan was received on 3/24/2023. The removal plan included in-service training for nursing staff on transcribing medication orders, medication administration, including competency checks for licensed staff, in-service training for medical staff on the policy of Physician Services and transcribing new residents' admission medication orders. Through observations, record review, and interviews the survey team verified all elements of the facility's IJ Removal Plan, and the immediacy of the deficient practice was removed on 3/22/2023. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). Findings include: Review of the Administrator Job Description reviewed 3/20/2023, revealed the job summary is to supervise, plan, develop, monitor, and maintain appropriate standards of care throughout all departments in the nursing home. Manages staff at the facility. Essential Functions include supervise and provide guidance and support to department heads. Review of the Director of Nursing Job Description reviewed 6/2021, revealed the job summary is to coordinate all departments relating to nursing. The DON is accountable for all functions, activities, training, and education of all nursing employees. Essential functions include develop and maintain nursing service objectives, standards of nursing practice, and policy and procedure manuals; evaluation of resident records to assure accuracy, care plans are current and complete, and residents are receiving optimal nursing care; supervise the direction of resident care; and coordinates and delegates nursing orientations and ongoing education for all nursing staff. 1. R#1 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, hypertension, epilepsy, pressure ulcer, and pneumonia. She was a direct admission from the community. She brought with her a packet of information from her primary care physician (PCP) with medication orders. Included in the packet was a list of medications that had another person's name on them. Licensed Practical Nurse (LPN) AA transcribed both medication lists into residents' electronic medical record, without identifying that the additional list of meds had another name on it. Resident was administered the wrong medications for five days including Jardiance, Lantus Insulin, Novolog Insulin, and Torsemide and had a decline in condition with lethargy and not waking up with a blood pressure of 73/48 and was hospitalized for six days. The resident did not have a diagnosis of diabetes, heart failure, or kidney disease. LPN AA was suspended on 2/9/2023 for three days. Upon her return on 2/18/2023, she was educated to the Five Rights of Medication Administration, transcribing admission orders, and confirming admission orders with a physician. The former Director of Nursing (DON) resigned her position on 2/13/2023 . 2. R#2 was admitted to the facility on [DATE] with DM, hypertension (HTN), stage 4 chronic kidney disease (CKD), and atrial fibrillation (A-fib). She was admitted from an acute care hospital. The hospital discharge summary indicated resident was to continue Vitamin D 50,000 units weekly and metoprolol succinate XL (extended release) 50 milligrams (mg) every day in the morning. Registered Nurse (RN) JJ transcribed the metoprolol succinate XL (a long-acting medication used to treat high blood pressure and usually administered once daily) as metoprolol tartrate (a short acting medication used to treat high blood pressure and usually administered two times daily). The Vitamin D 50,000 units was missed being transcribed until 3/10/2023, 9 days after admission. Multiple attempts to contact RN JJ for an interview were unsuccessful. 3. R#3 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes, HTN, ischemic heart disease, and bipolar disorder. She was admitted from an acute care hospital. Review of the hospital discharge summary indicated discharge medications include trazodone (a medication to treat depression) 100 mg, two tablets by mouth every day at bedtime. Next dose due was documented to be 2/24/2023 at 9:00 p.m. RN HH transcribed the trazadone dosage incorrectly as 100 mg, instead of the prescribed 200 mg. Interview on 3/16/2023 at 8:20 a.m. with RN HH, when asked how she knew orders for a new resident were entered correctly, she replied she trusted the system and believes orders are entered correctly. Interview on 3/23/2023 at 4:15 p.m., Interim DON stated the Administrator should be kept informed of pertinent clinical matters when they are identified and should not be withheld . Interview on 3/25/2023 at 4:10 p.m., Administrator stated he should have been informed of the incident when nursing determined there was significant medication error. He stated usually does not participate in the clinical portion of the morning meetings but relied on the nursing management to keep him informed of important clinical concerns. Cross Refer F760 The facility implemented the following actions to remove the IJ: 1. The Director of Nursing at the time that the R#l medication error occurred, is no longer employed at Meadowbrook H&R. She resigned her position with her last day of employment being 2/13/2023. The Interim Director of Nursing was appointed on 2/13/2023. 2. On 3/17/2023, an initial audit was conducted by the Interim DON for current residents with medication orders for insulin and accu-checks to ensure that an appropriate diagnosis for medication was present in the residents' electronic medical records and in the physician order for the medication. No discrepancies were found. 3. On 3/20/2023, the Regional Nurse Consultant and Regional VP of Operations, via Zoom conference, provided education to the Administrator and the Interim Director of Nursing regarding providing oversight to ensure that admission medication orders are accurate & services provided by a physician, ensuring staff competencies on these topics are completed, and facility's job descriptions were also reviewed for the positions of Administrator and Director of Nursing and found adequate. The Administrator will provide weekly oversight and monitoring of the results of medication audits, and the audit tools to ensure that compliance is maintained and will incorporate any findings into the facility's QAPI meetings to develop additional Performance Improvement Plans or Root Cause Analysis that should be indicated. 4. On 3/21/2023, the IDT team was re-educated by the Interim DON and/or Administrator that newly admitted residents' orders must be reviewed in the daily meeting that occurs M-F, to ensure accuracy. Participants in the IDT are the DON, MDS, Dietary, Nursing Unit Manager, Social Services, and Activities. 5. Review of completed audits and new audit tools was incorporated by the Administrator into the facility's Ad Hoc QAPI meeting that was held on 3/20/2023 and into subsequent QAPI meetings that are held at least quarterly. All corrective actions were completed on 3/21/2023. The facility alleges that the IJ is removed on 3/22/2023. Onsite Verification: The IJ was removed on 3/22/2023 after the survey team performed onsite verification that the Removal Plan had been implemented. Interviews were conducted with staff to ensure they demonstrated knowledge of the facility's policies and procedures. 1. Confirmed by a Separation Notice for the former DON, dated 2/13/2023. In addition, correspondence with DCH, dated 2/16/2023, notified DCH of the appointment of the Interim DON on 2/13/2023. 2. Confirmed audit was conducted, dated 3/16/2023, and signed by the Interim DON. 3. The Administrator's Job Description was reviewed with the RVP & RNC on 3/20/2023. 4. Confirmed by in-service sign-in sheet including the CRC. 5. Audit tools include: a. Admission Order Review Tool b. Competency: Medication Administration c. New Employee Orientation Checklist d. Physician Admission Audit Tool e. Staff Competency Audit Tool

Based on record review, staff interviews, and review of facility policies, the facility failed to ensure that one resident (R) (R#1) was free from significant medication errors, by failing to identify that admission medication orders for insulin, oral antidiabetic agents, and high dose diuretics were prescribed for another person. The orders were transcribed into R#1's electronic medical record (EMR), dispensed by the pharmacy and administered to the resident for three days, resulting in a change of condition and hospitalization for six days. In addition, the facility transcribed medication orders for R#2's metoprolol (antihypertensive medication) incorrectly and for R#3 trazadone (antidepressant medication) was transcribed incorrectly. The sample size was 22. On 3/20/2023 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator, Interim Director of Nursing, and Assistant Director of Nursing were informed of the Immediate Jeopardy (IJ) on 3/20/2023 at 3:09 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 2/3/2023. An Acceptable Removal Plan was received on 3/24/2023. The removal plan included in-service training for nursing staff on transcribing medication orders, medication administration, including competency checks for licensed staff, in-service training for medical staff on the policy of Physician Services and transcribing new residents' admission medication orders. Through observations, record review, and interviews the survey team verified all elements of the facility's IJ Removal Plan, and the immediacy of the deficient practice was removed on 3/22/2023. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). Findings include: Review of the policy titled Admission to facility F620, F621, F710 reviewed 5/2022, revealed policy interpretation and implementation number 2. Prior to admission of a resident the physician must provide the facility with information regarding the immediate care of the resident, including orders that state the type of diet, medications (including a medical condition or problem associated with each medication), and routine care orders. Review of policy titled Admission Orders F635 reviewed 5/2022, revealed policy interpretation and implementation number 1. Residents may be admitted to the facility on ly upon the written order of the resident's attending physician. Number 2. Physician orders for immediate care, obtained either written or verbal (telephone) should at minimum contain dietary, medications, if necessary, and routine care to maintain or improve the residents' functional abilities until staff can conduct a comprehensive assessment and develop an interdisciplinary care plan. Review of the policy titled Reconciliation of Medications on Admission reviewed 5/2022, General Guidelines number 4. Medication reconciliation helps to ensure that medications, routes, and dosages have been communicated to the attending physician and care team accurately. Steps in the procedure step 2. Ask resident/family for all physicians and pharmacies from which they have obtained medications. Step 3. Using an approved medication reconciliation form, list all medications from the medication history, discharge summary, and the admitting orders. Step 5. Review the list to determine discrepancies. Step 6. If discrepancies are identified take action to resolve the discrepancy. Step 7. Document the findings and results of the action. Review of the policy titled Administering Medications F760 reviewed 5/2022, revealed policy is medications shall be administered in a safe and timely manner and as prescribed. Policy Interpretation and Implementation number 3. Medications must be administered, and in accordance with the orders. Number 18. Medications ordered for a particular resident may not be administered to another resident, unless permitted by State law and facility policy, and approved by the Director of Nursing Services. Review of policy titled QAPI Plan for Failure to Transcribe Orders and Complete Documentation revised 1/2022, Number 1. Immediate medical intervention for any issues, problems, or injury. Number 2. Notify physician (MD) and family and document. Number 3. Suspend the employee immediately that did not transcribe orders or chart issues that resulted in neglect. 1. Review of the clinical record revealed R#1 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, hypertension, epilepsy, and pressure ulcer, and pneumonia. The resident's Discharge Minimum Data Set (MDS) dated [DATE] revealed resident was rarely able to make herself be understood and rarely understood others. She was unable to complete the Brief Interview for Mental Status (BIMS). Section G revealed she was dependent on two staff persons for activities of daily living (ADL). Section I had no evidence R#1 had a diagnosis of diabetes, heart failure, or kidney failure. Section N revealed R#1 received insulin injections and diuretics three of the seven days of the look back period. Review of admission paperwork from R#1 primary care physician (PCP) revealed an office note dated 10/22/2022, that documented active medications as clindamycin 300 milligrams (mg), ferrous gluconate 240 mg, hydrochlorothiazide-lisinopril 12.5 mg-10 mg, escitalopram 10 mg, Aricept 5 mg, Calcium 600 + D, and levetiracetam 500 mg. Included with R#1's active medication list was a list of medications belonging to another patient from the PCP's office, including atorvastatin 40 mg, cetirizine 10 mg, Plavix 75 mg, ergocalciferol 1.25 mg, Novolog 12 units three times a day, Lantus 24 units every night, Jardiance 10 mg, Cozaar 50 mg, metoprolol succinate ER 100 mg, Protonix 40 mg, torsemide 100 mg two times daily, and ferrous sulfate 325 mg. Review of February 2023 Order Audit Report revealed orders for R#1 dated 2/3/2023 for Jardiance 10 mg one tablet by mouth one time a day for diabetes; Insulin Glargine Solution 100 unit/milliliter (ml), inject 24 unit subcutaneously one time a day for diabetes; Novolog Solution 100 unit/ml inject 12 units subcutaneously before meals for diabetes; Torsemide Tablet 20 mg, give 100 mg by mouth two times a day for edema. The orders were transcribed by Licensed Practical Nurse (LPN) AA, and Jardiance, Lantus and Novolog were discontinued on 2/6/2023 and the Torsemide was discontinued on 2/8/2023, after they were identified to be prescribed for another patient. Review of the February 2023 Medication Administration Record (MAR) revealed Jardiance 10 mg was administered to R#1 on 2/4/2023 at 9: 00 a.m., Insulin Glargine 24 units subcutaneously at 9:00 p.m. on 2/3/2023 and 2/5/2023; Torsemide 100 mg at 9:00 a.m. and 5:00 p.m. on 2/4/2023, 2/5/2023, 2/6/2023, 2/7/2023, and 2/8/2023 at 9:00 a.m.; and Novolog 12 units subcutaneously on 2/5/2023 at 4:00 p.m. Review of Progress Note dated 2/6/2023 at 7:40 a.m. revealed resident blood sugar (BS) is at 49. Went in resident [sic] room at about 6:00 a.m. for routine accu-check. BS presented to be at 49. Tried to give resident a glucerna [sic], resident teeth were clinched. Administered glucagon at 6:30 a.m. Rechecked BS at 6:45 a.m. BS went up to 57. Rechecked BS at 7:00 a.m. BS went back down to 49. Notified MD via telehealth. Have not spoke [sic] with doctor (MD) as of yet. Notified niece via phone. Niece stated she's coming to see resident soon. Resident VSS (vital signs stable). B/P (blood pressure) 126/80, HR (heart rate) 82, T (temperature) 96.6, RR (respiratory rate) 18, SPO2 (spot oxygen) 97. Will continue to monitor. Review of Progress Note dated 2/6/2023 at 8:53 a.m. revealed resident BS is 51 after drinking a can of Glucerna and lost [sic] breakfast. Nurse Practitioner (NP) BB gave an order to give another glucagon and hold all insulin until further evaluation. Review of Progress Note dated 2/6/2023 at 9:00 a.m. revealed Glucagon given on RUQ (right upper quadrant). Resident BS recheck in 15 minutes. Review of Progress Note dated 2/6/2023 at 2:50 p.m. revealed resident received new orders from NP BB to discontinue (d/c) all her insulin, put her on accu-check before meals and at bedtime (AC/HS). Review of Progress Note dated 2/8/2023 at 11:01 a.m. revealed resident BP is 73/48, NP BB notified. Resident given an order for NS 0.9% at 100 ml/hr for one liter. Resident is lethargic, not waking up. NP BB order [sic] to send her out for further evaluation. 911 called waiting for transfer. Review of Progress Note dated 2/8/2023 at 11:23 a.m. revealed resident received new orders from NP BB to d/c Torsemide, Metoprolol, Losartan, cetirizine, and start NS 0.9% at 100 ml/hr for one liter. Review of Progress Note dated 2/8/2023 at 11:26 a.m. revealed resident is weak, resident is not waking up, she is lethargic. Review of Progress Note dated 2/8/2023 at 12:04 p.m. revealed 911 came and took resident to [facility name] per NP BB's order. Resident BP is 80/44. Review of Physician Note dated 2/7/2023 labeled as Admission History and Physical dictated by MD VV, indicated he reconciled R#1's medications from a list from a 2018/2019 medical clinic visit note. The DON was asked to request a current medication list from R#1's responsible party. Continued review of the Admission History and Physical revealed past medical history included diagnoses listed but not limited to hypertension, osteoarthritis, and seizure disorders. The document indicated chronic medical problems, current documents, and current medications were reviewed. Continue medications and treatments as ordered. This note was electronically signed by MD VV and dated 3/20/2023 at 12:26 p.m. Review of the situation, background, assessment, and recommendation (SBAR) form dated 2/8/2023 at 12:07 p.m. revealed there was a change in R#1 condition. Her vital signs (VS) were BP 73/48, pulse (P) 77, respirations (R) 18, pulse oximetry was 98% on room air, and blood glucose (BG) was 117. History listed diagnoses but not limited to Parkinson's disease, hypertension, epilepsy, weakness, and pressure ulcer. There were no medication changes listed for the past week. Mental status was listed as unresponsiveness. Nursing observations, evaluation, and recommendations were -R#1 was lethargic, not waking up, R#1 did not eat, and BP was 73/44. PCP responded with normal saline 0.9% at 100 ml/hr times one liter. Review of hospital records dated 2/8/2023 revealed R#1 had two days of confusion, poor oral intake, low blood sugar, and was minimally responsive. Chest X-ray revealed possible pneumonia and labs suggestive of dehydration. Admitting diagnoses was dehydration with acute metabolic encephalopathy, hypoglycemia, pneumonia, and seizure disorder. Interview on 3/15/2023 at 3:56 p.m., family of R#1 stated she was admitted to the facility from home. She stated that the facility called her to inform her that the resident was transferred to the hospital on 2/8/2023 because her blood pressure was low, and she was not eating. Interview on 3/16/2023 at 5:00 p.m., LPN AA stated she was the admitting nurse on duty 2/3/2023 when R#1 was admitted . She reported the resident's niece brought a packet of documents with her from resident's PCP, which included an office visit note with a list of active medications. She stated she reviewed the list of medications with NP BB, who verified the medications via verbal telephone conversation. During a further interview, she revealed the previous Director of Nursing (DON) double-checked the documents and informed her that there was an additional medication list. The DON instructed LPN AA to notify NP BB to review and verify the additional medications and then she entered the medications into the EMR. She stated she was suspended from work because of the error she made in transcribing R#1 orders into the EMR. Phone Interview on 3/16/2023 at 5:30 p.m. with Pharmacists MM and NN, revealed the orders received from the facility for R#1 on 2/3/2023 were electronically signed by Medical Doctor (MD) CC. The Pharmacists verified that R#1 orders included Novolog 12 units subcutaneous three times a day before meals, Jardiance 10 ml orally daily, torsemide 100 mg twice a day and Lantus 24 units subcutaneous at bedtime. Review of an email correspondence from Pharmacist NN dated 3/15/2023 at 5:40 p.m., revealed the potential side effects R#1, who was [AGE] years old and weighed 115 pounds, could have encountered because of the significant medication errors that occurred due to the transcription errors made when LPN AA transcribed the wrong orders into the EMR: Jardiance works by blocking the reabsorption of glucose and sodium by the kidney, which results in increased glucose excretion, reduced blood glucose concentrations. Jardiance is used to improve glycemic control in adults with type 2 diabetes mellitus (DM) and to reduce the risk of cardiovascular (CV) death in adults with type 2 DM and established CV disease. Adverse Reactions: increased risk of hypoglycemia when combined with insulin. Symptomatic hypotension can occur after initiating Jardiance. Novolog (Insulin aspart) is a rapid-acting insulin analog that is produced from a chemical modification of regular human insulin. Adverse Reactions: Hypoglycemia is the most common adverse reaction of insulin therapy. Severe hypoglycemia requiring emergency treatment is sometimes referred to as insulin shock. Torsemide is an oral loop diuretic used in the management of edema associated with heart failure, renal disease, or hepatic disease. Adverse Reactions: Torsemide can cause potentially symptomatic hypokalemia, hyponatremia, hypomagnesemia, hypocalcemia, and hypochloremia-associated metabolic alkalosis. Excessive diuresis may cause potentially symptomatic dehydration, hypovolemia, hypotension, and worsening renal function, including acute renal failure particularly in salt-depleted patients. Interview on 3/16/2023 at 12:10 p.m., Interim DON stated she was a travel nurse and has been working in the facility for about four weeks. She stated she was vaguely aware of the medication errors that occurred with R#1. She stated her expectation of the nursing staff was to check all paper orders and verify the resident's identity on each page. She further stated when transcribing orders, nurses should verify diagnosis with each medication and call the NP on call, physician, or telehealth to verify medication lists, prior to entering medications into the EMR. She further stated that a second nurse should verify that orders were entered correctly and if discrepancies are identified, they should be corrected immediately. 2. Review of the clinical record revealed R#2 was admitted to the facility on [DATE] with DM, hypertension (HTN), chronic kidney disease (CKD) stage 4, atrial fibrillation (A-fib). Review of Admission MDS dated [DATE] revealed she had a BIMs of 15 indicating no cognitive impairment. Section G revealed she required limited assistance with ADLs. Review of hospital discharge summary dated 2/28/2023 revealed current medications to continue included Vitamin D 50,000 units weekly and metoprolol succinate XL (extended release) 50 mg every day in the morning. Review of the Pharmacy Consultation Report dated 3/3/2023, revealed a discrepancy on the admission orders as follows: 1. Vitamin D 50,000 units by mouth weekly for 90 days is ordered according to the hospital After Visit Summary, but it is not being administered according to the electronic medical record. 2. Metoprolol succinate 24-hour extended release is ordered, but the immediate release product metoprolol tartrate is being administered once daily. Recommendation from the Pharmacist is to clarify these medication orders and to communicate with the prescriber and pharmacy as appropriate. There is a handwritten notation by the Director of Nursing indicating that the orders have been corrected on 3/6/2023. Review of March 2023 Physician Orders revealed metoprolol tartrate 50 mg every day was ordered 3/2/2023 and discontinued on 3/6/2023; metoprolol succinate 50 mg every day was ordered on 3/7/2023; Vitamin D 50,000-unit one capsule every week on Friday was ordered 3/10/2023. Review of the March MAR revealed metoprolol tartrate (a short acting medication used to treat high blood pressure and usually administered two times daily) 50 mg daily was administered on 3/3/2023, 3/4/2023, 3/5/2023, and 3/6/2023 at 9:00 a.m. The order was discontinued after the 3/6/2023 dose and metoprolol succinate (a long-acting medication used to treat high blood pressure and usually administered once daily) XL 50 mg daily was ordered to start on 3/7/2023 at 9:00 a.m. Interview on 3/16/2023 at 1:10 p.m., R#2 revealed she was admitted to the facility for rehabilitation and was looking forward to getting to go home soon. She stated she was not aware that the blood pressure medication she was given was not the same as what she had been taking. During further interview, she stated no-one informed her that she was given the wrong blood pressure medicine. Interview on 3/16/2023 at 1:25 p.m., Interim DON verified that R#2 had a medication error that was a result of incorrect transcription of orders into the EMR. She stated the Physician order for R#2 was for metoprolol succinate 50 mg daily, but was transcribed into the EMR as metoprolol tartrate 50 mg daily. R#2 was administered the incorrect medication, metoprolol tartrate, for three days before the medication error was identified and corrected to metoprolol succinate. During further interview, she stated the consultant pharmacist identified the error on 3/3/2023, but she did not get the email message until 3/6/2023. 3. Review of the clinical record revealed R#3 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes, HTN, ischemic heart disease, and bipolar disorder. Review of the Admission MDS dated [DATE] revealed she had a BIMs of 15 indicating no cognitive impairment. Section G revealed the resident required extensive assistance of two people for ADL's. Review of the hospital discharge summary dated 2/24/2023 revealed discharge medications listed include trazodone (a medication used to treat depression) 100 mg, two tablets by mouth every day at bedtime and next dose due was documented to be 2/24/2023 at 9:00 p.m. Review of February 2023 Physician Orders revealed trazodone 100 mg, one tablet nightly by mouth was ordered on 2/24/2023 and discontinued on 2/27/2023; trazodone 100 mg, two tablets by mouth nightly were ordered on 2/27/2023. Review of the February 2023 MAR revealed trazodone 100 mg was administered at 7:00 p.m. on 2/24/2023, 2/25/2023, and 2/26/2023. The order was discontinued on 2/27/2023 and trazadone 100 mg, two tablets were ordered to start on 2/27/2023 at 7:00 p.m. Interview on 3/16/2023 at 1:26 p.m., Interim DON verified and confirmed that R#3's order for trazodone 100 mg, two tablets orally at bedtime, but the medication was transcribed incorrectly as trazodone 100 mg, one tablet at bedtime. She stated her expectation is that the nursing staff are to notify the NP or Physician on call, or telehealth to verify all medication orders. During further interview, she stated the nurse should transcribe the orders into the EMR, and a second nurse should verify that orders were entered correctly and if discrepancies are identified, they should be corrected immediately. Interview on 3/16/2023 at 2:00 p.m., R#3 revealed she was admitted to the facility about two weeks ago. She stated she was not informed of any issues regarding her medications, or not being given the correct dosages. The facility implemented the following actions to remove the IJ: 1. R#l, medical record reflects that on 2/6/2023 resident experienced a change of condition related to abnormal blood sugar readings, low blood sugar(s). On 2/6/2023 it is also noted that new orders were received from the Nurse Practitioner to discontinue existing medication orders for Insulin. After discontinuation, there were no further recorded low blood sugar readings on 2/6/2023. On 2/8/2023, R#l was noted with a change of condition related to low blood pressure and lethargy. The MD was notified, and R#l was subsequently transferred to the hospital on 2/8/2023. R#l returned to Meadowbrook Health and Rehab on 2/14/2023 from the hospital. R#l is receiving the correct medications per hospital discharge summary, noted that admission orders reviewed at time of return by NP. Since returning from the hospital, the resident has had no noted symptoms of hypotension or hypoglycemia. 2. On 2/9/2023, upon receiving notification of a medication error that resulted in the hospitalization of R#l, the Administrator initiated an investigation during which the resident's attending physician was called to discuss the mixed medical records of another individual that was not caught by our nurse, and the referring physician was notified of the HIPAA breach by his office. The attending physician who is also our Medical Director, received education on 3/20/2023 by the Administrator regarding the policy on Physician Services to include that physician's personal approval of an admission recommendation must be in written form. The written recommendation for admission to the facility must be provided by a physician and cannot be provided by an NPP. This may be accomplished through a hospital transfer summary written by a physician, paperwork completed by the resident's physician in the community, or other written form by a physician. 3. LPN AA, as identified in the Immediate Jeopardy template, was suspended, pending investigation, on 2/9/2023, related to identification of the medication error for resident R#l. LPN AA was educated about new admissions paperwork, physician orders, and having a second nurse review the orders, by the Staff Development Coordinator on 2/13/2023. This employee normally works every other weekend. She returned to work on 2/18/2023. 4. On 2/10/2023, the Unit Manager(s) or ICP, LPN reviewed electronic medical records of current residents who were admitted to Meadowbrook H&R since 1/1/2023, to identify other residents with potentially incorrect admission medication orders, using theAdmission Order Review Tool. Results of this audit identified that of the 8 residents admitted , no medication errors were identified. 5. On 2/16/2023, the 5-day follow-up investigation report from the 2/9/2023 initial report was submitted by the Administrator to the Georgia Department of Community Health. 6. On 3/20/2023, LPN AA completed a competency evaluation by the Unit Manager regarding medication administration and physician order transcription to include preventing significant medication errors and the facility's policies and procedures related to admission orders. LPN AA successfully completed her competency evaluation. On 3/20/2023 and 3/21/2023, competency evaluations regarding Medication Administration and Physician Order transcription were provided to 25 of 26 current licensed nurses, including LPN AA. The remaining nurse will receive her competency evaluation prior to returning to work. 7. On 3/20/2023, the facility initiated an audit of current licensed nurses using the Staff Competency Audit Tool to identify other licensed nurses with potential lack of evidence of completed competency evaluations related to medication administration and Physician Order Transcription. The competency evaluation included verbal assessment and observation of the nurses' ability to provide care and services related to medication administration and physician order transcription with acknowledgment of understanding of the facility's policies and procedures. The audit revealed that 3 of 26 current licensed nurses had documentation of a competency evaluation. On 3/20/2023 and 3/21/2023, competency evaluations regarding Medication Administration and Physician Order Transcription was provided to 25 of 26 current licensed nurses, including the three nurses previously identified. The remaining nurse will receive her competency evaluation prior to returning to work. 8. Upon hire, or upon use of contract licensed nurses, facility will ensure that education is provided about admission orders, medication administration, and transcription of orders provided by a physician, during the new hire orientation process which will be completed by the Staff Development Coordinator (SDC), Unit Manager (UM) or the Assistant Director of Nursing (ADON). The New Employee Orientation Checklist was revised on 3/20/2023 to include this additional education. 9. Starting on 3/16/2023 and ending on 3/21/2023, education was provided to current licensed nurses regarding the facility's policies related to medication administration, new and readmission medication orders, diagnosis for each medication and only physicians may write admission orders, by the SDC/IP, Unit Manager and/or Assistant Director of Nursing or Interim Director of Nursing. As of 3/21/2023 there are 26 licensed nurses employed at Meadowbrook Health and Rehab. This education was provided to 1 of 1 RN DON 1 of 1 RN ADON, 1 of 1 LPN Unit Manager, 3 of 3 other RNs, 1 of 1 Staffing Coordinator LPN, and 18 of 19 other LPNs. 25 of 26 total Licensed Nurses have received education and the facility's percentage of completion is 96.15% as of 3/21/2023. The remaining nurse will receive this education prior to working her next scheduled shift. 10. Review of completed audits and new audit tools was incorporated by the Administrator into the facility's Ad Hoc QAPI meeting that was held on 3/20/2023 and into subsequent QAPI meetings to be held at least quarterly. The facility implemented the following actions to remove the IJ: 1. Confirmed by Progress Notes dated 2/6/2023 through 2/8/2023. 2. The Administrator filed a Facility Incident Report on 2/16/2023 related to the medication error for R#1. Confirmed correspondence to the referring physician regarding the HIPAA breach and medication error. 3. Confirmed suspension and re-education of LPN AA related to admission process, verification of physician orders with another nurse and the attending physician or telehealth physician, confirmation of name on all paperwork, and the 5 Rights of Medication +1 for Communication. 4. Review of the Admission Order Review Tools for 6 residents revealed no errors in admission order transcription. 5. Results of the facility investigation of the medication error were sent to Department of Community Health (DCH) on 2/9/2023 at 5:43 p.m. 6. Clinical competencies completed for 26 nurses, including the CRC, DON, & ADON related to medication administration. 7. Staff competency audit tool and competencies completed on 3/21/2023. 8. New Employee Orientation Checklist was updated on 3/20/2023. 9. 3/20/2023 - 3/21/2023: education provided for nurses related to medication order transcription, telephone orders, verbal orders, new admission paperwork, & QAPI oversight. 10. Policy: QAPI for Failure to Transcribe Orders and Complete Documentation, reviewed 1/2023-no concerns.

Based on record review, interviews, and policy review, the facility failed to ensure direct care nursing staff were adequately trained and evaluated to provide competent nursing care for three residents (R) (R#1, R#2, R #3) who were administered medications that were incorrectly transcribed into the electronic medical records (EMR). Specifically, R#1 was ordered and administered insulin, oral antidiabetic agents, and high dose diuretics that were ordered for another person; R#2 was ordered antihypertensive medication, but the incorrect medication type was transcribed and administered; and R#3 was ordered antidepressant medication, and the incorrect dosage was transcribed and administered. Sample size was 22. On 3/20/2023 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator, Interim Director of Nursing, and Assistant Director of Nursing were informed of the Immediate Jeopardy (IJ) on 3/20/2023 at 3:09 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 2/3/2023. An Acceptable Removal Plan was received on 3/24/2023. The removal plan included in-service training for nursing staff on transcribing medication orders, medication administration, including competency checks for licensed staff, in-service training for medical staff on the policy of Physician Services and transcribing new residents' admission medication orders. Through observations, record review, and interviews the survey team verified all elements of the facility's IJ Removal Plan, and the immediacy of the deficient practice was removed on 3/22/2023. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). Findings include: Review of the policy titled Medication Orders reviewed 5/2022, revealed the section titled Recording Orders number 1. When recording orders, specify the type, route, dosage, frequency, and strength of the medication ordered. Review of the policy titled Reconciliation of Medications on Admission reviewed 5/2022, General Guidelines number 4. Medication reconciliation helps to ensure that medications, routes, and dosages have been communicated to the attending physician and care team accurately. Steps in the procedure step 1. The nurse should obtain a medication history from the resident/family. This information should include all prescription medications, over-the-counter medications, herbal or dietary supplements, patches, creams, eye drops, inhalers, shots, and sample medications. Each medication should have a dose, route, frequency, and last dose taken recorded. Step 2. Ask resident/family for all physicians and pharmacies from which they have obtained medications. Step 3. Using an approved medication reconciliation form, list all medication from the medication history, the discharge summary, the previous medication administration record (MAR) (if applicable), physician records, pharmacy records and/or the admitting orders. Step 4. List the dose, route, and frequency. Step 5. Review the list to determine discrepancies. Step 6. If discrepancies are identified take action to resolve the discrepancy. Review of the policy titled Administering Medications F 760 reviewed 5/2022, revealed policy is medications shall be administered in a safe and timely manner and as prescribed. Policy Interpretation and Implementation number 2. Director of Nursing Services will supervise and direct all nursing personnel who administer medications. Number 3. Medications must be administered, and in accordance with the orders. Number 7. The individual administering medication must check the medication label three times to verify the right medication, right dose, right time, and right route of administration before giving the medication . Review of a document titled Primary Nurse RN/LPN Job Description reviewed 6/2021, revealed the job summary is assists nursing supervisor in responsibility for total resident care and maintains quality resident care following facility policies and procedures, federal and state regulations, and the nursing standards of practice. Performs any and all professional nursing duties as determined by qualifications and training. Essential functions include coordination with the health care team to assess, plan, implement, or evaluate resident care plans, monitor, record, and report symptom changes in resident conditions, and maintain accurate, detailed reports and records. Review of a document titled Director of Nursing Job Description reviewed 6/2021, revealed the job summary is to coordinate all departments relating to nursing. The DON is accountable for all functions, activities, training, and education of all nursing employees. Essential functions include develop and maintain nursing service objectives, standards of nursing practice, and policy and procedure manuals; evaluation of resident records to assure accuracy, care plans are current and complete, and residents are receiving optimal nursing care; supervise the direction of resident care; and coordinates and delegates nursing orientations and ongoing education for all nursing staff . Review of the Course Completion History for LPN AA, revealed there was no evidence that a competency evaluation had been completed for medication administration, use of the electronic medical record (EMR), documentation, or transcribing medication orders. Interview on 3/16/2023 at 5:00 p.m., LPN AA stated she has been employed at the facility since November of 2022. She stated she completed an orientation period but doesn't remember any specifics regarding what training she had during the orientation period. Interview on 3/20/2023 at 5:40 p.m., LPN QQ revealed she usually orientates new nurses to the unit. During further interview, she stated she assists with checking off the competency checklist during the new nurse orientation . Interview on 3/21/2023 at 3:00 p.m., Administrator revealed that LPN AA's computer-based training is incomplete because she was marked as in-active in the system. He stated that there was not a competency check list done for LPN AA. He stated his expectation was that all nursing staff complete a competency check off during their orientation period and then yearly during the facilities skills fair . Interview on 3/25/2023 at 2:40 p.m., ADON revealed the orientation check list is completed for all new staff during a 3-day preceptorship. She stated if the checklist is not completed within the three days, the orientation period may be extended or further education will be completed with the new employee. The facility implemented the following actions to remove the IJ: 1. LPN AA, as identified in the Immediate Jeopardy template, was suspended, pending investigation, on 2/9/2023, related to identification of the medication error for resident R#l. LPN AA was educated about new admissions paperwork, physician orders, and having a second nurse review the orders, by the Staff Development Coordinator on 2/13/2023. This employee normally works every other weekend. She returned to work on 2/18/2023. 2. On 3/20/2023, the facility initiated an audit of current licensed nurses using the Staff Competency Audit Tool to identify other licensed nurses with potential lack of evidence of completed competency evaluations related to medication administration and Physician Order Transcription. The competency evaluation included verbal assessment and observation of the nurses' ability to provide care and services related to medication administration and physician order transcription with acknowledgment of understanding of the facility's policies and procedures. The audit revealed that 3 of 26 current licensed nurses had documentation of a competency evaluation. On 3/20/2023 and 3/21/2023,competency evaluations regarding Medication Administration and Physician Order Transcription was provided to 25 of 26 current licensed nurses, including the 3 nurses previously identified. The remaining nurse will receive her competency evaluation prior to returning to work. 3. Starting on 3/16/2023 and ending on 3/21/2023, education was provided to current licensed nurses regarding the facility's policies related to medication administration, new and readmission medication orders, diagnosis for each medication and only physicians may write admission orders, by the SDC/IP, Unit Manager and/or Assistant Director of Nursing or Interim Director of Nursing. As of 3/21/2023 there are 26 licensed nurses employed at Meadowbrook Health and Rehab. This education was provided to 1 of 1 RN DON 1 of 1 RN ADON, 1 of 1 LPN Unit Manager, 3 of 3 other RNs, 1 of 1 Staffing Coordinator LPN, and 18 of 19 other LPNs. 25 of 26 total Licensed Nurses have received education and the facility's percentage of completion is 96.15% as of 3/21/2023. The remaining nurse will receive this education prior to working her next scheduled shift. 4. Upon hire, or upon use of contract licensed nurses, facility will ensure that education is provided about admission orders, medication administration, and transcription of ordersprovided by a physician, during the new hire orientation process which will be completed by the Staff Development Coordinator (SDC), Unit Manager (UM) or the Assistant Director of Nursing (ADON). The New Employee Orientation Checklist was revised on 3/20/2023 to include this additional education. All corrective actions were completed on 3/21/23. The facility alleges that the IJ is removed on 3/22/23. Onsite Verification: The IJ was removed on 3/22/2023 after the survey team performed onsite verification that the Removal Plan had been implemented. Interviews were conducted with staff to ensure they demonstrated knowledge of the facility's policies and procedures. 1. Review of document titled Coaching/Progressive Disciplinary Action Form revealed LPN AA was suspended from employment on 2/9/23 related to identification of medication errors. On 2/13/23 LPN AA received training/education via telephone regarding protocol on new admission paperwork, readmission paperwork, physician orders, and second nurse review and check orders entered in EMR. On 2/18/23 employee returned to work with 1:1 education done on date of return. This document was signed by LPN AA and a supervisor on 2/9/23 and 2/10/23. Review of record of Inservice dated 2/13/23 titled Admission revealed 1:1 education completed regarding new admission, readmission paperwork, procedure, and verifying orders with physician, tele-health, or the attending. Review of admission order with a second nurse verifying the 6 patient rights and ensure all documents received have residents name identified. 2. Review of document titled Meadowbrook Staff Competency Audit Tool revealed competencies were completed for 20 of 21 LPN's on 3/20/2023 and 3/21/2023 and 5 RN's on 3/20/2023 and 3/21/2023. The competency check off completed for medication administration was completed on 3/20-3/21/2023 for 20 of 21 LPN's and 5 of 5 RN's. 3. Review of Inservice Attendance Record titled Medication Order Transcription revealed twenty-six nurses received education reviewing medication orders, telephone/verbal orders, admission process, admission medication verification, reconcile orders with physician, and perform audit of orders with second nurse at time orders are entered in the EMR. Policies reviewed during this in-service were Telephone Orders F711, F755 last approved 5/2022, Verbal Orders F711, F555 last approved 5/22/2022, and Writing Orders - General Principles last approved 5/2022. 4. Review of document titled New Employee Orientation Checklist updated 3/20/23, revealed line-item education new employees are provided during their orientation period which included but not limited to admission orders, medication administration, and transcription of orders provided by physician.

Based on record review, interviews, and policy review, the Medical Director (MD) failed to assess and review admission medication orders for one resident (R) (R#1) being admitted to facility under his care. Specifically, R#1 was a direct admission from a community setting with orders from her primary care physician. The orders contained medications for another patient, and the orders were electronically signed by the MD, resulting in R#1 being admitted to the hospital with a diagnosis of dehydration, acute metabolic encephalopathy, and low blood sugar. The sample size was 22. On 3/20/2023 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator, Interim Director of Nursing, and Assistant Director of Nursing were informed of the Immediate Jeopardy (IJ) on 3/20/2023 at 3:09 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 2/3/2023. An Acceptable Removal Plan was received on 3/24/2023. The removal plan included in-service training for nursing staff on transcribing medication orders, medication administration, including competency checks for licensed staff, in-service training for medical staff on the policy of Physician Services and transcribing new residents' admission medication orders. Through observations, record review, and interviews the survey team verified all elements of the facility's IJ Removal Plan, and the immediacy of the deficient practice was removed on 3/22/2023. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). Findings include: Review of policy titled Physician Services F710 approved 5/2022, revealed each resident is under the supervision of a licensed physician. Policy Interpretation and Implementation number 1. The attending physician participates in the resident's assessment and care planning, monitoring changes in medical status, and provides consultation or treatment when called by the facility. Number 2. The physician is responsible for prescribing new therapy and ensures the resident receives quality care and medical treatment. Review of the Medical Director Agreement signed by MD CC on 10/30/2007 revealed Consulting Responsibilities number 1. Assume the administrative authority, responsibility, and accountability of implementing the medial services, policies, and procedures. Number 2. Coordinate medical care and implement methods to keep the quality of care under constant surveillance. Number 4. Ensure residents receive adequate services appropriate to their needs. Review of the clinical record revealed R#1 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, hypertension, epilepsy, pressure ulcer, and pneumonia. The resident's Discharge Minimum Data Set (MDS) dated [DATE] revealed resident was rarely able to make herself be understood and rarely understood others. She was unable to complete the Brief Interview for Mental Status (BIMS). Review of admission paperwork from R#1 primary care physician (PCP) revealed an office note dated 10/22/2022, that documented active medications as clindamycin 300 milligrams (mg), ferrous gluconate 240 mg, hydrochlorothiazide-lisinopril 12.5 mg-10 mg, escitalopram 10 mg, Aricept 5 mg, Calcium 600 + D, and levetiracetam 500 mg. Included with R#1's active medication list was a list of medications belonging to another patient from the PCP's office, including atorvastatin 40 mg, cetirizine 10 mg, Plavix 75 mg, ergocalciferol 1.25 mg, Novolog 12 units three times a day, Lantus 24 units every night, Jardiance 10 mg, Cozaar 50 mg, metoprolol succinate ER 100 mg, Protonix 40 mg, torsemide 100 mg two times daily, and ferrous sulfate 325 mg. Review of Physician Note dated 2/6/2023 revealed that Nurse Practitioner (NP) BB saw R#1 at the facility on 2/6/2023. The note indicated medication reconciliation was done from a medication list from residents' primary physician from 2018/2019. She documented that Director of Nursing (DON) was to request current medication list from responsible party. The note revealed R#1's diagnoses include hypertension, osteoarthritis, and seizure disorder. The note was electronically signed by NP BB and dated 3/20/2023 at 12:26 p.m. Review of Physician Note dated 2/7/2023 labeled as Admission History and Physical dictated by Medical Doctor VV, revealed medication reconciliation was done from a med list from a 2018/2019 medical clinic visit note. The DON was asked to request a current medication list from R#1's responsible party. Continued review of the Admission History and Physical revealed past medical history included diagnoses listed but not limited to hypertension, osteoarthritis, and seizure disorders. The document indicated chronic medical problems, current documents, and current medications were reviewed. Continue medications and treatments as ordered. This note was electronically signed MD VV and dated 3/20/2023 at 12:26 p.m. Review of the orders transcribed in the EMR revealed the following medications were ordered and electronically signed by Medical Director CC. 1. losartan potassium 50 mg tablet, give 100 mg by mouth daily ordered on 2/3/2023. 2. Metoprolol Succinate ER 100 mg daily ordered on 2/3/2023. 3. Torsemide 20 mg give 100 mg twice a day ordered on 2/3/2023. 4. Hydrochlorothiazide (HCTZ) 12.5 mg ordered on 2/3/2023. 5. Jardiance 10 mg daily ordered on 2/3/2023. 6. Lantus 24 units subcutaneous at bedtime (hs) ordered on 2/3/2023. 7. Novolog 12 units subcutaneous before meals ordered on 2/3/2023. Interview on 3/17/2023 at 10:41 a.m., NP BB revealed the admission process at the facility is that nursing calls the NP when a resident arrives for admission. If the resident arrives after hours, nursing calls the NP on call or telehealth. The nurse reviews diagnosis, age, and medications with the provider they contact. She revealed she spoke to the previous DON regarding R#1's medication list obtained from her primary care physician. She asked the DON to have the family bring the residents' current medications to the facility. She stated if any changes are made during the initial conversation with the admitting nurse, the nurse will document changes and what provider made the changes. She revealed when a nurse calls her with a new admission, she wants them to tell her the medications the resident is taking and the diagnosis that the resident has for that medication before she approves the medication to be given in the facility. She stated medications are entered into the EMR by the nurse, then the orders go to the pharmacy, and then to the Physician/Nurse Practitioner for verification and signature. During further interview, she stated she is not sure if she reviewed the list of medications that were transcribed into the EMR with the facility staff. Interview on 3/21/2023 at 11:01 a.m., MD CC revealed he was aware of the incident with R#1 receiving insulin and oral diabetic medications which resulted in a low blood sugar and receiving a diuretic that resulted in the resident blood pressure dropping and subsequently transferred to an acute care hospital for treatment. He stated that he did not have any conversations with R#1's community primary care physician prior to or after her admission to the facility. He stated when a resident is admitted to the facility then he and the physicians in his group become the residents primary care physician. He stated he was aware that she did receive insulin in error without an order, diagnosis of diabetes, or an order to monitor blood glucose levels. He stated he himself had not seen R#1 but one of his colleges had but stated he was not sure of the date. During further interview, he stated he did not believe there was a specific policy or admission process related to a resident admission from home. He stated his expectation is nursing receives orders/medication list to review then they call the physician and read the orders to the physician verbally over the phone for them to confirm and verify continuance of medications and/or treatments. The facility implemented the following actions to remove the IJ: 1. On 2/9/2023, upon receiving notification of a medication error that resulted in the hospitalization of R#l, the Administrator initiated an investigation during which the resident's attending physician was called to discuss the mixed medical records of another individual that was not caught by our nurse, and the referring physician was notified of the HIPAA breach by his office. The attending physician who is also our Medical Director, received education on 3/20/2023 by the Administrator regarding the policy on Physician Services to include that a physician's personal approval of an admission recommendation must be in written form. The written recommendation for admission to the facility must be provided by a physician and cannot be provided by an NP. This may be accomplished through a hospital transfer summary written by a physician, paperwork completed by the resident's physician in the community, or other written form by a physician. 2. Starting on 3/20/2023 and ending on 3/21/2023, the Administrator and/or the Assistant DON, RN, provided education to the Physicians and Nurse Practitioners about receiving & transcribing new residents' admission medication orders by a physician. Additionally, education included a review of the policy for Physician Services. 3 of 3 Physicians and 3 of 3 Nurse Practitioners received this education. 3. On 2/10/2023, the Unit Manager(s) or ICP, LPN reviewed electronic medical records of current residents who were admitted to Meadowbrook H&R since 1/1/2023, to identify other residents with potentially incorrect admission medication orders, using the Admission Order Review Tool. Results of this audit identified that of the 8 residents admitted during this timeframe, no medication errors were identified. 4. Since 2/10/2023 there were 2 new admissions noted with medication errors in which the MD was notified of the medication error. There have been no noted adverse events related to these medication errors being identified. 5. On 2/10/2023, the facility conducted an AD Hoc QAPI meeting in order to determine the root cause of this medication error. It was determined that new admission orders were not being reviewed timely by the Interdisciplinary Care Plan Team (IDT). IDT members include the Administrator, Business Office, Clinical Reimbursement Coordinators, Wound Nurse, Director of Nursing, Assistant Director of Nursing, Unit Manager(s), Rehab Manager, SDC/IP, and Activities. The facility initiated a new system and process to review newly admitted residents' admission orders during the Interdisciplinary Team Meeting that occurs daily (M-F) using the Admission Order Review Tool. On weekends, the RN on duty will review new admission orders using the Admission Order Review Tool and the IDT will conduct a secondary review of the orders on Monday. The QAPI Committee members who attended this Ad Hoc QAPI meeting were the Administrator, Medical Records, Rehab Manager, Admissions, Business Office, Clinical Reimbursement Coordinators (MDS), Wound Nurse, Maintenance, Environmental, SDC/IP, Activities, all in person and the Medical Director via telephone. 6. Upon admission of a new resident, the admitting nurse on duty will contact the physician and review the list of medications with the physician. This may be completed verbally via telephone, fax/email, virtual conference, or an in-person meeting with the physician, including electronic signatures by physician. 7. Starting on 3/16/2023 and ending on 3/21/2023, education was provided to current licensed nurses regarding the facility's policies related to medication administration, new and readmission medication orders, diagnosis for each medication and only physicians may write admission orders, by the SDC/IP, Unit Manager and/or Assistant Director of Nursing or Director of Nursing. As of 3/21/2023 there are 26 licensed nurses employed at Meadowbrook Health and Rehab. This education was provided to 1 of 1 RN DON 1 of 1 RN ADON, 1 of 1 LPN Unit Manager, 3 of 3 other RNs, 1 of 1 Staffing Coordinator LPN, and 18 of 19 other LPNs. 25 of 26 total Licensed Nurses have received education and the facility's percentage of completion is 96.15% as of 3/21/2023. The remaining nurse will receive this education prior to working her next scheduled shift. The Physicians and Nurse Practitioners received separate education provided by the Administrator to 3 of 3 physicians and 3 of 3 NPs on 3/20/2023 & 3/21/2023. 8. On 3/20/2023 the existing policies for Admissions to Facility and Physician Services were reviewed by facility Administrator and Director of Nursing. Policies are found to be adequate to achieve substantial compliance. Job Descriptions for licensed nurses were also reviewed and found to be adequate. 9. On 3/20/2023 the facility initiated an audit of the electronic medical records for current residents who were admitted since 1/1/2023, to ensure that the admission orders were written by a physician, using the Physician Admission Audit Tool. This audit was completed by the Interim Director of Nursing on 3/21/2023. Results of this audit identified that of the 25 residents admitted , 2 were admitted from a nursing home, 2 were admitted from home and 21 were admitted from a hospital. Errors found included: 1 of 2 residents admitted from home was identified with errors. R#l was 1 of the 2 admissions from home. 10. On 3/20/2023, an Ad Hoc QAPI meeting was conducted to review and discuss the Immediate Jeopardy Deficiencies. In attendance were: the Administrator, Interim DON, Human Resources, Social Services, Business Office, MDS x's 2, Admissions, Environmental, Maintenance, Unit Manager, Staffing Coordinator, in person. The Medical Director participated by telephone and the Governing Body Members X2 joined virtually. A root cause analysis was conducted and determined the facility must ensure that a Physician is writing admission orders. The facility's Performance Improvement Plan was reviewed and revised to include the additional interventions. 11. To ensure compliance is maintained, an ongoing audit of new admissions' orders will be conducted using the Admission Order Review Tool by the DON, ADON, and/or Unit Manager(s), to ensure that admission orders are correct, appropriate diagnosis is listed for medications present, and orders were written by a physician. The physician will be notified of any findings because of the audit. 12. Starting on 3/20/2023 and ending on 3/21/2023, the Administrator and/or the Assistant DON, RN, provided education to the Physicians and Nurse Practitioners about receiving new residents' admission medication orders by a physician. Additionally, education included a review of the policy for Physician Services. 3 of 3 Physicians and 3 of 3 Nurse Practitioners received this education. All corrective actions were completed on 3/21/2023. The facility alleges that the IJ is removed on 3/22/2023. Onsite Verification: The IJ was removed on 3/22/2023 after the survey team performed onsite verification that the Removal Plan had been implemented. Interviews were conducted with staff to ensure they demonstrated knowledge of the facility's policies and procedures. 1. Review of handwritten notes by the administrator dated 2/9/2023 at 3:00 p.m. revealed the former DON reported to the Administrator the events that occurred during transcription of orders that lead to medication errors resulted in the hospitalization of R#1. His notes indicated a plan to educate nursing staff regarding 5 rights of medication administration, proper transcription of orders, verify documents belonging to the resident. An addendum was noted on 2/17/2023 that the nurse reviewed the original medication list with the family and the former DON found additional orders and instructed the nurse to verify with the Nurse Practitioner (NP) and put orders in the electronic medical record (EMR). Review of document titled Facility Incident #202301442 dated 2/9/2023 at 5:34 p.m. revealed the facility incident report was received and a follow up report was due on 2/16/2023. The report contained details of the documents received by the facility from R#1's community Primary Care Physician (PCP) contained documents belonging to another patient and how the nurse had mistakenly entered this patient's information into R#1's EMR. Education provided to the nursing staff dated 2/13/2023 regarding chart checks, 5 medication administration rights, chart checks and re-checks on all new admission and new orders, verify all with tele-health and NP. Review of facility incident report revealed R#1's admission medications were verified with NP BB by the former DON. Action that was taken R#1 was sent to the ER for low blood pressure. Action taken by the facility was the suspension of LPN AA for 3 scheduled shifts. Review of the facilities Census List revealed R#1 was readmitted to the facility on [DATE] at 4:11 p.m. Review of the facility's Incident Audit Report dated 2/13/2023 revealed a description of the incident involving transcription of orders incorrectly and why R#1 was sent to the hospital. Review of a letter dated 2/10/2023 to R#1's community PCP from the facility's Administrator informing him of the HIPAA breach because of the office sending documents related to another patient in the admission packet intended for R#1. This letter also informed the community PCP of the medication error that occurred which resulted in low blood pressure and transfer to the hospital for treatment. Review of Documentation dated 2/9/2023 of notification of the transcription error which led to medication errors that resulted in the hospitalization of R#1 and the letter sent to the community physician regarding the HIPAA breach. Review of In-Service Attendance Record dated 2/13/2023 revealed that 22 nurses received inservice titled Admission/Documentation. Supporting documents revealed topics discussed included but not limited to changes in condition, skin tears, falls, hospital returns, 5 medication rights, new admission paperwork, check all new orders with a second nurse and the following day a third chart check will occur during the IDT meeting. 2. Review of documentation of education provided for the physicians and mid-level provider revealed education related to new admission orders written by a physician. NP's can review orders for new admissions but cannot write new admission orders. Two of the three physicians received educational information via a telephone call on 3/20/2023 and 3/21/2023 from the Administrator. The third physician received education in-person on 3/20/2023 by the Administrator. Three of the three nurse practitioners received educational information from ADON on 3/21/2023. Documents reviewed with each provider included a policy titled Physician Services F710 last approved 5/2022 and the document titled Authority for Non-Physician Practitioners to Preform Visits, Sign Orders and Sign Medicare Part A Certifications/ Re-certification when Permitted by the State. 3. Reviewed audit tool that revealed no orders were transcribed incorrectly for 6 of the 8 residents. Reviewed these charts to verify this was correct. 4. Reviewed audit tool and resident EMR to verify the two with noted medication errors and no adverse effects were documented in relation to the errors. 5. Reviewed notes from AD Hoc QAPI meeting on 2/10/2023 and verified all persons listed above signed in. Reviewed the Admission Order Review Tool, policy titled QAPI Plan for Failure to Transcribe Orders and Complete Documentation last approved 1/2022, and the 5 Whys form. The plan was to review new admission and readmission orders utilizing the admission order review tool and re-educate staff. 6. Review of Inservice Attendance Record titled Medication order Transcription revealed 26 nurses received this education and policies reviewed during this in-service were Telephone Orders F711, F755 last approved 5/2022, Verbal Orders F711, F555 last approved 5/22/2022, and Writing Orders - General Principles last approved 5/2022. 7. Review of document titled Meadowbrook Staff Competency Audit Tool revealed competencies were completed for 20 of 21 LPN's on 3/20/2023 and 3/21/2023 and 5 RN's on 3/20/2023 and 3/21/2023. Competency check off completed for medication administration was completed on 3/20-3/21/23 for 20 of 21 LPN's and 5 of 5 RN's. 8. New employee checklist reviewed and includes training during orientation to include admission orders, medication administration, and transcription of orders provided by physician. 9. Reviewed audit tool and the EMR of each resident identified with the tool and verified each resident had admission orders that were signed by a physician. 10. Prior to the Ad Hoc meeting the Interim Director of Nursing (DON) and the Administrator received education related to ensuring proper oversight to ensure residents remain free for significant medication errors. This education was facilitated by the regional vice president and the reginal nurse consultant on 3/20/2023 at 4:00 p.m. Review of the Ad Hoc QAPI meeting held on 3/20/2023 at 6:30 p.m., revealed signature of each person listed above as in attendance of the meeting. Topic: reviewed IJ deficiencies and abatement plan. Review of the form titled 5 Whys revealed nursing staff failed to follow current policies and plan for re-education related to medications and orders. Policies reviewed were titled Admissions to the facility F620, F621, F710 last approved 5/2022, Physician Services F710 last approved 5/2022, and Staff Competency F726, F947, F941 last approved 5/2022. 11. Review of audit tool revealed the tool has been revised to include a place to acknowledge that the reviewer verified the admission orders are correct, appropriate diagnosis is listed for medications, and orders were written and signed by a physician. There is a place for notation of discrepancies and action taken to resolve the discrepancy found. 12. Review of documentation of education provided for the physicians and mid-level provider revealed education related to new admission orders written by a physician. NP's can review orders for new admissions but cannot write new admission orders. Two of the three physicians received educational information via a telephone call on 3/20/2023 and 3/21/2023 from the Administrator. The third physician received education in person on 3/20/23 by the Administrator. Three of the three nurse practitioners received educational information from ADON on 3/21/23. Documents reviewed with each provider included a policy titled Physician Services F710 last approved 5/2022 and the document titled Authority for Non-Physician Practitioners to Perform Visits, Sign Orders and Sign Medicare Part A Certifications/ Re-certification when Permitted by the State.

Based on observations, staff interviews and review of facility Job Description for the Administrator and Director of Nursing (DON) Administration failed to ensure that the facility was administered in a way that enabled it to use its resources effectively and efficiently to maintain the highest practicable level of well-being for one of one residents (R7) receiving [CONDITION(S)] care. Specifically, Administration failed to ensure that competent nursing staff were available and trained to care for R7 who was admitted with a [CONDITION(S)]. The facility also failed to ensure staff had adequate supplies in the event R7 had an emergency related to his [CONDITION(S)]. On 2/2/2022, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator was informed of the Immediate Jeopardy (IJ) on 2/2/2022 at 9:08 p.m. The noncompliance related to the Immediate Jeopardy was determined to have existed on 1/25/2022. The IJ is outlined as follows: The facility failed to ensure that one of one residents with a [CONDITION(S)] had the necessary supplies in the event of a life-threatening emergency and failed to train facility nursing staff on the need and use of emergency [CONDITION(S)] kits at the bedside. On 12/10/2021, R7 was hospitalized and was readmitted to the facility on [DATE]. On readmission to the facility on [DATE], R7 had a new [CONDITION(S)] (a surgical opening in the neck to allow direct access for oxygen to be administered into the windpipe). R7 was the only resident in the facility with a [CONDITION(S)] ([CONDITION(S)]). Observation on 2/2/2022 at 4:07 p.m. revealed R7's oxygen cannula was observed to be dislodged to the left side of the resident's throat away from the resident's [CONDITION(S)] collar causing R7 to be unable to receive oxygen via the resident's [CONDITION(S)]. LPN1 was called into the room and placed the oxygen back on the resident's [CONDITION(S)] collar. Observations and interviews, at this time, revealed R7 did not have necessary emergency [CONDITION(S)] supplies at the bedside and additional supplies were not located in the facility. In addition, interviews on 2/2/2022 with the Director of Nursing (DON), LPN1, and LPN9, nursing staff responsible for providing care for R7, revealed a lack of knowledge and training regarding emergency [CONDITION(S)] supplies. The IJ was related to the facility's noncompliance with the program requirements as follows: 42 CFR 483.21(b)(1) -- Develop/Implement Comprehensive Care Plan (F656 Scope/Severity (S/S): J), 42 CFR 483.25(i) -- Respiratory/[CONDITION(S)] Care and Suctioning (F695 S/S: J), 42 CFR 483.35(a)(3)(4)(c) -- Competent Nursing Staff (F726 S/S: J), and 42 CFR 483.70 - Administration (F835 S/S: J). Substandard Quality of Care was identified with the requirements at 42 CFR 483.25(i) -- Respiratory/[CONDITION(S)] Care and Suctioning (F695 S/S: J) Although a removal plan to address the Immediate Jeopardy was submitted prior to the conclusion of the survey on 2/4/2022, it was not approved and the Immediate Jeopardy remained ongoing at the time of exit. Findings include: Review of the policy titled, Administrator Job Description date May 2021 as the last revision date indicates under job summary supervises, plans, develops, monitors and maintains appropriate standards of care throughout all departments in the nursing home. Review of the job description for the DON revealed the position was, Accountable for all functions, activities, training, and education of all nursing employees . 1. Administration failed to ensure care plan interventions regarding [CONDITION(S)] care were implemented for one of one residents with a [CONDITION(S)] (R7). Cross refer F656 2. Administration failed to have emergency [CONDITION(S)] supplies readily available at the bedside for one of one residents receiving [CONDITION(S)] care. The facility failed to ensure they had Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, the facility failed to label the tubing with date of change for two residents (R53 and R10) and the facility failed to ensure Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Cross refer F695 3. Administration failed to ensure nursing staff were appropriately trained to provide competent nursing care for one of one residents admitted to the facility with a [CONDITION(S)] (R7). Cross refer F726 An observation on 2/2/2022 at 4:07 PM of R7 revealed the resident was lying in bed on his right side. He had a [CONDITION(S)]; however, the supplemental oxygen had become detached so that the resident was not receiving oxygen through his [CONDITION(S)]. Further observation revealed there were not any supplies available at R7's bedside for emergency [CONDITION(S)] care. Licensed Practical Nurse (LPN) 1, who was assigned to care for R7, was asked to assist. LPN1 stated that she was not familiar with managing an emergency with R7's [CONDITION(S)]. A concurrent interview on 2/2/2022 at 4:15 PM with LPN1 and the Director of Nursing (DON) revealed neither knew where to access emergency supplies for R7's [CONDITION(S)] if they were not in the resident's room. The DON looked around R7's room and verified there were no emergency [CONDITION(S)] supplies available; although she was not; sure, what supplies would be needed to address an emergency with a [CONDITION(S)]. The DON stated that the facility did not have a Respiratory Therapist (RT) either contracted or employed by the facility. Review of the nursing training records provided by the facility revealed that there was not any evidence of documentation that training had been provided to the nursing staff regarding [CONDITION(S)] care. There was not any evidence that competency check offs had been completed to verify that the nurses caring for R7 knew how to care for his [CONDITION(S)]. During an interview on 2/2/2022 at 5:41 PM, the DON confirmed there was no evidence staff were trained in providing care for R7's [CONDITION(S)]. The DON confirmed she was unaware of what supplies were required to be kept at the bedside for an emergency related to a [CONDITION(S)] and verified staff had not been trained on emergencies related to tracheostomies. The DON was unsure if the facility had a policy regarding [CONDITION(S)] emergencies. The DON confirmed the facility should have staff 24 hours per day that were trained and able to care for a resident with a [CONDITION(S)]. An interview on 2/3/2022 at 11:45 AM with Central Supply Clerk (CS) 1 revealed she was responsible for ordering supplies for resident care. CS1 stated there was no system to ensure emergency [CONDITION(S)] supplies were on hand. CS1 stated that there had not been any specialized supplies requested for R7's [CONDITION(S)]. An interview on 2/3/2022 at 12:00 PM with the Administrator confirmed that he was responsible for ordering medical supplies, but the facility had no policy for ordering, and no system for obtaining [CONDITION(S)] supplies for R7. The Administrator produced an invoice, which verified [CONDITION(S)] supplies for R7 were ordered on 2/2/2022, which was seven days after R7 was admitted with a [CONDITION(S)]. The Administrator stated the facility's system for ordering supplies, including specialized [CONDITION(S)] supplies for R7, met his expectations and did not need to be changed. Cross refer to F695

Based on observations, record review, staff interviews, and review of the facility policy titled, Staff Competency F726, F947, F941 the facility failed to ensure nursing staff were appropriately trained to provide competent nursing care for one of one residents admitted to the facility with a new [CONDITION(S)] (R7) On 2/2/2022, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator was informed of the Immediate Jeopardy (IJ) on 2/2/2022 at 9:08 p.m. The noncompliance related to the Immediate Jeopardy was determined to have existed on 1/25/2022. The IJ is outlined as follows: The facility failed to ensure that one of one residents with a [CONDITION(S)] had the necessary supplies in the event of a life-threatening emergency and failed to train facility nursing staff on the need and use of emergency [CONDITION(S)] kits at the bedside. On 12/10/2021, R7 was hospitalized and was readmitted to the facility on [DATE]. On readmission to the facility on [DATE], R7 had a new [CONDITION(S)] (a surgical opening in the neck to allow direct access for oxygen to be administered into the windpipe). R7 was the only resident in the facility with a [CONDITION(S)] ([CONDITION(S)]). Observation on 2/2/2022 at 4:07 p.m. revealed R7's oxygen cannula was observed to be dislodged to the left side of the resident's throat away from the resident's [CONDITION(S)] collar causing R7 to be unable to receive oxygen via the resident's [CONDITION(S)]. LPN1 was called into the room and placed the oxygen back on the resident's [CONDITION(S)] collar. Observations and interviews, at this time, revealed R7 did not have necessary emergency [CONDITION(S)] supplies at the bedside and additional supplies were not located in the facility. In addition, interviews on 2/2/2022 with the Director of Nursing (DON), LPN1, and LPN9, nursing staff responsible for providing care for R7, revealed a lack of knowledge and training regarding emergency [CONDITION(S)] supplies. The IJ was related to the facility's noncompliance with the program requirements as follows: 42 CFR 483.21(b)(1) -- Develop/Implement Comprehensive Care Plan (F656 Scope/Severity (S/S): J), 42 CFR 483.25(i) -- Respiratory/[CONDITION(S)] Care and Suctioning (F695 S/S: J), 42 CFR 483.35(a)(3)(4)(c) -- Competent Nursing Staff (F726 S/S: J), and 42 CFR 483.70 - Administration (F835 S/S: J). Substandard Quality of Care was identified with the requirements at 42 CFR 483.25(i) -- Respiratory/[CONDITION(S)] Care and Suctioning (F695 S/S: J) Although a removal plan to address the Immediate Jeopardy was submitted prior to the conclusion of the survey on 2/4/2022, it was not approved and the Immediate Jeopardy remained ongoing at the time of exit. Findings include: The Facility Admission Capabilities document, undated, stated under the heading Respiratory, the facility would admit a resident with a new [CONDITION(S)] that needed complex (copious drainage) [CONDITION(S)] care. In addition, the facility would admit a resident who required suctioning hourly or less frequently. Review of the Primary Nurse RN/LPN job description revealed the primary nurse Performs any or all professional nursing duties as determined by qualifications and training . Maintains quality resident care in compliance with established policies and procedures . Review of the job description for the DON revealed the position was, Accountable for all functions, activities, training, and education of all nursing employees . Review of the facility policy titled, Staff Competency F726, F947, F941 dated May 2021 and provided by the facility revealed, Nursing staff will demonstrate competency in skills and techniques necessary to care for the resident's needs, as identified through resident assessments and resulting care plans . Premises of the competency based program include: a. Evaluation of current program to identify needs and opportunities; b. Identification of gaps in education that may lead to poor outcomes; c. Outlines what education is needed based upon the resident population served; d. Delineates specific training needed based upon the facility assessment; e. Details the tracking system utilized, and f. Ensures the competency based education is not reliant on one source, e.g. online training. Review of the Admission Record undated in the electronic medical record (EMR) under the profile tab, revealed R7 was originally admitted to the facility on [DATE]. Admission diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/2/2021 in the EMR and under the MDS tab, revealed the Brief Interview for Mental Status (BIMS) test was not completed. R7 was rarely or never understood; he had long and short-term memory impairment, and was severely impaired in decision-making. No behavioral indicators were present. R7 was dependent on two or more staff for activities of daily living (ADLS) such as bed mobility, transfers, dressing, toilet use, and hygiene. R7 was fed via a feeding tube. R7 was impaired in range of motion (ROM) on one side of the upper extremity and both sides of the lower extremities. Review of a Nursing Note dated 12/10/2021 at 2:47 PM in the EMR and under the progress notes tab, revealed R7 was sent to the emergency room (ER) to be evaluated and treated. Review of the undated Admission Record in the EMR under the profile tab, revealed R7 was readmitted to the facility from the hospital on 1/25/2022 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the readmission Physician's Orders dated 1/26/2022 in the EMR and under the orders tab, revealed the [CONDITION(S)] collar was to be changed weekly on Sunday night shift and the resident was to be suctioned via the [CONDITION(S)] with sterile water every four hours as needed for excessive secretions. There were no orders for use of the oxygen and no orders for [CONDITION(S)] care (cleaning). The size of the [CONDITION(S)] was not specified in the orders. Further review revealed there was not any evidence that nursing staff contacted the physician to obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Care Plan for R7 with a target date of 3/13/2022 (the date it was written was not documented) and in the EMR under the MDS tab revealed Interventions for the residents [CONDITION(S)] included keeping the extra [CONDITION(S)] tube and obturator (device to keep the airway open) at R7's bedside. Review of R7's EMR (Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . a. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The order for Vital signs every shift revealed R7's oxygen saturations were varied, from a low of 86% on day shift on 01/26/22 up to 97% on 01/31/22. There was no nursing note associated with the oxygen saturation of 86%. The resident's respirations were documented at 18 breaths per minute in every instance. b. Review of the MAR for February (up through 2/2/2022) revealed an oxygen saturation of 92%, 97% and 98% on 02/01/02. None were recorded on 2/2/2022. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 02/02/22 at 4:07 PM, R7 was observed without oxygen being administered into his [CONDITION(S)]. The oxygen cannula was dislodged to the left side of his throat away from the [CONDITION(S)] collar. R7's assigned nurse, LPN1, was called to the room and she placed the oxygen back on the resident's [CONDITION(S)] collar, verifying the resident had not been getting oxygen. LPN1 was asked about an emergency [CONDITION(S)] and a hemostat (scissor-like device to keep the airway open used when inserting an emergency [CONDITION(S)]) that was supposed to be at the bedside. She stated she did not know what a hemostat was. The Director of Nursing (DON) entered the room at 4:15 PM and looked for the emergency [CONDITION(S)] kit in the room; however, she could not find the replacement [CONDITION(S)] kit in the room. The DON verified the emergency [CONDITION(S)] kit should be in the resident's room. and stated she would go and look for one on the emergency cart. The DON was asked what the emergency [CONDITION(S)] kit consisted of and stated sponges, a cannula, and the [CONDITION(S)]. During an interview on 2/3/2022 at 11:39 AM, the DON confirmed the facility did not provide training for the licensed staff for care or management of residents with trachs and verified R7 was the only resident in the facility with a [CONDITION(S)]. The DON confirmed the last time the facility provided hands on training for licensed staff for management of resident with a [CONDITION(S)] was in 2019 and that training had been provided by the Staff Development Department. The DON confirmed she completed computer training called [CONDITION(S)] Management. The DON confirmed she had not had hands on training for [CONDITION(S)] care in over five years. During an interview on 2/3/2022 at 5:20 PM, LPN1 stated she worked for a staffing agency. LPN1 stated the facility had not provided her with any training for caring for residents with a [CONDITION(S)]. LPN1 stated, she did not suction R7's [CONDITION(S)] on 2/2/2022 (from 3:00 PM until he went to the hospital at 10:30 PM) and stated, I am unsure of what time he was suctioned on 2/2/2022. LPN1 further stated, I am not 100% sure what equipment that should be at the bedside for residents that have a [CONDITION(S)]. LPN1 confirmed R7 did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN1 confirmed that there was not a [CONDITION(S)] emergency kit was at the resident's bedside. LPN1 confirmed R7 was assigned to her care on 2/2/2022 starting at 3:00 PM (LPN worked the 3:00 p.m. to 11:00 p.m. shift). LPN1 confirmed she suctioned R7's [CONDITION(S)] on 2/1/2022. She stated she turned the oxygen up a little prior to suctioning by about two liters. LPN1 stated she did not ambu or hyper oxygenate the resident prior to suctioning. LPN confirmed residents should be hyperoxygenated with ambu prior to suctioning. LPN1 stated she did not know if the facility had a policy regarding suctioning [CONDITION(S)] residents. LPN1 stated R7 was supposed gets [CONDITION(S)] care every four hours and prn (as needed). During an interview on 2/4/2022 at 11:37 PM, LPN9 confirmed she had not received any hands-on [CONDITION(S)] care and management training at the facility. She confirmed she did not hyperoxygenate prior to suctioning and she was not aware hyperoxygenation was required prior to suctioning R7. LPN9 stated R7 was under her care on the 3 p.m. to 11 p.m. shift on 1/31/2022 and that this care included [CONDITION(S)] management. LPN9 stated, I performed suction to his [CONDITION(S)] tube on 1/31/2022 and I was not competent to perform the task. During an interview on 2/4/2022 at 12:28 PM, the RT denied conducting staff training while she was in the facility. The RT verified she was not on staff and there was no formal contract for her services. She stated she could come into the facility if they called her. The RT stated there should be specific training and competency check offs with agency nurses who worked with residents that have trachs. During an interview on 2/4/2022 at 6:23 PM, the Medical Director stated training regarding management of the [CONDITION(S)] should have taken place before R7 was readmitted to the facility with a new [CONDITION(S)] and that training should be provided on an ongoing basis. The Medical Director stated staff should be trained to suction a resident with a [CONDITION(S)]. Cross refer to F695

Based on observations, interviews, record review and policy review, the facility failed to have emergency [CONDITION(S)] supplies readily available at the bedside for one of one residents receiving [CONDITION(S)] care (R7) and the facility failed to ensure they had Physician orders for oxygen for one of three residents (R7) On 2/2/2022, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator was informed of the Immediate Jeopardy (IJ) on 2/2/2022 at 9:08 p.m. The noncompliance related to the Immediate Jeopardy was determined to have existed on 1/25/2022. The IJ is outlined as follows: The facility failed to ensure that one of one residents with a [CONDITION(S)] had the necessary supplies in the event of a life-threatening emergency and failed to train facility nursing staff on the need and use of emergency [CONDITION(S)] kits at the bedside. On 12/10/2021, R7 was hospitalized and was readmitted to the facility on [DATE]. On readmission to the facility on [DATE], R7 had a new [CONDITION(S)] (a surgical opening in the neck to allow direct access for oxygen to be administered into the windpipe). R7 was the only resident in the facility with a [CONDITION(S)] ([CONDITION(S)]). Observation on 2/2/2022 at 4:07 p.m. revealed R7's oxygen cannula was observed to be dislodged to the left side of the resident's throat away from the resident's [CONDITION(S)] collar causing R7 to be unable to receive oxygen via the resident's [CONDITION(S)]. LPN1 was called into the room and placed the oxygen back on the resident's [CONDITION(S)] collar. Observations and interviews, at this time, revealed R7 did not have necessary emergency [CONDITION(S)] supplies at the bedside and additional supplies were not located in the facility. In addition, interviews on 2/2/2022 with the Director of Nursing (DON), LPN1, and LPN9, nursing staff responsible for providing care for R7, revealed a lack of knowledge and training regarding emergency [CONDITION(S)] supplies. The IJ was related to the facility's noncompliance with the program requirements as follows: 42 CFR 483.21(b)(1) -- Develop/Implement Comprehensive Care Plan (F656 Scope/Severity (S/S): J), 42 CFR 483.25(i) -- Respiratory/[CONDITION(S)] Care and Suctioning (F695 S/S: J), 42 CFR 483.35(a)(3)(4)(c) -- Competent Nursing Staff (F726 S/S: J), and 42 CFR 483.70 - Administration (F835 S/S: J). Substandard Quality of Care was identified with the requirements at 42 CFR 483.25(i) -- Respiratory/[CONDITION(S)] Care and Suctioning (F695 S/S: J) Although a removal plan to address the Immediate Jeopardy was submitted prior to the conclusion of the survey on 2/4/2022, it was not approved and the Immediate Jeopardy remained ongoing at the time of exit. Findings include: Review of the [CONDITION(S)] Care policy dated October 2020 and provided by the facility revealed, The purpose of this procedure is to guide [CONDITION(S)] care and the cleaning and sterilization of reusable metal [CONDITION(S)] tubes . Provide [CONDITION(S)] care as often as needed, at least twice daily for old, established tracheostomies, and at least once per shift for residents with new [CONDITION(S)] sites . A replacement [CONDITION(S)] tube must be available at the bedside at all times. Review of the Suctioning the Upper Airway (Oral Pharyngeal Suctioning) policy dated December 2020 and provided by the facility revealed, The purpose of this procedure is to remove secretions, maintain a patent airway, and prevent infection of the lower respiratory tract . Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for suctioning . Obtain information about the resident's medical history, including the date of intubation ([CONDITION(S)]), respiratory signs and symptoms, and risk factors for increased secretions, decreased airway clearance and/or airway obstruction . Complications of suctioning the lower airway include trauma to the airway, infection, [CONDITION(S)], hypoxemia, and cardiac [CONDITION(S)] (resulting from hypoxemia) . Hyperoxygenate the resident by increasing the oxygen flow (as ordered) before the procedure and after suctioning. (Note: After the procedure, oxygen should be readjusted as ordered to prevent oxygen toxicity and C02 [carbon [MEDICATION(S)]] retention in [CONDITION(S)] residents.) Review of the Oxygen Administration policy dated June 2021 and provided by the facility revealed, The purpose of this procedure is to provide guidelines for safe oxygen administration . Verify there is a physician's order. 1. Review of the Admission Record undated in the electronic medical record (EMR) under the profile tab revealed R7 was originally admitted to the facility on [DATE]. Admission diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) for R7 with an Assessment Reference Date (ARD) of 11/2/2021 in the EMR and under the MDS tab, revealed the Brief Interview for Mental Status (BIMS) test was not completed. R7 was rarely or never understood; he had long and short-term memory impairment, and was severely impaired in decision making. No behavioral indicators were present. R7 was impaired in range of motion (ROM) on one side of the upper extremity and both sides of the lower extremities. Review of a Nursing Note dated 12/10/2021 at 2:47 PM in the EMR and under the progress notes tab, revealed R7 was sent to the emergency room (ER) to be evaluated and treated. Review of the undated Admission Record in the EMR under the profile tab, revealed R7 was readmitted to the facility from the hospital on 1/25/2022 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nursing Admission Evaluation, Respiratory Section, dated 1/25/2022 at 1:45 PM in the EMR and under the assessment tab, revealed R7's respirations were normal, he had frothy white sputum, breath sounds were diminished, the resident was administered 10 LPM (liters per minute) of oxygen with an oxygen saturation level of 95% via the [CONDITION(S)] collar. The [CONDITION(S)] was a #8 Shiley. Review of the Nursing Note dated 1/25/2022 at 4:47 PM in the EMR and under the progress notes tab, revealed the resident arrived at the facility at 1:30 PM. The resident had a #8 Shiley [CONDITION(S)] in place and was on 10 LPM of oxygen. The note indicated R7 had a contracture to his right arm. Review of a Therapy Note dated 1/25/2022 at 6:14 PM in the EMR and under the progress notes tab, revealed the Respiratory Therapist (RT) assessed R7 and wrote a note under a LPN's entry. The progress note read in full, Respiratory Therapy Note: Pt [patient] in bed resting currently on 4 LPM 02 [oxygen] via [CONDITION(S)] mask with humidity. BBS [bilateral breath sounds] reveal coarse crackles pt [patient] suctioned for copious amounts of thick white secretions. Stoma site is clean and dry, Inner cannula changed at this time. O2 sats [saturations] 96-97%, HR [heart rate] 110, RR [respiration rate] 18. Pt has an 8CN85H Adult Flexible [CONDITION(S)] Tube. [CONDITION(S)] is secure and patent. Respiration are even and unlabored. Review of the readmission Physician's Orders dated 1/26/2022 in the EMR and under the orders tab, revealed the [CONDITION(S)] collar was to be changed weekly on Sunday night shift and the resident was to be suctioned via the [CONDITION(S)] with sterile water every four hours as needed for excessive secretions. There were no orders for the use of the oxygen and no orders for [CONDITION(S)] care (cleaning). The size of the [CONDITION(S)] was not specified in the orders. Observations on 1/31/2022 at 4:36 PM, 2/1/2022 at 9:13 AM and on 2/2/2022 at 4:15 PM. revealed R7's right arm and hand were severely contracted with the right fist naturally located by the [CONDITION(S)] insertion site while the resident was lying in bed. During an interview on 2/2/2022 at 11:26 AM, Certified Nursing Assistant (CNA)1 stated R7 was dependent on staff for all care. She stated she used pillows to reposition R7; however, reported He won't stay how you turn him. He likes to stay on the right side, and he will turn back to the right. CNA1 stated, He takes it ([CONDITION(S)]) off; he will move it. During an interview on 2/2/2022 at 1:36 PM, Licensed Practical Nurse (LPN)2 stated she just changed R7's [CONDITION(S)] collar due to [MEDICATION(S)] and stated R7 had a lot of secretions. LPN2 and the surveyor entered the resident's room and LPN2 stated, It gets messy quick. LPN2 showed the surveyor the resident's ambu bag (handheld tool that is used to deliver positive pressure ventilation to a person with insufficient or ineffective breaths. It consists of a self-inflating bag, one-way valve, mask, and an oxygen reservoir) located in a drawer in the room. While in the room, R7 coughed vigorously several times. On 2/2/2022 at 4:07 PM, R7 was observed without oxygen being administered into the [CONDITION(S)]. The oxygen cannula was dislodged to the left side of his throat away from the [CONDITION(S)] collar. The resident was lying on his right side. R7's assigned nurse, LPN1, was called to the room and she placed the oxygen back on the resident's [CONDITION(S)] collar, verifying the resident had not been getting oxygen. LPN1 stated the oxygen concentrator was set at 3.5 LPM (Liters Per Minute). LPN1 was asked about an emergency [CONDITION(S)] and a hemostat (scissor-like device to keep the airway open used when inserting an emergency [CONDITION(S)]) that was supposed to be at the bedside. She stated she did not know what a hemostat was. She looked in the room but could not find the [CONDITION(S)] or device to keep the airway open and stated she did not know if there was an emergency kit in the building. The Director of Nursing (DON) entered the room at 4:15 PM and looked for the emergency [CONDITION(S)] kit in the room; however, she could not find a replacement [CONDITION(S)] kit in the room. The DON verified the emergency [CONDITION(S)] kit should be in the resident's room and stated she would go and look for one on the emergency cart. The DON verified if the [CONDITION(S)] came out, there was no equipment in the resident's room to keep R7's airway open. The DON stated the resident was readmitted to the facility on 10 LPM of oxygen, but the level had been decreased. She stated she was going to contact the RT who had assessed the resident on 1/25/2022 when R7 was readmitted . The DON stated the RT was not an employee of the facility; however, when R7 was admitted an RT came onsite and assessed R7 On 2/2/2022 at 5:03 PM, after leaving R7's room to look for emergency equipment on the emergency cart, the DON was only able to return with a size 7.5 mm [CONDITION(S)]. The DON reviewed the physician's orders and stated there was no order for use of oxygen and no specification on the order regarding the size of the [CONDITION(S)]. The DON said the oxygen was initially supposed to be at 10 LPM, but it had been titrated down. The DON stated she was not sure what level it should currently be. When asked to provide a [CONDITION(S)] kit, the DON provided a [CONDITION(S)] care cleaning kit, which did not contain the emergency [CONDITION(S)] or obturator (device for insertion). The DON stated she had not called the RT yet. During an interview on 2/2/2022 at 5:41 PM, the DON stated the RT assessed R7 and provided training to one LPN (LPN2) on R7's admitted ; however, she verified there was no record of the training. LPN2 was supposed to train the rest of the nursing staff; however, the DON confirmed there was no evidence staff were trained. The DON stated there was no ongoing contract for the RT or provision of respiratory services. The DON confirmed she was unaware of what supplies were required to be kept at the bedside for [CONDITION(S)] emergency and verified staff had not been trained on emergencies for the [CONDITION(S)]. The DON was unsure if the facility had a policy regarding [CONDITION(S)] emergencies. The DON confirmed the facility should have staff 24 hours a day that were trained and able to care for a resident with a [CONDITION(S)]. The DON confirmed R7 did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON confirmed R7 breathed through the [CONDITION(S)] site. An interview on 2/2/2022 at 6:33 PM with the Nurse Practitioner (NP) and she stated there should be orders for administration of oxygen through the [CONDITION(S)] collar. The NP stated oxygen should be administered at 10 LPM through the stoma through the [CONDITION(S)] collar and there should be an emergency [CONDITION(S)] kit at R7's bedside. She stated if there was no kit at the bedside, there would be no equipment to assist with R7's airway if the cannula became dislodged or came out. During an interview on 2/2/2022 at 7:35 PM with the Administrator revealed, he did not have a contract in his possession for the RT that came to the facility. He stated the RT who came to the facility when R7 was admitted was not contracted for ongoing services. Observation on 2/2/2022 at 8:09 PM, revealed R7 was lying in bed on his right side. The oxygen cannula was in place and oxygen was being delivered at 3.5 LPM. The suction container was approximately one third full of sputum. On 2/2/2022 at 10:30 PM, an ambulance arrived and R7 was transported to the hospital. During an interview on 2/3/2022 at 11:39 AM, the DON confirmed the facility was not equipped or trained to care or manage residents with trachs. During an interview on 2/3/2022 at 2:38 PM, the Administrator stated he found out prior to R7's readmission that a 10-liter oxygen concentrator was needed. He stated the facility did not have one, so he ordered one. He stated he was not aware of additional [CONDITION(S)] supplies that were needed. During an interview on 2/4/2022 at 11:37 PM, LPN9 confirmed she had not received any hands-on [CONDITION(S)] care and management training at the facility. LPN9 confirmed there were no [CONDITION(S)] emergency supplies at R7's bedside on 01/31/22. LPN9 confirmed in an emergency ([CONDITION(S)] dislodged) staff could not provide treatment without the emergency supplies at R7's bedside. During an interview on 2/4/2022 at 12:28 PM, the RT stated she came to the facility and assessed R7 shortly after he was admitted . She stated she listened to his breath and did an oxygen saturation it was about 100%. She stated R7 was on a high liter oxygen tank. The RT stated she was informed R7 was on 10 LPM of oxygen. The RT stated R7 should have been on a percentage, not a liter flow rate. She stated when a resident left the hospital and went to a nursing home, the oxygen should be changed to a percentage, for example four liters would be about 36%, so that would be the order. She stated she decreased the oxygen setting because 10 liters was too much. She stated, If you require 10 liters, you should not be admitted (to a nursing home). The RT stated, I walked him down . I put him on 4 liters and his sats [oxygen saturations] were at about 98%. The RT stated she did [CONDITION(S)] care and suctioned R7 while she was there. She stated she reported to the nurse on duty what she did and wrote a note under the nurse's name. The RT stated the typical order for suctioning was PRN. The RT stated there should be orders for cleaning the [CONDITION(S)], such as every shift and PRN. During an interview on 2/4/2022 at 6:23 PM, the Medical Director stated proper equipment should be in R7's room. and training regarding management of the [CONDITION(S)] should have taken place before he was readmitted and on an ongoing basis. The Medical Director stated the facility should have used the hospital discharge order for oxygen (10 liters). The Medical Director stated there should be a current physician's order for the oxygen. The Medical Director stated the facility should have emergency equipment in the room or readily available nearby. The Medical Director stated [CONDITION(S)] care should be on the physician's orders and on the care plan. The Medical Director stated staff should be trained to suction a resident with a [CONDITION(S)]. The Medical Director stated nursing staff should hyperoxygenate the resident prior to suctioning to the extent it could be achieved.

Based on observations, record review, staff interviews, and review of the facility policy titled, Care Plans - Comprehensive F656, F657, F658 the facility failed to ensure care plan interventions regarding emergency [CONDITION(S)] care were implemented for one of one residents with a [CONDITION(S)] (R7). On 2/2/2022, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator was informed of the Immediate Jeopardy (IJ) on 2/2/2022 at 9:08 p.m. The noncompliance related to the Immediate Jeopardy was determined to have existed on 1/25/2022. The IJ is outlined as follows: The facility failed to ensure that one of one residents with a [CONDITION(S)] had the necessary supplies in the event of a life-threatening emergency and failed to train facility nursing staff on the need and use of emergency [CONDITION(S)] kits at the bedside. On 12/10/2021, R7 was hospitalized and was readmitted to the facility on [DATE]. On readmission to the facility on [DATE], R7 had a new [CONDITION(S)] (a surgical opening in the neck to allow direct access for oxygen to be administered into the windpipe). R7 was the only resident in the facility with a [CONDITION(S)] ([CONDITION(S)]). Observation on 2/2/2022 at 4:07 p.m. revealed R7's oxygen cannula was observed to be dislodged to the left side of the resident's throat away from the resident's [CONDITION(S)] collar causing R7 to be unable to receive oxygen via the resident's [CONDITION(S)]. LPN1 was called into the room and placed the oxygen back on the resident's [CONDITION(S)] collar. Observations and interviews, at this time, revealed R7 did not have necessary emergency [CONDITION(S)] supplies at the bedside and additional supplies were not located in the facility. In addition, interviews on 2/2/2022 with the Director of Nursing (DON), LPN1, and LPN9, nursing staff responsible for providing care for R7, revealed a lack of knowledge and training regarding emergency [CONDITION(S)] supplies. The IJ was related to the facility's noncompliance with the program requirements as follows: 42 CFR 483.21(b)(1) -- Develop/Implement Comprehensive Care Plan (F656 Scope/Severity (S/S): J), 42 CFR 483.25(i) -- Respiratory/[CONDITION(S)] Care and Suctioning (F695 S/S: J), 42 CFR 483.35(a)(3)(4)(c) -- Competent Nursing Staff (F726 S/S: J), and 42 CFR 483.70 - Administration (F835 S/S: J). Substandard Quality of Care was identified with the requirements at 42 CFR 483.25(i) -- Respiratory/[CONDITION(S)] Care and Suctioning (F695 S/S: J) Although a removal plan to address the Immediate Jeopardy was submitted prior to the conclusion of the survey on 2/4/2022, it was not approved and the Immediate Jeopardy remained ongoing at the time of exit. Findings include: Review of the facility policy titled, Care Plans - Comprehensive F656, F657, F658 dated November 2017 and provided by the facility revealed, An individualized comprehensive person-centered care plan that includes measurable objectives and time frames to meet the resident's medical, nursing, mental and psychological needs is developed for each resident .The comprehensive care plan is based on a thorough assessment that include, but is not limited to, the MDS and physician's orders . Each resident's care plan is designed to : a. incorporate identified problem areas; b. Incorporate risk factors associated with identified problems; . Aid in preventing or reducing declines in the resident' functional status and/or functional levels; g. Enhance the optimal functioning of the resident . The facility's care planning/interdisciplinary team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. 1. Review of the Admission Record undated in the electronic medical record (EMR) under the profile tab, revealed R7 was originally admitted to the facility on [DATE]. Admission diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/2/2021 in the EMR and under the MDS tab, revealed the Brief Interview for Mental Status (BIMS) test was not completed. R7 was rarely or never understood; he had long and short-term memory impairment, and was severely impaired in decision-making. R7 was impaired in range of motion (ROM) on one side of the upper extremity and both sides of the lower extremities. Review of the undated Admission Record in the EMR under the profile tab, revealed R7 was readmitted to the facility from the hospital on 1/25/2022 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan with a target date of 3/13/2022 (the date it was written was not documented) and in the EMR under the MDS tab revealed a focus area of [CONDITION(S)] r/t [related to] impaired breathing. Goals included, no abnormal drainage around [CONDITION(S)] site . clear and equal breath sounds bilaterally . will have temp [temperature] within normal limits . no s/sx [signs or symptoms] of infection through the review date. Interventions included Give humidified oxygen as prescribed . Monitor the resident for complications such as unexplained removal of the [CONDITION(S)] . and airway complications such as tracheal infections, mucous plugging, tracheal erosion and stenosis . Monitor/document respiratory rate, depth and quality. Check and document a [every] shift/as ordered . Suction as necessary .Tube out procedures: keep extra [NAME] tube and obturator [device to keep the airway open] at bedside. If tube is coughed out, if tube cannot be reinserted, monitor/document for signs of respiratory distress. If able to breathe spontaneously, elevate HOB [head of bed] 45 degrees and stay with resident. Obtain medical help immediately .Use universal precautions. Assist with coughing as needed. Review of R7's January 2022 EMR (Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] b. Review of the MAR for February (up through 2/2/2022) revealed no nursing sign off (boxes were blank) for the order of Suction resident via [CONDITION(S)] with sterile water every four hours as needed for excessive secretions. On 2/2/2022 at 4:07 PM, R7 was observed without oxygen being administered into his [CONDITION(S)]. The oxygen cannula was dislodged to the left side of his throat away from the [CONDITION(S)] collar. The resident was lying on his right side. The DON verified if the [CONDITION(S)] came out, there was no equipment to keep R7's airway open. During an interview on 2/2/2022 at 5:41 PM, the DON confirmed the resident's current Care Plan was not being implemented. An interview on 2/2/2022 at 6:33 PM with the Nurse Practitioner (NP) if there was no kit at the bedside, there would be no equipment to assist with R7's airway if the cannula became dislodged or came out. Cross refer F695

Based on observations, record review, resident and staff interviews, and review of the facility policy titled, Goals and Objectives, Restorative Services the facility failed to provide two of two residents (R22 and R69) reviewed for range of motion (ROM) with treatment and services to address and prevent contractures. Actual harm was identified to have occurred when R22 who was admitted to the facility without a contracture developed a contracture to his left hand while in the facility without having received therapy and/or restorative services. Actual harm was also identified when facility staff failed to apply a splint to R69's left hand and the resident's contracture to his left hand worsened. Findings include: Review of the Goals and Objectives, Restorative Services policy dated December 2007 and provided by the facility revealed, Specialized rehabilitative service goals and objectives shall be developed for problems identified through resident assessments . Rehabilitative goals and objectives are developed for each resident and are outlined in his/her plan of care relative to therapy services . Goals may include, but are not limited to . Encouraging the resident to maintain his/her independence and self-esteem. 1. Review of the Admission Record undated, in the electronic medical record (EMR) and under the profile tab, revealed R22 was admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the residents Admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 9/23/2017 in the EMR under the MDS tab, revealed R22 was impaired in ROM to the lower extremity only (upper extremity was not documented as having impairment). Review of the Nursing: Contracture Eval dated 12/15/2017 in the EMR and under the Assessment tab, revealed no contracture of the residents left hand was present. Review of the EMR under the MDS tab, dated 12/21/2021 revealed R22 was cognitively intact with a Brief Interview for Mental Status Score (BIMS) of 15 out of 15 (score of 13 - 15 indicates cognition intact). R22 was impaired in ROM to the upper and lower extremity on one side. Review of the Clinical Physician's Orders dated February 2022 in the EMR and under the orders tab, revealed there were no orders for ROM, restorative, or therapy. During an interview and observation on 1/31/2022 at 3:02 PM, R22 stated he had several strokes and had left sided weakness. R22's left hand was contracted with his fingers curled towards his palm. R22 stated he had never been provided with a splint for his hand. R22 stated, I keep it (his hand) balled up and I cannot use it. R22 stated he was not offered restorative services or any type of exercise program but would be interested in participating and having a splint. R22 attempted to open his affected hand (left hand) with the other hand and stated, I can open it a little, but I cannot do it today. R22 moved his fingers minimally when he attempted to open his left hand. During an interview on 2/2/2022 at 2:20 PM, the Restorative Aide (RA) stated R22 had not been on any type of restorative program for at least a year. The RA stated she did not know if a splint had been tried for R22's contracted left hand. She verified she had not seen one in use and had not applied one. During an interview on 2/3/2022 at 3:15 PM, the Therapy Director reviewed the EMR and stated R22 had not been on therapy since 2018. She stated, He had no contractures when he received services (in 2018). When asked about a restorative program, she stated she had been informed by the therapists that there was no restorative program and the restorative program was, on the back burner. The Therapy Director stated there were no current orders for restorative for R22. The Therapy Director stated, We usually get a referral from nursing or CNAs of a new contracture. The Therapy Director stated they (therapists) needed a referral or permission and a physician's order to provide services. The Therapy Director stated if R22 had developed a contracture, he should have been referred to therapy but there was no evidence of this being done per her review of the EMR. When asked about the RA who was providing services to some residents currently, she stated she did not know who this person was and was not aware of restorative services being provided. At 3:44 PM, the Therapy Director and surveyor went into R22's room and R22 stated he had not received therapy in a long time and stated, They did not teach me how to stretch my hand. I cannot open my hand. I would like to be evaluated by therapy. I would like a splint. R22 attempted to open his left hand from the curled position; however, was able to move his fingers only minimally. After leaving the room, the Therapy Director stated R22's left hand was contracted and reported, He needs a splint. During an interview on 2/4/2022 at 5:44 PM, the Director of Nursing (DON) stated the facility previously had a restorative nurse; however, she left a few months ago. The DON stated she was trying to recruit for a restorative nurse. The DON stated the process should be if there was a resident that would benefit from a restorative program, nursing notified therapy and asked if they would evaluate the resident. The DON verified the RA was doing restorative with residents who had pre-existing programs in place prior to the restorative nurse's departure. The DON stated she did not remember him (R22) wearing any splint or device since he was admitted . The DON stated, We have not initiated any new restorative programs since the previous restorative nurse left. 2. Review of the Admission Record undated in the EMR under the profile tab, revealed R69 was admitted to the facility on [DATE]. Current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS with an ARD of 12/24/2021 in the EMR and under the MDS tab, revealed R69 was unimpaired in cognition with a BIMS score of 15 out of 15. R69 was impaired to the lower and upper extremities on one side. R69 was not documented as being on therapy, or a restorative nursing program including a ROM or receiving splint/brace assistance. Review of the Clinical Physician's Orders dated February 2022 in the EMR and under the orders tab revealed there was no order for therapy or restorative. Review of the paper Occupational Therapy [OT] Discharge Summary dated 10/05/2021 and provided by the Therapy Director, revealed R69 was most recently on therapy from 8/24/2021 through 10/05/2021. The document documented Patient will safely wear a resting hand splint on left hand for up to 5 hours w/[with] minimal s/s [signs and symptoms] of redness, swelling, discomfort or pain. During an interview on 1/31/2022 at 3:58 PM, R69 stated his left hand was contracted and he could not straighten his fingers. He stated it had gotten worse. His left hand was observed with his fingers curled towards his palm. The resident stated he had a splint for his left hand, but he had not worn it since receiving therapy a few months ago and did not know where it was. Observations revealed R69 was not wearing his hand splint on 1/31/2022 at 12:06 PM, on 2/02/2022 at 2:16 PM, R69's left hand splint was observed hanging off his wheelchair and the resident stated staff found his splint. R69 verified staff had not assisted him to put it on since it was located. Continued observation on 2/2/22 at 5:15 PM R69 was observed in his room without the splint on. The splint was observed hanging off the resident's wheelchair. On 2/3/2022 at 2:19 PM, R69 was observed in his room without the splint on. It was hanging off the wheelchair. R69 stated staff had not help to put it on since it was found. On 2/4/2022 at approximately 3:00 PM, R69 was observed in his room without the splint on. The splint was observed to be hanging off the residents wheelchair. During an interview on 2/2/2022 at 11:32 AM, CNA1 stated the resident did not wear a splint on his contracted left hand. She stated the CNAs did not apply splints; the restorative aide (RA) did this. During an interview on 2/2/2022 at 1:54 PM, LPN2 stated R69 had a hand splint, and it was in his room hanging off his chair. LPN2 stated the nurses and CNAs could put it on. LPN2 verified there was no order for the splint, but normally night shift would put splints on when residents got up. LPN2 stated she had seen R69's splint on only a couple of times. LPN2 stated R69 could not put the splint on by himself that Staff would have to assist him. During an interview on 2/2/2022 at 2:16 PM, the RA stated it had been a while since R69 had worn his hand splint and he was not currently receiving restorative services. The RA verified there was no Restorative Nurse currently and no new programs had been set up in at least a few months. She stated, No new people have come on restorative. The RA stated, I will be putting it (hand splint) on R69. There should be a program for him. During an interview on 2/3/2022 at 3:30 PM, the Therapy Director stated R69 received therapy (PT and OT) three different times last year with most recent service of OT (Occupational Therapy) being provided between 08/24/2021 through 10/18/2021. The Therapy Director confirmed that R69 had a splint for his hand. The goal was for the resident to increase the length of time he wore the splint to decrease the risk of further contractures. The Therapy Director stated nursing should put the splint on or the CNA, but not restorative staff. The Therapy stated splint application was part of day-to-day maintenance and it should be part of the daily routine. At 3:42 PM, the Therapy Director and the surveyor entered R69's room and R69 stated, Nobody going to put it on for me as he pointed to the splint that was hanging on his wheelchair. R69 showed the Therapy Director his left hand that was in a fist and tried but could not open it. The Therapy Director stated after leaving the room that the staff should put the splint on and verified the resident would not be able to put the splint on himself without assistance. The Therapy Director stated R69's hand was contracted and could get worse without a splint in place. During an interview on 2/4/2022 at 5:44 PM, the DON stated both the CNAs and RA could apply splints. Splint application should be on the care plan and documented as an assignment.

Based on observations, clinical record review, staff and local police Detective interview, review of facility policies titled Wandering, Unsafe Resident and Elopement, the facility failed to ensure one resident (R), (R#1) resided in a safe environment related to exiting the facility undetected through two unlocked doors on the evening of 4/9/2020. The location of R#1 was unknown until the afternoon of 4/10/2020. The sample size was three residents. An abbreviated/Partial Extended Survey to investigate complaints GA 822, GA 978, GA 274, GA 490, GA 389, GA 562, GA 566, GA 643, GA 696, GA 870, and GA 947 was initiated on April 15, 2020 and concluded on 7/16/2020. Complaints GA 974, GA 870, GA 696, GA 562, GA 566, GA 490, GA 274, GA 978 and GA 822 were unsubstantiated, GA 643 was partially substantiated without deficiencies, and Complaint GA 389 was substantiated with deficiencies. On 7/16/2020 past noncompliance IJ was alleged however, after Quality Assurance review, it was determined that past noncompliance had not been achieved and re-entry was necessary on 8/24/2020 and concluded on 8/27/2020. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Resident Form, the facility's census on April 15, 2020 was 120. On 8/24/2020 a determination was made that a situation in which the facility's noncompliance with one or more requirement of participation had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. On 8/24/2020 at 10:00 a.m. the facility's Administrator was informed of the Immediate Jeopardy (IJ). The noncompliance related to the Immediate Jeopardy was identified to have existed on 4/9/2020 when R#1 was able to exit the facility undetected from the Dementia Unit through two unlocked doors. His location was unknown until 4/10/2020 at approximately 2:30 p.m. when he was returned to the facility. The Immediate Jeopardy is out lined as follows: On 4/9/2020 R#1 exited the facility undetected through two unsecured doors on the Dementia Unit where he resided. The police responded to a call from the Administrator and issued a Mattie's Call to alert the community to watch for a nursing home resident who could not be located. The police also issued a Be On Look Out (BOLO) alert for law enforcement to be aware a nursing home resident was missing. The police searched for R#1 with canines and a helicopter the night of 4/9/2020 and early morning of 4/10/2020, but he could not be located. A passerby responded to the Mattie's Call the next afternoon and told the receptionist answering the telephone that he/she may have seen R#1 outside a gas station approximately a mile from the facility. The family of R#1, who had been waiting in the parking lot all night for news of R#1, then retrieved him as he was walking down a street near the gas station described by the passer-by, and brought him back to the facility on [DATE]. R#1 had a history of [REDACTED]. R#1 exited undetected through two doors left unlocked on the Dementia Unit and climbed over a four-foot gate to leave the facility grounds. The Immediate Jeopardy was identified to exist on 4/9/2020 in the area of CFR 483.20(g) Accuracy of Assessments, F641 Scope and Severity (S/S)- J; CFR 483.25(d) (1)(2) Free of Accidents, Hazards/Supervision/Devices, F689 S/S-J; CFR 483.70 Administration, F835 S/S-J Additionally, Substandard Quality of Care was identified with the requirements at CFR 483.25(d) (1) (2) Free of Accident, Hazards/Supervision/Devices (F689 Scope and Severity: J. A Credible Allegation of Compliance was received on 8/27/2020. Based on interviews, record reviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of 6/6/2020. Findings include: Review of the facility policy titled Wandering, Unsafe Resident last revised 11/2017, page 1 of 1, revealed in part: Policy Interpretation and Implementation The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement) during the evaluation completed upon admission, quarterly and as needed. Review of the facility policy titled Elopement last revised 11/2017, page 1 of 1, in part: Policy Interpretation and Implementation Upon admission and quarterly, each resident will be evaluated for elopement and wandering risk. Based upon the evaluation the resident will be deemed a. No Risk; b. Low Risk; c. Moderate Risk; d. High Risk for wandering and elopement Review of the clinical record for R#1 revealed an original admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Facility Incident Report dated 4/13/2020 revealed R#1 exited the Dementia Unit unobserved on 4/9/2020 between 7:15 p.m. and 8:45 p.m. R#1 was last seen by staff on 4/9/2020 at 7:15 p.m. on the Dementia Unit. The facility was searched inside and outside by staff. The Administrator, Director of Nurses (DON), the resident's Physician, the resident's spouse and the county police department were notified. The resident was located less than a mile away from the facility on 4/10/2020 at 1:00 p.m. and was returned to the facility. A head to toe assessment was conducted and R#1 had no observed signs of injuries. A psychosocial assessment was completed, and the resident did not have any fear or psychosocial issues. R#1 had said he was going to work and had worked nearby at a warehouse close to where he was found. Continued review of the Facility Incident Report revealed the steps taken to prevent further incidents included checking doors on the Dementia Unit to make sure they were working properly. Staff were re-educated on the Elopement Policy. An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held to determine the root cause of this elopement and to implement an action plan to prevent further occurrences. Elopement assessments were being reviewed and updated as needed. The staff is checking and documenting the location of R#1 every fifteen (15) minutes for the next seventy-two (72) hours, then hourly for two weeks. Review of the Be On the Look Out (BOLO) report related to the elopement of R#1, dated 4/9/2020 at 8:45 pm revealed all units were to be on the lookout for a seventy-three (73) year old male with brown eyes and gray hair last seen wearing a gray sweater and unknown colored pants. He left on foot from (address) of facility and (name) of facility. He was given his medicine and last seen at 2045 (8:45 p.m.). (Name of R#1) is diagnosed with [REDACTED]. Review of the police report related to the elopement of R#1 dated 4/10/2020 at 3:35 a.m. revealed the police responded to the facility on [DATE] at approximately 11:30 p.m The officer met with the Administrator. The Administrator advised R#1 was given his medication at approximately 7:00 p.m. At approximately 8:45 p.m. the staff were doing a walk through in each room and observed R#1 was missing. All staff members immediately checked every room in the building but were unable to locate R#1. The Administrator immediately called the police. The Administrator advised the officer that R#1 was diagnosed with [REDACTED]. The Administrator stated there was a biohazard room on the right side of the building near the room where R#1 resided which {sic} the door may have been unlocked. The Administrator advised R#1 could have possibly left the location through those doors and jump {sic} the gate that leads towards the roadway. SVU (Special Victims Unit) Detective was notified and arrived at the scene. K-9 unit was notified and arrived at the scene. Review of the monthly Wander Guard test list completed by the Director of Nursing (DON) revealed on 4/9/2020 when R#1 eloped there were no other residents provided with Wander Guards on the Dementia Unit. There were twenty-nine (29) residents on the Dementia Unit on 4/9/2020. A Wandering and Elopement Evaluation completed on the admission date of [DATE] at 12:59 p.m. revealed R#1 wandered after dark (sundowns). The Evaluation included information that the Brief Interview for Mental Status (BIMS) score for R#1 was not available, but that he was forgetful, with short attention span, was independently mobile, and was only oriented to person. The Evaluation indicated that current caregivers were to be interviewed. The Wandering and Elopement Evaluation did not include that R#1 had a history of [REDACTED]. The Evaluation also did not include that R#1 was a recent admission within the last thirty (30) days or that his [DIAGNOSES REDACTED]. Immediate interventions documented on the Evaluation included increased supervision by staff. There were no other interventions checked and there were no ongoing interventions checked. The scoring for the Wandering and Elopement Evaluation was four, which was calculated by the Electronic Medical Record System to be a low risk for wandering and elopement. A review of the staffing assignment sheet for 2/21/2020 revealed the Licensed Practical Nurse (LPN) who documented the evaluation was a charge nurse on the Dementia Unit. She was not available for an interview. The Director of Nursing (DON) was interviewed on 6/17/2020 at 7:30 a.m. related to the Admission Wandering and Elopement Evaluation for R#1. The DON revealed the only documentation for Wander Guard placement and function was the monthly checks she documented on the list of residents provided with Wander Guards. The DON revealed a new process was initiated after R#1 eloped for documentation of placement and function of Wander Guards every shift on the Medication Administration Record [REDACTED]. The DON also confirmed the facility had no policy for Wander Guards or any process the facility followed to determine what residents met criteria to be provided with Wander Guards and had not included them on care plans. The DON revealed she had reviewed the Admission Wandering and Elopement Evaluation and could see that pertinent information had not been included. The DON revealed that the scoring for this Evaluation was calculated by the Electronic Medical Record System and she was not aware of how the points were assigned, and that it was very likely the score would have been higher and more accurate if all the pertinent information had been completed. Review of Nursing Baseline Care Plan dated 2/22/2020 revealed R#1 was provided with a Wander Bracelet to minimize the risk of elopement. The Baseline Care Plan was developed by the Dementia Unit Manager who was not available for interview. A Behavioral Health Evaluation completed by the Social Worker on 3/6/2020 at 12:59 p.m. revealed R#1 had wandered daily, but the wandering did not place the resident at significant risk of getting to a potentially dangerous place. The Social Worker documented on the Behavioral Health Evaluation that a family member of R#1 had participated in the Evaluation and the family member, when interviewed, revealed R#1 had a history of [REDACTED]. The Social Worker was not available for interview. Review of the undated referral packet sent to the facility from the hospital where R#1 was admitted from 1/22/2020 to 2/21/2020 revealed in a Nursing Daily Shift Note Addendum dated 2/6/2020 that R#1 had attempted to leave the hospital and a one to one sitter was at the bedside for elopement risk. An interview was conducted with the Social Service Director (SSD) on 6/16/2020 at 12:45 p.m. revealed that she and the Social Worker do not review any of the information in the referral packet from the hospitals where residents were before admission to the facility. The SSD revealed they base their assessments on information in the morning clinical meetings that they attend each weekday, as well as review the clinical record, and interviews with staff and family members. The SSD revealed they discuss what is currently happening with the residents and not what has happened prior to admission. The SSD revealed she was not aware of what information the Social Worker had discussed with the family of R#1. The SSD revealed she had been aware that prior to facility admission R#1 had been provided a sitter for one to one observations at the hospital and the facility had been assured by the hospital that R#1 did not require one to one observation after leaving the hospital. The SSD revealed she had scheduled a psychiatric evaluation for R#1 because the Social Worker was not available. The evaluation on 6/8/2020 revealed R#1 had no suicidal ideation, depression, or anxiety symptoms. Review of the Comprehensive Care Plan for R#1 dated 3/2/2020 revealed a care plan as follows: (Name of R#1) is at high risk for elopement as evidenced by (AEB) disoriented to place, impaired safety awareness. Resident wanders aimlessly, diagnosis (dx) dementia. Interventions were reviewed as follows: Assess for fall risk Distract (name of R#1) from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. (Name of R#1) is on a secured unit secondary to elopement risk related to poor cognition, poor safety awareness, disorientation and wandering. Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. Review of additional care plans revealed R#1 was care planned for fall risk, potential for infection, potential for pressure ulcer development, Activities of Daily Living (ADL) deficit, risk for chronic pain, impaired cognitive function, and risk for side effects from anti-depressant medication. Review of care plan updates revealed the care plan for elopement risk was revised on 4/10/2020. A revised care plan was reviewed and was updated with the elopement of 4/9/2020 and Wander Guard to right leg was added as an intervention. Review of Nurses Skilled Progress Notes revealed R#1 had documentation of wandering, pacing, and was able to ambulate ten to fifty feet independently on 3/4/2020 at 9:39 a.m., 3/5/2020 at 9:39 a.m., 3/11/2020 at 9:39 a.m., 3/12/2020 at 9:39 a.m., 3/14/2020 at 9:39 a.m., 3/13/2020 at 9:39 a.m., 3/16/2020 at 9:39 a.m., 3/26/2020 at 11:18 a.m., 3/29/2020 at 11:21 a.m., 4/1/2020 at 9:36 a.m., 4/2/2020 at 9:36 a.m., 4/3/2020 at 9:36 a.m., 4/6/2020 at 9:36 a.m., 4/7/2020 at 9:36 a.m., 4/8/2020 at 9:36 a.m., and 4/9/2020 at 9:36 a.m. A telephone interview was conducted with the Administrator on 4/20/2020 at 3:35 p.m. related to the elopement. The Administrator revealed on 4/9/2020 after being informed R#1 could not be found he had checked the door from the hallway into the biohazard room and found it was just slightly ajar, the doorknob did not turn but the door was not closed enough to lock it. Then he checked the biohazard room door leading to the courtyard and he just remembers pushing open the door, not using the key, so it must not have been locked. The Administrator revealed this was the only way R#1 could have gotten out, a staff person must have left the doors that way because they use the doors to bring trash out to the dumpster in the courtyard every shift. The Administrator revealed he had checked all other doors, and all were secured. Staff on the 3-11p.m. shift were questioned and denied going in the biohazard room at all because they had not picked up trash yet, and they had not checked the two doors he found unsecured when they were looking for R#1. The Administrator revealed he had questioned the 7-3 p.m. shift staff and they all said they were sure they had closed both doors behind them when they took trash out. A telephone interview on 4/28/2020 at 3:00 p.m. was conducted with the Detective investigating the elopement of R#1 on 4/9/2020, revealed that when he arrived at the facility on 4/9/2020 the resident had already been missing for two hours and that made it more difficult to find the resident because he had more time to get away from the immediate area. The Detective revealed he had wondered why there were no cameras and alarms on all the outside doors. He had briefly reviewed security camera footage from the main entrance in the back of the facility which was the only door that had a security camera, with the Administrator, and it was clear that R#1 had not exited the facility through the main entrance. The Detective revealed he had called for a K-9 search and issued Mattie's Call and BOLO alerts and called for a helicopter search. The Administrator told him the back-yard service door was either left wedged open or just not locked. The Detective revealed there were heavy winds that night and the dogs kept losing the scent and the helicopter search was not successful. The officers that had first responded to the call had searched around the grounds of the facility and the neighboring areas also. The Detective revealed he had spoken to the family of R#1, waiting outside in the parking lot in their cars, for any news. He was told R#1 eloped from home at night several times last winter, and the family member had been unable to locate him once and the police had to be called to find him and bring him home. The Detective revealed he had sent an officer to the home to make sure R#1 had not tried to go there. The family had told him that R#1 was very familiar with the area and they did not doubt that he could remember his way around. The Detective also revealed the family had told him they had seen the gate in the courtyard off the Dementia Unit and they had no doubt that R#1 could get over the gate with no problems. A telephone interview with Certified Nursing Assistant (CNA) CC conducted on 5/7/2020 at 6:12 p.m. revealed she works the 3-11 p.m. shift on the Dementia Unit and was assigned to the care of R#1 when he eloped. CNA CC revealed R#1 wanders often and she watched him all the time. She revealed he just walks and sometimes says he is looking for his wife. She revealed she has never had a problem redirecting him to talk with her or have a snack. CNA CC revealed she had observed R#1 in his room a little after 7:00 p.m. and she went on to take care of some other residents. R#1 had not seemed any more confused than usual or like he was trying to leave the building. When she returned to the room of R#1 to get him ready for bed and he was not there. CNA CC revealed she had told the Charge Nurse and the other CNA right away and they let the staff on the other halls know and the staff all searched for R#1. The Charge Nurse called the Administrator and when he arrived, he began to search. CNA CC revealed she did not know how R#1 exited the building. She revealed she had not checked the biohazard room doors and had not entered the biohazard room that shift. She revealed she had not observed any other staff enter the biohazard room that shift because usually the only reason to use either of the doors would be to take the trash out at the end of the shift. CNA CC revealed sometimes the biohazard room door did not close by itself and had to be pulled closed but did not know if that was the case that evening because she had not entered the biohazard room. CNA CC revealed she had never reported this because the door closed most of the time by itself. CNA CC revealed she was aware that R#1 wore a Wander Guard and checked it each shift but was unable to remember if she had checked it during the shift prior to his elopement. Since R#1 eloped she has checked his location frequently and tried to ensure she was able to see him every 30 minutes. CNA CC and the other staff have checked the doors on the Dementia Unit to ensure they cannot be opened at the beginning of each shift, at the end of each shift and at least twice during the shift. A telephone interview conducted on 5/8/2020 at 5:35 p.m. with Licensed Practical Nurse (LPN) DD who works the 3-11 p.m. shift on the Dementia Unit revealed she was working the night R#1 eloped. She did not have any idea how he eloped. She said she searched with the two CNA's as soon as she was notified and then called the Administrator and DON. She revealed this was the usual amount of staff for the Dementia Unit on the 3-11 p.m. shift. LPN DD revealed she had not used the hallway or outside doors to the biohazard room at all that shift. She revealed no one uses other doors but the other doors all had keypads locks before R#1 eloped. LPN DD revealed she always checked R#1's Wander Guard each shift but did not remember if there was a place to document it or if it was on care plan, but the Wander Guard was on his ankle and she checked it every shift she worked. Now at each change of shift as soon as the narcotic count is done the oncoming and off going Nurses check all the doors. The key to the trash door was kept in a drawer at the Nurses Station and she was not aware of anyone getting it during the shift before the elopement. Normally a CNA would get the key late in the shift after they gathered up the trash so it would be empty for the oncoming shift. LPN DD revealed R#1 is checked every fifteen minutes now. He has been changed from his room that was farther away from the Nurses Station to one close so they can see him if he comes out of his room. A keypad lock was added to the hallway door of the biohazard room. LPN DD revealed she has never found that door unlocked and is still not sure R#1 exited the building that way. She had not observed R#1 have any increase in behaviors the night he eloped. She had not observed R#1 purposefully exit seeking. An interview was conducted on 7/14/2020 at 12:50 p.m. LPN PP, Wound Care Nurse who provided a wound assessment for R#1 when he returned from elopement on 4/10/2020 at 2:30 p.m. LPN PP remembered R#1 did not have any signs of injuries on his return, but could not remember if she saw a Wander Guard bracelet on him anywhere. The Administrator was interviewed 6/16/2020 at 10:40 a.m. and confirmed there were no security cameras on the Dementia Unit, no Wander Guard sensors on any of the doors in the Dementia Unit, and the biohazard room doors from the hall way and from the biohazard room to the courtyard did not have keypad locks until 4/16/2020. The doors had locked by a key that was kept on the charge nurse's key ring. The Administrator also confirmed that none of the doors on the Dementia Unit have alarms that indicate the doors have been opened or left open except the biohazard room door to the courtyard that has an alarm that was added on 4/16/2020. The Administrator revealed he did not know if any alarms or Wander Guard sensors could be added to any of the doors. The Administrator revealed there were four stairwell doors on other units that he had the communication company equip with numeric keypad locks on March 16, 2020. Two of the stairwells have doors that lead to the outside and two stairwells have doors that open to a therapy area are seldom used. The Administrator confirmed the biohazard room doors that lead to the courtyard are used about three times a day for the staff to take out the trash collected during their shift. The Administrator also confirmed the other five doors leading to the outside as well as the stairwell doors are rarely used, and he has cautioned staff not to use them. An observation on 6/16/2020 at 10:45 a.m. was conducted with the Administrator of the entry to the Dementia Unit and the biohazard room on the Dementia Unit. The entrance double doors from the main building were locked and could not be opened. The Administrator entered a numeric code on the keypad to the right of the double doors leading into the unit from the main building and the doors unlocked. The doors were opened by the Administrator with no sound indicating they were open. The double doors closed and locked securely behind the Administrator and the surveyor. The biohazard room was located on the main hallway of the Dementia Unit, out of sight of the Nurses Station. The hallway door was securely locked. The Administrator entered a numeric code on the keypad to the right of the door and the door unlocked, was opened by the Administrator, and locked behind the surveyor and the Administrator easily without being pulled shut. A door inside the biohazard room leading directly to a courtyard was locked and the Administrator entered a numeric code on the keypad beside the door. The door was then able to be opened and a loud alarm sounded. The door locked securely behind the Administrator and the surveyor and the alarm stopped. A chain link gate was observed across the courtyard locked with two large chains and two metal padlocks. The chain link fence surrounding the courtyard was covered in heavy growth of vegetation and the fence could not be reached but the gate was clear. After returning to the Dementia Unit the surveyor observed five additional doors leading to the outside that were locked, with keypad locks on the walls beside the doors. An observation was conducted on 6/16/2020 at 11:10 a.m. of R#1 ambulating in the hallways of the Dementia Unit with a steady gait. He did not touch doorknobs or try to push open any doors. R#1 had a Wander Guard bracelet on his right ankle. R#1 was looking outside at each door as he was ambulating around the unit. An interview with LPN EE, Charge Nurse on Dementia Unit, on 6/15/2020 at 2:45 p.m. revealed she documented R#1 wandering and pacing prior to his elopement but he never seemed focused on leaving the building. He did occasionally speak of finding his wife or going to work but he was always easy to redirect. His room was changed the day after his return and now it is easier to be sure of where he is. R#1 often will stay in his room most of the day shift, but when he does not, he wanders and walks and paces in the halls. LPN EE revealed she checked Wander Guards every shift, even before there was an area on the MAR indicated [REDACTED]. An interview with CNA LL on 6/16/2020 at 11:00 a.m. , who works the 7-3 p.m. shift Dementia Unit, revealed that the CNA has been employed by facility for twenty-eight (28) years, and an interview with CNA MM on 6/16/2020 at 11:05 a.m., Dementia Unit, had been employed by facility for twenty (20) years revealed they never expected R#1 to elope, he had never seemed unhappy and was easily distracted if he was agitated or standing around the doors. They revealed they would tell the nurse if he could not be distracted by food, conversation, television, or an activity. CNA LL and CNA MM revealed they checked that R#1 had his Wander Guard on every day. CNA LL and CNA MM revealed they have never left the biohazard room doors open and had never found either of the doors open or unlocked. The CNA's revealed they do not use any of the other doors but know the codes if they needed to use them. An interview was conducted with the Physician of R#1 on 6/29/2020 at 12:30 p.m who revealed he remembered being notified that R#1 had eloped. When he made his rounds at the facility, he was told the staff were trying to keep R#1 close to them or in his room, which had changed, and to observe the resident frequently and he did not have any additional suggestions for preventing elopement. The Physician was not sure if he had been told that R#1 wore a Wander Guard. The Physician revealed he had never considered the Dementia Unit as not secured and did not know what doors had alarms or automatic locking mechanisms. He also remembered attending a scheduled Quality Assurance Performance Improvement (QAPI) meeting and does not remember when it was but does not remember elopement being discussed. The Physician revealed he does not normally attend the Ad Hoc QAPI meetings because he is in different facilities each day. The facility implemented the following actions to remove the Immediate Jeopardy: 8. On April 9, 2020, the interior and exterior Biohazard room doors were immediately secured by keylock. Other doors were checked to be sure they were secure. The interior and exterior keypad codes were immediately changed. 9. On April 9, 2020, 14 on-duty employees were educated by the Administrator about our elopement policies. This included 2 RNs, 4 LPNs and 8 CNAs which was 100% of the on-duty staff on the night shift. 10. On April 10, 2020 upon the return of Resident #1 to the facility, a head to toe assessment was completed which indicated the resident had no injuries. 11. On April 10, 2020, using 15-minute check sheets, staff began monitoring and documenting the location of Resident #1 every 15 minutes for 72 hours and then hourly for two weeks. 12. 0n April 10, 2020, The QAPI Committed conducted an Ad Hoc QAPI meeting. A review of the Elopement policy was completed, and the policy is adequate without revisions. A root cause analysis indicated the interior door needed to be adjusted so it closes smoothly . The door was immediately repaired. The committee decided keypad locks should be installed on the interior and exterior biohazard room doors. 13. On April 10, 2020, the Administrator contacted the vendor who installs keypad locks and alarms at this facility. They said the earliest they could come to the facility was 04/15/2020. 14. Starting on April 10, 2020 and ending when the Bio-hazard keypad locks and alarm were installed on April 16, 2020, using 15-minute check sheets, the staff documented that the Bio-Hazard doors were locked. These doors are also part of a weekly check of all facility doors by the maintenance department to be sure they are working properly. 15. On April 10, 2020, the elopement books were reviewed by the Social Services Director to be sure they contained the face sheets and pictures of residents who have a moderate risk for elopement. 16. On April 13, 2020, Resident #1 was evaluated by his Physician and Nurse Practitioner. The Physician ordered PRN [MEDICATION NAME] for agitation. A psychiatric evaluation was recommended, and the recommendation was followed. 17. 0n April 15, 2020, the door lock vendor came to the facility to evaluate the biohazard doors and they ordered parts. 18. On April 16, 2020, the door lock vendor installed keypad locks on the interior and exterior Biohazard doors and added an alarm to the outside door which sounds when the door is opened. 19. On April 16, 2020 , 8 employees were educated about our elopement policies by the Staff Development Coordinator.This included 5 LPNs and 3 CNAs. 20. On April 21, 2020, the Wandering - Elopement assessments, accuracy of care plans and proper door functioning were part of the discussion during QAPI. 21. Starting on April 29, 2020 and ending on May 20, 2020 , 6 new hires were educated during New Employee Orientation on our elopement policy. This group consisted of 2 RNs, 3 LPNs and 1 CNA. 22. On May 6, 2020, 20 employees were educated on our Wandering - Elopement policies.This included 3 RNs, 4 LPNs and 13 CNAs. This was 100% of the on-duty day and evening shift staff. 23. On May 14, 2020, 5 employees were educated on our Wandering - Elopement policies. This included 2 LPNs and 3 CNAs. 24. On May 19, 2020, the Wandering - Elopement assessments, accuracy of care plans and proper door functioning were part of the discussion during QAPI. These topics will continue to be discussed during monthly QAPI meetings. 25. On June 2, 2020 , 8 Dietary employees and 4 contracted Therapy staff were educated on our Wandering - Elopement policies. 26. On June 3, 2020, 2 additional Dietary employees and 12 contracted Housekeeping and Laundry workers were educated on our Wandering - Elopement policies. 27. On June 5, 2020, 13 additional employees were educated on our Wandering - Elopement policies.T (TRUNCATED)

Based on observations, record reviews, interviews and review of the facility's Administrator Job Description the facility failed to be administered in a manner to provide a safe environment on the Dementia Unit related to ensuring adequate alarm and locking mechanisms for two doors that were left unsecured resulting in the elopement of R#1 on 4/9/2020. The sample size was three residents. An abbreviated/Partial Extended Survey to investigate complaints GA 822, GA 978, GA 274, GA 490, GA 389, GA 562, GA 566, GA 643, GA 696, GA 870, and GA 947 was initiated on April 15, 2020 and concluded on 7/16/2020. Complaints GA 974, GA 870, GA 696, GA 562, GA 566, GA 490, GA 274, GA 978 and GA 822 were unsubstantiated, GA 643 was partially substantiated without deficiencies, and Complaint GA 389 was substantiated with deficiencies. On 7/16/2020 past noncompliance IJ was alleged however, after Quality Assurance review, it was determined that past noncompliance had not been achieved and re-entry was necessary on 8/24/2020 and concluded on 8/27/2020. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Resident Form, the facility's census on April 15, 2020 was 120. On 8/24/2020 a determination was made that a situation in which the facility's noncompliance with one or more requirement of participation had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. On 8/24/2020 at 10:00 a.m. the facility's Administrator was informed of the Immediate Jeopardy (IJ). The noncompliance related to the Immediate Jeopardy was identified to have existed on 4/9/2020 when R#1 was able to exit the facility undetected from the Dementia Unit through two unlocked doors. His location was unknown until 4/10/2020 at approximately 2:30 p.m. when he was returned to the facility. The Immediate Jeopardy is out lined as follows: On 4/9/2020 R#1 exited the facility undetected through two unsecured doors on the Dementia Unit where he resided. The police responded to a call from the Administrator and issued a Mattie's Call to alert the community to watch for a nursing home resident who could not be located. The police also issued a Be On Look Out (BOLO) alert for law enforcement to be aware a nursing home resident was missing. The police searched for R#1 with canines and a helicopter the night of 4/9/2020 and early morning of 4/10/2020, but he could not be located. A passerby responded to the Mattie's Call the next afternoon and told the receptionist answering the telephone that he/she may have seen R#1 outside a gas station approximately a mile from the facility. The family of R#1, who had been waiting in the parking lot all night for news of R#1, then retrieved him as he was walking down a street near the gas station described by the passer-by, and brought him back to the facility on [DATE]. R#1 had a history of [REDACTED]. R#1 exited undetected through two doors left unlocked on the Dementia Unit and climbed over a four-foot gate to leave the facility grounds. The Immediate Jeopardy was identified to exist on 4/9/2020 in the area of CFR 483.20(g) Accuracy of Assessments, F641 Scope and Severity (S/S)- J; CFR 483.25(d) (1)(2) Free of Accidents, Hazards/Supervision/Devices, F689 S/S-J; CFR 483.70 Administration, F835 S/S-J Additionally, Substandard Quality of Care was identified with the requirements at CFR 483.25(d) (1) (2) Free of Accident, Hazards/Supervision/Devices (F689 Scope and Severity: J. A Credible Allegation of Compliance was received on 8/27/2020. Based on interviews, record reviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of 6/6/2020. Findings include: Review of the facility Administrator Job Description, revised 8/2018 Job Summary revealed the Administrator is expected to supervise, plan, develop, monitor and maintain appropriate standards of care throughout all departments in the nursing home. Essential Functions of the Administrator are listed in part as follows: Develop and implement procedures and controls necessary to provide quality resident care Review physical plant and direct repairs/new construction programs . Direct various committees of the facility, such as care plan, infection control, pharmaceutical, budget, quality assessment and assurance Make routine rounds and authorize or conduct tours with others Review of Facility Incident Report dated 4/13/2020 revealed R#1 eloped from the facility on 4/9/2020. The staff on the Dementia Unit were unable to locate R#1 at 8:45 p.m. The final report of this incident was dated 4/15/2020 revealed R#1 had been observed by staff when the charge nurse was administering medications on 4/9/2020 at 7:15 p.m. The staff had searched the Dementia Unit, the rest of the facility and the grounds. The final report revealed R#1 was assessed to have severe cognitive impairment with a Brief Interview for Mental Status Score of three (3). The local county police arrived at 10:30 p.m. and issued a Mattie's alert for the community to be aware of a missing person and a BOLO for law enforcement to watch for the resident. The final report revealed the Administrator received a phone call related to the Mattie's Alert on 4/10/2020. The police were notified. The family were notified of the location the caller had mentioned to the Administrator and the family drove to that location, found R#1 and returned him to the facility. Continued review of the final report revealed staff on the Dementia Unit had observed R#1 pushing numbers on the keypad equipped exit doors after his return to the facility. The final report revealed the resident would have to climb over a five-foot gate to exit the facility grounds. A telephone interview was conducted with the Administrator on 4/20/2020 at 3:35 p.m. revealed on 4/9/2020 after being informed R#1 could not be found that he had checked the biohazard room door leading from the hallway of the Dementia Unit into the biohazard room. The Administrator revealed he had discovered that although this doorknob would not turn, the door had been left slightly ajar and could be pushed open without using a key to unlock it. Then he checked the door from the biohazard room to an outdoor courtyard. This door could also be pushed open without using a key to unlock it. The Administrator revealed a staff person must have left the doors unlocked because there was no other way R#1 could have exited the building. He and the staff had checked all other doors, and all were securely locked. The Administrator revealed he had asked 3-11 staff on 4/9/2020 if they had checked the two biohazard room doors after they were unable to locate R#1 and they denied checking these two doors, but had told him they checked all the other doors and had not found any of them unlocked. The Administrator revealed he was aware the staff take the trash out to the dumpster in the courtyard at the end of each shift. The Administrator revealed there was only one door in the facility with a Wander Guard sensor and that was the main entrance double door on the ground level at the back of the building. This door had a security camera, also the only one in the building. The Administrator revealed he had reviewed the security camera footage briefly with the Detective from the local police who had responded to his call for assistance locating R#1 and there had been no sign that R#1 exited through this door. The Administrator confirmed no doors on the Dementia Unit have Wander Guard sensors. The Administrator confirmed the only way R#1 could have exited the building was through the two doors on the Dementia Unit that he had found unsecured. Continued interview with the Administrator on 6/29/2020 at 2:51 p.m. revealed he had just measured the chain link gate R#1 was suspected of climbing over and it was forty-eight (48) inches (four feet) high. An interview was conducted on 7/14/2020 at 12:01 p.m. with the Administrator who revealed he had a security company install keypad locks on four stairwell doors, not located on the Dementia Unit, on 3/16/2020. The Administrator revealed he had determined the seldom used stairwells to be a potential hazard to residents, because the doors locked with a key that had to be obtained from the charge nurse. The Administrator revealed the biohazard room doors on the Dementia Unit also locked with a key, kept on the nurse's key ring that also held keys to the medication cart, but he had not determined the biohazard room doors to be a possible hazard to residents. The Administrator revealed the biohazard room doors on the Dementia Unit were used by the Certified Nursing Assistants (CNA's) at the end of each shift to take trash out to the dumpster. A review of Quality Assurance Ad Hoc Minutes dated 3/16/2020 revealed on 3/16/2020 the security company had installed keypads on stairwell doors to limit access to the main entrance only. Review of Maintenance work history reports revealed the doors on the Dementia Unit were tested on [DATE] and 4/11/2020 and the doors and locks passed testing. The Maintenance Director was not available for interview. Cross refer to F 689 The facility implemented the following actions to remove the Immediate Jeopardy: 29. On April 9, 2020 at 9:00 pm, the Administrator was notified that the staff was unable to locate resident #1 . The Administrator gave instructions to search the entire building, every room, bathroom, stairwell and the property outside the facility. 30. On April 9, 2020, the administrator arrived at the facility at 9:35 pm and met with the staff on duty. The most recent search resulted in the resident not being found. The Administrator called the DeKalb County Police at 9:50 pm for assistance . The Administrator checked the interior and exterior Bio-hazard room doors. The interior door was locked and looked closed, but it was not pulled all the way shut. The exterior door was closed but not locked. The doors were immediately secured by keylock. The Administrator checked all of the doors on the secured unit to be sure they were secure. 31. On April 9, 2020, DeKalb County Police arrived at 10:00 pm. The Administrator met with the police and showed them the secured unit. Other police officers arrived and began searching outside the facility. The police brought in dogs in an effort to locate Resident #1. A police helicopter was also searching in the area. 32. 0n April 9, 2020 at 10:30 pm, the Administrator met with the resident's family to discuss the situation and ask them if they knew where the resident might go. They said he used to work about a mile from this facility at the nameWarehouse. The Administrator gave the police this information. 33. On April 9, 2020 at 11:00 pm, a Mattie's Alert was issued by the DeKalb County Police. 34. On April 9, 2020 , 14 on-duty night shift employees were educated by the Administrator about our elopement policies. 35. On April 10, 2020 at 1:00 am, the Administrator changed the interior and exterior keypad codes on all facility doors equipped with them. 36. On April 10, 2020, the missing resident was reported on the local news stations in the morning. 37. 0n April 10, 2020 at 1:00 pm, the Administrator received a phone call from a woman who said she saw the news that morning and thought she saw resident #1 walking on Hugh Howell Rd near Mountain Industrial Blvd. 38. On April 10, 2020 at 1:00 pm, the Administrator called the police to give them this information. The administrator told the family. A family member got in her car to go to that location. 39. On Apr il 10, 2020 at 1:45 pm, the family member returned resident #1 to the facility. 40. On April 10, 2020 upon the return of Resident #1 to the facility, a head to toe assessment was completed which indicated the resident had no injuries. 41. On April 10, 2020 , using 15-minute check sheets, staff began monitoring and documenting the location of Resident #1 every 15 minutes for 72 hours and then hourly for two weeks. 42. Starting on April 10, 2020 and ending when the Bio-hazard keypad locks and alarm were installed on April 16, 2020, using 15-minute check sheets, the staff documented that the Bio-Hazard doors were locked. These doors are also part of a weekly check of all facility doors by the maintenance department to be sure they are working properly. 43. 0n April 10, 2020, The QAPI Committed conducted an Ad Hoc QAPI meeting. A review of the Elopement policy was completed, and the policy is adequate without revisions. A root cause analysis indicated the interior door needed to be adjusted so it closes smoothly. The door was immediately repaired.The committee decided keypad locks should be installed on the interior and exterior biohazard room doors. 44. On April 10, 2020 , the Administrator contacted the vendor who installs keypad locks and alarms at this facility. They said the earliest they could come to the facility was 04/15/2020. 45. Starting on April 10, 2020 and ending when the Bio-hazard keypad locks and alarm were installed on April 16, 2020, using 15-minute check sheets, the staff documented that the Bio-Hazard doors were locked. These doors are also part of a weekly check of all facility doors by the maintenance department to be sure they are working properly. 46. On April 10, 2020, the elopement books were reviewed by the Social Services Director to be sure they contained the face sheets and pictures of residents who have a moderate risk for elopement. 47. On 04/10/2020, the facility reassessed Resident #1 for wandering and elopement risk and his care plan was updated to indicate he is a moderate risk for elopement. Resident #1 was reassessed for wandering and elopement risk again on 07/15/2020. 48. On April 10, 2020, the Wandering-Elopement assessments completed in January, February and March 2020 for the residents on the secured unit were reviewed. No other residents were identified as having exit-seeking behavior. 49. Starting April 11, 2020, the Interdisciplinary Care Plan team (IDT) met weekly to review the current week's list of residents with Wander Guards. Care plans and MOS assessments were reviewed for accuracy and updates were made if needed. 50. The Clinical Reimbursement Coordinators were educated by the Regional CRC Manager about providing accurate assessments and evaluations regarding wandering, elopement and Wander Guards. 51. On April 13, 2020, Resident #1 was evaluated by his Physician and Nurse Practitioner. The Physician ordered as needed (PRN) [MEDICATION NAME] for agitation. A psychiatric evaluation was recommended, and the recommendation was followed. 52. On April 15, 2020, the door lock vendor came to the facility to evaluate the biohazard doors and they ordered parts. 53. On April 16, 2020, the door lock vendor installed keypad locks on the interior and exterior Biohazard doors and added an alarm to the outside door which sounds when the door is opened. 54. On April 16, 2020, 8 employees were educated about our Wandering - Elopement policies by the Staff Development Coordinator. This included 5 Licensed Practical Nurses (LPNs) and 3 Certified Nursing Assistants (CNAs). 55. On 04/21/2020 , the Wandering-Elopement assessments, accuracy of care plans and proper door functioning were part of the discussion during Quality Assurance Performance Improvement (QAPI). 56. Starting on April 29, 2020 and ending on May 20, 2020, 6 new hires were educated during New Employee Orientation on our elopement policy. This group consisted of 2 Registered Nurse (RNs), 3 LPNs and 1 CNA. 57. On April 30, 2020, the (Company Name) Health Regional Vice President of Operations met with the Administrator to review his job description and responsibilities to the facility and the company. The Administrator acknowledged the expectations. 58. On May 6, 2020, 20 additional employees were educated on our Wandering - Elopement policies. 59. On May 14, 2020, 5 additional employees were educated on our Wandering - Elopement policies. 60. On May 19, 2020, the Wandering - Elopement assessments, accuracy of care plans and proper door functioning were part of the discussion during QAPI. These topics will continue to be discussed during monthly QAPI meetings. 61. On June 2, 2020, 8 Dietary employees and 4 contracted Therapy staff were educated on our Wandering - Elopement policies. 62. On June 3, 2020, 2 additional Dietary employees and 12 contracted Housekeeping and Laundry workers were educated on our Wandering - Elopement policies. 63. On June 5, 2020, 13 additional employees were educated on our Wandering - Elopement policies. This included 1 Receptionist, 1 RN, 6 LPNs and 5 CNAs. 64. Including the contracted staff, 101 out of 115 staff received education on our Wandering - Elopement policies between April 9, 2020 and June 5, 2020. This represents 88%. The State Survey Agency (SSA) validated the facility's Immediate Jeopardy (IJ) Removal Plan as follows: Items for: 29, 30, 31, 33, 35 and 36. An interview with the Administrator on 8/24/2020 at 1:38 p.m. revealed that he was notified by the Director of Nursing (DON) on 4/9/2020 that R#1 was missing. He gave instructions for staff to search every room, bathroom, the entire building, and the grounds. He and the DON arrived at the facility around 9:35 p.m. and after conferring with the staff he called 911 at 9:50 p.m. The Administrator revealed that he had also checked the locked unit and discovered the interior door to the biohazard room was locked but not completely closed and the exterior door was closed but not locked. These doors utilized a key to lock and the Administrator secured and locked both doors. The Administrator checked all doors in the facility and confirmed they were locked and closed. The Administrator revealed that he had changed the codes for all keypad locks early morning on 4/10/2020. The Administrator further revealed that the police arrived at 10:00 p.m. The Administrator met with the officers and took them to the secured unit. Other police officers and K-9 officers began arriving and searching for the resident. The police department also utilized a helicopter in their search. The Administrator revealed that the police department issued a Mattie's Call at 11:00 p.m. The Administrator revealed that the Mattie's Call was broadcast on the local television stations. Review of the police report dated 4/9/2020 revealed the police were onsite, with officers and K-9 units and the police helicopter. A Be on the Look Out (BOLO) was issued by the police department stating the resident was last seen at 8:45 p.m. A telephone interview on 4/28/2020 at 3:00 p.m. was conducted with the Detective investigating the elopement of R#1 on 4/9/2020, revealed that when he arrived at the facility on 4/9/2020 the resident had already been missing for two hours and that made it more difficult to find the resident because he had more time to get away from the immediate area. The Detective revealed he had wondered why there were no cameras and alarms on all the outside doors. He had briefly reviewed security camera footage from the main entrance in the back of the facility which was the only door that had a security camera, with the Administrator, and it was clear that R#1 had not exited the facility through the main entrance. The Detective revealed he had called for a K-9 search and issued Mattie's Call and BOLO alerts and called for a helicopter search. The Administrator told him the back-yard service door was either left wedged open or just not locked. The Detective revealed there were heavy winds that night and the dogs kept losing the scent and the helicopter search was not successful. The officers that had first responded to the call had searched around the grounds of the facility and the neighboring areas also. The Detective revealed he had spoken to the family of R#1, waiting outside in the parking lot in their cars, for any news. He was told R#1 eloped from home at night several times last winter, and the family member had been unable to locate him once and the police had to be called to find him and bring him home. The Detective revealed he had sent an officer to the home to make sure R#1 had not tried to go there. The family had told him that R#1 was very familiar with the area and they did not doubt that he could remember his way around. The Detective also revealed the family had told him they had seen the gate in the courtyard off the Dementia Unit and they had no doubt that R#1 could get over the gate with no problems. Items for: 32, 37, 38 and 39. The family of R#1 was notified and came to the facility which was confirmed by interview. A telephone interview with the family of R#1 on 4/24/2020 at 12:45 p.m., revealed they were notified about 10:30 p.m. and came to the facility. They met with the Administrator and the police to determine where the resident might be going. The family revealed that the resident is very familiar with the area and had worked in this area. The family member revealed that the resident is very mobile and capable to climbing over a five-foot gate to escape. The resident had eloped several times, while living with the family, and that they would have to call the police to help find him. The family member stated that the Mattie's Call was on Television and someone from the community called the facility saying they had seen the resident. The family had been waiting in their car at the facility and were notified by the Administrator of the siting. The family left to look for the resident and found him walking down the road. The family returned the resident to the facility around 2:00 p.m. and stated he had a little mud on his pants although he had no injuries. An interview with the Administrator on 8/24/2020 at 1:38 p.m. revealed that after getting the citizen's call that R#1 had been seen, he contacted the family and police department. Review of Facility Incident Report dated 4/13/2020 revealed R#1 exited the Dementia Unit unobserved on 4/9/2020 between 7:15 p.m. and 8:45 p.m. R#1 was last seen by staff on 4/9/2020 at 7:15 p.m. on the Dementia Unit. The facility was searched inside and outside by staff. The Administrator, Director of Nurses (DON), the resident's Physician, the resident's spouse and the county police department were notified. The resident was located less than a mile away from the facility on 4/10/2020 at 1:00 p.m. and was returned to the facility. A head to toe assessment was conducted and R#1 had no observed signs of injuries. A psychosocial assessment was completed, and the resident did not have any fear or psychosocial issues. R#1 had said he was going to work and had worked nearby at a warehouse close to where he was found. Continued review of the 34. Review of the In-service Attendance Record Sign-in sheet dated 4/9/2020 revealed that 14 staff were in-serviced on Elopement. 40. Review of the nursing notes dated 4/10/2020 at 14:30 (military time) Resident received back to facility around 2:30 p.m. a head to toe assessment was completed. The resident was ambulating with a steady gate and did not appear to be in any distress. The resident was smiling and thanking the staff for caring. An interview with LPN PP on 8/27/2020 at 10:45 a.m. revealed that she was working when the resident was brought back to the facility. She completed a head to toe assessment and found no injuries were noted. Record review of the Nurses Notes dated 4/10/2020 at 14:30 Wound Note revealed a complete skin assessment was completed after the resident returned to the facility. No injuries or wounds were noted, and the resident tolerated the procedure well. The note was signed by Licensed Practical Nurse (LPN) PP. 41. An interview with the Administrator on 8/24/2020 at 12:00 p.m. revealed that the resident was placed on every 15-minute check for two weeks. Review of the every 15-minute check sheets dated 4/10/2020 through 4/26/2020 revealed they were completed by staff. An interview on with LPN PP on 8/27/2020 at 10:45 a.m. revealed that once the resident was returned to the facility that staff began every 15-minutes check on the resident which was documented. An interview with CNA LL on 8/25/2020 at 11:47 a.m. confirmed that staff made every 15-minute checks on the resident and documented on the check sheet. Items for: 42 and 45. Record review of the Mandatory 15-minute Door Checks beginning on 4/10/2020 through 4/16/2020 revealed the every 15-minute door checks were completed and documented. An interview with CNA MM on 8/26/2020 at 10:26 a.m. revealed that staff had to check that the biohazard doors were closed and locked every 15-minutes and document their findings on the check sheet. This began after the resident was returned to the building. She further revealed being in-serviced on the staff's responsibilities to keep the residents safe and secure. Review of the Logbook Documentation weekly door checks revealed that all doors on every hall, in Dietary and Physical Therapy and checked starting on 4/11/2020 and continues. 43. An interview with the Administrator on 6/16/2020 at 10:40 a.m. revealed he had discussed the elopement of R#1 in an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting on 4/10/2020 and reviewed the Elopement policy, without changes, prior to the return of R#1. Further interview revealed that the QAPI Committee did a root cause analysis which determined that even though the biohazard room door was locked, it may not have been pulled all the way shut because it scrapes the door jam. Apparently (name of R#1) was able to get past the inside door, exit through the outside door, climb over the fence, and leave the facility premises. 44. Review of the security company invoice dated 4/16/2020 revealed the company had been to the facility on [DATE] and 4/16/2020 and had installed two keypads and an alarm. Observation and interview on 8/24/2020 at 10:40 a.m. with Housekeeping Aide XX revealed that she entered the code into the keypad on the biohazard room then unlocked, via the keypad, and opened the exterior door which alarmed. She revealed that the codes for the keypads are changed monthly. 46. Review of a written statement by the Social Services Director which revealed On 4/10/2020, the Social Services Director updated each Elopement Book in the facility by adding new resident face sheets with pictures. Also, removing residents who are no longer in the facility or those residents no longer assessed as at risk. An observation and interview with the Social Services Director (SSD) on 8/25/2020 at 2:10 p.m. revealed that after R#1 eloped that she updated every Elopement Book on each nursing unit to ensure they included photographs of the current residents who were at risk of elopement. Review of the Locked Unit Elopement Book with the SSD, at this time, revealed the book contained the current residents' photographs, face sheets and risk assessments. 47. Record review revealed that R#1 was reassessed for wandering/elopement upon his return on 4/10/2020. The Assessment risk was found to be a moderate risk. The resident was reassessed on 7/5/2020 and remained at moderate risk. 48. An interview on 8/24/2020 at 1:38 p.m. with the Administrator revealed that the DON reviewed the wandering/elopement risk for accuracy of the assessments for the resident on the locked unit. He further revealed that no additional risk were identified for these residents. Review of the assessment sheet overview dated 4/10/2020 and signed by the DON revealed that 29 residents on the locked unit, with wandering/elopement assessment between January 2020 and March 2020 were review without a change to the assessed risk. 49. A telephone interview with the DON 8/28/2020 at 11:15 a.m. revealed that the Interdisciplinary Care Plan team (IDT) which includes the Assistant DON, MDS Coordinator, Unit Managers, Social Services, and Staff Development Nurse. The IDT meet during the Clinical Morning meeting where the happenings of the last 24 hours are discussed. The discussion would also include elopement and residents with a Wander Guard. Review of the Nursing Quality Assurance (QA) meeting reports for April 2020 and May 2020 indicated that Care Plans and MDS assessments were reviewed for accuracy and updated if needed. 50. Review of the Education sign-in sheet, dated 4/11/2020, titled Assessment Accuracy included signatures of two RNs and five LPNs. An interview with RN, Staff Development Coordinator, and Interim DON, on 8/27/2020 at 2:30 p.m. revealed that she had attended the in-service on 4/11/2020 on accuracy of assessments. She revealed that education continues for all shifts on all aspects of wander/elopement and accuracy of assessments. 51. Review of Nurse's Progress Notes for R#1 revealed documentation of Physician and NP assessing R#1 on 4/13/2020 at 10:46 a.m. and providing new orders. A review of the April 2020 Medication Administration Record [REDACTED]. A Psychiatric Evaluation dated 6/8/2020 for R#1 was reviewed and there were no concerns identified and there were no changes in medications. Interviews were conducted on 6/29/2020 at 12:30 p.m. with the Physician for R#1 and on 6/29/2020 at 1:41 p.m. with the NP for R#1 and they revealed they were made aware of the elopement and discussed this with the Administrator, assessed R#1 and ordered PRN medication. Both revealed they had no concerns related to security on the Dementia Unit and agreed with the interventions implemented by the Administrator to prevent elopements. Items for: 52 and 53. Review of the security company invoice dated 4/16/2020 revealed the company had been to the facility on [DATE] and 4/16/2020 and had installed two keypads and an alarm. Observation and interview with the Administrator on 6/16/2020 at 10:45 a.m. of the Dementia Unit (locked unit) revealed that the interior and exterior biohazard doors were locked. The Administrator entered the code on the keypads to open the interior door which closed easily behind the surveyor and locked without pulling on the doors. The door to the courtyard from the biohazard room alarmed loudly when opened. Observation and interview on 8/24/2020 at 10:40 a.m. with Housekeeping Aide XX revealed that she entered the code into the keypad on the biohazard room then unlocked, via the keypad, and opened the exterior door which alarmed. She revealed that the codes for the keypads are changed monthly. 54. Review of the in-service sign in sheets dated 4/16/2020 revealed that eight staff were educated on Elopement with the facility elopement policy and procedure reviewed by the Staff Development Coordinator (SDC). 55 and 60. Record review of the Monthly QA meeting reports for April 2020 and May 2020, revealed that elopement assessments were reviewed for accuracy weekly during these months. 56. Review of the New Employee Orientation Checklist for two RNs, three LPN's and one CNA from 4/29/2020 through 5/20/2020 revealed that policies and procedures were reviewed with the employees which included elopement. An interview with the SDD on 8/27/2020 at 2:30 p.m. revealed that she completed the training for the new hires. She also conducts standard in-services for all shifts three times per week and comes in on the evening and night shift to ensure that all staff is trained. She is currently functioning as the Interim DON during the DON's leave. 57. Review of an in-service, dated 4/30/2020, for the Administrator signed by the Regional Vice President of Operations, which reviewed the job description an (TRUNCATED)

Based on record review, staff interviews and review of facility policies titled Comprehensive Assessments, and Wandering, Unsafe Resident the facility failed to accurately assess one resident (R) (R#1) for wandering behaviors on the Quarterly Minimum Data Set ((MDS) dated [DATE], from a sample of three residents. Resident #1 eloped from the facility on the evening of 4/9/2020 and was not returned to the facility until the afternoon of 4/10/2020. An abbreviated/Partial Extended Survey to investigate complaints GA 822, GA 978, GA 274, GA 490, GA 389, GA 562, GA 566, GA 643, GA 696, GA 870, and GA 947 was initiated on April 15, 2020 and concluded on 7/16/2020. Complaints GA 974, GA 870, GA 696, GA 562, GA 566, GA 490, GA 274, GA 978 and GA 822 were unsubstantiated, GA 643 was partially substantiated without deficiencies, and Complaint GA 389 was substantiated with deficiencies. On 7/16/2020 past noncompliance IJ was alleged however, after Quality Assurance review, it was determined that past noncompliance had not been achieved and re-entry was necessary on 8/24/2020 and concluded on 8/27/2020. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Resident Form, the facility's census on April 15, 2020 was 120. On 8/24/2020 a determination was made that a situation in which the facility's noncompliance with one or more requirement of participation had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. On 8/24/2020 at 10:00 a.m. the facility's Administrator was informed of the Immediate Jeopardy (IJ). The noncompliance related to the Immediate Jeopardy was identified to have existed on 4/9/2020 when R#1 was able to exit the facility undetected from the Dementia Unit through two unlocked doors. His location was unknown until 4/10/2020 at approximately 2:30 p.m. when he was returned to the facility. The Immediate Jeopardy is out lined as follows: On 4/9/2020 R#1 exited the facility undetected through two unsecured doors on the Dementia Unit where he resided. The police responded to a call from the Administrator and issued a Mattie's Call to alert the community to watch for a nursing home resident who could not be located. The police also issued a Be On Look Out (BOLO) alert for law enforcement to be aware a nursing home resident was missing. The police searched for R#1 with canines and a helicopter the night of 4/9/2020 and early morning of 4/10/2020, but he could not be located. A passerby responded to the Mattie's Call the next afternoon and told the receptionist answering the telephone that he/she may have seen R#1 outside a gas station approximately a mile from the facility. The family of R#1, who had been waiting in the parking lot all night for news of R#1, then retrieved him as he was walking down a street near the gas station described by the passer-by, and brought him back to the facility on [DATE]. R#1 had a history of [REDACTED]. R#1 exited undetected through two doors left unlocked on the Dementia Unit and climbed over a four-foot gate to leave the facility grounds. The Immediate Jeopardy was identified to exist on 4/9/2020 in the area of CFR 483.20(g) Accuracy of Assessments, F641 Scope and Severity (S/S)- J; CFR 483.25(d) (1)(2) Free of Accidents, Hazards/Supervision/Devices, F689 S/S-J; CFR 483.70 Administration, F835 S/S-J Additionally, Substandard Quality of Care was identified with the requirements at CFR 483.25(d) (1) (2) Free of Accident, Hazards/Supervision/Devices (F689 Scope and Severity: J. A Credible Allegation of Compliance was received on 8/27/2020. Based on interviews, record reviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of 6/6/2020. Findings include: A review of facility policy titled Comprehensive Assessments last revision 11/2017 page 1 of 2 revealed in part: Policy Interpretation and Implementation The purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity. Information derived from the comprehensive assessment enables the staff to plan care that allows the resident to reach his/her highest practicable level of functioning. A review of facility policy titled Wandering, Unsafe Resident last revised 11/2017 revealed in part: Policy Interpretation and Implementation 1. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement) during the evaluation completed on admission, quarterly and as needed. 2. The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering. Record review revealed that R#1 was admitted to the facility on [DATE]. Review of the undated face sheet revealed admission [DIAGNOSES REDACTED]. Hospital records were reviewed for R#1's hospital stay prior to admission to the facility. A Nursing Note Addendum dated 2/6/2020 at 5:50 p.m. revealed R#1 attempted to leave the hospital and was talked back into his room. One to one (1:1) observation was ordered, and a physician's orders [REDACTED]. The referral packet for R#1 sent by the hospital prior to his admission to the facility was reviewed and Nurses Daily Shift Notes revealed R#1 had 1:1 observation with a sitter at the bedside from 1/26/2020 through 2/6/2020. Review of the facility Admission Wandering, and Elopement Evaluation dated 2/21/2020 at 12:59 p.m. revealed no Brief Interview for Mental Status (BIMS) score was available but R#1 was only oriented to person and exhibited forgetfulness or short attention span and was independently mobile. The Wandering and Elopement Evaluation indicated that current caregivers should be interviewed for information related to wandering and exit seeking patterns. No check marks indicated that R#1 had a history of [REDACTED]. The Evaluation did indicate R#1 wandered after dark. The Evaluation included that R#1 had a [DIAGNOSES REDACTED].#1 also had [DIAGNOSES REDACTED]. The Evaluation did not include that R#1 was a recent admission. The scoring for the Wandering and Elopement Evaluation was 4, which indicated a low risk. Review of the Nursing Admission Evaluation dated 2/21/2020 at 12:59 p.m., revealed the Evaluation was conducted by the same nurse as the Wandering and Elopement Evaluation and revealed the resident had not wandered. Review of the Nursing Baseline Care Plan dated 2/22/2020 for R#1 revealed he had been provided with a Wander Bracelet to minimize the risk of elopement. Review of the Admission Minimum Data Set (MDS) for R#1 dated 3/2/2020 revealed R#1 had not exhibited wandering behavior during the seven day look back period from 2/25/2020 through 3/2/2020. Review of Section P: Alarms revealed the MDS had not been assessed to reflect the Wander Guard that had been provided to R#1. Section C: Cognitive Function revealed R#1 was had severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of 5. A review of the monthly Wander Guard Test list with documentation by the Director of Nurses (DON) revealed R#1 had a Wander Guard on his right ankle on 2/21/2020, 3/6/2020 and 4/6/2020. No additional documentation of the Wander Guard bracelet provided to R#1 to minimize the risk of wandering and elopement could be found in Wandering and Elopement Evaluations, Behavioral Evaluations, Nurse's Progress Notes, care plans, physician's orders [REDACTED]. The monthly Wander Guard Test list revealed there were no other residents residing on the Dementia Unit wearing Wander Guards. Review of the Quarterly MDS for R#1 dated 4/6/2020 revealed during the seven day look back period from 3/29/2020 through 4/5/2020 no behavior of wandering nor was the Wander Bracelet assessed. BIMS scoring indicated severe cognitive impairment with a BIMS of 3. Review of facility Nurses Notes from 3/31/2020 through 4/6/2020 revealed R#1 had experienced pacing and wandering on the following four of the seven-day lookback period: 4/1/2020 at 9:36 a.m., 4/2/2020 at 9:36 a.m., 4/3/2020 at 9:36 a.m., and 4/6/2020 at 9:36 a.m. An interview was conducted with the Social Service Director (SSD) on 6/16/2020 at 12:45 p.m. who revealed she had assessed R#1 for behaviors for the Quarterly MDS assessment dated [DATE]. The SSD revealed she had not been aware of the Wander Guard the facility had provided to R#1 to minimize the risk of wandering and elopement. The SSD revealed she interviews staff and reviews nursing documentation and observes residents when she conducts behavioral assessments. The SSD revealed if she did not observe R#1 exhibiting wandering behavior during the look back period and when she interviewed staff, and they did not tell her that R#1 wandered then she may not have assessed him as exhibiting wandering behavior. The SSD confirmed that the four nursing notes that documented R#1 wandered during the lookback period of seven days should mean the resident would be assessed for wandering. An interview was conducted on 6/17/2020 at 7:30 a.m. with the Director of Nurses (DON) who confirmed the Admission MDS dated [DATE] did not accurately reflect the use of a Wander Guard bracelet. The DON also confirmed the Quarterly MDS dated [DATE] did not accurately reflect that R#1 wandered, paced and had been provided with a Wander Guard. The DON revealed she had re-evaluated R#1on 4/10/2020 for Wandering and Elopement after his return and her evaluation revealed R#1 was at moderate risk for elopement. The DON confirmed the Nurse's Progress notes included information related to the resident wandering on 4/1/2020, 4/2/2020, 4/3/2020 and 4/6/2020 that should have been reflected on the Quarterly MDS assessment dated [DATE]. An interview was conducted with MDS Nurse NN on 6/16/2020 at 11:10 a.m. who revealed the SSD or Social Worker assess behaviors for the MDS, but he does not consider any resident on the Dementia Unit at risk for elopement because they are on a secured unit. MDS Nurse NN revealed he had never been aware that R#1 had a Wander Guard. He revealed he does assess Section P and the Wander Guard should have been included there, but whoever first provided the Wander Guard had not followed the process of obtaining a Physician Order, and that is where he looks for information for Section P. Additionally, due to the resident being on a locked unit he did not feel it was likely that the resident could elope from the locked unit. Observation and interview with on 8/24/2020 at 10:40 a.m. with Housekeeper XX of the Biohazard room, on the memory unit, revealed that she opened the locked door via a keypad by entering the code. She revealed that the keypad code is changed monthly. The second, outside door, was then opened by entered a code on the keypad which had an audible alarm. Observation of R#1 on 8/24/2020 at 12:25 p.m. revealed the resident lying in bed on the secured memory care unit. The resident's room is located across from the nurse's station and the resident's door was open. Observation of the Biohazard room on 8/25/2020 at 10:15 a.m., 8/26/2020 at 10:15 a.m. and 8/27/2020 at 10:15 a.m. revealed the door was locked and the keypad lock was in place. Record review revealed that R#1 was reassessed for wandering/elopement upon return to the facility on [DATE] and was assessed as moderate risk and was reassessed on 7/5/2020 with the risk remaining as moderate risk. Cross refer to F 689 The facility implemented the following actions to remove the Immediate Jeopardy: Resident #1 eloped from Meadowbrook Health and Rehab between 7:15 pm and 8:45 pm on April 9, 2020 . He was returned to the facility on [DATE] at approximately 1:40 pm. This document is my allegation that the Immediate Jeopardy should be removed on June 6, 2020. 1. On April 10, 2020, the facility reassessed Resident #1 for wandering and elopement risk and his care plan was updated to indicate he is a moderate risk for elopement. Resident #1 was reassessed for wandering and elopement risk again on 07/15/2020 . 2. On April 10, 2020 an Ad Hoc QAPI meeting was held. The Wandering-Elopement policy was reviewed, and no revisions were necessary. 9 QAPI members were educated on the Wandering - Elopement policy. This included 1 Administrator, 2 Admissions Coordinators, 1 Business Office Manager, 3 CNAs, and 2 Social Workers. 3. On April 10, 2020, the Wandering-Elopement assessments completed in January, February and March for the residents on the secured unit were reviewed. No other residents were identified as having exit-seeking behavior. 4. Starting April 11, 2020, the Interdisciplinary Care Plan team (IDT) met weekly to review the current week's list of residents with Wander Guards. Care plans and MDS assessments were reviewed for accuracy and updates were made if needed. 5. On April 11, 2020 , 2 RNs and 5 LPNs who complete Wandering - Elopement assessments were educated by the Director of Nursing regarding accuracy . This is 100% of the staff responsible for this task. 6. Fifteen other residents on the secured unit were re-assessed for Wandering - Elopement risk on or before 06/05/2020. 7. Weekly IDT care plan documentation will be reviewed by the QAPI Committee monthly to be sure systemic changes are effective or systems are revised to improve effectiveness at which time additional education will be provided to staff by the Regional Clinical Reimbursement Coordinator and/or the Staff Development Coordinator. The State Survey Agency (SSA) validated the facility's Immediate Jeopardy (IJ) Removal Plan as follows: 1. Record review confirmed that R#1 was reassessed for wandering/elopement on 4/10/2020 upon return to the facility. The resident was found to be at moderate risk. The resident was reassessed on 7/5/2020 without change to the assessment. 2. Review of the Ad Hoc QA committee sign in sheet dated 4/10/2020 related to Elopement, included the Administrator, two Admissions staff, two Social Service staff, Business Office Manager, Medical Records, Restorative Certified Nursing Assistants (CNA), Activities CNA, and the DON. An interview with the Administrator on 8/24/2020 at 1:38 p.m. revealed that the Ad Hoc Quality Assurance (QA) committee was held on 4/10/2020. The Administrator revealed the committee had reviewed the Elopement Policy and Procedure which required no changes, a root cause analysis tool completed by the Ad Hoc QA Committee on 4/10/2020. The Administrator revealed that the Root Cause Analysis contained an error to the second Why and that all the exit doors were not secured with keypad locks, at that time, and that the two biohazard room doors were not secured with keypad locks until 4/16/2020. 3. An interview on 8/24/2020 at 1:38 p.m. with the Administrator revealed that the DON reviewed the wandering/elopement risk for accuracy of the assessments for the resident on the locked unit. He further revealed that no additional risk were identified for these residents. Review of the assessment sheet overview dated 4/10/2020 and signed by the DON revealed that 29 residents on the locked unit, with wandering/elopement assessment between January 2020 and March 2020 were review without a change to the assessed risk. 4. A telephone interview with the DON 8/28/2020 at 11:15 a.m. revealed that the Interdisciplinary Care Plan team (IDT) which includes the Assistant DON, MDS Coordinator, Unit Managers, Social Services, and Staff Development Coordinator. The IDT meet during the Clinical Morning meeting where the happenings of the last 24 hours are discussed. The discussion would also include elopement and residents with a Wander Guard. Review of the Nursing Quality Assurance (QA) meeting reports for April 2020 and May 2020 indicated that Care Plans and MDS assessments were reviewed for accuracy and updated if needed. 5. Review of the Education sign-in sheet, dated 4/11/2020, titled Assessment Accuracy included signatures of two Registered Nurse (RNs) and five Licensed Practical Nurse (LPNs). An interview with LPN OO on 8/25/2020 at 11:37 a.m. revealed that she had been in-serviced on the facility's Policy and Procedures for wandering/elopement and attended the in-service on 4/11/2020 regarding accuracy of assessments. An interview with LPN II on 8/26/2020 at 10:33 a.m. revealed that she had been in-serviced on accuracy of assessments, the facility's Policy and Procedure for elopement/wandering. An interview with RN, Staff Development Coordinator, and Interim DON, on 8/27/2020 at 2:30 p.m. revealed that she had attended the in-service on 4/11/2020 on accuracy of assessments. She revealed that education continues for all shifts on all aspects of wander/elopement and accuracy of assessments. 6. A telephone interview on 8/28/2020 at 11:15 a.m. with the DON (who is on leave) revealed that 15 other residents at risk for wandering/elopement who had their quarterly assessments in January, February and March 2020, were reassessed in April 2020 and no additional residents were identified at risk. The DON revealed that two Registered Nurses (RN) and five Licensed Practical Nurses (LPN) perform the wandering/elopement assessments. Record review revealed that the 15 residents were reassessed by 5/28/2020. Further review revealed the remaining residents were reassessed as their Quarterly assessment was due and were completed by June 6, 2020. An interview with Licensed Practical Nurse SS on 8/24/2020 at 10:30 a.m. revealed that residents are assessed quarterly for wandering/elopement and assessments are completed for new admissions. 7. An interview with the RN Staff Development Coordinator on 8/27/2020 at 2:30 p.m. revealed that she is a member of the IDT which meets weekly. Elopement and wandering residents are discussed, assessments are reviewed at the meetings. She states that the DON runs the IDT meetings. Record review of the Monthly QA meeting reports for April 2020 and May 2020, revealed that elopement assessments were reviewed for accuracy weekly during these months.

Based on observation, record review, resident interview, family interview, and staff interview, the facility failed to promote care in a manner that maintained the dignity of one (1) resident ("Y") related to bedpan use, and for two (2) additional residents ("S" and "Z"), who sustained intrusion into their rooms by residents having wandering behavior, of thirty (30) sampled residents. This failure resulted in psychological harm for Resident "Y", who voiced embarrassment and shame after being transferred to the hospital while atop a soiled bedpan. This failure also resulted in psychological harm for Resident "S", who stated she had been scared after awakening to find a wandering resident to have entered the room at night, removed her pants, and sat on the bed of Resident "S"'s roommate. Findings include: 1. Record review for Resident "Y" revealed a Quarterly Minimum Data Set (MDS) assessment having an Assessment Reference Date of 04/06/2014 which documented the resident's 02/07/2014 Entry Date to the facility, and documented in Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) Summary Score of 15, indicating that the resident was cognitively intact. Section H - Bladder and Bowel of this MDS documented that Resident "Y" had always been incontinent of both bowel and bladder during the look back period, and Section G - Functional Status documented that the resident required the extensive assistance of staff for both bed mobility and toilet use. The Admission Record for Resident "Y" also documented the resident's 02/07/2014 facility admission, and documented [DIAGNOSES REDACTED]. During an interview with Resident "Y" conducted on 04/18/2014 at 10:35 a.m., the resident stated that she was totally dependent on the staff to clean her while in bed because she could not walk, stand, or take herself to the bathroom. She said that she used to ask staff for the bedpan, but that staff would allow the bedpan to sit under her so long that she stopped asking for it anymore, stating that it had taken up to three (3) hours to provide care after a bowel movement. Resident "Y" recalled one event during which staff had placed her on the bedpan, and then she was transferred to the hospital related to head pain. She stated that the hospital emergency room doctor was assessing her and found the bedpan still underneath her, with bowel movement in the pan. Resident "Y" said that she was embarrassed and wanted to "disappear." She said she kept apologizing to the doctor and hospital staff, and that a hospital technician stated that the bedpan was not one utilized by the hospital. Resident "Y" stated that she felt ashamed because of that one incident at the emergency room and would not ask for the bedpan again. During an interview with a family member of Resident "Y" conducted on 04/18/2014 at 3:25 p.m., the family member stated that the resident had been transferred to the emergency roiagnom on [DATE], and confirmed that the bedpan was in fact still underneath the resident upon her arrival at the hospital. During an interview conducted on 04/21/2014 at 1:00 p.m., the Director of Nursing stated she was unaware of the incident during which Resident "Y" had been transferred to the hospital with a bedpan positioned underneath the resident. 2. Record review for Resident "S" revealed a Quarterly MDS assessment having an Assessment Reference Date of 04/03/2014 which documented in Section C - Cognitive Patterns that the resident had a BIMS Summary Score of 14, thus indicating that the resident was cognitively intact. Section G - Functional Status of this MDS documented that Resident "S" was totally dependent on staff for transfers and for walking. During interview with Resident "S" conducted on 04/22/2014 at 8:53 a.m., the resident stated Resident #30 had wandered into her room the previous night of 04/21/2014, between 9:00 p.m. and 10:00 p.m. Resident "S" stated that she was asleep but was awakened by Resident #30, who was in the room. Resident "S" stated Resident #30 removed her pants and laid them on the bed, and then sat on the bed of Resident "S"'s roommate. A CNA was called to remove Resident #30 from the room. Resident "S" stated that it scared her to wake up and find someone in her room, and that it was hard for her to fall back asleep. Record review for Resident #30 revealed an Admission Record form which documented the resident's 04/07/2014 admitted , and documented [DIAGNOSES REDACTED]. The Admission MDS, having an Assessment Reference Date of 04/14/2014, documented in Section C - Cognitive Patterns that Resident #30 had a BIMS Summary Score of 04, indicating severe cognitive impairment, and Section E - Behavior documented wandering behavior. Resident #30's Interim Plan of Care identified an entry, dated 04/16/2014, which indicated that the resident was a wanderer, and that staff were to redirect. However, during a 04/22/2014, 10:10 a.m. observation, Resident #30 was observed wandering up and down the hallway, but with no staff redirection. This was despite the resident's Interim Plan of Care referenced above which specified staff redirection for the resident's wandering behavior. During an interview with CNA "FF" conducted on 04/28/2014 at 9:50 a.m., CNA "FF" acknowledged that Resident #30 would sometimes wander into the rooms of other residents, and that at times, Resident #30 wandered more at night. CNA "FF" stated that when Resident #30 wandered, the CNA would request that Resident #30 come out of other residents' rooms, but would provide no additional intervention. During an interview with CNA "GG" conducted on 04/28/2014 at 11:00 a.m., CNA "GG" also acknowledged that Resident #30 had wandering behavior, and that she would at times redirect Resident #30. However, CNA "GG" further stated there was no specific intervention, other than redirecting Resident #30 back to her hall, that she would provide when the resident wandered. 3. Record review for Resident "Z" revealed a Quarterly MDS assessment having an Assessment Reference Date of 03/24/2014 which documented in Section C - Cognitive Patterns that the resident had a Brief Interview for Mental Status (BIMS) Summary Score of 15, thus indicating that the resident was cognitively intact. During an interview with Resident "Z" conducted on 04/21/2014 at 11:37 a.m., Resident "Z" stated that she had experienced multiple episodes of residents wandering into her room. She specifically referenced an incident during which Resident #26 wandered into her room and was attempting to remove an item. Resident "Z" stated she called a nurse, but that while the nurse was redirecting Resident #26 from the room, Resident #26 expressed a profane word. During a subsequent interview conducted on 04/28/2014 at 11:35 a.m., Resident "Z" stated that she felt like residents such as Resident #26 should not be in her room. Record review for Resident #26 revealed a Quarterly MDS assessment with an Assessment Reference Date of 01/08/2014 which indicated in Section C-Cognitive Patterns a BIMS Summary Score of 07, indicating that the resident had severe cognitive impairment. Section E - Behavior documented that Resident #26 had experienced wandering behavior during 1 to 3 days of the look back period. The Care Plan of Resident #26 identified the resident to have wandering behavior, and included an Intervention for staff to distract the resident from wandering by offering diversions such as food and conversation. During an interview with Certified Nursing Assistant (CNA) "GG" conducted on 04/28/2014 at 11:00 a.m., this CNA acknowledged that Resident #26 did exhibit wandering behavior, and stated that at times she would redirect Resident #26 from wandering. However, during this interview, the CNA stated that when she provided redirection for Resident #26, she would return the resident to her hall, but further acknowledged that she would not provide the resident with any diversional activities.

Based on observation, record review, resident interview, and staff interview, the facility failed to provide care during toileting via bedpan in accordance with the Care Plan for one (1) resident ("Y") who was incontinent and whose Care Plan specified that staff provide care during toilet use; failed to provide supervision regarding wandering behavior in accordance with the Care Plan for one (1) resident (#26) who had wandering behavior and whose Care Plan specified that staff provide distraction and diversion for this behavior; and failed to provide [MEDICAL CONDITION] care in accordance with the Care Plan for one (1) resident (#1) who had a [MEDICAL CONDITION] and whose Care Plan specified that staff provide [MEDICAL CONDITION] care as ordered, on the total survey sample of thirty (30) residents. This failure resulted in psychological harm for Resident "Y" who expressed feeling embarrassed and ashamed after being transferred to the hospital while seated on a bedpan soiled with bowel movement. Findings include: 1. Record review for Resident "Y" revealed a Quarterly Minimum Data Set (MDS) of 04/06/2014 in which Section C - Cognitive Patterns documented a Brief Interview for Mental Status (BIMS) Summary Score of 15 (intact cognition), and in which Section G - Functional Status indicated the resident required extensive assistance for toilet use. Review of the Care Plan of Resident "Y" revealed a Focus area, originally dating from 04/02/2014, indicating that the resident had a deficit in Activities of Daily Living (ADL) Self-Care performance related to the disease process of [MEDICAL CONDITION], and also related to limited mobility. An Intervention to address this ADL deficit indicated that Resident "Y" was totally dependent on staff for toilet use, and that certified nursing assistant staff were to provide care for toilet use. During an interview conducted on 04/18/2014 at 10:35 a.m., Resident "Y" stated that she was totally dependent on the staff for toileting. However, Resident "Y" expressed concern, stating that on one recent occasion, staff placed her on the bedpan but that she was subsequently transferred to the hospital while still seated on the bedpan which was soiled with bowel movement. Resident "Y" said that this incident had caused her to feel embarrassed and ashamed. Cross refer to F241, example 1, for more information regarding Resident "Y". 2. Record review for Resident #26 revealed a Quarterly MDS assessment of 01/08/2014 which documented in Section C-Cognitive Patterns a BIMS Summary Score of 07, indicating severe cognitive impairment, and indicated in Section E - Behavior that the resident had experienced wandering behavior. Review of the Care Plan of Resident #26 revealed a Focus area, originally dating from 09/18/2013, which indicated that the resident had wandering behavior and would wander aimlessly. An Intervention to address Resident #26's wandering behavior specified for staff to distract the resident from wandering by offering diversions which included providing structured activities, and offering food, conversation, television and books. However, during an interview conducted on 04/28/2014 at 11:00 a.m., Certified Nursing Assistant (CNA) "GG" stated that sometimes she would redirect Resident #26 from wandering, but that she would only return the resident to her hall and would not provide diversional activities. Cross refer to F241, example #3, for more information regarding Resident #26. 3. Record review for Resident #1 revealed a Quarterly MDS assessment of 04/01/2014 which documented in Section O - Special Treatments and Programs that the resident received [MEDICAL CONDITION] care, and the April 2014 physician's orders [REDACTED].#1 utilize a [MEDICAL CONDITION]. Review of Resident #1's Care Plan revealed a Focus area, originally dated 07/29/2013, which identified the resident's use of a [MEDICAL CONDITION] related to [MEDICAL CONDITION]. Interventions referenced on this Care Plan related to Resident #1's [MEDICAL CONDITION] use included, but were not limited to, providing [MEDICAL CONDITION] care as ordered. Further review of Resident #1's April 2014 PO form referenced above, which ordered the [MEDICAL CONDITION], also revealed an order that the back of the resident's neck be cleaned with normal saline solution and an abdominal pad be applied daily. However, a 04/28/2014, 9:32 a.m. observation revealed no abdominal pad in place on the back of Resident #1's neck, despite the PO referenced above specifying the daily application of the pad, and despite the Care Plan specifying that [MEDICAL CONDITION] care be provided as ordered. A 04/28/2014, 9:17 a.m. interview with the Treatment Nurse acknowledged the absence of the neck dressing for Resident #1. Cross refer to F328 for more information regarding Resident #1.