Every finding on record at Tuskawilla Nursing and Rehab Center

Based on observation, interview, and record review, the facility failed to ensure the intravenous (IV) dressing was changed as ordered for 1 of 2 residents, (#5), and failed to obtain orders for IV dressing changes for 2 of 2 residents, (#5 & #13), reviewed for IV therapy, of a total sample of 32 residents. Findings: 1.Resident #5 was admitted to the facility on [DATE] with diagnoses of end stage renal disease, endocarditis (infection of the heart), type 2 diabetes, & bacteremia (bacteria in the blood). A care plan for IV medication use was initiated on 5/04/26 that instructed staff to monitor the central line IV to his right chest, to receive antibiotics and fluids. Interventions included dressing changes as ordered, observe the site, and flush it. A central line-central venous catheter (CVC) is a long, flexible tube that is similar to an IV line, but stays in place longer. The tube is inserted into a vein in the neck, chest, arm or groin, and passed through until it reaches a large vein near the heart in the vena cava, (retrieved on 5/22/26 from https://www.hopkinsmedicine.org) Review of resident #5's Electronic Medical Record revealed a physician's order that instructed staff to change the central line dressing with transparent dressing every week. An antibiotic order dated 4/16/26 indicated Ceftriaxone two grams was ordered daily until 5/28/26. The Annual Minimum Data Set (MDS) assessment dated [DATE] showed the resident had a Brief Interview for Mental Status (BIMS) assessment of 14/15, which meant he was cognitively intact. On 5/19/26 at 9:35 AM, resident #5's central line dressing was dated 5/1'/26 with an approximate 2 mm line visible after the 1. He stated he was on IV antibiotics for six weeks for an abscess they removed from his heart valve, he did not remember the last time his IV dressing was changed by staff. On 5/19/26 at 9:38 AM, Licensed Practical Nurse (LPN) A said she was unsure when the dressing was last changed. When she examined the dressing, she could not determine if the writing indicated either 5/01/26 or 5/11/26. The LPN didn't how often the IV dressings were supposed to be changed, but recalled an alert usually appeared on Treatment Administration Record (TAR). She said she would check the order and come back. On 5/19/26 at 9:42 AM, the Director of Nursing (DON) stated IV dressings should be changed weekly or as needed and confirmed it could pose a risk of infection if not done regularly. On 5/19/26 at 2:14 PM, the DON commented the last time resident #5's IV dressing had been changed was 5/11/26. She said she would check the TAR and come back with documentation. She stated she and the Unit Managers did IV audits weekly, and the nurses had just completed an IV certification class on 5/20/26, including how to put in orders and change the dressings. She stated the nurses should know how often to change them. The facility was unable to provide documentation of the TAR or progress notes to indicate resident #5's IV dressing had been changed since the resident arrived. On 5/21/26 at 11:00 AM, the DON explained the nurse who got the order for the IV was responsible for entering in the batch orders for care of the IV, so that the alert would appear on the TAR to inform the nurses the dressing was due to be changed. She confirmed there were no batch orders in the TAR for IV care for resident #5. Review of the facility's Central Access Device Dressing Change Policy dated 1/15/04, the catheter insertion site was a potential site for bacteria to enter, that could cause catheter-related infection. The policy indicated sterile dressing changes should be performed at least weekly so the site was cleaned properly, and the nurse should document after care was given. 2. Resident #13 was admitted to the facility from an acute care hospital on [DATE] with diagnoses that included sepsis, systemic inflammatory response syndrome (SIRS), chronic kidney disease stage 3, and anemia. Review of the MDS Quarterly assessment dated [DATE] revealed resident #13 had a BIMS score of 7 out of 15, indicating severe cognitive impairment. The assessment noted he had an IV and was receiving medications through it. On 5/18/26 at 10:36 AM, resident #13 was in bed with eyes closed. He had a midline IV inserted on his left upper arm with a clear dressing dated 5/18/26. The Order Summary Report for resident #13 showed he had been receiving IV fluids intermittently on 12/08/25, 1/02/26, 5/08/26, and 5/11/26. Orders for midline IV insertion had been entered for each date but there were no orders for dressing changes or monitoring of the IV site to correspond with the IV insertion. On 5/18/26 at 3:45 PM, Registered Nurse (RN) B, the assigned nurse for resident #13, confirmed she was unable to find the orders for IV dressing changes or monitoring in the resident's medical record. She acknowledged there was no documentation in the Medication Administration Record (MAR) that showed dressing changes had been scheduled or that staff were monitoring the IV site. The [NAME] Wing Unit Manager was present during the interview and attempted to find the orders, but she confirmed they had not been entered and believed they might have been missed. On 5/20/26 at 9:43 AM, RN C confirmed she had received the orders from the physician on 5/11/26 to insert the midline IV for resident #13. She explained there were batch orders for IVs, which included dressing changes and monitoring, but said when she entered the order, she did not add them because she was unsure when the IV team would come to insert the midline IV. The RN said the IV team sometimes would come the next day and if she had entered the dressing change order it would have interfered with the 24-hour dressing change that had to be done after the initial IV insertion. She confirmed all nurses were aware that IV dressing changes were done in the first 24 hours after insertion and every seven days after that. RN C said she reported to the 11 PM to 7 AM nurse that the IV team would come to insert the IV and said she expected the nurse would enter the dressing change and monitoring orders after the IV team had completed the insertion. RN C explained the nurse must have missed it and acknowledged the orders were missed by every nurse who cared for resident #13 since, for almost eight days. On 5/20/26 at 3:53 PM, the DON acknowledged there were no orders for dressing changes or monitoring of resident #13's IV. She said she expected nurses to follow the process for entering IV orders to ensure all associated orders, including dressing changes and monitoring of IV site, were included. She said this would ensure IV dressing changes were not missed. The facility's Procedural Guidelines for Physician Orders dated 6/28/24 instructed staff to enter new orders into the TAR as soon as they were received.

Based on observation, interview, and record review, the facility failed to maintain resident medical records in accordance with accepted professional standards and practices that are accurately documented and complete for 1 of 2 residents reviewed for personal property, of a total sample of 32 residents, (#3).Findings: Resident #3 was admitted to the facility on [DATE] with diagnoses that included encephalopathy (brain dysfunction), chronic respiratory failure, chronic obstructive pulmonary disease and unspecified obstructive sleep apnea (OSA). A review of the Quarterly Minimum Data Set (MDS) assessment with reference date 5/07/26 revealed resident #3 had a Brief Interview for Mental Status Score of 15 out of 15 which meant her cognition was intact. The MDS assessment also indicated the resident used a noninvasive mechanical ventilator. Continuous positive airway pressure (CPAP) is a non-invasive ventilation machine that involves the administration of air usually through the nose by an external device at a predetermined level of pressure, (retrieved from State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities on 5/22/26). On 5/20/26 at 9:54 AM, resident #3 stated she did not use her CPAP machine for a while and was not sure why the staff removed it or if she still needed it. Review of the physician orders started on 12/16/25 showed an order for CPAP at 10 with fraction of inspired oxygen (Fio2) at 8 at bedtime and as needed (prn) via full face mask at bedtime for OSA. The order was discontinued on 5/18/26 at 4:30 PM. A review of the Treatment Administration Record (TAR) for the month of April 2026, showed resident #3 received CPAP therapy every day except on 4/28/26. For the Month of May 2026, the TAR showed she received CPAP therapy every day except on 5/8, 5/9 and 5/15. Review of the nurses' corresponding progress notes for 5/08/26 read, Resident stated she no longer has a CPAP machine. The corresponding progress notes for 5/15/26 read, No device available. An excerpt from a Pulmonary Note on 4/09/26 indicated, Patient is noncompliant with CPAP use and states she does not wish to continue therapy despite counseling. Discussed in detail the risks of untreated OSA. At this time, CPAP will be discontinued per patient preference. Review of the resident's plan of care showed no refusal of care. On 5/20/26 at 3:48 PM, the East Wing Unit Manager (UM) said that resident # 3 had declined to use the CPAP machine and believed the order was discontinued a while back, however, she said it was actually discontinued on 5/18/26. The East Wing UM explained the CPAP was a rental and did not belong to resident #3. She said she would find out what date the machine was returned to the rental company. The East Wing UM reviewed the TAR for April and May as well as the corresponding progress notes and could not explain why nurses were documenting the treatment was given when there were inconsistencies in documentation over whether the machine had been returned. Licensed Practical Nurse (LPN) D who was standing at the nurse's station, reviewed the TAR and acknowledged she signed the TAR on 5/16/26 and 5/17/26. The nurse stated she documented the resident had the CPAP at the bedside because she believed it was there and applied it. After LPN D explained she provided the therapy over the weekend, the East Wing UM said she tried to figure out what happened and was able to show the other discontinued batch orders for the CPAP was on 4/18/26. She explained the order should have been discontinued then, but it seemed as though it remained and was actually discontinued on 5/18/26 but should have been discontinued with all the others on 4/18/26. She said she was still trying to see when the CPAP was returned to the rental company. She continued to explain it seemed like the doctor came in and discontinued the order on 5/18/26 after realizing it was still an active order. On 5/20/26 at 4:20 PM, Certified Nursing Assistant (CNA) E said she had worked at the facility for over a year and usually worked evening and night shift. CNA E said she was familiar with resident #3 and she would often refuse the CPAP. CNA E said she had not seen the CPAP machine at resident #3's bedside for about one month. On 5/20/26 at 4:58 PM, the Director of Nursing (DON) said nurses were documenting that CPAP therapy was provided, but it seemed as though they were just signing off on the treatment form. She said it might have been because it was a batch order, she did not know if they could have missed or may not have even looked at it because it was only one out of the batch orders for CPAP. The DON said her expectation for documentation on treatments is the same for medication administration where you cannot just sign off as administered without any verification. The DON acknowledged the medical record was inaccurate.The facility could not provide a policy on documentation or accuracy of medical record.

Based on observation, interview, and record review, the facility failed to support the resident's right to voice a grievance concerning missing property for 1 of 2 residents reviewed for personal property, of a total sample of 32 residents, (#3).Findings:Resident # 3 was admitted to the facility on [DATE] with diagnoses that included encephalopathy (brain dysfunction), chronic respiratory failure, chronic obstructive pulmonary disease and unspecified obstructive sleep apnea. A review of the Quarterly Minimum Data Set assessment with reference date 5/07/26 revealed resident #3 had a Brief Interview for Mental Status Score of 15 out of 15, which meant her cognition was intact.On 5/18/26 at 10:38 AM, resident #3 said she was missing about three blankets, including an electric blanket and her Continuous Positive Airway Pressure (CPAP) machine used for sleep apnea. She said staff were aware of the missing items, but she had not heard back anything from them regarding the status of the grievance. The resident stated her blankets were labelled with her information.5/20/26 at 3:20 PM, the Social Services Director (SSD) said she was also the Grievance Officer. The SSD said issues with misplaced clothing can happen often and facility staff would try to talk to resident and family to get more information. She explained sometimes the items were found. The SSD said if the items were not found, the facility would reimburse or replace the item based on the situation. The SSD explained grievances were acted upon immediately and the facility tried to resolve them within three to five days. She said that CPAPs were rented and the facility did not allow the use of electric blankets but would follow up immediately with resident #3 because she was unaware of the missing items and verified there were no grievances on file for resident #3 regarding missing property. On 5/20/26 at approximately 4:00 PM, the Infection Preventionist nurse, who was the assigned nurse for resident #3 on 5/18/26 and 5/19/26 confirmed the resident had previously informed her about missing blankets, including an electric blanket. She explained the Nursing Home Administrator (NHA) was aware and was working on it.On 5/20/26 at 4:20 PM, Certified Nursing Assistant (CNA) E said that if a resident complained of missing clothing she would first try to find it, then follow up with the laundry department. CNA E said she was aware of the resident's missing blankets including an electric blanket and had told the Laundry Manager of the missing items.On 5/20/26 at 5:13 PM, the NHA said he first heard about the resident complaint in the resident council and acknowledged a grievance should have been filed at that time for the missing items.On 5/20/26 at 5:25 PM, the Director of Nursing (DON) and NHA explained that they had recently spoken with the resident's son for clarification of the missing items. They acknowledged many staff members were aware of resident #3's complaint and a grievance should have been filed when they first learned about it. They both acknowledged a grievance would have been in progress or resolved prior to survey if they had followed their process for grievances.The facility's policy on Grievances, revised August 2023, stated in the Purpose was to, To support each resident's right to voice grievances and to ensure that after a grievance has been received, the center will actively work through a conclusion while communicating progress to the resident and /or anyone working on their behalf in a timely manner.

Based on interview, and record review, the facility failed to thoroughly investigate a possible elopement for 1 of 2 resident reviewed for elopement, of a total sample of 32 residents, (#22). Findings: Resident #22 was admitted to the facility on [DATE] with diagnoses including dementia, major depressive disorder, psychotic disorder with delusions and cognitive communication deficit. Review of the Minimum Data Set quarterly assessment with Assessment Reference Date 5/12/24 noted resident #22 had long-term and short-term memory problems and had severely impaired cognitive skills for daily decision making. The assessment showed resident #22 wandered 4 to 6 days out of 7 and used a wander/elopement alarming device daily. The medical record contained a care plan revised 11/16/23 which indicated resident #22 was at risk for elopement as evidenced by impaired safety awareness. Interventions included the use of an alerting bracelet and picture of resident to be kept in elopement binders. The most recent revision to interventions was 1/19/23. Review of the facility Elopement Drills revealed a drill with sign-in sheet dated 6/05/24. The drill sheet indicated a resident with a wander alert bracelet tripped the alarm at the front door. The alarm sounded and the nurse checked the alarm panel without delay. The nurse immediately directed a Certified Nursing Assistant (CNA) to go to the front door where she then observed resident #22 directly outside the front door and she returned him to the unit. On 6/19/24 at 3:36 PM, CNA A stated she worked the night resident #22 set off the front alarm. She recalled Registered Nurse (RN) C sent CNA F to the front door. CNA A stated she remained on the unit. She recalled the Administrator came to the facility that night because the resident had gotten out the front door and staff completed an in-service on elopement. On 6/19/24 at 3:41 PM, Licensed Practical Nurse (LPN) B stated she was working the night resident #22 pushed the front door and got outside the door. She stated she heard the alarm at the nurses' station, and she then checked each resident on the unit as per policy. She recalled she heard resident #22 got out the front door but not very far. She stated the Administrator came in and held an in-service and a mock drill that same day. On 6/19/24 at 3:47 PM, RN C confirmed she worked the night resident #22 set off the front door alarm. She recalled she gave him his medication at approximately 8:00 PM. RN C said she was at the nurses' station when she heard the alarm. She remembered she immediately turned and looked at the panel and saw it was the front door alarm. RN C explained CNA F was standing at the nurses' station and she sent CNA F to the front door at once. RN C stated the alarm was turned off and sounded again. RN C recalled she went to the front door and observed CNA F just outside the door with resident #22. On 6/19/24 at 3:59 PM, LPN D stated she had worked the night of 6/05/24. She recalled she heard an overhead announcement at approximately 8:30 PM, which indicated a resident was missing. She stated she immediately started checking her residents. LPN D stated a CNA got the resident and brought him back inside the building. She recalled the Administrator came in a little later and did a walk through, then had everyone sign an in-service attendance sheet. On 6/20/24 at 11:16 AM, CNA F confirmed she worked the night of 6/05/24. She recalled resident #22 was by the nurses' station when she went to answer a call light. When she returned to the nurses' station, resident #22 was no longer there. She stated the alarm went off and she went to the front door to check the area. She explained she saw the resident right outside the door and immediately went out to get him. CNA F stated he came back inside without any resistance. CNA F reported resident #22 did wander at times but had never seen him go to the front door previously. She stated the Administrator came to the facility that night and did an in-service with staff. CNA F recalled she told him what she knew but she was not asked to provide a written statement of what happened that night until 6/18/24. Review of the incident log provided by the facility revealed no record of an incident report for the possible elopement on 6/05/24. Review of the medical record for resident #22 revealed no progress note was documented by staff regarding the incident on 6/05/24. A new elopement risk evaluation was not completed following the incident. On 6/19/24 at 5:44 PM, the Administrator stated he went to the facility the night of 6/05/24 after he was notified a resident set off the exit alarm. He reported he spoke to the nurse and CNA assigned to resident #22 and got verbal statements that evening. The Administrator acknowledged he did not have statements from any other employees nor did not obtain written statements from the assigned nurse and CNA until 6/18/24. He explained he viewed video of the incident that night and created a timeline from the video but did not preserve the video itself. The Administrator reported resident #22 was considered an elopement risk but had never left the facility previously. He did not know why resident #22 tried on this date. The Administrator explained he thought questioning the two assigned staff members and watching the video was enough to determine resident #22 did not elope and therefore used the experience as a drill. The Administrator could not answer why staff did not complete a new elopement risk screening or incident report. He also could not explain why there were no progress notes relating to the incident. The Administrator acknowledged documentation of the incident including his investigation could have been better. The facility's policies and procedure for Resident Elopement dated 8/2023 indicated when the resident was returned to the facility, the Director of Nursing or Charge nurse would complete an Incident/Accident report, document in the resident's medical record, investigate how the resident exited and review and update care plans.

Based on observation, interview, and record review, the facility charged costs for transportation not specifically requested by 1 of 1 resident reviewed for allocation of personal funds out of a total sample of 37 residents, (#54). Findings: Review of resident #54's medical record revealed she was admitted to the facility on [DATE], and readmitted from an acute care hospital on 3/24/2022. Her diagnoses included diabetic retinopathy, cataracts in both eyes, diabetes mellitus with complications, left above the knee amputation, depression, and anxiety. The Minimum Data Set quarterly assessment with Assessment Reference Date 5/12/2023 noted the resident required corrective lenses for sight and scored 12 out of 15 on the Brief Interview for Mental Status, that indicated the resident had mild cognitive impairment. The assessment noted the resident required extensive staff assistance for Activities of Daily living, and she depended on staff to assist with locomotion off the unit. Review of the Order Summary Report showed medication orders for Cyclopentolate eye drops to the right eye for eye surgery, ordered 11/08/2022, Ketorolac eye drops to the left eye for eye surgery, ordered 11/08/2022, Prednisolone eye drops to the left eye for cataracts, ordered 4/17/2023, and orders for ophthalmology appointments scheduled outside the facility on 2/22/2023, 4/03/2023, 4/17/2023, 4/18/2023, and 5/15/2023. The comprehensive care plan included focus for impaired vision related to diabetic retinopathy, dependence on glasses, and cataracts in both eyes. The care plan noted the resident required staff assistance with mobility, transfers, and dressing, related to impaired cognitive functioning, anxiety, and depression, On 5/22/2023 at 11:46 AM, resident #54 stated she had been having difficulty with the facility assisting her with transportation so she could get to her eye doctor appointments. She explained she recently had surgery and was very concerned because she had blurry vision and discomfort. She said she had transportation benefits included in her Medicaid plan at no cost to her, but the facility wanted her to use the community bus service and she had to pay for it. She said she was worried as it's very expensive. On 5/25/2023 at 9:30 AM, the West Unit Manager said residents were transported by various service providers to medical appointments outside the facility. She explained some residents had Medicaid benefits for it, and those who didn't have family available to take them often used the community bus service that required, money in their account. On 5/25/2023 at 10:00 AM, the Social Services Director explained she assisted residents with transportation arrangements to medical appointments outside of the facility. She said it was a tedious process to make transport appointments through many of the Medicaid benefits providers. She explained resident #54 sometimes became distressed about getting to her eye doctor appointments and the facility had enrolled her in the community bus service a few months prior. On 5/26/2023 at 11:39 AM, the Business Office Manager explained fees for the community bus service were withdrawn from the resident's trust account when they have one. She said the facility paid for the service if residents did not have a trust account. She recalled resident #54's son had recently set up an account for her. She provided a, Resident Statement Landscape form that showed debits for bus fare. During a telephone interview on 5/26/2023 at 12:25 PM, resident #54's son said there had been several times in the past his mother was distressed about her transportation. He said he reached out to the Social Services Director multiple times for help over the past months, but he never received any responses. He explained he was concerned because his mother told him she needed money for the bus, and she was very distressed because she didn't have the cash for the fare. He said he reached out to the Medicaid case worker who assured him there was no cost transportation benefits available, and recalled the resident often had difficulty with being assisted by staff to get to the pickup location on time. He stated he set up an account for his mother to help her with her distress over the [NAME]. On 5/26/2023 at 11:50 AM, the Social Services Director recalled enrolling resident #54 in the community bus service program. She said she did not offer other choices, and she did not have a list. She checked the medical record and acknowledged there were no notes or care plan to note resident #54 or her family representative specifically chose to use the bus. She said all resident preferences and choices should be included in the plan of care, and she would make sure she included them in the future. She explained the facility uses the bus service because oftentimes the transportation benefit service provider, doesn't work out. The facility's admission packet included information titled, Nursing Home Resident Rights and Responsibilities, that read, (a) 5. The facility may not impose a charge against the personal funds of a resident for any item or service for which payment is made under Title XVII or Title XIX of the Social Security Act. (i) The right to be fully informed, in writing and orally, . during his or her stay, of services available in the facility and or charges for such services, including any charges for services not covered under Title XVII or Title XIX of the Social Security Act or not covered by the basic per diem rates .

Based on interview, and record review, the facility failed to refer a resident with a newly evident mental disorder for Level II Preadmission Screening and Resident Review (PASARR) evaluation and determination for 1 of 1 resident reviewed for PASARR, out of a total sample of 37 residents, (#67). Findings: Resident #67 was admitted to the facility on [DATE] with active diagnoses including bipolar disorder, metabolic encephalopathy, major depressive disorder, anxiety disorder and unspecified dementia. Review of the Minimum Data Set (MDS) admission assessment with assessment reference date (ARD) of 4/26/23 revealed resident #67 had a Brief Interview for Mental Status (BIMS) score of 03 which indicated she was severely cognitively impaired. The document indicated her active diagnoses included anxiety disorder, depression (other than bipolar) and bipolar disorder. Review of resident #67's electronic medical record (EMR) revealed a care plan initiated 4/25/23 for use of psychotropic medications related to anxiety disorder, behavior management, depression and bipolar disorder. The interventions included to identify common behavioral expressions and expected responses to interventions and implement appropriate, individualized person-centered interventions and to describe how the behaviors impact the resident and others (e.g., increases resident distress, dangerous to the resident or others). Resident #67's EMR contained a Level I PASARR dated 4/24/23 which did not indicate she had a mental illness (MI) diagnosis. The Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (3008) sent from the hospital at time of admission indicated resident #67 had a diagnosis of bipolar disorder. Resident #67's EMR contained a progress noted dated 4/26/23 which read, Resident was admitted with DX (diagnosis) of Bipolar Disorder. On 5/26/23 at 11:04 AM, the Social Services Director (SSD) stated the admissions department usually obtained a resident's PASARR prior to admission. She explained the clinical team then reviewed the PASARR upon admission. The SSD stated she was responsible for completing a new PASARR if one was not sent upon admission or contained incorrect information. She reviewed resident #67's Level I PASARR and acknowledged the screening did not indicate resident #67 had a MI diagnosis. The SSD reviewed the 3008 transfer form sent from the hospital upon admission and verified it indicated resident #67 had a diagnosis of bipolar disorder. She acknowledged the PASARR was inaccurate. The SSD explained she was on vacation at the time of resident #67's admission. She was unsure if a new PASARR had been completed or if resident #67 had been referred for a Level II screening. On 5/26/23 at 1:02 PM, the Director of Nursing (DON) stated resident #67's PASARR was reviewed upon admission and was identified as inaccurate. She explained she did not have access to complete a new PASARR screening and the SSD was on vacation. The DON stated she reached out to a sister facility for assistance in completing a new PASARR. The sister facility agreed but did not send one over. The DON acknowledged the Level I PASARR screening for resident #67 was inaccurate upon admission and she was not referred for a Level II PASARR evaluation and determination.

Based on interview, and record review, the facility failed to ensure a vulnerable, cognitively impaired resident was free of physical restraint for 1 resident reviewed for restraint and seclusion, of a total of 5 sampled residents (#1). This failure could have resulted in the potential for multiple types of injuries, and even death. Using the reasonable person concept there was potential for psychosocial harm such as agitation, aggression, anxiety, development of delirium, feelings of imprisonment or restriction of freedom of movement. Findings Resident #1, a 95- year-old male, was admitted to the facility on [DATE]. His diagnoses included generalized anxiety disorder, major depressive disorder, cerebral infarction, cardiac pacemaker, history of falls, and malignant neoplasm of prostate. The resident's admission Minimum Data Set (MDS) assessment with Assessment Reference Date of 3/22/23, revealed the resident's cognition was moderately impaired with a Brief Interview for Mental Status (BIMS) score of 8 out of 15. The assessment noted resident #1 required extensive assistance of two staff persons for bed mobility, dressing, and personal hygiene, and was dependent on staff for transfers, and toilet use. Section P indicated restraint was not used for the resident. Review of the resident's Admission Data Set assessment dated [DATE] indicated the resident was admitted to the facility from home. The document indicated the resident had intermittent confusion, and he was chair/bed bound. A Fall Risk Evaluation dated 3/22/23 revealed a score of 14.00 which indicated the resident was assessed as being at risk for falls. Documentation on the form revealed that a score above 10, indicated the resident was assessed to be at risk for falls. On 5/11/23 at 10:24 AM, the West Wing Licensed Practical Nurse / Unit Manager (LPN/UM) recalled resident #1 was admitted to the facility two to three months ago. She said he was assessed to be at risk for falls, and shortly after his admission, the resident had a fall from his wheelchair and had two recent falls while he was in bed. The UM stated that it was her understanding that a sheet was used to help to keep the resident in bed on 5/06/23. She verbalized the facility was a restraint free facility. The LPN/UM said that about a week ago, there was a change in the resident's condition, and he was noted to be more anxious at nights. She recalled the Advance Registered Nurse Practitioner (ARNP) was made aware and recommended a psych consult/follow-up visit. The UM stated the resident was not placed on any additional medication, since he was already on psychotropic medication, Trazadone at nights. Trazadone: This medication is used to treat depression. It may help to . Decrease anxiety. (Retrieved on 5/22/23 from www.WebMD.com) On 5/11/23 at 11:27 AM, LPN A confirmed she was assigned to resident #1 on the 11 PM to 7 AM shift on 5/05/23. She recalled she made rounds with the off going nurse LPN D. She recalled the resident was in a low bed, with his legs coming off the bed. LPN A stated she removed the blanket from the bottom of the resident's legs and placed them back in the bed and covered him. She verbalized she did not notice any sheet tied across the resident. LPN A recalled she was in another hallway caring for residents, and the resident's assigned Certified Nursing Assistant (CNA) B came to get her and showed her the resident had a sheet around his mid-section tied to both sides of the resident's bed frame. LPN A recalled they tried to remove the sheet, but could not get it untied, and she had to cut the knot with her scissors. She explained the resident was lying with his arms at his side, and he would not be able to turn, get up, or sit up with the sheet tied around him, and attached to both sides of the bed. She recalled the restraint was noted between 1:30 AM and 2:00 AM, and she did not know who tied the resident with the sheet. She said the only staff on the shift along with her were two other CNAs. She said the resident's assigned CNA alerted her to the incident, and said she did not know who did it, and the other CNAs also denied any knowledge of the incident. LPN A stated she cared for the resident prior to the incident of 5/06/23, and the resident was confused, and was not able to make his needs known. She stated he was at risk for falls, was not resistant to care, and did not exhibit any aggressive behavior. On 5/11/23 at 12:26 PM, the Administrator stated he received a phone call on 5/06/23 from 7 AM to 3 PM CNA C who informed him that she received report from the off going CNA B that she discovered a sheet tied across the resident's mid abdomen attached to the bed frame. CNA C reported that CNA B said she went into the resident's room to provide care when she made the discovery. The Administrator recalled he contacted the staff who worked on the 3 PM to-11 PM shift on 5/05/23, and LPN D denied any knowledge of the resident being tied down with a sheet. He stated the Weekend Supervisor who informed him was made aware of the incident by LPN A. The Administrator stated he arrived at the facility around 8:40 AM on 5/06/23 and reviewed the video surveillance footage which showed CNA E entering and exiting the resident's room a lot. At 9:47 AM the Administrator recalled he went to talk with the resident who had a BIMS of 08/15 and his roommate who had a BIMS of 12/15, and both residents denied having knowledge of the incident. At 12:55 PM he called Law enforcement, and a deputy visited forty-five minutes later, and asked for resident #1's medical record and the names and phone numbers of all staff who cared for the resident. He noted LPN A was interviewed by the deputy at that time. He said the deputy assessed the resident's room, took pictures, and prior to his exit, he informed the facility they would be investigating abuse. The Administrator indicated he called CNA E who was the resident's assigned CNA on the 3 PM to 11 PM shift on 5/05/23, and she denied having any knowledge of a sheet tied across the resident. On 5/08/23 he reviewed the video surveillance in depth, and the video footage revealed that on 5/05/23 at 9:08 PM, CNA E went into the resident's room with a sheet and emerged five minutes later empty handed, without the sheet. At 9:36 PM, LPN D went into the resident's room, came out at 9:38 PM and talked and gestured to CNA E in the hallway. The Administrator verbalized he spoke to both LPN D and CNA E on 5/08/23, and both denied being aware of the sheet tied across the resident. He said he reviewed the surveillance video footage with them, and they still denied they knew there was a sheet tied across the resident and tied to both sides of the bed frame. He stated video footage showed both LPN D and CNA E in the resident's room several times during their shift. On 5/11/23 at 1:12 PM, the Director of Nursing (DON) stated she was notified by the Administrator on 5/06/23, that LPN A, and CNA B discovered resident #1 had a sheet over him that was tied to the bed frame. The DON stated she was told the resident was checked, assessed, and had no adverse effect. She recalled she came to the facility on [DATE], and spoke with the resident, along with the deputy who spoke Spanish, and the resident did not remember the event. She spoke with the resident's roommate, and he did not notice anything out of the ordinary. The DON stated the facility was a restraint free facility. On 5/11/23 at 1:37 PM, CNA B confirmed she was assigned to resident #1 on the 11 PM to 7 AM shift on 5/05/23. She recalled she was told by off going CNA E that the resident was trying to get out of bed. CNA B verbalized she started making rounds about 1 AM and got to resident #1's room about 2 AM. She recalled that when she went into the resident's room, he was in bed with his blanket across him. She recalled she pulled the blanket back to provide care for the resident, and noted he had a top sheet tied across his abdomen, which was attached to both sides of his bed frame. CNA B stated she tugged on the knot to remove the sheet the sheet but it was tight. She said she then went to get his assigned nurse, LPN A. She recalled the LPN was caring for another resident, so she had to wait, and they got back to resident #1's room around 3 AM. She explained to the LPN what she discovered. The CNA said she and LPN A attempted to remove the sheet, but it was tied tightly and the knot was tied to the frame. She explained the more they tried to move the bed to loosen the knot, the more it was stuck in the frame. She reported that LPN A ended up cutting the sheet off the resident with her scissors, and they threw the sheet in the thrash. The CNA stated LPN A said she would take care of it and would talk with the two CNAs and the nurse from the previous shift. CNA B reported that in the morning she waited to be relieved, and when CNA C came, she told her about the incident, and immediately CNA C called the Administrator. She informed him of the incident, and she reported her discovery to both the oncoming weekend supervisor and the Administrator. CNA B said usually when she had the resident, he would place his leg over the side of the bed, and when she instructed him to put his leg back in bed he would laugh and then do as asked. She stated the resident did not refuse care, and him being tied to the bed was a form of abuse. On 5/11/23 at 2:08 PM, LPN D recalled that on 5/05/23 around 7:30 PM to 8:00 PM, she did a dressing to resident #1's left heel and spoke to him in Spanish. LPN D said sometimes the resident was confused and did not comprehend what was said. The LPN stated that when she went down the hallway, she glanced into the resident's room, and he had his legs over the side of his bed, and his cover sheet was up to his chest. LPN D recalled she said, what are you doing, she lifted the cover, and placed his legs back in the bed. She verbalized that around 9:30 to 10:00 PM, CNA E was sitting in the hallway doing her charting. She recalled she told the CNA to keep an eye on the resident, because he kept trying to get out of bed. She told the CNA that the resident was a fall risk, he could fall, and she did not want any falls to occur on her shift. LPN D recalled she told CNA E that if the resident continued to attempt to get out of bed, she should inform her, so that they could get him up in his wheelchair, and place him at the nurses' station. LPN D stated that when LPN A came in, they did walking rounds starting from the back of the hall to the front. When they went into resident #1's room, he had his legs over the side of the bed, and his sheet was below his waist. The LPN stated she placed his feet back in bed and continued giving report to LPN A. She stated she did not see any sheet tied across the resident and tied to both sides of the bed frame, and verbalized she heard about the incident on 5/06/23 when the Administrator called her. She said she was shocked, and had no idea why someone would do that, verbalizing that (action) was against the law. On 5/11/23 at 2:53 PM, CNA E confirmed she was assigned to resident #1 on the 3 PM to 11 PM shift on 5/05/23. She recalled that when she came to work, the resident was sitting in his wheelchair at the nurses' station. He went to the dining room for supper, and then he was sitting in the hallway, and was placed to bed probably around 8 PM. CNA E said she checked on the resident, because lately he had been falling from his low bed. She said that during the shift, the resident would often have his legs over the side of his bed. She would place his legs back in bed, and a couple minutes later he would have his legs over the side of the bed again. She said every twenty minutes she observed him with his legs over the side of his bed. CNA E said LPN D told her that she found the resident with no gown on. She said the LPN told her she placed a gown on him and repositioned him. The CNA said she went to check on the resident and his sheet, and blanket were on the floor, and his legs were out of the bed. She said she told the 11 PM to 7 AM CNA to be sure to keep an eye on the resident because he was trying to get out of bed. CNA E stated she did not place a sheet across the resident and tied it to the bed frame. She verbalized that on 5/06/23 she saw a text on her phone from the Administrator instructing her to come to the facility. She reported she was interviewed by the Administrator, he documented the interview, and she signed the statement. The CNA denied tying a sheet across the resident, and said she observed the resident every thirty minutes, and would have seen if he was tied down with a sheet. On 5/11/23 at 3:38 PM, in a telephone interview CNA C stated she worked from 6:45 AM to 11:00 PM on the weekends. She explained when she came to work on 5/06/23, she was informed by CNA B that resident #1 was tied to the bed frame so tightly, they had to cut him out. CNA C stated she was in disbelief. She recalled CNA B said she told LPN A who wanted to talk to the evening nurse about it. CNA C recalled she told CNA B, we have to tell someone important. She said she called the Administrator and left a voice message. When the Administrator called back, she told him about the incident, and what CNA B told her. The Administrator then spoke with CNA B. On 5/11/23 at 4:07 PM, the video recording for 5/05/23 was reviewed with the Administrator. The recording noted that at 6:59 PM CNA E rolled the mechanical lift to resident #1's room door. At 7:00 PM, she transferred the resident via wheelchair from the nurse station to his room. At 7:03 PM, CNA E came out of the resident's room, retrieved the mechanical lift, and re-entered the resident's room. CNA E remained in the resident's room for approximately eleven minutes. At 7:14 PM, she placed the mechanical lift in the hallway. At 9:08 PM, CNA E walked from the clean linen room with a sheet into resident #1's room. At 9:14 PM, the CNA exited the resident's room empty handed. On 5/11/23 at 4:40 PM, in a telephone interview, Registered Nurse (RN) Weekend Supervisor stated that on 5/06/23 at 7 AM, she was met by CNAs B and C in the hallway, who told her they wanted to talk to her regarding an incident that happened overnight. She explained CNA B told her she found the resident with a sheet across his chest, and the sheet was tied on both sides to the frame of his bed. She stated she spoke with the Administrator and was directed to do a full head to toe skin assessment on the resident. The Weekend Supervisor stated the resident was asleep when they walked into the room, and when she started to evaluate him, he woke up. She verbalized he had no injury, red areas, or bruising, and exhibited no behavior. On 5/12/23 at 10:55 AM, in a telephone interview, resident #1's daughter said the facility informed her of the incident of 5/06/23 and she was very surprised that someone would do that. She recalled she was told by various staff members the facility did not use restraints, and she never expected that would be done to her father. She explained her father was forgetful and his logic was not there. The resident's daughter indicated she would have been very upset if he had sustained any skin issues or was hurt in any way. She said she would not want it to happen again. On 5/12/23 at 12:47 PM, in a telephone interview, the Psych ARNP said she saw resident #1 on 5/08/23. She recalled she was told the resident's blanket was tight over him. She said she assessed him and he had no issues and his affect was good. She explained the resident was not able to voice his concerns or recall the incident due to confusion. The ARNP stated she was not aware the sheet was tied to the bedframe, and scissors had to be used to cut and release the sheet. 5/12/23 1:18 PM, the DON stated the facility did not have a policy pertaining to physical restraints since the facility was a restraint free facility. She said the policy for Abuse, Neglect and Exploitation covered seclusion. The facility's learning module Protecting Resident Rights in Nursing Facilities copyright 2017 Relias Learning, Section 2: Resident Rights read, Freedom from restraints All residents have the right to be free from restraints, both chemical and physical, used for the purposes of discipline or convenience AND not used to treat a resident's medical symptoms . Restraints must only be used as a last resort or when medically necessary for the treatment of a medical condition. The facility's policy Abuse &Neglect Prohibition with effective date of 10/24/2022 documented that Involuntary seclusion was the separation of a resident from other residents or confinement to his or her room (with or without roommates) against the resident's will, or the will of the resident's legal representative.

Based on interview, and record review, the facility failed to report an alleged violation of abuse within the regulatory guidelines for 1 of 1 resident reviewed for restraint and seclusion of a total sample of 5 residents, (#1). Findings: Resident #1, a 95- year-old male, was admitted to the facility on [DATE]. His diagnoses included generalized anxiety disorder, major depressive disorder, cerebral infarction, cardiac pacemaker, history of falls, and malignant neoplasm of prostate. The resident's admission Minimum Data Set (MDS) assessment with Assessment Reference Date of 3/22/23, revealed the resident's cognition was moderately impaired with a Brief Interview for Mental Status (BIMS) score of 8 out of 15. The assessment noted resident #1 required extensive assistance of two staff persons for bed mobility, dressing, and personal hygiene, and was dependent on staff for transfers, and toilet use. Section P indicated restraint was not used for the resident. On 5/11/23 at 11:27 AM, Licensed Practical Nurse (LPN) A confirmed she was assigned to resident #1 on the 11 PM to 7 AM shift on 5/05/23. LPN A recalled she was in another hallway caring for residents when the resident's assigned Certified Nursing Assistant (CNA) B came to get her. She said they proceeded to resident #1's room and the resident had a sheet around his mid-section tied to both sides of the resident's bed frame. LPN A recalled they tried to remove the sheet, but could not get it untied. She said she had to cut the knot with her scissors. She said the resident was lying with his arms at his side, could not turn, get up or sit up. She recalled the restraint was noted by CNA B between 1:30 AM to 2:00 AM. LPN A said she did not report the finding to anyone since the resident did not have any injuries and added she was going to report it later in the morning. LPN A acknowledged the restraint was discovered between 1:30 AM to 2:00 AM and was not reported until approximately 7:15 AM to the oncoming supervisor. She verbalized she should have documented the incident, and initiated an incident report, but she did not. The LPN did not give a reason for the omission. On 5/11/23 at 12:26 PM, the Administrator stated he received a phone call on 5/06/23 from 7 AM to 3 PM shift CNA C who informed him that she received report from off going CNA B of a sheet tied across the resident's mid abdomen attached to the bed frame. CNA C reported that CNA B said she went in to provide care for the resident when she made the discovery. The Administrator stated he did not know why the incident was not reported to him immediately. He said it was discovered on the 11 PM to 7 AM shift, and the expectation was that staff would notify the Administrator, Director of Nursing (DON), and Abuse Coordinator immediately of any unusual occurrence or event. He confirmed the incident was not submitted to the relevant State agencies in the required regulatory timeframe. On 5/11/23 at 1:12 PM, the DON explained she was notified by the Administrator on 5/06/23, that LPN A, and CNA B discovered resident #1 had a sheet over him that was tied to the bed frame. She conveyed the incident should have been reported immediately. She noted all staff had education abuse abuse and neglect, and that any suspicion of abuse was to be reported immediately. On 5/11/23 at 1:37 PM, CNA B confirmed she was assigned to resident #1 on the 11 PM to 7 AM shift on 5/05/23. She recalled at about 2 AM, the resident was in bed with his blanket across him. She said she pulled the blanket back to provide care for the resident, and noted a top sheet tied across his abdomen that was tied to both sides of the bedframe. CNA B said she tried to remove the sheet but it was tight and she called for the assigned nurse, LPN A. She recalled the LPN was caring for another resident, so she had to wait, and they got back to resident #1's room around 3 AM. She said the knot was tied to the frame where the bed moved up and down, and the more they tried to move the bed to loosen the knot, the more it stuck in the frame. She said LPN A ended up cutting the sheet off the resident with her scissors, and they threw the sheet in the thrash. The CNA stated LPN A said she would take care of it and would talk with the two CNAs and nurse from the previous shift. The facility's policy Abuse & Neglect Prohibition with effective date of 10/24/2022 read, the center will investigate any alleged abuse/neglect . in accordance with state or federal law. The center will report such allegations to the state, .The center will report immediately but no later than 2 hours after forming the suspicion if the events that caused the allegation involve abuse. The facility's policy Incident Reporting for Residents or Visitors revised on 1/13/2017 directs that All incidents and unusual occurrences involving a resident will be documented and reported so as to meet all regulatory (state, and federal) requirements.

Based on interview, record review, and surveillance video recording, the facility failed to consistently implement care plan interventions for transfers with a mechanical lift for 2 of 2 residents of a total sample of 5 residents, (#1, #2). Findings 1. Resident #1, a 95- year-old male, was admitted to the facility on [DATE]. His diagnoses included generalized anxiety disorder, major depressive disorder, cerebral infarction, cardiac pacemaker, low back pain, history of falls, and malignant neoplasm of prostate. The resident's admission Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 3/22/23, revealed the resident's cognition was moderately impaired with a Brief Interview for Mental Status (BIMS) score of 8 out of 15. The assessment noted resident #1 required extensive assistance of two staff persons for bed mobility, dressing, and personal hygiene, and was dependent on staff for transfers, and toilet use. On 5/11/23 at 2:53 PM, Certified Nursing Assistant (CNA) E confirmed she was assigned to resident #1 on the 3 PM to 11 PM shift on 5/05/23. She recalled that when she came to work, the resident was sitting in his wheelchair at the nurses' station. He went to the dining room for supper, and then he was sitting in the hallway, and was transferred to bed probably around 8 PM. CNA E stated the resident required a mechanical lift for transfers. She acknowledged she transferred the resident from his wheelchair to his bed with the mechanical lift by herself. She said she knew that two persons were required to transfer residents with mechanical lift, but when there were three CNAs on the unit, they were busy. She stated she transferred the resident by herself as the other CNAs were busy. She said she did not ask the nurse to help her. She verified the resident's care plan/Kardex indicated he required two persons for transfer with a mechanical lift. On 5/11/23 at 3:49 PM, CNA F stated he was assigned to resident #1 on prior shifts. He stated the resident was a fall risk and required transfer with a mechanical lift with two persons. On 5/11/23 at 4:07 PM, video recording for 5/05/23 was reviewed with the Administrator. The recording showed at 6:59 PM, CNA E rolled the mechanical lift to resident #1's room door. At 7:00 PM, she transferred the resident via wheelchair from the nurses' station to his room. At 7:08 PM, CNA E came out of the resident's room, retrieved the mechanical lift, and re-entered the resident's room and remained there for eleven minutes. At 7:14 PM she placed the mechanical lift in the hallway. On 5/12/23 at 1:06 PM, the Director of Nursing (DON) stated staff were educated on hire, annually, and as needed regarding mechanical lift, and following the resident's care plan. She stated CNA E told them she did not request assistance from anyone to transfer resident #1 who required a mechanical lift for transfers. An intervention on the resident's care plan for ADL (Activities of Daily Living) self-care performance initiated/created on 3/18/23 and revised on 3/20/23, noted Transfers:2 person assist with (mechanical) lift. 2. Resident #2 was admitted to the facility on [DATE] with diagnoses including ataxia, fibromyalgia,, muscle weakness, and Parkinson's disease. The resident's quarterly MDS assessment with ARD of 4/23/23 revealed the resident's cognition was intact with a BIMS score of 13 out of 15. The assessment noted resident #2 required extensive assistance of two staff persons for bed mobility and was totally dependent on staff for transfers. On 5/12/23 at 2:46 PM, resident #2 stated she was bed ridden and staff transferred her from bed to chair twice a week with a mechanical lift for showers. She said sometimes the transfer was done by one staff person but there should be two staff. The resident's ADL self-care performance care plan initiated 10/14/22 with revision on 5/03/23 indicated Transfers were via mechanical lift with two persons assist. The facility's policy Resident Transfer: Mechanical Lift revised on 8/29/2017 read, A mechanical lift is used to safely facilitate transfers of residents whose functional ability .requires use of a lift. Mechanical lifts requires a 2- person assist.

Based on interview and record review, the facility failed to meet the requirements for discharge prior to issuing a discharge notice for 1 of 3 resident reviewed for discharge (#1). Findings: Resident #1's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, atrial fibrillation, chronic obstructive pulmonary disease, and heart failure. The Minimum Data Set (MDS) quarterly assessment with the assessment reference date of 11/21/22 revealed resident #1 had a Medicare and Medicaid number. Resident #1 had a Brief Interview for Mental Status (BIMS) score of 12 out 15 which indicated she had moderate cognitive impairment. A 15 indicates an intact cognitive response. The assessment indicated Resident #1 required extensive to total assistance with Activities of Daily Living (ADLs) and did not plan to return to the community. Resident #1's electronic medical record (EMR) demographic information revealed her primary payer source was Medicaid pending. A discharge care plan, initiated 9/11/21 and revised 12/02/21, indicated Resident #1's discharge goal was long-term care. Review of the Order Summary Report, retrieved 2/02/23, did not reveal a physician's order for discharge, discharge planning, or referral to outside services for discharge. Resident #1's EMR did not reveal any progress notes regarding discharge. The record contained a Nursing Home Transfer and Discharge Notice dated 12/08/22. The document stated the reason for discharge or transfer read, Your bill for services at this facility has not been paid after reasonable and appropriate notice to pay. The notice was signed by the Social Services Director (SSD). In a phone interview on 2/02/23 at 12:09 PM, Resident #1's sister and Durable Power of Attorney (DPOA) confirmed she received a Nursing Home Transfer and Discharge Notice from the facility. She stated she was working with an attorney to get Medicaid approval for Resident #1 but the application was still pending. On 2/02/23 at 11:45 AM, the Social Services Director recalled Resident #1 was issued a Nursing Home Transfer and Discharge Notice for non-payment. She explained an appeal was filed and the resident remained in the facility. On 2/02/23 at 12:25 PM, the Business Office Manager (BOM) stated the Medicaid process for Resident #1 started in November 2021. She explained Resident #1's attorney filed the Medicaid application. She recalled the original application was denied due to lack of documents to determine benefits. The BOM stated another application was filed in May 2022 by Resident #1's attorney which had not been approved. The BOM reviewed Residents #1's account and reported a past due balance of $50,000 since the Medicaid application had not been approved. She explained the past due balance was the reason the Nursing Home Transfer and Discharge Notice was issued. The BOM clarified Resident #1's sister was sending the estimated patient liability every month which is the amount a resident would owe if Medicaid was approved. On 2/02/23 at 3:07 PM, the Administrator stated he was aware a Nursing Home Transfer and Discharge Notice was issued to Resident #1. He clarified the SSD and BOM would have initiated the notice. He explained the facility attempted to work with Resident #1's sister to get Medicaid approval but she did not provide the documentation needed to submit a Medicaid application. The Administrator acknowledged he was aware Resident #1's sister was working with an attorney to apply for Medicaid. The Administrator could not recall Resident #1's primary payer at the time and was not aware if the facility had received any money toward resident #1's account. In a meeting with the Administrator, SSD and BOM on 2/02/23 at 3:15PM, the SSD acknowledged she signed the Nursing Home Transfer and Discharge Notice form. She explained she had a conversation with the BOM and Resident #1's sister regarding the notice. The SSD stated she reviewed the form with Resident #1's sister to be sure she understood the form and her right to appeal. The BOM re-iterated the original Medicaid application dated November 2021 was denied. She acknowledged Resident #1's sister paid privately for November 2021 through May 2022 when a new application was filed. At that time, Resident #1's primary payer was switched from private pay to Medicaid pending. The BOM confirmed Resident #1's sister has been sending the estimated patient liability since May 2022 to present. The Administrator was unable to state why a Nursing Home Transfer and Discharge Notice was issued to a Medicaid pending resident who was paying the estimated patient liability.

Based on observation, interview, and record review, the facility failed to ensure nursing staff had the appropriate competencies and skills to comprehend and implement the plan of care related to appropriate level of assistance required during bed mobility and bathing tasks to prevent a fall with fracture for 1 of 3 residents reviewed for falls (#1), and ensure the safety of 2 of 4 residents reviewed for activities of daily living (ADL) care (#2 & #3), of a total sample of 7 residents. After resident #1 fell from her bed, she experienced excruciating pain, extreme confusion, and disorientation. Resident #1 suffered significant decline in her physical health, and functional and cognitive status which ultimately led to admission to hospice services. Residents #2 and #3 were denied the appropriate level of staff assistance to promote safety during ADL care, which had the likelihood of causing them serious injuries, harm, or impairment. On 6/15/22 at approximately 10:55 AM, the facility failed to prevent resident #1, a physically impaired, vulnerable resident, from suffering a fall and fracture. The resident's plan of care indicated she required assistance from two staff members for bed mobility and bathing, but the assigned Certified Nursing Assistant (CNA) completed the tasks by herself. During a bed bath, the CNA positioned resident #1 onto her right side and began to apply lotion to her back. The resident's head and upper body rolled off the edge of the mattress and she landed face-first into a chair beside the bed. The CNA attempted to hold onto the resident's body to prevent a fall but was unable to do so as her gloves were slippery with lotion. Resident #1's lower body landed on the floor beside the bed before the CNA was able to run around the bed and catch her. The CNA lowered the resident's upper body from the chair to the floor to place her in alignment and then called for assistance. The facility's failure to ensure staff understood and implemented approaches in the plan of care to provide the appropriate level of staff assistance for bed mobility and bathing contributed to resident #1's fall and fracture and placed all dependent residents at risk for serious injury/impairment/death. This failure resulted in Immediate Jeopardy which began on 6/15/22 and was removed on 8/05/22. Findings: Cross reference F689 1. Review of the medical record revealed resident #1, a [AGE] year-old female, was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's Admission Record showed she was readmitted to the facility on [DATE] with a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident census revealed resident #1 was deemed appropriate for hospice services on 7/28/22. Review of the Minimum Data Set (MDS) Quarterly assessment with assessment reference date (ARD) of 6/06/22 revealed resident #1 required extensive assistance of two or more staff to provide weight-bearing support during bed mobility and she was totally dependent on one staff person for bathing support. Review of resident #1's medical record revealed a care plan for ADL self-care performance related to functional deficits was initiated on 8/16/19. The goal was the resident would maintain her current level of function. Care plan interventions revealed instructions for nursing staff to provide two-person assistance for bed mobility and one-person assistance for bathing. A care plan for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .safety measures that need to be taken in order to reduce risk of falls. The CNA care plan or Kardex dated 6/15/22 reflected ADL interventions on the nursing care plan that specified resident #1 required assistance from two persons for bed mobility, and assistance from one staff for bathing. Review of an Occurrence Note dated 6/15/22 at 3:08 PM revealed a CNA reported to a Registered Nurse (RN) that resident #1 was on the floor. The note read, CNA reports to this RN resident rolled off the bed during bed bath. On 8/03/22 at 11:53 AM and 8/04/22 at 7:52 AM, in telephone interviews, CNA A confirmed she was assigned to care for resident #1 on the day she fell from her bed. She did not remember the Kardex instructions for ADL care tasks at that time, but said, I was working with her alone. She described resident #1 as being on the heavy side and stated the bed did not have side rails. CNA A explained while she gave the resident a bed bath, she rolled and positioned her to wash the front, back and sides of her body. She stated she positioned the resident onto her right side and began to apply lotion to her back. CNA A recalled resident #1 started to roll and her head and shoulders went over the edge of the mattress and stopped on the seat of the chair beside the bed. She stated she tried to hold onto the resident's body, but her gloves were slippery, and she was not able to prevent her from falling. CNA A explained she ran around the foot of the bed and noted resident #1's lower body on the floor and her head remained in the chair in an awkward position. She stated she lowered the resident's upper body to the floor to make her more comfortable, left her on her back, then ran to alert the nurse. CNA A acknowledged after the resident fell , the DON told her the resident needed assistance from two people for bed mobility. CNA A explained before the incident, she was not aware the term bed mobility included rolling the resident from side to side during her bath. She stated she had worked at the facility for over six months, and always thought bed mobility referred to how many CNAs were required to pull a resident up in bed. CNA A stated if the Kardex directed bathing with assistance from one person, she used to believe everything during the bath could be done by one CNA. On 8/03/22 at 3:07 PM, resident #1's fall incident was reviewed with the facility's Administrator and Director of Nursing (DON). The DON validated the resident's MDS assessment noted she required assistance from one person for bathing and two people for bed mobility. She acknowledged CNA A did not have assistance from another staff member when she turned and positioned resident #1 during the bed bath. The Administrator confirmed there was only one CNA in the room at the time the resident fell . The DON stated the facility educated all CNAs after resident #1's fall regarding the importance of following the instructions on the Kardex, and the definitions of bed mobility and bathing. However, the DON acknowledged the facility did not educate licensed nurses although they provided and/or assisted with resident care. She confirmed floor nurses supervised CNAs and should be knowledgeable of and able to clarify required levels of assistance associated with ADL care and provide definitions of bed mobility and bathing for CNAs. 2. Review of resident #2's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Admission assessment with ARD of 7/18/22 revealed resident #2 required extensive assistance of two or more persons for bed mobility. Review of the resident's care plan for ADL self-care performance deficit, initiated on 7/11/22, included instruction for CNAs to perform bed mobility with two persons. The CNA Kardex reflected the nursing care plan and read, BED MOBILITY: 2 person assist. On 8/04/22 at 10:39 AM, CNA C was at resident #2's bedside. She held a plastic bag with soiled and wet linen and said, I just finished morning care. CNA C stated she completed all ADL care by herself as the resident required only one person for assistance with bathing and bed mobility. She confirmed she recently received education on following the Kardex, and said, Earlier this morning I got a reminder. On 8/04/22 at 11:01 AM, CNA C demonstrated how to view the electronic Kardex and validated the instructions noted resident #1 needed two persons to perform bed mobility. CNA C was asked to explain why she chose to disregard the Kardex instructions. She said, It says two persons but I feel that she is good at being mobile. That means how she rolls in the bed. She looks like she is getting better. I usually do one person with her. The therapist people think that she is doing pretty good too. 3. Review of resident #3's medical record revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Admission assessment with ARD of 6/24/22 revealed resident #3 required extensive assistance of two or more persons for bed mobility, dressing, toilet use, and personal hygiene. The document indicated she was totally dependent on two or more staff for bathing. Review of the resident's care plan for ADL self-care performance deficit, initiated on 6/19/22, included instructions for CNAs to perform bathing, bed mobility, dressing and toileting with two persons. The care plan intervention for personal hygiene, created on 6/19/22, did not reflect the MDS assessment finding that the resident needed assistance from two persons for this task. The CNA Kardex reflected the nursing care plan and directed two CNAs to perform bathing, bed mobility and dressing tasks for resident #3. On 8/04/22 at 10:32 AM, resident #3 was in bed while CNA B filled a basin with water to give her a bed bath. CNA B explained only one staff member was required to bathe and position the resident and described herself as very experienced. She said, I roll her and turn by myself. On 8/04/22 at 11:04 AM, during review of resident #3's electronic Kardex with CNA B, she verified the instructions indicated the resident required assistance of two CNAs for bathing, bed mobility, and dressing. CNA B confirmed she performed those tasks without any assistance. She stated she knew she was supposed to have another CNA to assist with the resident but reiterated she was experienced and could easily manage resident #3 by herself. On 8/04/22 at 11:08 AM, the East Unit Registered Nurse (RN) Unit Manager (UM) was informed observations of and interviews with CNAs B and C revealed they did not provide ADL care for residents #3 and #2 respectively, according to the levels of assistance documented in the plans of care. The East Unit RN UM stated CNAs were expected to follow instructions on residents' Kardexes and not proceed with care until the required number of staff was present. She explained the interdisciplinary team (IDT) determined the level of assistance a resident needed for each ADL task. She stated CNAs should report any changes in ADL status to a nurse or supervisor, but they were not permitted to make changes or act outside of the plan of care as that required a licensed staff member such as a nurse or therapist. On 8/04/22 at 10:47 AM, RN D stated she worked in the facility through a staffing agency, and confirmed her responsibilities included supervising and assisting CNAs with resident care. She acknowledged residents #2 and #3 were on her assignment and she was asked how she would identify the levels of assistance both residents required with ADL care, particularly bed mobility and bathing tasks. After several minutes of searching through the electronic medical record, RN D was unable to find a nursing care plan for ADL care. On 8/04/22 at 12:00 PM, the DON stated after resident #1 fell from her bed during ADL care, the facility educated all CNAs on the importance of following Kardex instructions and the written plan of care. The DON did not respond when asked if residents continued to be at risk for falls during bed mobility and bathing tasks as CNAs ignored the plan of care. She expressed surprise that RN D did not know how to find a Kardex, and that CNAs B and C did not follow the plan of care as written in the Kardexes for residents #2 and #3. The DON and Administrator were informed despite the facility's attempts to educate staff, there were still current concerns regarding residents' safety during ADL care. Review of the facility's job description for Certified Nursing Assistant updated on 11/27/17, revealed a CNA provided personal care and services including assistance with ADLs. The document indicated CNAs would adhere to professional standards and facility policies and procedures. The facility's job description for Director of Nursing updated on 11/27/17, revealed the DON would ensure quality care that is consistent with company and regulatory standards. The document indicated the DON would ensure nursing staff provided appropriate resident care. The DON's essential duties and responsibilities included providing orientation and training to maintain sufficient and qualified staff and ensuring staff performance met or exceeded expectations. Review of the Facility Assessment Tool dated 5/23/22 revealed the facility offered general care and services such as ADL care and mobility and fall or fall with injury prevention. The document indicated facility staff would provide competent, person-centered care including identification of risks and hazards for residents. The assessment detailed education and competencies for CNAs including education on the importance of resident safety and provides care consistent with the residents' care plans. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On 6/15/22, the APRN was notified of resident #1's fall and gave orders for x-rays and routine Tylenol for two days. The East Unit RN UM completed a pain evaluation and resident #1's representative was notified of her mother's fall and pending orders. *On 6/15/22 at 12:20 PM, the Administrator and DON started immediate re-education of CNAs with emphasis on following Kardex instructions, notifying the UM or DON on changes in resident status that might affect accuracy of the Kardex, using two persons to perform any task that specifies two-person assist, and CNAs rolling residents towards themselves when providing care, whether assistance from one or two persons is required. 100% staff education was achieved on 6/21/22. *On 6/15/22, staff reviewed the Kardexes of all 88 residents in the facility. Thirty of 88 were updated to ensure accuracy. *On 6/15/22, the facility held an Ad Hoc Quality Assurance and Performance Improvement (QAPI) committee meeting to review and confirm there was sufficient staffing to meet residents' needs. *On 6/16/22, the APRN assessed the resident and gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . *On 6/16/22, the facility held another Ad Hoc QAPI meeting to identify additional opportunities. The committee reviewed investigative findings and performed a reenactment of the incident. The team determined the root cause of resident #1's fall was her impromptu movement. *On 6/21/22, the facility initiated retention questions related to education provided. 100% CNAs completed the retention questions on 7/19/22. *On 6/22/22, the facility initiated weekly, random audits of five residents' Kardexes to validate fall interventions are in place, to be completed by the DON or designee. *On 8/04/22, the Administrator and DON initiated re-education of all staff on reviewing each resident's Kardex at the start of the shift and providing care according to instructions on the Kardex. Achieved 96% compliance so far. *On 8/04/22, the facility initiated education for all agency staff prior to first worked shift regarding following Kardex instructions for ADL care. PRN (as needed) staff must receive education prior to next worked shift *On 8/04/22, the facility updated the new hire orientation packet to include education on Kardex instructions with a post-test to validate retention. *On 8/05/22, the facility re-interviewed CNA A and determined she did not follow resident #1's plan of care for bed mobility. *On 8/05/22, the facility held another Ad Hoc QAPI meeting to review new investigative findings and update the previous root cause analysis. Review of in-service attendance sheets revealed staff signatures to reflect participation in education and post-tests on reviewing the Kardex and implementing interventions according to the plan of care. From 8/04/22 to 8/05/22, interviews were conducted with 17 staff members who represented all shifts. 16 of 17 staff, including 11 CNAs, 4 Licensed Practical Nurses, and 1 RN were able to verbalize knowledge and understanding of the education provided. The resident sample was expanded to include 2 additional residents at risk for falls and 4 residents who were dependent on staff for ADL care. Observations, interviews, and record review revealed no concerns for residents #4, #5, #6, and #7.

Based on observation, interview, and record review, the facility failed to provide the appropriate level of assistance during bed mobility and bathing tasks to prevent a fall and left [CONDITION(S)] for 1 of 3 residents reviewed for falls (#1) and failed to implement the plan of care regarding activities of daily living (ADLs) to ensure the safety of 2 of 4 residents reviewed for ADL care (#2 & #3), of a total sample of 7 residents. After resident #1 fell from her bed, she experienced excruciating pain, extreme confusion, and disorientation. Resident #1 suffered significant decline in her physical health, and functional and cognitive status which ultimately led to admission to hospice services. Residents #2 and #3 were denied the appropriate level of staff assistance to promote safety during ADL care, which had the likelihood of causing them serious injuries, harm, or impairment. On [DATE] at approximately 10:55 AM, the facility failed to prevent resident #1, a physically impaired, vulnerable resident, from suffering a fall and fracture. The resident's plan of care indicated she required assistance from two staff members for bed mobility and bathing, but the assigned Certified Nursing Assistant (CNA) completed the tasks by herself. During a bed bath, the CNA positioned resident #1 onto her right side and began to apply lotion to her back. The resident's head and upper body rolled off the edge of the mattress and she landed face-first into a chair beside the bed. The CNA attempted to hold onto the resident's body to prevent a fall but was unable to do so as her gloves were slippery with lotion. Resident #1's lower body landed on the floor beside the bed before the CNA was able to run around the bed and catch her. The CNA lowered the resident's upper body from the chair to the floor to place her in alignment and then called for assistance. The facility's failure to adhere to the plan of care and provide the appropriate level of staff assistance for bed mobility and bathing contributed to resident #1's fall and fracture and placed all dependent residents at risk for serious injury/impairment/death. This failure resulted in Immediate Jeopardy which began on [DATE] and was removed on [DATE]. Findings: Cross reference F726. 1. Review of the medical record revealed resident #1, a [AGE] year-old female, was admitted to the facility on [DATE]. Her diagnoses included dementia with behavioral disturbance, age-related [CONDITION(S)], [CONDITION(S)], generalized [CONDITION(S)], chronic pain syndrome, and anxiety disorder. The resident's Admission Record showed she was readmitted to the facility on [DATE] with a new diagnosis of left [CONDITION(S)] which occurred during her stay in the facility. The resident census revealed resident #1 was deemed appropriate for hospice services on [DATE]. Review of the Minimum Data Set (MDS) Quarterly assessment with assessment reference date (ARD) of [DATE] revealed resident #1 was usually able to express her ideas and wants and comprehend most conversation. The resident's Brief Interview for Mental Status (BIMS) score was 10, which indicated she had moderately impaired cognition. The MDS assessment showed resident #1 had no behavioral symptoms and did not reject evaluation or care necessary to achieve her goals for health and well-being. The document revealed the resident required extensive assistance of two or more people to provide weight-bearing support during bed mobility and she was totally dependent on one person for bathing support. Resident #1 was always incontinent of bladder and bowel, did not receive either scheduled or as needed pain medication, and had no falls since admission or the prior assessment. She was 5 feet 5 inches tall and weighed 177 pounds. Review of resident #1's medical record revealed a care plan for ADL self-care performance related to functional deficits was initiated on [DATE]. The goal was the resident would maintain her current level of function. Care plan interventions revealed instructions for nursing staff to provide two-person assistance for bed mobility and one-person assistance for bathing. A care plan for diagnosis of [CONDITION(S)], initiated on [DATE] directed staff to monitor the resident for risk of falls and provide education on .safety measures that need to be taken in order to reduce risk of falls. The CNA care plan or Kardex dated [DATE] reflected ADL interventions on the nursing care plan. The document specified resident #1 required assistance from two persons for bed mobility task, and assistance from one staff for bathing. The Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1 dated [DATE], revealed bed mobility was defined as how a resident moved to and from a lying position, turned from side or side, and positioned his or her body while in bed. The manual defined bathing as how a resident took a full body bath or sponge bath. Review of an Occurrence Note dated [DATE] at 3:08 PM revealed a CNA reported to a Registered Nurse (RN) that resident #1 was on the floor. The note read, CNA reports to this RN resident rolled off the bed during bed bath. The nurse documented resident #1 complained of right hip pain and had skin tears on her left elbow, left forearm and right anterior elbow above the right forearm. The note indicated the nurse received a physician order for stat or priority x-rays. A nursing progress note dated [DATE] at 8:00 PM revealed x-ray still had not been done. A Health Status note dated [DATE] at 10:36 AM revealed an Advanced Practice Registered Nurse (APRN) assessed resident #1 and gave orders to send her to the hospital for orthopedic evaluation and treatment. Review of resident #1's hospital record included a History of Present Illness dated [DATE] which noted the resident had tenderness on palpation of her externally rotated left hip. The document indicated x-rays showed a mildly displaced intertrochanteric fracture of the left hip. Review of an Orthopedic Consult Note dated [DATE] at 4:19 PM, revealed during examination, resident #1 experienced pain with range of motion evaluation and swelling of her left hip and thigh. The orthopedic surgeon noted, Left Hip XRAYS show impacted intertrochanteric [CONDITION(S)]. The document revealed after discussion of the risks and benefits of surgery with resident #1's daughter, the decision was made to proceed with surgery. A Neurology Consultation Note dated [DATE] at 7:50 PM, revealed a hospital neurologist was consulted for resident #1's unexplained lethargy post-surgery. The assessment showed the resident kept her eyes closed and did not answer questions or follow directions. The neurologist noted resident #1's left arm was contracted, she did not move her lower extremities and moaned when her legs were moved. The hospital Brief Discharge Note dated [DATE] at 12:06 PM revealed resident #1 suffered post-surgical complications including a drop in hemoglobin that required blood transfusion, and significant [CONDITION(S)] with [CONDITION(S)]. The document indicated resident #1 would be discharged from the hospital back to the facility and noted if she continued to have worsening mental status and poor food and fluid intake, hospice services could be appropriate. [CONDITION(S)] is damage or disease that affects the brain and can cause altered mental status or confusion (retrieved on [DATE] from www.webmd.com). On [DATE] at 11:53 AM and [DATE] at 7:52 AM, in telephone interviews, CNA A confirmed she was assigned to care for resident #1 on the day she fell from her bed. She did not remember the Kardex instructions for ADL care tasks at that time, but said, I was working with her alone. She described resident #1 as being on the heavy side and stated the bed did not have side rails. CNA A explained while she gave the resident a bed bath, she rolled and positioned her to wash the front, back and sides of her body. She stated she positioned the resident onto her right side and began to apply lotion to her back. CNA A recalled resident #1 started to roll and her head and shoulders went over the edge of the mattress and stopped on the seat of the chair beside the bed. She stated she tried to hold onto the resident's body, but her gloves were slippery, and she was not able to prevent her from falling. CNA A explained she ran around the foot of the bed and noted resident #1's lower body on the floor and her head remained in the chair in an awkward position. She stated she lowered the resident's upper body to the floor to make her more comfortable, left her on her back, then ran to alert the nurse. CNA A stated resident #1 was alert, able to feed herself, had a good appetite and conversed with staff, especially regarding her daughter, prior to the fall. CNA A stated since re-admission after her fall, resident #1 had declined as she now rarely spoke or accepted food and no longer fed herself. CNA A said, Miss [name of resident] just lies there in bed. On [DATE] at 3:07 PM, resident #1's fall incident was reviewed with the facility's Administrator and Director of Nursing (DON). The DON validated the resident's MDS assessment noted she required assistance from one person for bathing and two people for bed mobility. She acknowledged CNA A did not have assistance from another staff member when she turned and positioned resident #1 during the bed bath. The DON was asked if the resident's fall could have been prevented if two staff had properly positioned and aligned her in the center of the bed. She explained it was not possible to say there would have been a different outcome if two staff members were present. The DON stated the facility's investigation determined the root cause of the fall was the resident made an impromptu movement. The Administrator confirmed there was only one CNA in the room at the time the resident fell . However, she explained the interdisciplinary team felt the resident fell after she was already positioned and stationary, so the fall was not related to the bed mobility task. On [DATE] at 1:59 PM, the Director of Rehab stated resident #1 was screened on a quarterly basis by each therapy discipline. She stated screenings done in 2022 prior to the resident's fall and fracture showed the resident was at baseline, and had not experienced any decline or improvement in status. The Physical Therapist (PT) stated he was familiar with resident #1's abilities and explained she could not roll herself in the bed neither prior to nor after the fall. The Occupational Therapist (OT) stated resident #1 was on her caseload prior to the fall and she had progressed to feeding herself with set up assistance from staff. The OT explained on return from the hospital post-fall, resident #1 could not feed herself and showed no interest in food. She said, She does not want to eat at all since the fall. She was discharged [from OT services] because she did not participate. The Certified Occupational Therapy Assistant (COTA) stated prior to her fall, resident #1's bed mobility status was she had to be rolled from side to side by staff. When the PT, OT, and COTA were asked if resident #1 would have been able to move her upper body towards the edge of the mattress during a bed bath, they all responded in unison that she would not have been able to move herself without staff assistance. On [DATE] at 3:38 PM, the Lead MDS Coordinator reviewed resident #1's ADL care plan and confirmed the document showed the intervention related to bed mobility with assistance of two persons was initiated on [DATE] and revised on [DATE] and [DATE]. She explained the bed mobility intervention remained unchanged throughout care plan reviews and revisions, and accurately reflected the level of assistance required by resident #1 for this task in [DATE], at the time of the fall. The Lead MDS Coordinator stated the intervention for assistance with bathing, created on [DATE], indicated resident #1 initially required assistance of two persons for this task and revisions on [DATE] and [DATE] showed the intervention remained the same. She explained the level of assistance required for bathing was decreased from two persons to one person in a care plan revision on [DATE], although the resident still required assistance from two persons for bed mobility. The MDS Coordinator stated she added the new intervention to reflect the findings of the MDS Quarterly assessment with ARD of [DATE] which indicated resident #1 was totally dependent on only one staff member for bathing. She could not explain how it was determined resident #1 required less assistance from staff with bathing. The Lead MDS Coordinator acknowledged in addition to reviewing CNAs' documentation, MDS staff were expected to review progress notes and assessments, and interview licensed clinicians regarding any changes in resident status prior to altering the plan of care. She was not able to provide any therapy or nursing documentation to show resident #1 had improved in self-performance for the bathing task to make assistance of one person an appropriate intervention. On [DATE] at 1:32 PM and [DATE] at 1:47 PM, in telephone interviews, resident #1's daughter confirmed on [DATE] she was informed her mother fell . She said, I was told she rolled out of the CNAs' hands when they were giving her a bath. The daughter stated the facility never informed her that prior to the fall, her mother had been rolled and positioned in bed by only one CNA instead of two as required in the plan of care. Resident #1's daughter expressed concern that her mother was not transferred to the hospital for 24 hours after the fall, and then had to wait another day for surgery. She stated when her mother got to the hospital she was very combative, disoriented and continuously pulled at everything placed on her. She said, She was definitely in pain, not crying all the time, but if you touched that area or had to move her for anything she would wail out. Resident #1's daughter stated the surgeon described her mother's options as a catch 22 when he explained her mother could have negative side effects from surgery related to anesthesia, but the alternative was she would have to live with pain. The daughter stated she selected surgical repair of the [CONDITION(S)]. She stated her mother suffered a major decline after the fall and hip surgery. She explained when the facility's Social Services Director (SSD) contacted her approximately two weeks ago regarding her mother's decline, she gave her permission to arrange hospice services. The daughter described her mother's hands as scrunched up and stated she no longer even tried to feed herself. She recalled in the past, her mother would sit up and speak to her, but when she last visited a few days ago, her mother did not recognize her and during the 45-minute visit, nursing staff repeatedly tried to arouse her. Resident #1's daughter said, She would open her eyes and said a few words, but I don't think she really knew I was there. I had to keep moving her to get a response. On [DATE] at 2:13 PM, the SSD confirmed she contacted resident #1's daughter and offered hospice services as a resource since her mother had experienced a significant change in status. The SSD described resident #1 as not thriving and explained she was not eating or participating in her care. The SSD stated she did not believe resident #1 had experienced a decline in her quality of life and felt her demeanor was unchanged. She explained she could not speak on clinical decline, but acknowledged that anesthesia and surgery could have a negative impact on residents. On [DATE] at 3:08 PM, in a telephone interview and on [DATE] at 4:18 PM, during an in-person interview, the hospice RN stated she conducted resident #1's initial assessment on [DATE]. She stated the resident was bedbound, oriented to person only, quiet, withdrawn, and in the early phase of the dying process. The hospice RN stated she contacted the resident's daughter to obtain additional information and learned the resident had become more confused and withdrawn since she fractured her hip in [DATE]. The hospice RN stated during discussion of resident #1's plan of care with the hospice team, the hospice physician informed her the resident's death had to be reported to the Medical Examiner if she died within three months of admission to hospice services, before the end of [DATE]. The hospice RN explained this action was required as resident #1 fell , fractured and declined and the Medical Examiner would need to determine the cause of her death. 2. Review of resident #2's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included a brain bleed, [CONDITION(S)], and [CONDITION(S)]. The MDS admission assessment with ARD of [DATE] revealed resident #2 required extensive assistance of two or more persons for bed mobility. Review of the resident's care plan for ADL self-care performance deficit, initiated on [DATE], included the instruction for CNAs to perform bed mobility with two persons. The CNA Kardex reflected the nursing care plan and read, BED MOBILITY: 2 person assist. On [DATE] at 10:39 AM, CNA C was at resident #2's bedside. She held a plastic bag with soiled and wet linen and said, I just finished morning care. CNA C explained she completed all ADL care by herself as the resident required only one person for assistance with bathing and bed mobility. On [DATE] at 11:01 AM, CNA C stated she usually cared for resident #1 without assistance. She demonstrated how to view the electronic Kardex and validated the instructions noted resident #1 needed two persons to perform bed mobility. 3. Review of resident #3's medical record revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included dementia, generalized muscle weakness, and altered mental status. The MDS Admission assessment with ARD of [DATE] revealed resident #3 required extensive assistance of two or more persons for bed mobility, dressing, toilet use, and personal hygiene. The document indicated she was totally dependent on two or more staff for bathing. Review of the resident's care plan for ADL self-care performance deficit, initiated on [DATE], included the instructions for CNAs to perform bathing, bed mobility, dressing and toileting with two persons. The care plan intervention for personal hygiene, created on [DATE], did not reflect the MDS assessment finding that the resident needed assistance from two persons for this task. The CNA Kardex reflected the nursing care plan and directed two CNAs to perform bathing, bed mobility and dressing tasks for resident #3. On [DATE] at 10:32 AM, resident #3 was in bed while CNA B filled a basin with water to give her a bed bath. CNA B explained only one staff member was required and described herself as very experienced. She said, I roll her and turn by myself. On [DATE] at 11:04 AM, during review of resident #3's electronic Kardex with CNA B, she verified the instructions indicated the resident required assistance of two CNAs for bathing, bed mobility, and dressing. CNA B confirmed she performed those tasks without any assistance. She reiterated she was experienced and could easily manage resident #3 by herself. On [DATE] at 11:08 AM, the East Unit RN Unit Manger (UM) was informed observations of and interviews with CNAs B and C revealed they did not provide ADL care for residents #3 and #2 according to the levels of assistance documented in the plans of care. The East Unit RN UM stated CNAs were expected to follow instructions on residents' Kardexes and not proceed with care until the required number of staff was present. She explained the interdisciplinary team (IDT) determined the level of assistance a resident needed for each ADL task. She stated CNAs should report any changes in ADL status to a nurse or supervisor, but they were not permitted to make changes or act outside of the plan of care as that required a licensed staff member such as a nurse or therapist. On [DATE] at 12:00 PM, the DON stated after resident #1 fell from her bed during ADL care, the facility educated all CNAs on the importance of following Kardex instructions and the written plan of care. The DON did not respond when asked if residents continued to be at risk for falls during bed mobility and bathing tasks as CNAs ignored the plan of care. Review of the facility's job description for Certified Nursing Assistant updated on [DATE], revealed a CNA provided personal care and services including assistance with ADLs. The document indicated CNAs would adhere to professional standards and facility policies and procedures. The facility's job description for Director of Nursing updated on [DATE], revealed the DON was responsible for the overall direction, coordination and evaluation of nursing care and services provided to residents. The document indicated the DON would ensure nursing staff provided appropriate resident care. The DON's essential duties and responsibilities included schedules and performs resident patient rounds to monitor and evaluate the quality and appropriateness of nursing care. Review of the Facility Assessment Tool dated [DATE] revealed the facility offered general care and services such as ADL care and mobility and fall or fall with injury prevention. The document indicated facility staff would provide competent, person-centered care including identification of risks and hazards for residents. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On [DATE], the APRN was notified of resident #1's fall and gave orders for x-rays and routine Tylenol for two days. The East Unit RN UM completed a pain evaluation and resident #1's representative was notified of her mother's fall and pending orders. *On [DATE] at 12:20 PM, the Administrator and DON started immediate re-education of CNAs with emphasis on following Kardex instructions, notifying the UM or DON on changes in resident status that might affect accuracy of the Kardex, using two persons to perform any task that specifies two-person assist, and CNAs rolling residents towards themselves when providing care, whether assistance from one or two persons is required. 100% staff education was achieved on [DATE]. *On [DATE], staff reviewed the Kardexes of all 88 residents in the facility. Thirty of 88 were updated to ensure accuracy. *On [DATE], the facility held an Ad Hoc Quality Assurance and Performance Improvement (QAPI) committee meeting to review and confirmed there was sufficient staffing to meet residents' needs. *On [DATE], the APRN assessed the resident and gave an order for her to be transferred to the hospital. *On [DATE], the facility held another Ad Hoc QAPI meeting to identify additional opportunities. The committee reviewed investigative findings and performed a reenactment of the incident. The team determined the root cause of resident #1's fall was her impromptu movement. *On [DATE], the facility initiated retention questions related to education provided. 100% CNAs completed the retention questions on [DATE]. *On [DATE], the facility initiated weekly, random audits of five residents' Kardexes to validate fall interventions are in place, to be completed by the DON or designee. *On [DATE], the Administrator and DON initiated re-education of all staff on reviewing each resident's Kardex at the start of the shift and providing care according to instructions on the Kardex. Achieved 96% compliance at this time. *On [DATE], the facility re-interviewed CNA A and determined she did not follow resident #1's plan of care for bed mobility. *On [DATE], the facility held another Ad Hoc QAPI meeting to review new investigative findings and update the previous root cause analysis. Review of in-service attendance sheets revealed staff signatures to reflect participation in education and post-tests on reviewing the Kardex and implementing interventions according to the plan of care. From [DATE] to [DATE], interviews were conducted with 17 staff members who represented all shifts. 16 of 17 staff, including 11 CNAs, 4 Licensed Practical Nurses, and 1 RN were able to verbalize knowledge and understanding of the education provided. The resident sample was expanded to include 2 additional residents at risk for falls and 4 residents who were dependent on staff for ADL care. Observations, interviews, and record review revealed no concerns for residents #4, #5, #6, and #7.

Based on observation, interview and record review, the facility failed to ensure respiratory therapy was provided as per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: 1. Review of resident #23's medical record revealed he was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/12/21 at 10:30 AM, resident #23 was observed in his room sitting up in bed. He was alert and oriented to person, place, and time. He received oxygen via nasal cannula (NC) attached to a portable oxygen concentrator set at 4.25 liters per minute (LPM). He said, he used oxygen because his breathing was not good. The resident had a care plan dated 9/5/20 for impaired gas exchange/ineffective airway clearance related to history of [CONDITION(S)] exacerbation, shortness of breath and wheezing at times with intervention to provide oxygen via nasal cannula per physician orders. On 7/12/21 at 10:40 AM, the resident's assigned Registered Nurse (RN) B checked the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN B said she had already given the resident's morning medications but had not observed the oxygen concentrator's flow rate. On 7/12/21 at 10:43 AM, the East Wing Unit Manager (UM) entered resident #23's room and checked the setting on the oxygen concentrator. She said it was set at 4.25 LPM and the resident was not getting oxygen as ordered. The UM then adjusted the rate to 2 LPM and asked the resident if he had adjusted his settings. He denied changing the settings. The UM said the assigned nurse should have checked the oxygen settings when she gave his morning medications. On 7/12/21 at 1:15 PM, the Director of Nursing (DON) said the expectation was that nurses check the oxygen setting every time they entered a resident's room. She explained that a resident with [CONDITION(S)] could become more short of breath if given too much oxygen. 2. Review of resident 136's medical record revealed she was admitted to the facility from an acute care hospital on 7/2/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Agency for Health Care Administration (AHCA) Transfer Form 5000-3008 from the hospital dated 7/2/21 noted Oxygen at 2 LPM continuous via NC. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/13/21 at 9:45 AM, resident #136 was in her room lying in bed. She was alert and oriented to person and place. The resident had oxygen via concentrator with the flow rate set at 1.5 LPM. On 7/13/21 at 2:32 PM, the East Wing UM entered resident #136's room and checked the oxygen setting. She said there was something wrong with the concentrator as the ball on the flow rate was moving up and down. She was informed the rate was at 1.5 LPM, the same as observed earlier. The UM acknowledged the resident did not receive oxygen as ordered a 2 LPM. On 7/13/21 at 2:43 PM, the resident's assigned nurse, RN A said he had checked resident #136's oxygen flow rate earlier today while he was standing near the concentrator. He said it was between 3-4 LPM. LPN A said he did not know the order was for 2 LPM. On 7/13/21 at 2:43 PM, the East Wing UM said nurses should be looking at the oxygen concentrator settings at eye level and not from standing position. Review of the policy dated 5/22/18 and titled, Oxygen Administration read, The purpose of this procedure. A resident will need oxygen therapy when hypoxemia (low oxygen in blood) occurs The resident's disease, physical condition, and age will help determine the most appropriate method of administration. A licensed nurse or a respiratory care practitioner performs this procedure Check physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observation, interview, and record review, the facility failed to provide intravenous (IV) care and services according to standards of practice and plan of care for 1 of 1 resident reviewed for IV care of a total sample of 40 residents, (#66). Findings: Resident #66 was admitted to the facility on [DATE] from an acute care hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a Peripherally Inserted Central Catheter (PICC) line present in his left arm for antibiotics upon admission to the facility. A PICC line is a long, thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart A PICC line gives your doctor access to the large central veins near the heart. It's generally used to give medications A PICC line requires careful care and monitoring for complications, including infection and blood clots (https://www.mayoclinic.org). On 7/12/21 at 12:10 PM, resident #66 was observed lying in bed. He had a PICC line in his right upper arm covered with a dressing dated 7/3. The PICC line was covered with a clear dressing and the tape around the dressing was gray and dirty. The resident said he was getting IV antibiotics by the PICC line for infection in his right knee. He added that the nurses had not changed the PICC line dressing since 7/3, 9 days ago. He said he wanted the dressing changed and had not refused any care to the PICC line. A review of the resident's care plan initiated on 6/15/21 for IV Therapy included interventions to Observe PICC site for signs and symptoms of infection/infiltration, monitor IV line for patency, flush as ordered and prn (as needed) and dressing changes as ordered Review of the residents' Electronic Medical Record (EMR) revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Another order dated 7/1/21 read, measure arm circumference at site every week with dressing change and every shift every 7 days. An additional order dated 7/1/21 read, Change PICC line dressing every week (transparent dressing) every evening shift on Thursday. A review of the Medication/Treatment Administration Records and EMR showed no documentation the resident's PICC line dressing was changed on 7/3 as noted on the dressing. The EMR noted the last time the PICC line dressing was changed was 7/1/21 which did not match the date on the dressing. On 7/12/21 at 12:20 PM, the resident's assigned Registered Nurse (RN) C noted the resident's outdated and soiled IV dressing. RN C could not explain what the standard of practice was regarding the frequency of IV dressing changes and indicated she would need to check the facility policy. On 7/12/21 at 1:06 PM, the Director of Nursing (DON) said the standard of practice was to change transparent PICC line dressings at least every 7 days or more often if soiled. She did not explain why the resident's PICC line dressing had not been changed. She reviewed resident #66's medical record and noted there was no evidence that he refused his PICC line dressing change. The DON said if he refused, the nurses should have documented in the medical record and educated the resident regarding potential for complications such as [CONDITION(S)] (blood infection). The DON added, if the resident refused care the nurses on the following shifts should have attempted to provide the needed care. She explained the nurses should have looked at the IV site when doing the flushes and should have noticed that it was due to be changed from 7/10 to 7/11. On 7/13/21 at 3:39 PM, RN D said she worked on the 7-3 shift Saturday 7/10 and only documented that resident #66 refused his medication. RN D added that she knew his PICC line dressing was due to be changed and did not document his refusal of IV dressing change or education regarding potential for infection. She said she did not report the resident's IV dressing needed to be changed to the oncoming shift nurse. On 7/14/21 at 1:08 PM, RN B said she worked the day shift on 7/10 and 7/11 and was assigned to resident #66. RN B said she signed the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . She said the IV dressing looked soiled but the resident did not want the dressing changed at that time. She said she did not document doing any education with the resident of potential for infection if dressing was soiled and not changed. On 7/15/21 at 3:19 PM, RN E said he worked 7/10 and 7/11 on the 11:00 PM to 7:00 shift. He said he did not notice the date or that the IV dressing was dirty when he flushed the line as it was dark in the residents' room. He could not recall if the prior nurse had informed him the resident's IV dressing needed to be changed. He could not remember if the resident had declined prior attempts to change the dressing. He noted that PICC line dressing should be changed every 72 hours and as needed. Attempts were made to interview RN G and F who also provided care to the resident on 7/10 to 7/11 but the nurses did not return the calls. The facility's policy and procedure, Central Vascular Access Device (CVAD) revised May 1, 2016 read, Licensed nurses according to state law and facility policy. The nurse is responsible and accountable for obtaining and maintaining competence with infusion therapy CVADs include: Peripherally Inserted Central Catheter (PICC) The catheter insertion site is a potential entry site for bacteria that may cause a catheter-related infection. A transparent dressing is the preferred dressing Sterile dressing change using transparent dressing is performed: 24 hours post insertion or upon admission, at least weekly, if the integrity of the dressing has been compromised (wet, loose or soiled)

Based on interview and record review, the facility failed to maintain complete medical records that accurately reflected clinical status, changes in condition, and physicians' order for transfer for 1 of 4 sampled residents (#1). Findings: Resident #1 was admitted to the facility from the community on 1/31/20 with [DIAGNOSES REDACTED]. Resident #1's nurses' note, dated 8/22/20 at 2:46 PM, read, Nurse called to shower room to observe area to residents left great toe. Top of toe black .Call placed to MD (medical doctor) and MD ordered resident to be sent out to ER (emergency room ). On 8/31/20 at 2:15 PM and 9/01/20 at 8:07 AM, telephone interviews were conducted with resident #1's primary physician A. The physician was asked, did Unit Manager (UM) B requested her to check the resident's toe approximately 1 month ago? Physician A said, The first time that I heard about his toe was when I went to the facility to see him on 8/27/20 and he was not there. The facility staff said he was sent to the hospital because of his toe. Physician A stated in a second interview, They do call me all the time, however they never called me when he went out to the hospital, such an important thing how did it slip their mind. A review of resident #1 medical record did not show any evidence in the physician, nursing or therapy notes that the physician was ever notified regarding area of redness on resident #1's left great toe. The nurses' notes did not specify which physician was notified of transfer to the hospital on [DATE] and there was no physician order for [REDACTED].>On 9/01/20 at 1 PM, an interview was conducted with Licensed Practical Nurse C and the Director of Nursing (DON). The DON verified that she is the nurse who wrote the nurse's note dated 8/22/20 with time of 2:46 PM, regarding resident #1 going out to the hospital. The resident was assigned to LPN C who notified the physician of transfer. LPN C said that she spoke to the physician that was on call who was a female. However, she is not sure who she talked to and did not document the name of the physician she spoke to or write an order for [REDACTED]. A review of Occupational Therapist (OT) D's note dated 7/28/20 read, Patient educated on use on new non-skid socks during ambulation The OT's note did not include an observation regarding new redness of resident #1's left great toe. On 9/01/20 at 12:26 PM, OT D was questioned regarding resident #1 and her encounter with him on 7/28/20. She said that on this date she saw redness to the left great toe ventral side approximately the size of a nail head. She then got UM B to assess the toe. After looking at it, the UM indicated to her that she would follow up. The OT said, I should have included my observation of the resident's left great toe in the my documentation. The OT said she was only able to remember the date that she saw his toe because of the date on sock receipt. She had taken it upon herself to order special non-skid socks for him because the ones the facility provided kept sliding down his ankles. She had a note in the medical record which validated that she applied the socks on 7/28/20. On 9/01/20 at 12:48 PM, an interview was conducted with UM B and the DON. The UM was asked why she did not document the change in resident #1 skin condition. She said, The area was a pinpoint and blanchable redness. I don't even know whether it was the right or left toe. The OT asked me to look at his foot. The physician came in to look at his foot the next day and there was nothing there. The UM did not remember what day she or the physician looked at resident #1's foot. The UM then said, Had it been non-blanchable, I would have documented, but because it was blanchable and the doctor saw nothing is why I did not document it. The DON then stated, Someone should have documented something, either the nurse or the OT, describe it and what was done about it. Review of the Medical Record Management policy last revised 5/23/20 read, The facility must maintain medical records on each resident, in accordance with accepted professional standards and practice and state and federal law. Medical records must be complete, accurately documented The medical record must contain enough information to show that the facility knows the status of the resident

Based on observation, interview and record review, the facility failed to provide adequate care and services to identify, monitor, treat and promote healing for a change in skin condition related to pressure and non-pressure injuries, for 1 of 4 residents reviewed for pressure ulcers (#22), and failed to report abnormal labs values to the physician in a timely manner causing a delay in treatment for [REDACTED].#6) of a total sample of 36 residents. Findings: 1. Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) admission assessment dated [DATE], revealed resident #22 had clear speech, was able to express her ideas and had clear comprehension. Resident #22 had a Brief Interview for Mental Status (BIMS) score of 14 that indicated she had little to no cognitive impairment. The MDS assessment indicated resident #22 did not reject evaluation or care. She required extensive assistance for bed mobility, toilet use and personal hygiene, was totally dependent on staff for transfers and bathing, and used a wheelchair. Resident #22 was always incontinent of bowel and bladder. The MDS assessment revealed resident #22 was at risk for developing pressure ulcers, but did not have any ulcers, wounds or skin problems on admission to the facility. She received a daily diuretic or water pill which increases urine output, and was on hospice care. Resident #22 had a care plan for risk for impaired skin integrity, initiated on 10/17/19 and revised on 12/16/19. The interventions included keep skin clean and dry and treatments as ordered. A care plan for bowel and bladder incontinence, initiated on 10/23/19 had interventions to provide pericare as needed after incontinence episodes and monitor skin integrity. The certified nursing assistant (CNA) care plan or kardex had instructions to keep resident #22's skin clean and dry and provide pericare after incontinence episodes. On 12/16/19 at 1:37 PM, resident #22 was seated in her wheelchair in her room. She stated CNA L got her out of bed that morning, and told her she had to stay in the chair for a while because she was not going to go to the trouble of getting her up then putting her back to bed soon after. Resident #22 explained it required 2 staff members to transfer her out of and into bed with a mechanical lift. She stated she often remained in her wheelchair for 4 to 5 hours and did not receive incontinence care during that period. Resident #22 explained she had IBS which sometimes caused sudden or frequent bladder and bowel incontinence. She said, I have to wait until I get back into bed to be changed. When asked if she had any skin issues, resident #22 stated she recently complained about a painful area on her bottom. She explained facility staff did not pay attention for a few days, but the visiting hospice registered nurse (RN) listened to her and looked at it. Resident #22 stated the hospice RN discovered a pressure ulcer, measured it, and told her it was about 1 centimeter (cm) long. She said, It hurts to sit on it and explained she had to ask someone to provide a special cushion. Observation of the wheelchair revealed resident #22 was seated on a foam cushion. Resident #22 said, I was told (the dressing) should be changed when it was wet, but they don't even change it every day. I'm a retired nurse. They don't know what they're doing. In interviews on 12/16/19 at 2:08 PM and 12/18/19 at 9:57 AM, certified nursing assistant (CNA) L confirmed she provided personal hygiene and incontinence care for resident #22 before she got her out of bed at about 11:00 AM on 12/16/19. She acknowledged she did not provide incontinence care again or put resident #22 back to bed before she finished her shift at 3:00 PM that day. CNA L stated when she gave report to the on-coming evening shift CNA, resident #22 was still seated in her wheelchair in her room. She explained it was difficult to put resident #22 back to bed because the transfer required 2 people and it was sometimes hard to find another person to assist. On 12/17/19 at 10:55 AM, resident #22 was observed in bed. She stated she was still waiting for someone to get her cleaned up. A few minutes later at 11:03 AM, resident #22's assigned CNA was asked if she gave care to resident #22 since her arrival at 7:00 AM that morning. CNA M said, I haven't had a chance to do it yet. CNA M validated she was supposed to check and change her assigned residents every 2 hours. During observation of incontinence care on 12/17/19 at 11:08 AM, CNA M removed resident #22's disposable brief. The brief was saturated with urine, and a brown stained area covered the back half of the garment. Resident #22 had redness to both sides of her groin. There was a stained dressing dated 12/16/19 across both buttocks, and a dark red area was observed to the left of the dressing. Resident #22 had bright red skin noted on both inner buttocks and on the sacrum above the dressing. In addition, there was a small, uncovered open area, approximately 1 cm by 0.5 cm, on her coccyx that was surrounded by white macerated tissue. Maceration is defined as The softening and breaking down of skin resulting from prolonged exposure to moisture. (www.medical-dictionary.thefreedictionary.com) CNA M used 1 pre-moistened disposable wipe to clean resident #22's groin and outer labia, and another wipe to clean her buttocks around the dressing and the open area on the coccyx. CNA M did not use a skin cleanser nor a protective barrier cream before she applied a clean brief. She did not inform the nurse resident #22's dressing was soiled or that there was significant redness to her buttocks and an uncovered open area. During the procedure, resident #22 stated she was last changed by the CNA who worked on the night shift. Later that afternoon at 3:51 PM, CNA M was interviewed at the nurses' station with the West Wing unit manager (UM) and interim director of nursing (DON) present. CNA M confirmed she provided incontinence care only once during the 8-hour shift, at about 11:00 AM, and did not use a skin cleanser or barrier cream. In interviews on 12/17/19 at 1:42 PM and 12/18/19 at 1:09 PM, the hospice RN recalled on 12/11/19, resident #22 told her she had pain and discomfort on her bottom. The hospice RN stated she assessed the area and discovered a stage 2 pressure ulcer on resident #22's coccyx and an area of friction or shearing on her left buttock. The National Pressure Ulcer Advisory Panel (NPUAP) defines a pressure injury as . localized damage to the skin and underlying soft tissue usually over a bony prominence as a result of . intense and/or prolonged pressure A stage 2 pressure injury involves partial-thickness skin loss with a visible pink or red, moist wound bed. The hospice RN stated she informed the assigned facility nurse, licensed practical nurse (LPN) O, of her assessment findings and obtained an order from the physician for skin prep, a liquid film-forming dressing, to be applied around the wounds and to cover with a dry dressing. The hospice RN explained the skin prep should be applied to the peri-wound skin, not in the wound itself. She said, I would never order skin prep to an open area. She stated the dressing was to be changed every 2 to 3 days and as needed. The hospice RN said, Because she is incontinent it will be changed much more often. The expectation is to check and change, to give incontinence care, at least every 2 hours. However, the hospice RN stated resident #22 complained to her about waiting long periods for incontinence care and to be transferred back to bed. She acknowledged neither the facility nor hospice ordered a different cushion for resident #22's wheelchair after the wounds were identified. Instead, she explained resident #22's friends brought in an inflatable donut-shaped cushion. The hospice RN did not recall seeing the wound since 12/11/19 because resident #22 was in the wheelchair whenever she visited. She was not aware of the status of the wounds or the significant redness to resident #22's buttocks and coccyx. On 12/17/19 at 3:01 PM, resident #22 remained seated in her wheelchair and said, I've been asking to go back to bed. The assigned evening shift staff, CNA N and LPN O entered the room and transferred resident #22 into bed with a mechanical lift. An inflatable donut cushion was observed on top of a foam cushion in the wheelchair. LPN O was informed resident #22 was last changed by CNA M at about 11:00 AM. LPN O stated incontinent residents should be checked and changed at least every 2 hours, and more often if necessary. She explained some residents, including resident #22, could require incontinence care as often as every hour if they took diuretics. A few minutes later at 3:18 PM, CNA N removed resident #22's brief. The brief was again saturated and the dressing was tan colored and wet. The date and initials on the dressing were now blurred and fading. LPN O validated the dressing was the same one she applied, initialed and dated on the previous afternoon. She confirmed the dressing did not cover either area of skin breakdown on the left buttock or the coccyx as ordered. LPN O removed the soiled dressing, cleansed both areas with normal saline and applied skin prep to the left buttock and coccyx wound that measured approximately 1.0 x 0.5 cm. She recalled when the hospice RN identified the skin breakdown the previous week, resident #22 had 2 open areas surrounded by intact skin and no redness. LPN O said, When I came in yesterday there was no dressing on the area. She described resident #22's buttocks and coccyx as light, blanchable pink when she applied the day before. However, LPN O stated the significant area of redness that spread from both inner buttocks to the sacrum had worsened in 24 hours. She said, Now it's red, like on fire. It is not good for her to keep sitting on it or to be wet. We have to call the doctor for a change in condition . On 12/17/19 at 3:35 PM, the West Wing UM observed resident #22's buttocks and validated the change in condition as there was no redness at the time the wounds were identified by the hospice RN. The West Wing UM explained the facility provided a combination skin cleanser/barrier product and staff were expected to use it for resident #22's incontinence care. She acknowledged resident #22 did not have an order for [REDACTED].#22's skin condition by nurses or CNAs. She said, The hospice nurse told me that things were looking better and she hoped by next week it would be resolved. The West Wing UM was informed the hospice RN had not done a full skin assessment since the skin injuries were identified as resident #22 was in her wheelchair at the times she visited. On 12/18/19 at 10:54 AM, resident #22 and the occupational therapist (OT) were observed in front of the therapy gym. The OT stated that morning she received a referral to evaluate resident #22 for wheelchair positioning and provided her with a new gel cushion. The OT stated someone gave resident #22 an inflatable donut cushion and said, Those are horrible. Later that afternoon at 2:21 PM, the OT explained it was not appropriate for resident #22 to use a donut cushion on top of a foam cushion. She stated a foam cushion was a standard intervention for comfort, but if skin was compromised either a gel or air cell cushion was appropriate. The OT stated although a donut cushion relieved pressure in the center, it could cause a new area of pressure around the ring itself. On 12/18/19 at 10:56 AM, the East Wing UM stated the wound physician assessed resident #22 the previous evening. She explained resident #22 was diagnosed with [REDACTED]. She confirmed staff were expected to keep resident #22 clean and dry by checking and changing her every 2 hours and more often if necessary. The East Wing UM stated the wound physician validated the previously identified open area on resident #22's coccyx was a stage 2 pressure ulcer. She stated to her knowledge, application of skin prep to an open pressure ulcer was not an appropriate intervention. The East Wing UM explained the wound physician ordered a daily wound treatment of [REDACTED].#22's wheelchair. The facility provided manufacturer's information related to use of skin prep protective liquid barrier dressing that read, Do not apply directly to open wound . Do not apply to infected areas of skin. Review of the wound physician's Initial Wound Evaluation & Management Summary dated 12/17/10 revealed resident #22 had a stage 2 pressure wound of the medial coccyx . that measured 0.8 x 0.4 x 0.1 cm. In addition to a new dressing treatment plan and the gel cushion, the wound physician's recommendations included off-loading the wound, repositioning and Vitamin C 500 milligrams twice daily. The document revealed resident #22 also had fungal infections of the groin, peri-anal/sacral areas and under both breasts. Resident #22's weekly Skin Check head-to-toe evaluation dated 12/06/19 indicated her skin was clear, with no change in condition. A change in condition note dated 12/11/19 at 11:40 AM and a nurse's progress note dated 12/11/19 at 12:44 PM revealed the hospice RN assessed resident #22 and identified 2 stage 2 pressure wounds. Both notes were struck out by LPN O and replaced later that afternoon at 1:48 PM with a progress note that read, Resident noted with 1 x 1 cm open area coccyx and 1.5 cm x 1.5 cm open are(a) to left buttocks wounds are superficial and appear to be related to shearing . The physician's orders [REDACTED]. There was no direction to apply the skin prep to the peri-wound area as intended by the hospice RN. The medical record included an Unavoidable Skin Breakdown evaluation dated 12/11/19 that indicated resident #22 was at risk for skin breakdown due to 1 condition, immobility, although the form indicated 2 or more conditions placed the resident at risk. The incomplete and inaccurate form, signed by a physician on 12/12/19, revealed the physician reviewed resident #22 and believed her pressure ulcers met the criteria to be unavoidable. However, a weekly Skin Check head-to-toe evaluation completed the following day, on 12/12/19 revealed resident #22's skin was clear, with no change in condition, despite documentation of pressure ulcers and/or shearing wounds on 12/11/19. The policy and procedure (P&P) for Pressure Ulcer Treatment revised on 4/25/17, indicated staff would avoid positioning residents on a pressure ulcer by raising them off the support surface, select a dressing to keep the wound bed moist and prevent maceration of the surrounding tissue, keep dressings intact, protect wounds from contamination and consult a dietitian. On 12/19/19 at 8:42 AM, the interim DON acknowledged resident #22's wounds were identified by the hospice RN, rather than during daily care by facility nursing staff. She stated her expectation was CNAs would provide incontinence care in a timely manner. The interim DON explained the frequency of care varied, but approximately every 2 hours was appropriate. She stated CNAs should report any changes in skin condition to the assigned nurse. She validated inadequate incontinence care could contribute to skin breakdown and fungal infections. The interim DON confirmed resident #22 had a stage 2 pressure ulcer on her coccyx, as noted initially by the hospice RN. She explained although RNs were qualified to stage wounds, the facility's process was to call the physician for a change in skin condition and describe the wound. An appropriate treatment order would be implemented, but the wound would not be staged until the physician assessed it. The interim DON stated resident #22's physician gave an order for [REDACTED].#22's care plans with the interim DON revealed the care plan for skin impairment was not revised until 12/16/19, 5 days after the wounds were identified. She confirmed the facility's process involved IDT discussion of new wounds in the daily clinical meeting, and care plans would be updated with appropriate interventions at that time. Review of the medical record with the interim DON revealed no nutritional assessment was conducted for resident #22 after identification of the wounds, according to the facility's P&P. She validated the nurse who documented on resident #22's skin condition on 12/12/19 did not identify the presence of the wounds on her buttock and coccyx. Review of the facility's P&P for Pressure Ulcer & Skin Care Management revised on 4/25/17 read, . a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection and reduce the risk of new pressure ulcers developing. The procedure included weekly skin checks of the entire body, review of findings by the interdisciplinary team (IDT) and . select the treatment procedures appropriate for the resident and the type of pressure ulcer or wound. 2. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/16/19 at 10:21 AM, resident #6 said she was having burning on urination and had reported this to the nursing staff. On 12/17/19 at 4:43 PM, resident #6 said she still had burning on urination stating, I told the nurses many times before it [MEDICAL CONDITION] I pee. On 12/18/19 at 2:17 PM, resident #6 stated, I let them both know, the CNAs (certified nursing assistants) and the nurses, every time I go, [MEDICAL CONDITION] hurts. A review of resident #6's medical record noted that a urine specimen was collected for culture and sensitivity on 12/3/19 as per physician's orders [REDACTED].#6 had a urinary tract infection [MEDICAL CONDITION]. The results read [MEDICATION NAME] faecalis greater than 100,000 colony forming unit per milliliter (cfu/ml). On 12/17/19 at 3:34 PM, licensed practical nurse (LPN) A said the facility received lab results by fax and via their electronic health record system. She stated, whatever shift the lab results come in, the nurse will follow up and notify the physician. The physician will prescribe the right antibiotic according to the culture and sensitivity. She stated that resident #6 was not prescribed any antibiotics currently, but she should be on something if her culture was greater than 100,000. Review of nurses' progress notes on 12/17/19 at 4:30 PM did not reveal any documentation that the physician had been notified of resident #6's abnormal lab results received on 12/06/19. Review of the Medication Administration Record [REDACTED]. On 12/17/19 at 4:33 PM, the East wing unit manager, registered nurse (RN) B, stated, I haven't found where the physician was notified of resident #6's lab results from 12/03/19. RN B stated that symptoms of a urinary tract infection included, burning on urination and high temperature. She said that resident #6 had a fever of 101.2 degrees Fahrenheit yesterday, 12/16/19. RN B said, The nurse who received the lab should have notified the physician of the abnormal labs and antibiotics should have been ordered. On 12/18/19 at 11:19 AM, licensed practical nurse (LPN) C stated, Labs come to us by (electronic system) and by fax throughout the day. All nurses are responsible for checking lab results. Every shift is responsible for checking fax machine and pending labs. I don't know how resident #6's lab results were missed. She (resident #6) is alert and knows when she's getting a UTI. On 12/19/19 at 1:08 PM, the director of nursing stated Our process is that we get lab results on the computer and faxed to the units. Whichever nurse gets the lab results should let the physician know the results and process any new orders. I interviewed the nurse on duty when resident #6'2 lab results were faxed and she did not remember seeing the lab results. Review of facility policy, Infection Control, dated, (MONTH) 2014, read, This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of disease and infections 2. The objectives of our infection control policies and practices are to: a. Prevent, detect, investigate and control infections in the facility; b. Maintain a safe, sanitary, and comfortable environment for personnel, residents e. Maintain records of incidents and corrective actions related to infections

Based on observation, interview and record review, the facility failed to obtain and honor preferences for daily routine and activities for 1 of 2 residents reviewed for choices, of 36 total sampled residents, (#22). Findings: Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. [MEDICATION NAME] degeneration is a common eye disorder that causes blurred or reduced central vision, due to thinning of the retina. As the condition progresses, vision worsens and the ability to read and recognize faces is affected. (www.mayoclinic.org) Review of the Minimum Data Set (MDS) admission assessment dated [DATE] revealed resident #22 had impaired vision and wore corrective lens. She had clear speech and a Brief Interview for Mental Status (BIMS) score of 14 that indicated she had little to no cognitive impairment. Resident #22 required extensive assistance with bed mobility, dressing and personal hygiene, was totally dependent on staff for transfers, and used a wheelchair. Section F of the MDS assessment, Preferences for Customary Routine and Activities included instructions to Attempt to interview all residents able to communicate. If resident is unable to complete, attempt to complete interview with family member or significant other. Resident #22 was not interviewed for this assessment although the MDS assessment indicated she was cognitively intact and able to communicate. Instead, a staff member completed the assessment for resident #22's daily routine and activity preferences. Unlike an interview, the staff assessment was not designed to identify how important each activity and daily routine was to a resident. On 12/16/19 at 1:37 PM, resident #22 explained her preferred routine was to eat breakfast in her room, then get dressed and go out for activities by about 9:30 AM. Resident #22 stated she had worsening [MEDICATION NAME] degeneration and her vision loss prevented her from actively participating in many activities. She explained she enjoyed the group trivia activity in the morning because it did not involve her eyesight and she could participate fully. Resident #22 stated she was usually tired after lunch and wanted to go back to bed at that time. She explained it required 2 staff members to transfer her out of and into bed with a mechanical lift. Resident #22 said, A lot of the staff get mad at me because it's a hassle to put me back to bed. I heard them talking one day and they said just ignore her. Resident #22 stated certified nursing assistant (CNA) L got her up too late to attend trivia that morning, and told her she had to stay in the chair for a while because she was not going to go to the trouble of getting her up then putting her back to bed soon after. On 12/16/19 at 2:08 PM, CNA L entered resident #22's room. She confirmed she got resident #22 out of bed at about 11 AM that morning. CNA L approached resident #22 and offered to take her to join an afternoon activity with other residents making gingerbread houses. Resident #22 informed CNA L she could not participate in many of the afternoon activities including that one because of her vision issues. She told CNA L she liked trivia and the morning activities and wanted to go back to bed after lunch. CNA L said, Ok then quickly documented on her tablet and left the room without offering to put resident #22 back to bed. On 12/18/19 at 9:57 AM, CNA L confirmed she did not put resident #22 back to bed before she finished her shift at 3 PM. She stated when she gave report to the on-coming evening shift CNA, resident #22 was still seated in her wheelchair in her room. CNA L acknowledged resident #22 was alert, oriented and able to make her choices and needs known. However, CNA L explained it was difficult to transfer resident #22 because it required 2 people and it was sometimes hard to find another person to assist. On 12/17/19 at 10:55 AM, resident #22 was observed in bed. She stated she was still waiting for someone to get her cleaned up. Resident #22 said, I wanted to get up for activities but I'm still in bed. A few minutes later at 11:03 AM, resident #22's assigned CNA was asked if she had given care to resident #22 that morning. CNA M said, I haven't had a chance to do it yet. She was informed resident #22 was waiting to get dressed and participate in morning activities. Later that morning at about 11:40 AM, CNA M transported resident #22 from her room to the dining room where a group trivia activity was in progress. The West Wing unit manager (UM) stated she was aware resident #22 did not participate in many activities due to her vision issues. The UM acknowledged resident #22 liked to attend trivia as it was an appropriate activity for her. On 12/17/19 at 1:28 PM, resident #22 was observed seated in her wheelchair in her room. Later that afternoon at 3:01 PM, resident #22 remained seated in her wheelchair. She said, I've been asking to go back to bed. I'm tired. On 12/18/19 at 12 PM, the Activities Director stated resident #22 preferred religious activities, socials, music and trivia because those activities did not require good vision. The Activities Director stated she was not on staff when resident #22 was admitted , but confirmed her choices regarding specific daily routines and activities should have been obtained for the MDS assessment. The Activities Director explained the group trivia activity usually started at about 9:30 AM. She confirmed there was a religious activity the previous day at 10 AM. On 12/18/19 at 12:24 PM, the MDS Coordinator validated resident #22 was not interviewed regarding her daily routine and activity preferences. He was not able to explain why the assessment was not completed appropriately. Review of the medical record revealed a Therapeutic Recreation/Activity Review form dated 10/18/19. The document indicated resident #22 required assistance to get to and from activities via wheelchair. The document revealed resident #22 was self-directed in choosing her preferred activities. Her current interests were listed as games, music, religious activities, being outdoors and educational and intellectual pursuits. The activity participation flow sheet for month of (MONTH) 2019 revealed resident #22 participated in trivia on 5 days, religious activities on 3 days, men's and women's group on 1 day, and music on 2 days. In (MONTH) 2019, the flow sheet indicated resident #22 participated in trivia on 12/16/19, although CNA L confirmed resident #22 remained in bed until 11 AM that morning. She attended religious activities on 1 day and was not available for 2 days, including the morning of 12/17/19, when CNA M did not get her out of bed in time. Resident #22's care plan for activities, initiated on 10/18/19, had the goal to make her own choices regarding daily activities. The interventions included offer assistance to activities of potential interest, offer religious activities of choice, and respect her right to choose to attend planned group activities. Resident #22's care plan directed staff to provide her with a monthly activity calendar despite her significantly impaired vision, and the interventions were not individualized to reflect the preferred and current interests documented on admission. The care plan for activities of daily living (ADLs), initiated on 10/15/19, revealed resident #22 required extensive assistance due to her [DIAGNOSES REDACTED].#22's choices for her daily routine such as preferences related to times to get up and go to bed or bath type and schedule. Review of the CNA care plan or kardex revealed categories for person-centered care, activities and ADLs, but no interventions related to resident #22's choices for daily routine and preferred activity schedules. On 12/19/19 at 8:42 AM, the interim director of nursing (DON) stated residents' choices and preferences should be identified on admission and throughout their time in the facility. She explained appropriate staff members from the activities and/or nursing departments should create and update care plans to reflect residents' choices and preferences to promote individualized care. The interim DON stated her expectation was staff would honor residents' choices. The facility's policy and procedure Resident Rights, revised on 3/26/19, revealed each resident had the right to self-determination. The document read, Residents have freedom of choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care . Review of the Facility Assessment Tool, dated 12/11/19, revealed the facility offered person-centered care and services. The document indicated specific practices including to Find out what resident's preferences and routines are; what makes a good day for the resident; what upsets him/her and incorporate this information into the care planning process. Make sure staff caring for the resident have this information

Based on interview and record review, the facility policy in the Resident Admission & Financial Agreement waiving the facility's responsibility for any potential or loss of resident's personal property did not ensure compliance with Federal regulations. Findings: The facility policy titled, . Resident Admission and Financial Agreement page 9 section III, under personal Items noted, All articles retained by the Resident (including dentures, hearing aids, eyeglasses, jewelry and documents) shall be the responsibility of the Resident. The resident may purchase, at the resident's expense, casualty insurance to cover potential damage to or loss of any of the Resident's personal property. On 12/19/19 at 1:53 PM, the administrator validated the facility's Resident Admission and Financial Agreement and said she was not aware that it waived the facility's responsibility in case of loss/theft.

Based on observation, interview and record review, the facility failed to ensure a pain medication refill was acquired in a timely manner to meet the needs of 1 of 4 residents reviewed for pain management (#18), and failed to ensure scheduled medications were administered as ordered, according to accepted professional standards during the 7 AM to 3 PM shift, on 2 of 2 units for 38 of 47 residents on the East Wing and 7 of 36 residents on the West Wing, for a total of 45 of 83 residents (#6, 13, 31, 32, 33, 43, 50, 55, 59, 61, 66, 351, 360, 367, 370, 372, 373, 375, 376, 377, 378, 380, 381, 382, 383, 384, 385, 386, 387, 388, 389, 390, 392, 393, 394, 395, 396, 397, 398, 400, 401, 404, 407, 408 & 419). Findings: On 8/01/19 at 10:14 AM, licensed practical nurse (LPN) M was observed at his medication cart. He confirmed he was still not finished passing morning medications. On 8/01/19 at 11:04 AM, LPN A was observed at her medication cart preparing medications. She confirmed she was late with administration of scheduled 9 AM and 10 AM medications for her assigned residents. LPN A scrolled through the medication administration record (MAR) and stated she probably had about 10 residents' morning medications left, including residents #32, #381, #61, #389, #31, #59, #400, #391 and #388. She confirmed the medications should be given within the timeframe of 1 hour before and 1 hour after the scheduled time. LPN A stated she was a full time day nurse and acknowledged she occasionally ran late with medication administration. On 8/01/19 at 11:19 AM, LPN D stood at her medication cart. After review of her computer screen, LPN D validated she was still administering morning medications after the scheduled times. She stated one of the regional nurses directed the unit coordinator to assist her within the last 30 minutes. The unit coordinator, LPN K acknowledged she was not assigned to the medication cart, but was directed to assist LPN D as the medications were late. LPN D stated it was impossible for any nurse on her assignment to administer the large amount of medications within the required window. On 8/01/19 at 11:26 AM, LPN K stated although she was assisting LPN D there were several residents who had not received their scheduled 9 AM medications. She looked at the MAR and stated residents #382, #360, #380, #66,# 394, #395, #351 and #384 still had not received their 9 AM medications. LPN K said, We are very late with meds. This has happened regularly over the past 2 weeks. She stated she was told the regional nurse at the nurses' station called a physician to get orders for late administration of that morning's scheduled medications. LPN K stated she was not aware of late administration orders being obtained on other occasions in the last 2 weeks when residents did not receive their scheduled medications as on time. On 8/01/19 at 11:29, LPN A was observed at her medication cart preparing to do blood glucose checks. She explained it was almost lunch time, so she had to check residents' blood sugars before they ate. LPN A acknowledged she still had not completed administration of scheduled 9 AM and 10 AM medication. She said, I had to stop the morning med pass do insulins. At 12:25 PM, LPN A admitted 6 residents on her assignment had not received their 9 AM medication. LPN A stated she was aware medications were very late. On 8/01/19 at 12:27 PM, the Senior Regional Clinical Director (SRCD) acknowledged she updated residents' medical records within the last hour to reflect an order that authorized late administration of morning medication by 12 PM. The SRCD stated the assigned nurses did not call the attending physicians to notify them that medications were late, and to request orders to hold or continue administration of medications. She explained she called the facility's medical director to get an order to cover multiple residents. When asked who usually notified physicians of late medications, the SRCD stated the unit coordinator or unit manager. From the East Wing nurses' station, both assigned nurses were observed at their carts on different hallways, still administering morning medications. The SRCD was informed it was past 12 PM and LPNs A and D had not completed morning medication pass. She was asked if late medication administration occurred regularly on the East Wing. She said, I've been here every day for 3 months To my knowledge this is the first time in 3 months that meds are that late. I've never had to call before. On 8/01/19 at 1:49 PM, LPN D confirmed she still had not completed scheduled 9 AM medications for some of her assigned residents including residents #393, #397, #383, #398 and #394. She confirmed all the 12 PM scheduled medications were also late. LPN D validated the policy was to call the physician if any medication was not administered within the 2 hour window. She stated although a physician was notified today, that was not the usual practice. LPN D stated it was not possible to give medication to her assigned residents in 2 hours. She explained the nurses assigned to her cart often ran late with medications. On 8/01/19 at 3:11 PM, LPN D, was observed in the hallway outside a resident's room. She stated she was almost finished medication administration for the 7 AM to 3 PM shift. LPN D explained she had only one scheduled 12 PM medication left. Review of the Medication Admin Audit Report for the day shift on 8/01/19, as of 2:25 PM revealed the following: 1. Resident #351 had not received her scheduled 9 AM medications as of 2:25 PM, including Carvedilol 6.25 milligrams (mg.) for high blood pressure and [MEDICATION NAME] 5 mg. for anxiety ordered twice daily (BID). Neither the scheduled 9 AM nor 1 PM doses of Ramipril 5 mg. for high blood pressure, ordered three times daily (TID), was given. 2. Resident #419 had not received his scheduled 9 AM medications as of 2:25 PM. The medications included [MEDICATION NAME] 40 mg. injection to prevent blood clotting, Duloxetine 60 mg. for depression, and [MEDICATION NAME]-HCTZ 20-12.5 mg. for high blood pressure. He also had an order for [REDACTED]. for anxiety BID. 3. Resident #408 had not received her scheduled 8 AM and 9 AM medications as of 2:25 PM, including [MEDICATION NAME] XL 100 mg. ordered BID. 4. Resident #389 received scheduled 8 AM [MEDICATION NAME]-[MEDICATION NAME]-Entacapone 31.25-125-200 mg. for [MEDICAL CONDITION], ordered 4 times daily (QID), at 12:30 PM. He received the next dose scheduled for 12 PM at 1:05 PM, only 35 minutes later. Resident #389 received his scheduled 9 AM medications at 12:30 PM, including [MEDICATION NAME] eye drops for dry eye syndrome and [MEDICATION NAME] 300 mg. for chronic pain that were ordered BID. 5. Resident #13 had physician's orders [REDACTED]. QID for [MEDICAL CONDITION]. His scheduled 12 PM dose was administered at 1:39 PM, and the scheduled 2 PM was given at 2:17 PM, less than 40 minutes later. Resident #13's scheduled 9 AM medications were administered at 11:30 AM, and a scheduled 12 PM antidepressant [MEDICATION NAME] was given at 1:39 PM. 6. Resident #398 received his scheduled 8 AM dose of [MEDICATION NAME]-[MEDICATION NAME] 25-100 mg, ordered TID for [MEDICAL CONDITION], at 12:30 PM. He had not received the scheduled 12 PM dose of the medication as of 2:25 PM. His scheduled 9 AM medications were administered at 12:30 PM, including [MEDICATION NAME] extended release for cough and Memantine 10 mg. for [MEDICAL CONDITION], ordered BID. 7. Resident #392 had not received scheduled 12 PM medications as of 2:25 PM, including Pregabalin 100 mg. ordered TID for [MEDICAL CONDITION], and Pyridostigmine [MEDICATION NAME] 90 mg. ordered every 4 hours (q4h) for muscle function. 8. Resident #50 received her scheduled 8 AM [MEDICATION NAME]at 10:25 AM and 7 AM nasal spray at 10:29 AM. Her scheduled 9 AM medications were administered at 10:26 AM, including [MEDICATION NAME] 75 mg. for heart failure, [MEDICATION NAME] 60 mg. for [MEDICAL CONDITION], and [MEDICATION NAME] 500 mg. for diabetes, all ordered BID. 9. Resident #61 received his scheduled 9 AM medications between 1:23 PM and 1:31 PM, including [MEDICATION NAME] 0.25 mg. for [MEDICAL CONDITION] and [MEDICATION NAME] 10 mg. for [MEDICAL CONDITION], both ordered BID. 10. Resident #383 received his scheduled 8 AM dose [MEDICATION NAME] 40 mg. at 11:16 AM. The physician's orders [REDACTED]. His 8 AM dose of [MEDICATION NAME] and the scheduled 9 AM medications were given between 11:19 AM and 11:29 AM. The 9 AM medication included [MEDICATION NAME] 40 mg. for [MEDICAL CONDITION] that was ordered BID. Resident #383 received his 12 PM dose of [MEDICATION NAME] 60 mg. for high blood pressure, ordered for every 6 hours (q6h), at 2:20 PM. 11. Resident #32 received her scheduled 9 AM medication at 2:08 PM, including Memantine 5 mg. for dementia and [MEDICATION NAME] 150 mg., that were ordered BID. Resident #32 also received a scheduled 12 PM [MEDICATION NAME] antibiotic eye drops at 2:08 PM. The eye drops were ordered q6h. 12. Resident #373 received his scheduled 8 AM and 9 AM medications at 10:40 AM, including [MEDICATION NAME] 200 mg. for high blood pressure that was ordered BIS, [MEDICATION NAME] ER 500 mg. for [MEDICAL CONDITION], ordered TID, and [MEDICATION NAME] units, ordered TID. 13. Resident #59 received scheduled 9 AM [MEDICATION NAME] 100 mg. for high blood pressure, ordered TID, at 10:17 AM. He received his 9 AM [MEDICATION NAME] 100 mg for high blood pressure, ordered BID, at 1:20 PM, and the 9 AM [MEDICATION NAME] 10 mg. for high blood pressure at 1:19 PM. 14. Resident #400 received scheduled 9 AM medications between 12:35 PM and 12:38 PM, including Eliquis 2.5 mg., ordered BID for [MEDICAL CONDITION], and [MEDICATION NAME] 60 mg. for heart failure. 15. Resident #375 received scheduled 9:30 AM medications at 11:56 AM. 16. Resident #360 received her scheduled 9 AM medications between 1:43 AM and 11:47 AM, including Apixaban 10 mg. for blood clots and [MEDICATION NAME] 500 mg. for diabetes that were ordered BID. 17. Resident #66 received scheduled 9 AM and 9:30 AM medications between 11:51 AM and 11:59 AM, including Quetiapine [MEDICATION NAME] 12.5 mg. for [MEDICAL CONDITION], [MEDICATION NAME] 40 mg. for acid reflux, and [MEDICATION NAME] Acid 500 mg. for wound healing that were ordered BID. 18. Resident #372 received his scheduled 9 AM medications at 11:40 AM. The high blood pressure medications Carvedilol 6.25 mg., [MEDICATION NAME] 0.2 mg. and Entresto 24-26 mg. were ordered BID, and [MEDICATION NAME] 25 mg. TID. Resident #372 received his scheduled 2 PM dose of [MEDICATION NAME] at 2:22 PM, less than 3 hours after the morning dose. 19. Resident #382 received her scheduled 9 AM medication at 1:23 PM, including medications ordered BID, [MEDICATION NAME] 20 mg for acid reflux, Carvedilol 3.125 mg. for high blood pressure, and [MEDICATION NAME] Sodium 25 mg. for inflammation and pain. 20. Resident #384 received her 9 AM medications at 12:48 PM, including [MEDICATION NAME] 80 mg. for high blood pressure, and [MEDICATION NAME] 10 mg. for inflammation. Resident #384 scheduled 11:30 AM doses of Insulin [MEDICATION NAME] at 12:59 PM. 21. Resident #381 received her scheduled 9 AM medication at 12:42 PM, including medications for mood and depression, [MEDICATION NAME] 20 mg. once daily (QD), [MEDICATION NAME] 10 mg. BID, and [MEDICATION NAME] 100 mg. BID. 22. Resident #31 received scheduled 9 AM doses Tylenol 650 mg. for pain, and [MEDICATION NAME] 500 mg. for diabetes at 12:20 PM. Both medications were ordered BID. 23. Resident #380 received her scheduled 9 AM medication at 12:20 PM, including [MEDICATION NAME] 5 mg. and [MEDICATION NAME] 5 mg. for high blood pressure. 24. Resident #388 received her scheduled 9 AM medication at 12:17 PM, including [MEDICATION NAME] 100 mg. for constipation, Glimepiride 4 mg. and [MEDICATION NAME] 1000 m.g for diabetes that were ordered BID. 25. Resident #395 received her scheduled 9 AM medications between 12:01 PM and 12:10 PM, including Potassium Chloride 10 milliequivalents (mEq) for low potassium, and [MEDICATION NAME] 25 mg. for high blood pressure, ordered BID. 26. Resident #377 received his scheduled 8 AM and 9 AM medications between 11:18 AM and 11:25 AM, including the [MEDICATION NAME] mg., [MEDICATION NAME] 50 mg. for high blood pressure, [MEDICATION NAME] inhaler for wheezing and [MEDICATION NAME] 600 mg. that were ordered BID. The medications also included [MEDICATION NAME] 100 mg. for cough and [MEDICATION NAME] 400 mg. for [MEDICAL CONDITION] ordered TID. 27. Resident #397 received scheduled 8 AM, 9 AM and 9:30 AM medications between 11:06 AM and 11:08 AM, including [MEDICATION NAME] 100 mg. for cough, ordered TID, and [MEDICATION NAME] nasal spray, ordered BID. She received scheduled 12 PM dose 2 tablets [MEDICATION NAME] 650 mg., ordered q6h for pain, at 2:07 PM. 28. Resident #404 received his scheduled 9 AM medication between 10:48 AM and 10:55 AM, including [MEDICATION NAME] 10 mg. for arthritis ordered once weekly, and Eliquis 2.5 mg. BID for [MEDICAL CONDITION]. 29. Resident #370 received her 9 AM medications at 10:44 AM. 30. Resident #396 received her scheduled 8 AM and 9 AM medications between 10:18 AM and 10:30 AM, including Potassium Chloride 20 mEq for low potassium, [MEDICATION NAME] 40 mg. for [MEDICAL CONDITION], [MEDICATION NAME] 100 mg. for uric acid that were ordered BID. She received the scheduled 8 AM dose Tylenol 650 mg., ordered q4h, at 10:18 AM. Resident #396 received scheduled 9 AM [MEDICATION NAME] 15 mg., ordered q12h for pain, at 10:21 AM, and scheduled 9 AM [MEDICATION NAME] 5 mg., ordered BID for mood, at 10:24 AM. 31. Resident #33 received her scheduled 8 AM medication from 9:45 AM to 9:47 AM, including Eliquis 5 mg. BID for [MEDICAL CONDITION], and [MEDICATION NAME] 600 mg. TID for [MEDICAL CONDITION]. 32. Resident #385 received her scheduled 9 AM medications at 10:40 AM, including Carvedilol 3.125 mg. for high blood pressure, ordered BID. 33. Resident #367 received her scheduled 8 AM medication at 10:32 AM. 34. Resident #43 received her scheduled 8 AM and 8:30 AM medications at 9:54 AM, including a [MEDICATION NAME] capsule for gastrointestinal health and Napafenac eye drops for allergies [REDACTED]. 35. Resident #407 received scheduled 8 AM medications at 9:26 AM, and scheduled 1 PM medication at 2:21 PM. 36. Resident #394 received scheduled 9 AM and 10 AM medications at 12:15 PM, including [MEDICATION NAME] 0.1 mg. and [MEDICATION NAME] 240 mg. for high blood pressure, ordered BID. The medications also included [MEDICATION NAME] 50 mg. for high blood pressure and [MEDICATION NAME] 800 mg. for [MEDICAL CONDITION], that were ordered TID. Resident #394 received her 12 PM scheduled [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg. for pain, ordered q6h, at 2:19 PM. 37. Resident #390 received scheduled 8 AM, 8:30 AM and 9 AM medications between 10:56 AM and 11 AM, including Memantine 10 mg. for [MEDICAL CONDITION], and the blood thinner Apixaban 5 mg. that were ordered BID. 38. Resident #393 received scheduled 8 AM and 9 AM medications between 10:52 AM and 10:55 AM, including [MEDICATION NAME] 1000 mg. for diabetes and Carvedilol 25 mg. for high blood pressure, ordered BID, and [MEDICATION NAME] antibiotic eye drops ordered q4h. The medications included [MEDICATION NAME] 300 mg. for [MEDICAL CONDITION], and [MEDICATION NAME] 75 mg. for high blood pressure, ordered TID. 39. Resident #401 received scheduled 9 AM medications between 10:41 AM and 11:21 AM, including Dabigatran Etaxilate [MEDICATION NAME] 150 mg. for blood clots, ordered BID. 40. Resident #378 received her scheduled 8 AM medications from 9:18 AM to 9:26 AM, including an antibiotic Bactrim DS 800-160 mg., ordered BID. 41. Resident #386 received scheduled 9 AM medications at 10:09 AM. 42. Resident #376 received scheduled 8 AM medication at 9:56 AM. 43. Resident #387 received scheduled 8 AM Brimodine [MEDICATION NAME] eye drops, ordered BID, at 9:48 AM. 44. Resident #55 received scheduled 7 AM and 9 AM medication at 10:13 AM. 45. Resident #6 received scheduled 9 AM medications at 10:09 AM. In an interview conducted on 8/01/19 at 9:13 AM, resident #360 said, I don't really have a schedule for my pills. I get them at any time .sometimes it's 4 hours late. At 12:31 PM, resident #360 was asked if she received her morning medication on time. She said, I got my medicine today at almost noon. Review of the Medication Admin Audit Report for all shifts on Saturday 7/27/19 revealed resident #360 received her scheduled 9 AM medications at 5:05 PM, 8 hours after the ordered time. The Medication Admin Audit Report for all shifts on Saturday 7/27/19 revealed 78 residents received medication on either one or more shifts on that day. Review of the report indicated 67 residents received scheduled medication between 1 and 8 hours after the ordered time. On 8/01/19 at 4:39 PM, the Regional Director of Clinical Services validated the medication report showed the issue regarding late administration of medication occurred in the facility prior to 8/01/19. Review of the facility's policy and procedure for Medication Pass Guidelines, revised 4/25/17, read that the purpose was To assure the most complete and accurate implementation of physicians' medication orders and to optimize drug therapy for each resident by providing administration of drugs in an accurate, safe, timely, and sanitary manner. The procedure indicated nurses were expected to Administer medications within 60 minutes of the scheduled time. The document included an example related to an ordered 8 AM medication that must be given between 7:00 a.m. and 9:00 a.m. in order to be considered timely. 46. Resident #18 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. On 6/16/19, the physician ordered [MEDICATION NAME] 5 mg. q4h as needed (prn) for pain. That order was changed to [MEDICATION NAME] 5 mg. q4h around the clock (ATC) and not prn, and a pain evaluation every shift. The Admission Minimum Data Set (MDS) was completed on 6/23/18. The resident's Brief Interview of Mental Status (BIMS) was 15/15. The MDS reflected the resident required extensive assist of one to two persons for all activities of daily living (ADLs) except eating-supervision. Pain in past 5 days pain has made it hard to sleep. The MAR reflected that there was no medication available for 6/29/19 doses at 6 AM, 10 AM, and 2 PM. A dose was received at 4 PM and administration times changed to reflect q4h ATC. On 7/02/19, medication was not available for 8 PM, 12 AM, 4 AM, and 8 AM. The resident received a dose at 12 PM on 7/03/19. Progress notes reflected the following: 6/29/19 at 5:06 PM - Pain scale 10. Reports that pain occurs multiple times a day. Resident position changed. non-medication interventions did not provide relief. The resident missed 3 doses of medication this day. 7/03/19 at 8 AM - Awaiting for arrival of medication, patient didn't receive pain medication that was scheduled. MD notified on previous shift Pt requested medication 3:30 AM. 7/03/19 at 8:20 AM Called pharmacy to see if any remaining pain medications was available. Pharmacy stated 'no'. Called and left message with on call service 7/03/19 at 8:05 PM - Resident family requested immediate discharge from facility. discharged home with daughter.

Based on interview and record review, the facility failed to ensure sufficient nursing staff on 1 of 2 units (East Wing) on the 7 AM to 3 PM shift to meet residents' needs related to timely administration of scheduled medications, for 38 of 47 residents on the East Wing, of a total census of 83 residents (#13, 31, 32, 59, 61, 66, 351, 360, 367, 370, 372, 373, 375, 376, 377, 378, 380, 381, 382, 383, 384, 386, 388, 389, 390, 392, 393, 394, 395, 396, 397, 398, 400, 401, 404, 407, 408 & 419). Findings: Observations and interviews conducted on the East Wing on 8/01/19 during the 7 AM to 3 PM shift revealed there were 2 nurses assigned to the unit's 3 hallways. The East Wing's census was 47, with a capacity of 58 residents. On 8/01/19 at 11:04 AM, licensed practical nurse (LPN) A confirmed she was a regular full-time nurse on the day shift. She acknowledged she was sometimes unable to complete medication administration in the required timeframe, within 1 hour before and after the scheduled time. LPN A stated she still had at least 10 residents' 9 AM and 10 AM medications left to administer. She validated she was running late and said, I try to do the best I can. On 8/01/19 at 11:19 AM, LPN D stated she was a regular day shift nurse. LPN D validated scheduled 9 AM medications for her assigned residents were late. She explained one of the regional nurses directed the unit coordinator, LPN K, to assist her. LPN K confirmed she was asked to assist with administration of scheduled 9 AM medications. LPN D confirmed her medications were very late. She said, It has been like this since there was a change in staffing. They went down to 2 nurses, 2 weeks ago on Friday. LPN D explained her assigned residents had lots of scheduled medications in addition to as needed (PRN) pain medications since many residents were there for rehabilitation after surgery. LPN D explained during morning medication administration that she might also have to answer call lights and discuss issues with her residents, families and other staff. She stated it was impossible for anyone to give all the scheduled medications within the window of 2 hours, and do other required tasks, including documentation. On 8/01/19 at 11:26 AM, LPN K said, We are very late with meds. This has happened regularly over the past 2 weeks. She explained there were days when nurses used to run a little late, but never happened to this extent. On 8/01/19 at 11:29 AM, LPN A stated she had to stop morning medication administration to do lunchtime blood glucose testing and insulin injections. LPN A explained she would resume administration of 9 AM and 10 AM scheduled medications for her assigned residents afterward. At 12:25 PM, LPN A stated she still had 6 residents' scheduled 9 AM medications left to administer. She stated she was aware the medications were very late. On 8/01/19 at 1:49 PM, LPN D confirmed all her 9 AM scheduled medications had not been given. She explained even the 12 PM medications were late at this time. LPN D stated sometimes she had up to 26 residents and they were high acuity. She explained with that ratio, nurses assigned to her cart were often late with medications. LPN D explained it took time to prepare the medications and double check to make sure they were correct. She stated when in the room, she would evaluate residents for pain and listen to what they had to say. LPN D said, It's not fair to rush residents. She explained LPN K helped out sometimes, but she had her assigned duties. LPN D said, This is impossible. I just want to give good care. On 8/01/19 at 3:11 PM, LPN D stated she was just about to administer the last 12 PM scheduled medication on her assignment. She confirmed her shift should have been over at 3 PM but she still had documentation and treatments to complete. She stated LPN K offered to assist with wound care. Review of the Medication Admin Audit Report for the day shift on 8/01/19 revealed that as of 2:25 PM, 38 of the 47 residents on the East Wing, #13, #31, #32, #59, #61, #66, #351, #360, #367, #370, #372, #373, #375, #376, #377, #378, #380, #381, #382, #383, #384, #386, #388, #389, #390, #392, #393, #394, #395, #396, #397, #398, #400, #401, #404, #407, #408 and #419 did not receive their medication in the required timeframe. The Medication Admin Audit Report for all shifts on Saturday 7/27/19 revealed 78 residents received medication on either one or more shifts on that day. Review of the report indicated 67 residents received scheduled medication between 1 and 8 hours after the ordered time. On 8/01/19 at 4:39 PM, the Regional Director of Clinical Services (RDCS) validated the medication reports for 7/27/19 and 8/01/19 showed there was an issue in the facility, particularly on the East Wing, regarding late administration of medication. Review of the report for 7/27/19 with the RDCS revealed a day nurse, LPN L administered scheduled 9 AM scheduled medications after 5 PM. The RDCS recalled LPN L complained she had 28 residents on her assignment that day. She said, We did not recognize that was an issue before, but we adjusted the assignments so they were equal. The RDCS stated LPN L contacted her the following day and informed her she was not returning. On 8/02/19 at 8:52 AM, an interview was conducted with the Staffing Coordinator (SC) and the RDCS. The SC explained the number of nurses scheduled depended on the census and acuity of the residents on each unit. The SC stated the leadership team ultimately decided on what was necessary to meet the needs of the residents. The SC acknowledged recently there were usually 2 nurses on each unit, and this was a change in the number of nurses scheduled. The director of nursing (DON) stated the East Wing was a higher acuity unit with sub-acute residents, and a capacity of 58. The DON explained when at capacity, the East Wing was staffed with 3 nurses, one for each hallway, and a unit coordinator. The DON stated if the census was low, the East Wing had 2 nurse. The SC was asked if there had been any changes with staffing ratios or hours in the past 2 weeks, and she confirmed within the last 2 weeks I was told by administration, Let's go by the numbers. At 9:34 AM, the SC explained the facility was having problems with staffing as many nurses and CNAs quit within the last few months. The SC said, Nurses tell me they are overworked. The nurses quit because they say the load is too heavy. It has happened more than once that nurses finish up a shift and come to me and say they aren't coming back. The SC stated nurses have expressed frustration regarding lack of staff, and residents complain about lack of continuity. She said, They get accustomed to nurses and they don't like to have so many changes. On 8/02/19 at 9:05 AM, the RDCS validated the unit now had 2 rather than 3 nurses on the day shift due to a decrease in the census. The RDCS was asked to calculate how much time was allotted to each nurse to administer morning medications for each resident. She stated each nurse that morning should have 24 residents, so in the 120 minutes allotted for 9 AM medication pass, the nurse would have a maximum of 5 minutes per resident. When asked if that was a manageable assignment, the RDCS said, As a nurse it would be hard to do it in that time. I did not do the math before. They would definitely need more support to manage the sub-acute unit. The RDCS acknowledged it would be difficult to administer medications with adequate attention to ensure accuracy and spend an adequate amount of time with the resident. She acknowledged rushing through the procedure might present dignity concerns. She stated she made daily rounds but was not aware late medication administration was a concern until it was brought to her attention within the last 24 hours. The RDCS stated after the issue was brought to her attention, she interviewed the nurses on the East Wing, and they confirmed they were not able to administer the medications as ordered. On 8/02/19 at 10:43 AM, the administrator said, When the facility's census drops to the 80s, we go down to 2 nurses on each unit. He explained the facility met the goal of a minimum of 1 nurse to 40 residents. The State's minimum staffing ratio was acknowledged, and the administrator was asked if the facility's goal was to meet minimum standards only, or if other factors affected staffing decisions. The administrator explained when the East Wing was full, each of the 3 nurses had 19 to 20 residents. He was informed that by staffing according to the facility's total census, the needs of the sub-acute residents on the East Wing were not necessarily met. He was informed nurses on the East Wing could have assignments of 25 or more residents even if the facility's census was in the 80s, significantly more than the ratio of 19 to 20 when the East Wing was full. The administrator said, It would make a difference in the sense that the nurse has more patients (residents). Review of the Facility Assessment Tool, updated and reviewed on 7/17/19, revealed individual staff assignments would be based on resident need, and be reviewed daily to ensure that residents are receiving the appropriate amount of services and needs are met.

Based on observation, interview and record review, the facility failed to provide adequate supervision and a secure environment for newly admitted residents at risk for elopement for 1 of 1 sampled resident (#1). These failures contributed to the elopement of resident #1, placing him at risk for serious injury/impairment/death. While the resident was out of the facility unsupervised, there was a high likelihood the resident could have been hit by a car, drowned in the retention pond or got lost. Resident #1 was the only newly admitted resident that was capable of leaving the facility at the time of the survey. On 5/07/19 at 3:38 PM, resident #1 exited the facility through the main lobby doors, less than 24 hours after admission. He walked along the facility's driveway, passing between 2 retention ponds, crossed a 2 lane road and a private driveway, then entered a commercial complex. Resident #1 wandered into an office at the far end of the complex, 0.25 miles away from the facility. The concerned office employees contacted 911. Resident #1's whereabouts were unknown to the facility until law enforcement notified them approximately 40 minutes after the resident exited the facility. The facility's failure to provide adequate supervision and a secure environment resulted in substandard quality of care at the Immediate Jeopardy level, starting on 5/07/19. The Immediate Jeopardy was ongoing at the time of the exit on 5/16/19. Findings: Cross reference to F835. Resident #1 was a [AGE] year old male admitted to the facility from the hospital on [DATE]. His primary [DIAGNOSES REDACTED]. According to the National Institutes of Health, [MEDICAL CONDITION] is a term used to describe . any diffuse disease of the brain that alters brain function or structure. Causative factors could be infections and decreased blood flow to the brain. The main indicator of [MEDICAL CONDITION] is altered mental state with symptoms including progressive memory loss and decreased cognitive ability. Although treating the underlying cause of metabolic [MEDICAL CONDITION] may improve symptoms, . the [MEDICAL CONDITION] may cause permanent structural changes and irreversible damage to the brain. (www.ninds.nih.gov) The patient transfer form, AHCA Form 5000-3008 completed by a hospital physician on 5/06/19, certified that resident #1 required nursing facility services after discharge from the hospital. The document revealed that resident #1 needed a surrogate for decision-making and had altered mental status and dementia. The form indicated that resident #1's mental and cognitive status at the time of transfer was, Alert, disoriented but can follow simple instructions. Assessment of resident #1's physical function revealed that he was able to ambulate and transfer with assistance. Review of the Resident Data Set, revealed that resident #1 was admitted on [DATE] at 8:00 PM for rehabilitation. The document indicated resident #1 was alert but had short and long-term memory problems. Resident #1 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. Although he was disoriented and knew only that he was in a nursing home, the data collection form indicated that resident #1 had modified independence in cognitive skills for decision-making rather than moderate impairment. Evaluation of the level of assistance that resident #1 required for activities of daily living (ADLs) revealed he was independent with set up for bed mobility and eating, and needed limited assistance with set up for transfers. The document showed he leaned while walking and had unsteady balance. The Elopement Risk Screen completed on admission revealed resident #1 was physically able to leave the building on his own and had cognitive impairment. The screening tool indicated that resident #1 did not make repetitive statements about going home or have a history of wandering or elopement. The evaluation form revealed a score of 9 and read, Category: Evaluate for Alerting Bracelet Placement. However, review of resident #1's Order Summary Report revealed an alerting bracelet was not implemented at that time. A Health Status note indicated the admission nurse called resident #1's wife on 5/06/19 at 8:25 PM to obtain a verbal consent for treatment. There was no documentation of any attempt to obtain additional information from the wife at that time, to ensure accuracy of the admission evaluation or to further question about possible elopement. On 5/15/19 at 9:57 AM, the Director of Nursing (DON) stated that on the afternoon of 5/07/19, the day following his admission, resident #1 walked out the front door and did not sign out. The DON stated prior to this, resident #1 displayed no behaviors that suggested a risk for elopement. She explained that when he left the building, he looked like a visitor and walked without an assistive device. She explained the lobby doors were locked at all times, but as resident #1 walked towards the front door, receptionist A released the lock allowing him to exit the facility unsupervised. The DON stated receptionists sat at a desk in the lobby and were able to unlock the doors with a remote. She said, We would like her to verify who is leaving the building. The DON stated that she was not aware resident #1 exited the building until she received a telephone call from emergency medical service (EMS) personnel on 5/07/19 at about 4:15 PM. She stated that EMS and law enforcement returned resident #1 to the facility at about 4:20 PM. She said that 1:1 supervision was implemented at that time and the attending physician and his wife were notified. An alerting bracelet was placed on the resident's right ankle. The East Wing Unit Manager (UM) stated that after she notified resident #1's wife that he eloped from the facility, the wife informed her that he had wandered away from home once before. Review of the facility's video surveillance showed resident #1 walking through the lobby on 5/07/19 at 3:38 PM. He walked at a moderate pace, directly towards the front door. He did not pause and the doors opened immediately. Resident #1 crossed the left side of the parking lot and walked along the left side of the driveway. When he reached the end of the driveway resident #1 was hidden from the camera by trees. A car that left the facility's parking lot soon after resident #1 left camera range was observed maneuvering from the right side of the driveway to the left, possibly to avoid him. Resident #1 was next observed on the sidewalk on the other side of the moderately busy 2 lane street, and continued walking out of camera range. The administrator stated that there were no cars on the street at the time resident #1 crossed from the facility's driveway to the opposite sidewalk. He explained the road was, considered a side street, and not very busy. However, video surveillance revealed about 10 cars passed the area in front of the facility's driveway where resident #1 crossed the road between the time he exited the front doors and the time he disappeared from camera range. On 5/15/19 at 11:04 AM, the surveyors retraced resident #1's elopement route from the facility's front door to the commercial complex where resident #1 was found. The section of the circular driveway that led from the front door to the left side of the parking lot was steeply sloped and had a section of uneven pavement. The section of the driveway that led towards the road had no sidewalks. Uneven, sloping grassy areas stretched about 20 feet from the sides of the driveway towards the marshy area and water in large retention ponds on both sides. The driveway ended at a 2 lane street that connected 2 nearby major thoroughfares. Resident #1's route revealed he stepped over a curb to access the opposite sidewalk, and then crossed a driveway that led into the parking lot of a business complex. The sidewalk continued until it sloped over a drain at the corner of a road to the left that led into a commercial complex. The elopement route continued along the road and onto the sidewalk, ending at the last building in the commercial complex. The total distance of the route was approximately 0.25 miles or between 600 and 700 steps. The weather was sunny, and the temperature was approximately 89 degrees Fahrenheit that afternoon. (www.weather.gov) On 5/16/19 at 10:16 AM, the surveyor interviewed the employee of the company who first interacted with resident #1 after he eloped from the facility by telephone. He stated that on the afternoon of 5/07/19, he was in his office when resident #1 simply walked right in and took a seat. The employee described resident #1 as tired, hot, sweaty and unsteady. The employee stated resident #1 had a yellow wristband that read Fall Risk and another with a name and barcode. He said, I recognized he must have been from a facility. The employee recalled resident #1 asked if he could help him get home. He said resident #1 kept talking about his wife who left him somewhere, and that he wanted to go to a soccer game. The employee said, I couldn't make any sense of what he was saying . He stated law enforcement and EMS were called, and they arrived soon after. He explained EMS attempted to interview resident #1 but he was initially not able to give his name and was drifting in and out regarding time. The employee stated that law enforcement made phone calls and were able to locate resident #1's facility. On 5/15/19 at 11:48 AM, resident #1 was in his room with his wife at bedside. He was pleasantly confused and responded appropriately to simple questions related to his basic needs. Resident #1 recognized his wife but was not oriented to place or time. During surveyor attempts to assess his cognitive status, resident #1 used humor to mask his forgetfulness and inability to respond to some questions. The wife stated that she was informed her husband left the facility, ended up at a nearby business and was returned by law enforcement. She stated the following day, when asked why he left the facility; resident #1 told her he was going to see a soccer game. The wife explained that resident #1 suffered from frequent UTIs, usually accompanied by altered mental status. She stated her husband wandered away from the house early one morning in (MONTH) 2019 while she was still in bed. She called the police and they found him about a mile away on a dirt road. Resident #1's wife stated that the hospital was supposed to call her prior to his discharge, but they did not. She explained the facility contacted her when her husband arrived and asked if she would be in the next day to sign his paperwork. She said, They didn't really ask anything about him. Resident #1's wife explained she accompanied him to doctors' appointments for the last [AGE] years as he was becoming increasingly forgetful and confused. She confirmed he would not be able to answer any questions about his medical history. She said, He jokes a lot but really doesn't know anything. He's like my eldest child. Resident #1's wife stated that on the first day she visited the facility; she did not have to sign in. She said, I just walked right in, and did not recall having to sign out when she left the facility. Resident #1 eloped that afternoon, a short time after his wife's departure. On 5/15/19 at 2:36 PM, receptionist A stated that she had been on staff for about 2 months. She confirmed she was at work on the afternoon of 5/07/19 and received a telephone call from the Fire Department enquiring if resident #1 was from the facility. Receptionist A stated she confirmed resident #1 was on the census and turned the call over to the DON. She said that the resident was escorted back into the facility by law enforcement and the Fire Department. Receptionist A said, As far as I know I was the first person who became aware that resident (#1) was missing. She explained that prior to resident #1's elopement, visitors would come to the desk, give their names and who they were visiting. When they were leaving I just let them out. Receptionist A did not recall seeing resident #1 leave, but acknowledged that after she viewed the video, she realized she let him out. She explained that resident #1 looked like any other visitor so she used the remote to open the front door when he walked towards it. She stated, He just kept walking. On 5/15/19 at 3:24 PM, licensed practical nurse (LPN) B, confirmed she completed the admission paperwork for resident #1, and described the process as a normal admission. LPN B stated that during the interview, she noted resident #1 was confused. She said, For confused residents we call the family. I called the wife to get verbal consent. She told me she would come the following day. LPN B acknowledged she did not ask resident #1's wife about elopement or any issues related to admission data collection. LPN B explained that nursing judgement could be used to implement an alerting bracelet, but resident #1 gave no indication of risk for elopement. However, she stated during rounds she observed resident #1 returning to bed from the bathroom by himself. She said, I was surprised because the paperwork said assist with walking. LPN B stated she watched while resident #1 got back into bed. She stated when she found out resident #1 had eloped she was astonished and said, I don't have an answer for how it happened. On 5/16/19 at 9:22 AM, LPN C stated resident #1 was on her assignment for the 7:00 AM to 3:00 PM shift on 5/07/19. LPN C stated that the off-going night nurse gave her a change of shift report, but she was not informed that resident #1 was confused. She said, He did not seem like an elopement risk. LPN C stated that resident #1's wife was present during the shift and asked several questions about the procedure for toileting her husband. LPN C stated she oriented the wife to the room and facility routines. She explained resident #1's wife did not mention he was at risk for elopement. However, LPN C acknowledged she did not ask if the resident had any prior elopements. She stated she tried to check on newly admitted residents more frequently than other residents because she did not know them. LPN C explained it her personal standard, not required by the facility, and was not done on a specific schedule. LPN C stated she last saw resident #1 between 1:00 PM and 1:15 PM, approximately 2 hours before the end of her shift. She confirmed the East Wing UM did not discuss resident #1's risk for elopement with her prior to the elopement incident. On 5/15/19 at 2:04 PM, a tour of the facility was conducted with the Maintenance Director. He demonstrated measures used to secure the facility's exit doors. He explained the back door and the front lobby had an electronic system that would lock the door and trigger an alarm if a wander alert bracelet approached the sensor. The Maintenance Director acknowledged that if resident #1 had been wearing an alarming bracelet, the door would have locked and the receptionist would not have been able to open it until resident #1 stepped away from the door. On 5/16/19 at 1:19 PM, LPN D stated on hire, she was trained that all newly admitted residents were to be monitored by certified nursing assistants (CNAs) every 30 minutes for 72 hours. She explained CNAs used special forms to document the checks. On 5/16/19 at 1:25 PM, the East Wing desk nurse, LPN E, stated CNAs used a safety check form to document monitoring of new admissions every 30 minutes for 72 hours. She explained this procedure was in place when she started working at the facility approximately 4 years ago. LPN E explained there was a binder kept at the nurses' station for completed safety check forms. Review of the binder labeled Resident Safety Check revealed the last form was dated 3/29/19. LPN E stated to her knowledge admission nurses were still supposed to initiate 30-minute safety checks for new residents. She said, Nobody told me we are not using the book anymore. On 5/16/19 at 1:27 PM, LPN F stated she had been on staff for about 1 year and was trained in orientation to implement 30-minute monitoring for new admissions. She said, I was taught to fill out the form. On 5/16/19 at 11:00 AM, the DON stated that checking on residents every 2 hours was standard for daily normal care. She denied the facility had a policy regarding frequent monitoring of new residents. She stated there was no requirement to implement a custom 30-minute check intervention. The DON acknowledged it might have been part of the admission process at one time, and that explained the conflicting information and inconsistent monitoring. On 5/16/19 at 11:09 AM, the administrator explained there was a receptionist at the front desk from 8:00 AM to 8:00 PM. He stated visitors who arrived outside these hours used the front doorbell that rang at the East Wing nurses' station. Staff were expected to respond via an intercom and buzz visitors in. The administrator confirmed there was no live video monitoring of the front door from the East Wing nurses' station. He acknowledged that staff could not actually see who was coming in or monitor if a resident exited when the door was opened remotely. The administrator stated that staff that should accompany after hours visitors to the front door and use the keypad to unlock the door for exit. On 5/16/19 at 3:17 PM, the physical therapist (PT) stated that she did resident #1's initial evaluation on 5/07/19 at about 11:00 AM. She stated he was alert and oriented to himself but did not know where he was. The PT stated she interviewed his wife, who explained resident #1 walked around the house by himself. The wife mentioned he had 2 recent hospitalization s and worsening memory issues. The PT stated her assessment showed resident #1's gait was small steps and he was more steady with a 2-wheeled walker. She stated that he was able to walk 75 feet on a level surface with contact guard assist or hands-on support. The PT recalled resident #1's wife said, He can walk a lot. When the PT was informed that resident #1 left the facility unsupervised, without an assistive device, and traveled a distance of about ¼ mile, down a slope, navigated up and down sidewalks, curbs and some uneven pavement, she said, I would not think that was safe. On 5/16/19 at 4:07 PM, the Business Office Manager (BOM) stated she was responsible for training and supervising the receptionists. She stated at the start of every shift the receptionist was expected to review the list of residents at risk for elopement and photographs in the elopement binder. The BOM stated that the nursing department was responsible for updating the list. However, a review of the list of Patients at Risk for Elopement dated 5/16/19 revealed an inaccuracy as one resident whose photograph was in the binder was no longer on the list, although he still wore an alarming bracelet. The BOM explained that all receptionists were trained to ensure all guests signed upon entrance and exit, and wore visitor badges when in the building. She reviewed the orientation binder used to train the receptionists, but was not able to provide proof of training related to the use of a sign in and out process. The BOM did not respond when asked if the receptionist visualized resident #1 or attempted to speak to him regarding signing out as he left the building unsupervised. On 5/16/19 at 4:26 PM, the DON validated that unit managers updated the list of residents at risk for elopement every morning and throughout the day as indicated. She confirmed the list printed by the receptionist that morning had one resident's name omitted in error. She stated that there was not any system in place currently to ensure accuracy of the list at the receptionist's desk. Review of the facility's job description for receptionists revealed essential duties and responsibilities included answering the telephone, maintaining a current resident directory and announcing emergency codes and instructions. However, the job description did not include the receptionists' key role in prevention of elopement related to operation of the front lobby doors and maintaining an accurate list of residents at risk for elopement. Review of the Facility Assessment Tool updated on 4/22/19, revealed the facility accepted residents with cognitive impairment, behaviors that required interventions, Alzheimer's dementia and other types of dementia. The document did not include the ability to provide appropriate care and services for residents at risk for elopement related to these conditions, or identify the risks posed by the close proximity of 2 large retention ponds.

Based on observation, interview and record review, the facility failed to use its resources effectively to provide an adequate level of supervision to ensure the safety of newly admitted residents at risk for elopement; and failed to implement and monitor the procedure for entering and exiting for 1 of 1 sampled resident (#1). These failures contributed to the elopement of resident #1, placing him at risk for serious injury/impairment/death. While the resident was out of the facility unsupervised, there was a high likelihood the resident could have been hit by a car, drowned in the retention pond or got lost. Resident #1 was the only newly admitted resident that was capable of leaving the facility at the time of the survey. On 5/07/19 at 3:38 PM, resident #1 exited the facility through the main lobby doors, less than 24 hours after admission. He walked along the facility's driveway, passing between 2 retention ponds, crossed a 2 lane road and a private driveway, then entered a commercial complex. Resident #1 wandered into an office at the far end of the complex, 0.25 miles away from the facility. The concerned office employees contacted 911. Resident #1's whereabouts were unknown to the facility until law enforcement notified them approximately 40 minutes after the resident exited the facility. The facility's failure to identify the need for supervision for newly admitted residents and maintain a secure environment resulted in substandard quality of care at the Immediate Jeopardy level, starting on 5/16/19. The Immediate Jeopardy was ongoing at the time of the exit on 5/16/19. Cross reference to F689 Findings: Resident #1 was a [AGE] year old male admitted to the facility from the hospital on [DATE]. His primary [DIAGNOSES REDACTED]. According to the National Institutes of Health, [MEDICAL CONDITION] is a term used to describe any diffuse disease of the brain that alters brain function or structure. Causative factors could be infections and decreased blood flow to the brain. The main indicator of [MEDICAL CONDITION] is altered mental state with symptoms including progressive memory loss and decreased cognitive ability. Although treating the underlying cause of metabolic [MEDICAL CONDITION] may improve symptoms, the [MEDICAL CONDITION] may cause permanent structural changes and irreversible damage to the brain. (www.ninds.nih.gov) The Elopement Risk Screen completed on admission revealed that resident #1 was physically able to leave the building on his own and had cognitive impairment. The screening tool indicated that resident #1 did not make repetitive statements about going home or have a history of wandering or elopement. The evaluation form revealed that resident #1 had an elopement risk score of 9 indicating he was in the Category: Evaluate for Alerting Bracelet Placement. Despite this recommendation, the admission nurse decided that resident #1 was not at risk for elopement and did not place an alerting bracelet. On 5/16/19 at 9:46 AM, the East Wing Unit Manager (UM) confirmed that the nurse who evaluated resident #1 on admission did not think he was at risk for elopement. She explained that there was no process in place related to the frequency of monitoring new residents. The East Wing UM stated her expectation was that all residents would be monitored at least every 2 hours. On 5/15/19 at 9:57 AM, the Director of Nursing (DON) acknowledged that the elopement risk score indicated a bracelet should have been considered. She was asked why resident #1 did not receive an alerting bracelet based on the recommendation related to his elopement risk score. The DON explained, We were not using the actual score on its own. She stated that even if a newly admitted resident was cognitively impaired and could physically leave the facility; the alerting bracelet would not be placed unless there was a positive response to additional evaluation questions regarding a history of wandering or requests to go home. The DON stated that after resident #1's wife was informed of his elopement, she informed the facility he had a recent history of elopement. She said, If we had known he eloped before he would have had (an alerting bracelet). The DON validated resident #1 was admitted with [DIAGNOSES REDACTED]. In addition, the admission evaluation revealed he was disoriented and had moderate cognitive impairment. However, staff did not attempt to interview his wife to ensure accuracy of the elopement evaluation. The administrator confirmed that the receptionist on duty unlocked the front lobby door and resident #1 left the facility without supervision. He explained that the correct procedure was for the receptionist to ensure residents and visitors signed out prior to exiting the facility. The Regional Clinical Director (RCD) explained the facility was still investigating the elopement incident. She said, We are still narrowing down to find the root cause. We do not have a root cause yet. On 5/15/19 at 4:20 PM, the DON explained her expectation was during the normal course of the day, staff would monitor residents. She confirmed there was no specific frequency for doing rounds and safety checks on newly admitted residents. The DON acknowledged that some nurses initiated 30-minute checks for newly admitted residents, but the intervention was not consistent. The DON said, We're still investigating and trying to figure out what we can do better. We are still in the process of looking at that. We do not often get residents who wander. On 5/16/19 at 11:09 AM, the administrator explained that after-hours visitor were allowed entrance through the front lobby doors. He acknowledged that staff used an intercom system with no camera, and could not ensure residents did not leave the facility unsupervised once the door was unlocked remotely to allow visitors to come in. The Vice President of Clinical Services (VPCS) confirmed that the facility had safety meetings; however, the administrator was doubtful whether the facility assessment or the environmental hazard assessment addressed the danger of the 2 large retention ponds on both sides of facility's driveway. The Vice President of Operations (VPO) described the elopement incident as a system error and confirmed it was still under review by the Quality Assurance (QA) committee. He stated resident #1 should not have been buzzed out and acknowledged the receptionist's training was done after the fact. On 5/16/19 at 3:35 PM, the Medical Director was interviewed by telephone. She stated that newly admitted residents did not need to be monitored more frequently than familiar residents. The Medical Director said, I would expect him to be monitored just like any other resident. I believe that every 30 minutes would be too much for the staff. Every 2 to 4 hours should be sufficient for all residents including new ones. On 5/16/19 at 4:26 PM, the DON explained the system for monitoring new residents needed to be clarified and standardized. She acknowledged recent review of new admissions revealed conflicting information regarding residents' cognitive levels that affected elopement risk scores. The DON validated newly admitted residents required frequent monitoring as they could display changes in behaviors and cognitive levels during the period of adjustment to the facility's routine. She confirmed UMs were responsible for providing receptionists an updated list of residents at risk for elopement every morning. However, she confirmed that there was not any system to verify receptionists printed an accurate list as evidenced by an omission noted on the list for 5/16/19. On 5/16/19 at 5:19 PM, review of the facility's QA process related to the elopement was conducted with members of the administrative team including the administrator, DON and East Wing UM. They explained the facility was still investigating the elopement incident, but had not yet successfully determined the root cause. The DON stated the facility was still identifying new concerns during the investigative process. It was not clear how the facility decided on appropriate preventative measures without establishing a root cause for the incident. The team acknowledged the investigation had not identified the potential for elopement after hours related to staff unlocking the front lobby door without being able to visualize the area. In addition, the administrative team neither identified the need to closely monitor newly admitted residents, nor the need to properly educate and supervise receptionists to ensure adherence to procedures to prevent elopement. Review of the Facility Assessment Tool updated on 4/22/19, revealed the facility accepted residents with cognitive impairment, behaviors that required interventions, Alzheimer's dementia and other types of dementia. The document did not include the ability to provide appropriate care and services for residents at risk for elopement related to these conditions, or identify the risks posed by the close proximity of 2 large retention ponds.