Every finding on record at Village Care of King

Based on record review and Administrator interview, the facility failed to maintain and produce documented evidence of a comprehensive and ongoing Quality Assurance and Performance Improvement program that demonstrated systematic identification, reporting, investigation, analysis, and prevention of adverse events; and the development, implementation, and evaluation of corrective actions or performance improvement activities for calendar year 2025. This deficient practice had the potential to affect all 94 of 94 facility residents. Findings included: Review of the facility's 2025 Quality Assurance and Performance Improvement plan policy revealed outlined principles of making resident care decisions based on data, goal setting for performance, the measurement of progress towards said goals and the utilization of all collected quality improvement data to guide day-to-day operations within the facility.Review of the Quality Assurance and Performance Improvement committee meeting minutes from January 2025 through December 2025 revealed signatures of interdisciplinary staff members in attendance at each months' meeting. However, the reviewed meeting minutes contained no documentation of topics discussed, no identified concerns, no data tracking of concerns nor any measures taken or planned to address any such concerns in the form of a Performance Improvement Plan. In an interview with the Administrator on 1/8/26 at 3:40 PM, the Administrator said the Quality Assurance and Performance Improvement committee met every month. The Administrator said they conducted their meetings in person but used a computer-based documenting system, and they did not take down formal meeting minutes. The Administrator said that concerns were discussed verbally. The Administrator was unable to provide documentation of any identified concerns, data tracking or goals nor any ongoing Performance Improvement Plans for calendar year 2025 from the computer-based system utilized by the facility nor from any other source. She revealed there were in fact no formal ongoing Performance Improvement Plans occurring at the time of this interview nor for the previous calendar year 2025. The Administrator said that she realized it was very important to have a complete Quality Assurance and Performance Improvement plan and that it was very important to document the meeting minutes and discussion of concerns as well as to track those concerns. She indicated she would be ensuring this was done going forward.

Based on record review and staff interviews, the facility failed to develop comprehensive care plans addressing behaviors and post-traumatic stress disorder (Resident #96) and hospice care (Resident #13) for 2 of 19 residents reviewed.The findings included: 1. Resident #96 was admitted to the facility on [DATE] with diagnoses that included major depression, post-traumatic stress disorder (PTSD), and anxiety.The admission Minimum Data Set (MDS) assessment (4/24/25) indicated Resident #96 was cognitively intact and was marked as having major depression, PTSD and anxiety. Resident #96 was not marked for any behaviors and received two antidepressants during the assessment period. The most recent quarterly MDS dated [DATE] did not include any behaviors. Review of Psychiatric note dated (9/29/25) confirmed diagnoses of major depressive disorder, PTSD, and insomnia; medications included duloxetine (antidepressant) daily for depression and trazodone (antidepressant) for depression and insomnia. It was noted Resident #96 had no significant mood or anxiety concerns at that time and no changes to the medication regimen. Review of nurse progress notes from September 2025 to present documented verbal abuse toward staff and refusal of weights and blood draws. Review of Resident #96's comprehensive care plan dated 4/24/25 (last revised 12/22/25) included depression, antidepressant use, and rejection of care. There were no care plans that addressed the resident's verbal behaviors and PTSD diagnosis. During an interview with Nurse Aide #1 on 1/8/26 at 10:36 AM, she stated Resident #96 was alert and oriented and could make his needs known. She stated he was also challenging to care for at times due to refusal of care. Nurse Aide #1 stated they will usually take 2 aides in and if he is in one of his moods, they will leave the room, allow him to calm down, and then attempt the care again. During an interview with the MDS nurse on 1/8/26 at 1:48 PM, she stated that Resident #96 was not marked for behaviors on any of the MDS's since admission because they weren't everyday occurrences so there may not have been any specific verbal behaviors during his look back period. The MDS nurse stated she thought the Social Worker did the care plans for mental illness and behavior needs. During an interview on 1/8/26 at 2:08 PM with the Social Worker (SW) she stated she did not do any portions of the care plans, adding that the nursing staff would do those.During an interview with the Director of Nursing on 1/8/26 at 2:20 PM, she stated that she was aware of Resident #96's behaviors and stated he should have been care planned for verbal behaviors against staff, as well as PTSD which was stable and followed by psychiatry. The DON further stated that there was not one person responsible for creating care plans and that any nurse could update the care plan as needed and the facility would be looking into creating a process. 2. Resident # 13 was re-admitted [DATE] with hospice services following hospitalization; hospice services began 11/10/25.Review of the hospice provider notes indicated Resident #13 was accepted into hospice care services on 11/10/25. Resident #13's care plan (last revised 9/19/25) lacked a focus area, goals, or interventions for hospice care. Review of the significant change Minimum Data Set (MDS) assessment (11/12/25) confirmed hospice services. During an interview on 1/8/25 at 2:30 PM with the MDS Nurse #1, she stated hospice care services should have been included in the care plan for Resident #13. The MDS nurse indicated there wasn't just one person responsible for care plans and that any nurse could update the care plan as needed. During an interview with the Director of Nursing on 1/8/25 at 2:25 PM, she stated that not adding Hospice to Resident #13's care plan was an oversight and she revealed her expectation would have been that hospice care services were included in the care plan for Resident #13. The DON further stated that there was not one person responsible for creating care plans and that any nurse could update the care plan as needed and the facility would be looking into creating a process.

Based on record review and staff interviews, the facility failed to submit a request for an evaluation for a Level II Preadmission Screening and Resident Review (PASRR) for a resident with a serious mental health disorder for 1 of 3 residents reviewed for PASRR (Resident #96).Findings included:A PASRR Determination Notification letter dated 10/24/22 revealed Resident #96 had a Level I PASRR with no expiration date.Resident #96 was admitted to the facility on [DATE] with diagnoses that included major depression, post-traumatic stress disorder (PTSD), and anxiety.The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #96 had a serious mental illness and/or intellectual disability. He received antidepressant medication during the MDS assessment period. Pertinent diagnoses included major depression, insomnia, anxiety, and PTSD. A Psychiatric progress note dated 9/29/25 revealed Resident #96 was seen for evaluation of major depressive disorder, PTSD, and insomnia. He was taking duloxetine (an antidepressant) daily for depression and trazodone (an antidepressant) for depression and insomnia. It was noted Resident #96 had no significant mood or anxiety concerns at that time and no changes to the medication was needed. Review of Resident #96's medical record revealed there was no evidence of a Level II PASRR evaluation.The facility was unable to provide documentation that a request for an evaluation for a Level II PASRR had been submitted for Resident #96.During an interview on 1/8/26 at 2:48 PM with the Social Worker (SW) she stated Resident #96 came in with a Level 1 PASRR when he was admitted in April 2025 and she had not submitted a request for an evaluation for a Level II PASRR for him. The SW stated that the facility team usually discussed new admits during morning meetings and that was how she would know that a new admission needed PASRR screening. The SW stated she must have inadvertently missed submitting one for Resident #96.During an interview on 12/04/25 at 2:00 PM, the Administrator revealed she started employment at the facility a little over a year ago and was not sure if requests for evaluations for Level II PASRR had been submitted for Resident #96 or any resident. The Administrator stated she would expect the SW to submit a request for a new evaluation for a Level II PASRR if a resident was admitted with a serious mental health diagnosis even if they had a Level 1 done previously by another facility.

Based on record review, and staff, family member, Resident, Physician Assistant, and Medical Director interviews, the facility failed to provide supervision for Resident #1 who had a diagnosis of dementia, an addiction to cigarettes, and required supervision/touching assistance for walking 10 feet. Resident #1 left the facility unnoticed and unattended, walking along the side of a 35 mile an hour two-lane road to obtain cigarettes at a nearby store. Resident #1 was located approximately 1/2 mile away from the facility standing in a grassy field near the side of the road. The walking route to where the resident was located included an upward sloping sidewalk, a downward sloping sidewalk with a pond to the left, and then a dirt path that ended at the edge of the grassy field. Resident #1 did not have a phone, money or means to pay for cigarettes and stated she had hoped someone at the store would be kind enough to give her a cigarette and a lighter. There was a high likelihood of a serious adverse outcome for Resident #1 who had a diagnosis of dementia when she left the facility unsupervised to obtain cigarettes and was walking along the side of a 35 mile an hour two-lane road. The deficient practice occurred for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #1). Findings included:Documentation on a hospital discharge summary for the hospitalization of Resident #1 from 5/15/2025 to 5/23/2025 provided the following information. Resident #1 had the life limiting illness of progressive dementia. Resident #1 resided with Family Member #2 before her hospitalization. Resident #1 had required more help with activities of daily living over the last few months and had declining memory. Resident #1 had a fall at home resulting in fractured multiple ribs on the left side and occipital hematoma. Resident #1 was to start taking five 0.5 milligrams (mg) tablets of haloperidol (an antipsychotic medication) orally at bedtime for the treatment of agitation. Resident #1 was to stop taking 21 mg of nicotine every 24 hours, in the form of a transdermal patch.Resident #1 was admitted to the facility on [DATE] from the hospital with diagnoses of closed fracture of multiple ribs on the left side, dementia, chronic obstructive pulmonary disease, and chronic kidney disease. Resident #1 was not admitted to the facility with an initial diagnosis of agitation. Resident #1's Family Member #1 was interviewed on 6/30/2025 at 4:43 PM. Family Member #1 revealed Resident #1 had dementia and was a strong-willed person. Family Member #1 further revealed Resident #1 could not read and ambulated with a shuffling gait. An interview was conducted with the Director of Admissions on 7/1/2025 at 8:46 AM and she provided the following information. Resident #1 had previously been admitted to the facility in September 2024 for 14 days. Resident #1 did not have any issues with the non-smoking policy of the facility during her previous admission in 2024. The hospital liaison, who requested a bed offer on behalf of Resident #1 to the facility for the most recent admission, was aware the facility was a smoke free facility. The Director of Admissions reiterated and explained to Resident #1 upon admission that the facility was a smoke free facility. Resident #1 completed her own admission paperwork. In addition, the family members of Resident #1 agreed Resident #1 was cognizant enough to complete her own admission paperwork. The Director of Admissions explained all the paperwork to Resident #1, and she seemed to understand. The Director of Admissions went over the non-smoking policy of the facility with Resident #1 who responded with acknowledgment that she already knew that. The Director of Admissions revealed Resident #1 was discussed during the morning meeting when she was first admitted because she was trying to get out of the building to go outside to smoke. The Director of Admissions was not aware Resident #1 did not know how to read and felt Resident #1 had answered questions appropriately. Documentation on admission observations completed on 5/23/2025 at 1:35 PM by Nurse #2 revealed Resident #1 had no identified risks for elopement. The admission observations indicated Resident #1 did not have any diagnoses indicating cognitive impairment. In addition, admission observations noted Resident #1 was a current smoker but intended to remain non-smoking. Documentation on the baseline care plan initiated 5/23/2025 listed a care plan problem for admission of Resident #1 to the facility for skilled care. One of the approaches under this care plan problem was for wandering, stating Resident #1 would be monitored to minimize the risk of wandering or eloping. Resident #1 had a physician's order initiated on 5/23/2025 for 0.5 milligrams of haloperidol to be administered orally in the amount of 5 tablets for a total of 2.5 mg at bedtime for the diagnosis of dementia, unspecified severity, with other behavioral disturbance. An interview was conducted with the weekend Receptionist #2 on 7/1/2025 at 9:17 AM, and the following information was revealed. The first weekend Resident #1 was at the facility (5/24/2025-5/25/2025), she came to the front of the building wanting to go out the front door. Receptionist #2 did not allow Resident #1 to go outside and told her she would have to contact her nurse to make sure it was okay. Resident #1 became very argumentative and took a swing at Receptionist #1. Resident #1 left very angry to return to her room because she was not allowed outside by Receptionist #2.An interview was conducted with the Activity Director on 7/1/2025 at 11:07 AM and the following information was obtained. The only activity Resident #1 participated in while she was at the facility was the coffee and snack cart every Tuesday. The only thing Resident #1 was interested in doing was smoking. The Activity Director brought the coffee and snack cart to the room of Resident #1 on the first Tuesday (5/27/2025) she was at the facility. Resident #1 told the Activity Director that she drank a pot of coffee every morning and smoked while she drank coffee. The Activity Director stated that she saw Resident #1 in the parking lot smoking in a car with her family members the first week Resident #1 was at the facility, noting this was against the rules of the facility. An interview was conducted with the facility's Social Worker on 7/1/2025 at 10:17 AM, and the following information was revealed. The facility had an interdisciplinary meeting/care plan meeting on 5/27/2025, during which input from Resident #1 and Resident #1's family members was considered as a part of the process for new admissions. Resident #1 was reminded that she was not allowed to smoke on the facility property, but family members could come and take her off the facility property if she wanted to smoke. Resident #1 was not happy about the facility's non-smoking policy and refused the offer for nicotine patches or nicotine gum. Resident #1's family members relayed to the Social Worker that Resident #1 was a smoker, and they could not come to the facility all the time to take Resident #1 off the property to smoke. Resident #1's family members requested that an alternate placement be found for Resident #1. The Unit Manager for the hall in which Resident #1 resided, Nurse #5, was interviewed on 7/1/2025 at 3:07 PM. Nurse # 5 stated that when Resident #1 was initially admitted to the facility, it was suspected she was smoking in the bathroom because staff reported they smelled smoke in her bathroom. Nurse #5 revealed that Resident #1 told him she had been smoking since she was [AGE] years old, and she was going to die smoking because she was addicted, and it was hard to stop. Nurse #5 indicated Resident #1 was discussed in the morning clinical meetings because everyone was not sure she should be allowed outside on her own due to her cognition. Nurse #5 stated Resident #1 was usually alert and oriented to herself but had some confusion. An interview was conducted with Nurse Aide (NA #3) on 6/30/2025 at 4:11 PM. NA #3 revealed he worked the 3:00 PM to 11:00 PM shift on the hallway where Resident #1 resided. NA # 3 revealed the first week Resident #1 was in the facility, a nurse found Resident #1 with a lighter and took it away from her. NA #1 could not remember which nurse it was. NA #3 stated he recalled getting a report from a nurse aide who worked the 7:00 AM to 3:00 PM shift that Resident #1 was suspected of smoking in her bathroom because they smelled smoke in her bathroom. NA #3 reported that Resident #1 would get very frustrated at times because she wanted to try to get out the front door, but the doors lock after 5:00 PM and would not open without a code. NA #3 revealed that Resident #1 would tell him she wanted to go outside to go home to smoke. Documentation in a Situation, Background, Appearance, and Review (SBAR) dated 5/28/2025 at 3:15 PM for Resident #1, written by Nurse #4, revealed the situation or change in condition was increased agitation. The SBAR further revealed in the nursing notes portion of the document, Resident (#1) had increased agitation on wanting to smoke a cigarette. The floor nurse offered to get Resident (#1) a nicotine patch. Resident (#1) kept stating she would just leave and walk home and started to pack her belongings. Family notified and stated they would come in and talk with Resident (#1). Nurse #4 was interviewed on 7/1/2025 at 10:39 AM, and she revealed the following information. On 5/28/2025 Resident #1 was trying to get outside to smoke. Resident #1 had previously been suspected of lighting a cigarette in her bathroom on the 7:00 AM to 3:00 PM shift on that day. Staff said they smelled cigarette smoke in her bathroom, and Resident #1 was quickly flushing something down the toilet when she was confronted. A search in her belongings for cigarettes or a lighter was not conducted because Resident #1 was an alert and oriented resident. Nurse #4 explained that the Physician Assistant (PA) #1 was made aware and an order for the antipsychotic Haloperidol administered intramuscularly for Resident #1 was obtained. Resident #1 was irate and wanted to go outside to smoke. A Family Member #2 was called by Nurse #4, and she could not come to the building, so another Family Member #3 was sent to try to calm Resident #1 down. Nurse #4 had already stayed past the end of the shift, ending at 3:00 PM, to try to calm Resident #1 down, so she left before the arrival of Family Member #3. The Director of Nursing (DON) and Nurse #3 were assisting to try to calm Resident #1 down. Nurse #4 spoke with Resident #1 the following day, 5/29/2025. Resident #1 told Nurse #4 that she was so mad she was not allowed to go out and smoke the previous day, she threw her cell phone at Family Member #3 and broke it. Resident #1 told Nurse #4 she was sorry because she no longer had a functional phone. The DON was interviewed on 6/30/2025 at 12:15 PM. The DON revealed she witnessed part of a confrontation Resident #1 had with Family Member #3 next to the front office. The DON stated the argument was about cigarettes, and Resident #1 was being very physical. The DON indicated Resident #1 put her hands around the neck of Family Member #3, and Family Member #3 threw her hands down fast from her neck. The DON did not recall what day it was that she witnessed the confrontation. Nurse #3 was interviewed on 6/30/2025 at 12:18 PM. Nurse #3 revealed PA #1 was contacted on 5/28/2025 because Resident #1 was getting very agitated. Nurse #3 revealed the provider gave an order for 5 milligrams (mg) of haloperidol lactate to be administered intramuscularly (IM) via syringe every two hours as needed. Nurse #3 revealed Resident #1 did not receive the IM haloperidol on that day because it was decided she would be given her scheduled 2.5 mg tablets of haloperidol by mouth earlier, instead of at bedtime. Nurse #3 added that if Resident #1 had been allowed to smoke, she would have been fine. PA #1 was interviewed on 6/30/2025 at 2:04 PM. PA #1 explained that Resident #1 was having early symptoms of dementia such as sundowning while she was at the facility. PA #1 revealed she was notified by the Unit Manager, Nurse #5, that Resident #1 was showing physical aggression, agitation, and combativeness. PA #1 further explained Resident #1 did not have a formal diagnosis of dementia, but it was suspected she had underlying dementia. PA #1 stated Resident #1 was very agitated because she was not allowed to smoke so the order for haloperidol was for her suspected dementia and her agitation. Documentation on a care plan problem area initiated on 5/29/2025 revealed that Resident #1 had impaired cognitive function, impaired thought process relative to a diagnosis of dementia. The interventions were: use of simple, direct statements during communication to ensure resident understood; provision of cueing and prompting to ensure resident made attempts about own care before offering assistance; provision of a calm and relaxing environment; monitoring/observation and reporting changes in cognitive status; medication per physician orders; laboratory tests per physician orders; explanation of each activity/care procedure prior to beginning it and throughout procedure; establishment of daily routine; ensure resident's physiological needs were met; completion of BIMS (Basic Interview Mental Status) with MDS (Minimum Data Set) schedule and as needed; and anticipation of needs and observe for non-verbal cues.Documentation on a care plan problem area initiated on 5/29/2025 revealed Resident #1 had a health and safety risk relative to smoking. The interventions under this problem were to ensure Resident #1 was aware of the no smoking policy in the community, consultation with a medical professional for the possible use of transdermal nicotine patches to facilitate quitting, encouragement to express feelings/frustrations, and offering of a smoking cessation program.Documentation on the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was coded as cognitively intact. Resident #1 was coded as having non-Alzheimer's dementia, depression, and nicotine dependence on the assessment. The same assessment coded Resident #1 as having physical behaviors one to three days, verbal behaviors one to three days, rejection of care one to three days, and wandering behavior one to three days of the assessment period. Resident #1 was coded as using a walker and a wheelchair requiring supervision/touching assistance for walking 10 feet. The assessment coded Resident #1 as currently using tobacco.The Verification of Receipt of the Resident Handbook for the facility was signed by Resident #1 on 5/30/2025. The signature of Resident #1 verified she received a copy of the resident handbook that gave information pertaining to the rules of the facility, to include the no smoking policy on the facility property.Documentation on a care plan problem area initiated on 6/1/2025 revealed that Resident #1 required a supervised leave of absence related to dementia and impaired mobility. The interventions under this care plan problem were the education of the resident and/or family members on leave of absence policy/procedure, obtaining an order for leave of absence indicating either supervised or unsupervised leave of absence, and Resident #1's family/friend/responsible party to sign resident in or out and notify the nurse when leaving and returning with resident.An interview was conducted with the Speech Therapist #1 on 6/30/2025 at 4:35 PM. Speech Therapist #1 stated she knew Resident #1 had a diagnosis of dementia. Speech Therapist #1 relayed that on 6/2/2025, Resident #1 asked her to take her to the nearby store to get cigarettes. Speech Therapist #1 explained she told Resident #1 she was not allowed to take her from the building and reminded her of the facility no-smoking policy. Speech Therapist #1 stated she did not call a family member to tell her of the plan Resident #1 had to go to the nearby store to get cigarettes.Documentation in an MDS progress note dated 6/3/2025 at 9:01 AM, written by Nurse #1, revealed the following information. Resident #1 had wheeled herself independently outside to the front of the building with a cup of coffee. Nurse #1 informed Resident #1 that she would have to sign out if she was leaving the building, and she verbalized her understanding. Nurse #1 visualized Resident #1 park her wheelchair and lock the wheels. Nurse #1 made the staff aware that Resident #1 was outside.Nurse #1 was interviewed on 6/30/2025 at 9:57 AM. Nurse #1 confirmed she saw Resident #1 outside in front of the building on 6/3/2025. Nurse #1 revealed she informed the Director of Nursing and the Administrator at the morning stand-up meeting that Resident #1 was outside, sitting in the front of the building. Nurse #1 said she also sent an electronic message at 8:57 AM to alert the leadership that Resident #1 was outside, for which Nurse #5, the unit manager, reacted to the alert with a thumbs up.Nurse #2 was interviewed on 6/30/2025 at 10:18 AM and revealed the following information. Nurse #2 recalled she saw Resident #1 on the morning of 6/3/2025 with her coffee cup in her room during her morning medication administration pass. As the nurse aides were picking up the breakfast trays from the resident rooms, a therapist (Occupational Therapist (OT) #1) asked Nurse #2 where Resident #1 was. Nurse #2 told OT #1 that she did not know where Resident #1 was.OT #1 was interviewed on 6/30/2025 at 11:19 AM. OT #1 stated she was looking for Resident #1 on the morning of 6/3/2025, but she was not in her room. OT #1 stated she went on to provide therapy services to another resident and did not look for Resident #1. OT #1 revealed that later that day when she saw Resident #1, she told her she had left the building to obtain cigarettes at a nearby store. OT #1 indicated she had no knowledge of Resident #1's absence from the facility prior to that. OT #1 also indicated Resident #1 was a very independent person who was able to do all her activities of daily living but required supervision. OT #1 explained that Resident #1 was very motivated to do therapy, progressed quickly, and was cooperative.Receptionist #1 was interviewed on 6/30/2025 at 12:01 PM. Receptionist #1 explained that a part of her front desk responsibilities was to keep a written log of times the residents leave the building and the time they return inside. Receptionist #1 consulted her log and stated that on 6/3/2025, Resident #1 left the building at 8:54 AM and sat in front of the window in her view from her desk and reentered the building at 9:08 AM. Receptionist #1 stated Resident #1 told her she was going to her room to get a sweater. Receptionist #1 revealed she documented on the log that Resident #1 went back outside at 9:37 AM in her wheelchair on the other side of the front of the building so that she was not in the view of her desk.Nurse Aide (NA) #1 was interviewed on 6/30/2025 at 10:53 AM and relayed the following information as occurring on the morning of 6/3/2025 between 9:00 AM and 10:00 AM. NA #1 and NA #2 were giving a shower to a resident who required assistance from two people. NA #1 and NA #2 came out of the shower room, with the other resident, returned him to his room, and noted Resident #1 was standing at the nurses' station next to her wheelchair. NA #1 and NA #2 were in the other resident's room assisting him with care and exited his room together upon completion of care. Then, as NA #1 and NA #2 were walking down the hall, they noted Resident #1 was not in her room. NA #1 and NA #2 went to look in the therapy room to see if she was in there, and they did not find her. NA #1 and NA #2 knew that Resident #1 liked to sit outside, so they went to the front of the building. NA #1 and NA #2 asked Receptionist #1 if she had seen Resident #1. Receptionist #1 told NA #1 and NA #2 that Resident #1 was sitting outside in her wheelchair. NA #1 and NA #2 went outside and saw Resident #1's empty wheelchair in the front of the building. NA #1 and NA #2 went back into the building and ran back to the hall to tell Nurse #2 that Resident #1 was missing. After speaking to Nurse #2, NA #1 and NA #2 ran to the back of the building and out the door to look for Resident #1 in all the doorways and parking lots around the building. NA #1 stated that Resident #1 was dressed in a purple sweatsuit and shoes on the morning of 6/3/2025.NA #2 was interviewed on 6/30/2025 at 11:25 AM. NA #2 explained the same series of events as happened on the morning of 6/3/2025 that NA #1 had relayed in her interview regarding Resident #1 leaving the facility.Receptionist #1 was interviewed on 6/30/2025 at 12:01 PM and relayed the following events. NA #1 and NA #2 came to the front of the building and asked Receptionist #1 if she knew where Resident #1 was. Receptionist #1 told them she was sitting outside in the front of the building in her wheelchair. NA #1 and NA #2 hurried back into the building after checking outside, saying Resident #1 was not in front of the building. NA #1 and NA #2 ran to the back of the building. Receptionist #1 then received a phone call from either a family member or a friend of Resident #1 telling her that Resident #1 was at a nearby store getting cigarettes. The caller also told Receptionist #1 they were going to call the police. The Business Office Manager came to Receptionist #1's desk and asked her what was happening. After telling the Business Office Manager about the phone call, the Business Office Manager told the Maintenance Director to come with her in her car and run outside to the parking lot.The Business Office Manager was interviewed on 6/30/2025 at 10:39 AM and provided the following information. The Business Office Manager overheard Receptionist #1 talking with someone with alarm and concern in her voice, so she went to Receptionist #1's desk to find out what was happening. The Business Office Manager asked Receptionist #1 if the facility had a resident at the nearby store. The Receptionist lowered the phone and told her it was Resident #1. The Business Office Manager grabbed her car keys, saw the Maintenance Director, and told him to get in her car. When the Business Office Manager got to her car she saw NA #1 and NA #2 running around the side of the building, and the Maintenance Director was still in front of the building. The Business Office Manager told NA #1 and NA #2 to get in her car, realizing that the only reason they would be outside of the building was to look for Resident #1. The Business Office Manager drove her car up the road and saw Resident #1 standing on the grass on the left-hand side of the road, approximately half a mile from the facility. The Business Office Manager parked her car in a parking lot across the street. NA #1 and NA #2 exited the vehicle, crossing the street to get to Resident #1. Resident #1 was in a good mood and confirmed she was not injured. NA #1 and NA #2 assisted Resident #1 into her vehicle, and they all returned to the facility. As they pulled into the facility, a police car pulled in after them, stopping only momentarily to make sure they had Resident #1.The following observations were made outside on 7/1/2025 at 8:25 AM of the route, walking environment, and road speed limit taken by Resident #1 to the nearby store based on the information provided by the Business Office Manager on 6/30/2025 at 10:39 AM. Resident #1 would have had to start on an upward sloping sidewalk after exiting the facility. The sidewalk passed by a downward sloped area with a pond off to the left. Directly after the pond, the sidewalk ended, and a dirt path continued next to a forest of trees close to the road. The dirt path was uneven and continued to gradually slope uphill. After approximately a 15 to 20 minute walk, the dirt path ended at the edge of a grassy field, where Resident #1 was located on the morning of 6/3/2025. Beyond the grassy field, another 10-minute walk, was a shopping center with parking lots and intersecting roads. The posted speed limit on the road next to the facility was 35 miles per hour.Documentation on a historical weather data website revealed on 6/3/2025 there was no precipitation and temperatures at 9:00 AM were 69 degrees Fahrenheit in the location of the facility.Documentation in a nursing progress note dated 6/3/2025 at 10:35 AM written by Nurse #2 revealed the following information. Nurse #2 spoke with Resident #1's daughter advising her that Resident #1 left the front part of the building to walk to the local store to obtain cigarettes. Resident #1 was transported back to the facility by staff with a police escort. Resident #1 was assessed with no acute injuries.Nurse #2 was interviewed on 6/30/2025 at 10:18 AM. Nurse #2 explained that NA #1 and NA #2 ran to her on 6/3/2025 and told her Resident #1 was missing. Nurse #2 stated she locked her medication cart and ran to the front of the building to discover the Business Office Manager was running out the door to retrieve Resident #1 from the nearby store. Nurse #2 revealed she waited outside in front of the building with Resident #1's wheelchair, and when she returned, Nurse #2 did a quick assessment to be sure she was not injured. Nurse #2 then returned Resident #1 to her room to complete a full assessment to include neurological checks, skin assessment, and vital signs. Nurse #2 revealed she had a long talk with Resident #1, who explained to her she just wanted to get some cigarettes and smoke. Nurse #2 discovered from Resident #1 that she had called somebody who was not her daughter and told them she was going to the nearby store for cigarettes despite not having any money. Nurse #2 confirmed she called Resident #1's family members to tell them of the morning events and that Resident #1 was okay.Resident #1 was interviewed on 7/1/2025 at 1:37 PM. Resident #1 confirmed she recalled the events of 6/3/2025 when she tried to walk to a nearby store from the facility. Resident #1 stated, I've lost some of my [curse word] mind, but not all of it. Resident #1 confirmed she did not have a phone, and she was not injured on that day. Resident #1 denied she called her family on 6/3/2025 and would have cussed out who notified the facility she left the faciity on that day. Resident #1 explained she was good at walking and all she wanted was a cigarette. Resident #1 acknowledged she did not have any money or means of paying for cigarettes that day, and she did not know how she was going to obtain cigarettes on that day. Resident #1 indicated she had hoped someone at the store would have been kind enough to give her a cigarette and a lighter.Family Member #1 was interviewed on 7/1/2025 at 8:28 AM. Family Member #1 revealed Resident #1 had been smoking since she was [AGE] years old, and prior to her hospitalization, she smoked a pack of cigarettes a day or every two days. Family Member #1 also revealed that Resident #1 was not allowed to smoke when she was in the hospital, but it was not a problem. Family Member #1 confirmed Resident #1 had no means of paying for cigarettes and did not have a personal phone on 6/3/2025.Family Member #2 was interviewed on 7/1/2025 at 2:43 PM. Family Member #2 revealed she was out of town when she was called by the facility on 6/3/2025, notifying her that Resident #1 had left the faciity on her own to try to obtain cigarettes. Family Member #2 said the facility asked her to come to the facility because Resident #1 was very upset that she could not go to the nearby store. Family Member #2 said Resident #1 had only one thought, and that was how she was going to get a cigarette that day.The DON was interviewed on 6/30/2025 at 8:15 AM. The DON explained that the facility was a smoke-free facility, and the family of Resident #1 was aware of this before she was admitted . The DON stated that Resident #1's family and Resident #1 both said she would not smoke while she was at the facility, or they would take her off the property to smoke. The DON further explained that staff members who smoke or residents who were smokers at the time of the transition to a non-smoking facility, had to go to the edge of the facility property and stand in a field to smoke. The DON confirmed there was no smoking on the facility property to include the parking lot. The DON acknowledged that Resident #1 was adamant about smoking cigarettes and refused any nicotine gum or patches after she was admitted . The DON also acknowledged that Resident #1 was not safe to walk by herself outside. The DON explained that Resident #1 was alert and oriented and had a strong personality, so multiple conversations were had with the family to try to resolve the issue of the facility being smoke-free.The facility Administrator was interviewed on 7/1/2025 at 1:17 PM. The Administrator stated Resident #1 had a plan and she was aware she did not have any money on 6/3/2025. The Administrator stated that Resident #1 told her she was going to have someone give her a cigarette at the local store.The facility Medical Director was interviewed on 7/7/2025 at 11:16 AM. The Medical Director stated that he saw Resident #1 one time upon admission. The Medical Director relayed that he knew cognition was an issue for Resident #1, as she had sufficient cognitive skills to leave the building undetected with a purposefully executed plan, but lacked the cognitive skills to realize it was a poor decision.The facility was notified of the immediate jeopardy on 7/1/2025 at 4:00 PM.The facility provided the following corrective action plan: 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice.On 6/3/25 Resident #1 had an unsupervised departure from the facility. She walked down the side of a two-lane road to obtain cigarettes from a local grocery store. Resident #1 was visualized going outside on to the covered porch to drink coffee around 8:54am and was observed around 9:37am going back outside after getting a sweatshirt. The receptionist received a phone call from the resident's family member stating Resident # 1 had called her to report that she was walking to the store to obtain cigarettes. The business office manager and two certified nurse assistants got into a vehicle and observed resident #1 walking on the side of the road. Resident #1 got into the vehicle with staff and returned to the facility at approximately 10:00am. A licensed nurse completed a head-to-toe assessment on resident #1 and no injuries were noted. The provider was notified, and an order was obtained to place a wander guard alarm, and resident #1 was also placed on 1:1 supervision by facility staff as an immediate intervention to keep Resident #1 safe. Resident #1 remained on 1:1 staff supervision until she was discharged on 6/5/25 to an Assisted Living Facility that allowed smoking. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. On 6/3/25 when the facility was made aware that resident #1 had departed the building unsupervised the director of nursing completed an immediate head count of other residents in the facility, all other residents were accounted for. The maintenance director immediately checked door alarms and the wander guard system. Doors and the wander guard system were found to be in working order. The director of nursing and nurse managers reviewed current residents with a wander guard alarm to ensure that their wander guards were in place and functioning correctly. No issues were identified. The director of nursing or designee reviewed all residents in the facility for changes in behaviors and completed another elopement assessment. There were no other residents newly identified at risk for elopement. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Beginning 6/3/25 the director of nursing or designee educated all staff in the facility on the facility elopement policy. 1. Upon discovery that a resident cannot be located a head count will be conducted. If the resident is still missing a code green is to be announced on the facility paging system to alert all staff to assist in locating the missing resident. 2. The clinical supervisor will notify the Administrator, the Director of nursing and the attending physician. 3. The highest-ranking staff member will become the team leader and coordinate the search. 4. The

Based on record review and staff interviews, the facility failed to implement their abuse policy and procedure in the area of reporting when Nursing Assistant (NA) #6 failed to immediately report she had observed NA #5 physically and verbally abuse Resident #4 when NA #5 held the resident's arms down on the bed, told him to shut up and put her gloved hand over Resident #4's mouth while providing incontinence care for 1 of 2 residents reviewed for abuse (Resident #4). The findings included: The facility policy for Abuse, Neglect and Exploitation, last reviewed on 7/11/2024, revealed the following statement: All allegations of abuse, neglect, involuntary seclusion, injuries of unknown source, and misappropriation of resident property must be reported immediately to the Administrator and Director of Nursing (DON). Review of the investigation report specified an allegation of abuse for Resident #4 that occurred on 6/26/2025 at about 11:00 PM. This allegation was reported by NA #6 to the facility Administrator on 6/27/25 at 3:40 PM. NA# 6 observed NA #5 put her hand over Resident #4 mouth without any type of force and told him to shut up. NA #5 was immediately suspended and skin checks completed on Resident #4. Interviews with alert and oriented residents were conducted by the facility. NA #6 was reeducated on timely reporting. A telephone interview on 7/8/2025 at 1:05 PM with NA # 6 revealed that she was working with NA #5 on 6/26/2025 during second shift (3:00 PM -11:00 PM). NA #7 and NA #8 arrived at work for the third shift (11:00 PM - 7:00 AM), and during the rounds, NA #7 stated that there were residents who were not dry. NA #7 instructed NA #5 to provide incontinence care for Resident #4. NA #6 stated that she and NA #5 and went to Resident #4's room to provide incontinent care. NA #6 indicated NA# 5 held Resident #4's arms down because he flailed his arms during care. NA #6 recalled NA #5 voiced, Sometimes you have to be aggressive with them. Resident #4 growled, and NA #5 told him to Shut up. NA #6 stated that Resident #4 was lying on his side, and she had turned her back to retrieve a washcloth from the nightstand. When she turned around, NA #5 quickly removed her gloved hand from over Resident #4's mouth, and they finished his care and covered him with a blanket. NA #6 stated she was shocked by NA #5's behavior and went home and told her family member what had happened. The family member told NA #6 to tell the facility. She indicated that she was a new nursing assistant graduate, and she hated confrontation, and she was afraid that NA #5 might say something to her if she said anything about what she saw. The next day, she reported what she saw to Scheduler. NA #6 further stated she was educated during orientation on abuse, and she couldn't remember who to tell. NA#6 explained that she felt very comfortable who to report abuse and when to report abuse. Now that she had gone through this situation and had been reeducated. She was shocked by NA#5 behavior towards the resident and told the Scheduler because she was comfortable with her. During a telephone interview on 7/11/2025 at 9:13 AM, NA #5 stated that on 6/26/2025, she was behind on her incontinent rounds and had not completed Resident #4's incontinent care. She worked in the same hall as NA #6, and they provided care for Resident #4. NA #5 stated that Resident #4 didn't like to have incontinence care, and he hit and scratched during care. NA #5 stated she tried to explain to Resident #4 that she was going to change him. NA #5 said she gently held his arms to the bed while he was lying on his back. NA #6 pulled the incontinent product from under him and Resident #4 had completely saturated the bed. NA #5 stated that he was soaked because she couldn't get to him earlier in the shift because she helped NA #6 with her assignment. She denied that she told Resident #4 to shut up or that she put her hand over his face. NA #5 indicated she usually did rounds after dinner and at 10:30 PM. During a telephone interview on 7/8/2025 at 2:29 PM Nurse #7 stated he was the nurse during the evening shift on 6/26/2025 and was not told about the abuse by NA #6. He did not observe any behavior from NA #6 that gave him an indication that she had observed abuse. Nurse #7 indicated he did not observe behavior from NA #5 that was out of the ordinary, it was a normal evening shift. He had not heard any residents cry out while NA #5 was providing care. An interview was conducted on 7/27/2026 at 2:58 PM with the Scheduler, who stated that NA #6 came into her office on 6/27/2025 around 3:45 PM and expressed she needed to talk. The Scheduler stated NA #6 shut the door and proceeded to explain the incident involving Resident #4 that had occurred on the night of 6/26/2025. NA #6 explained she had helped NA #5 with care the previous and NA #5 told Resident #4 to shut up. The Scheduler had NA #6 stop explaining, and both (Scheduler and NA #6) went directly to speak with the Director of Nursing (DON). During an interview with DON on 7/8/2025 at 12:23 PM, she stated that Nursing Assistants from the 3rd shift had complained that NA #5 did not like to do rounds and that she had residents who required incontinence care at the beginning of the shift change. The DON stated she thought that she had provided NA #5 with reeducation for not providing care but was not sure. NA #6 reported to the DON on 6/27/2025 around 3:40 PM that she had observed NA #5 physically and verbally abusing Resident #4 on 6/26/25 and that NA #5 held her hand over Resident #4's mouth. NA #6 also reported to the DON that NA #5 told Resident #4 to shut up during care. The DON explained that NA #6 was immediately reeducated to report any abuse immediately to the supervisor. The DON stated Resident #4 was not interviewable and underwent a head-to-toe body assessment; there were no injuries observed or noted Resident #4 did not exhibit any changes in behavior. The facility started an abuse investigation on 6/27/2025. On 7/8/2025 at 4:21 PM, the Administrator was interviewed and stated that all abuse should be reported to her immediately. The Administrator further expressed that she was informed by the Director of Nursing of the abuse allegation on 6/27/2025. The facility provided the following corrective action plan with a compliance date of 6/28/25. How will corrective action be accomplished for those residents found to have been affected by the deficient practice? On 6/27/2025, Certified Nursing Assistant #6 reported an allegation of abuse that happened the night before to the Director of Nursing. The Director of Nursing notified the Administrator. The Director of Nursing called CNA #5 (the accused staff member), suspended her, and took her statement regarding the incident. The NHA notified the Police Department, Adult Protective Services, and submitted an initial allegation to the Department of Health Services Regulation. The DON started abuse education for staff who were present in the facility. Nurse #1 performed a head-to-toe assessment of Resident #4 with no negative findings noted. Nurse # 1 notified the Provider with no new orders given and notified Resident #4's responsible party. The Administrator interviewed CNA #6 and obtained her statement. CNA #6 was educated on the Abuse Policy to include immediate reporting of suspected abuse by the DON on 6/27/2025. NHA provided emotional support for Resident #4, who was calm and had no recollection of any incident. NA #5 informed the Director of Nursing that she resigned from her position on 7/2/25. How will the facility identify other residents having the potential to be affected by the same deficient practice? On 6/27/25, the social worker or designee interviewed all alert and oriented residents to determine if they were aware of any abuse. The Director of Nursing or designee performed a skin check on all non-alert residents. The Director of Nursing/Designee interviewed all staff to determine if they were aware of any abuse that had not been reported. These interviews and observations were completed by 6/27/2025. No other maltreatment was identified as not reported. What measures will be put into place or systemic changes made to ensure that the deficient practice will not occur?To prevent this from happening again, the DON/Designee educated current staff on the abuse policy, including immediately reporting abuse to the administrator. This education was completed on 6/27/2025. Any staff member not working received the education before working their first shift. Agency staff were educated on first shift working. Newly hired staff to the facility will be educated on the onboarding procedure. The scheduler is responsible for ensuring all agency staff are educated, and Human Resources is responsible for ensuring that all newly hired staff are educated. How will the facility monitor its corrective actions to ensure the deficient practice will not recur?To monitor and maintain ongoing compliance, the DON/Designee will interview two staff members if they have any knowledge of abuse that has not been reported, and if they know when abuse should be reported, weekly for 12 weeks. Any negative findings will be followed immediately by the Administrator. The Administrator and Director of Nursing discussed Resident #4's allegation of abuse on 6/27/2025 and determined to have an ADHOC Quality Assurance Process Improvement (QAPI) meeting. ADHOC QAPI was held on 6/27/2025 with the Interdisciplinary team to discuss the incident with Resident #4 and educate the team on the interventions that were put into place to prevent further incidents. The Medical Director was notified by the Director of Nursing via phone on 6/27/2025 regarding the abuse allegation and the interventions that were put in place for Resident #4 and the plan of correction for late abuse reporting. The Director of Nursing implemented the plan of correction for late abuse reporting on 6/27/2025. The Interdisciplinary team will review and provide recommendations on the audit results provided by the Director of Nursing and or Designee during the QAPI meeting for the next 3 months to ensure sustained compliance if supposed noncompliance was identified during these three months. In that case, immediate correction, re-education to staff members, and an ADHOC QAPI meeting will be held to address the noncompliance and make recommendations for adjustments to the plan. The Administrator and Director of Nursing will ensure the corrective action plan is implemented. Alleged Date of Compliance: 6/28/2025The facility's corrective action plan was validated on 7/7/2025 by validating the following:- NA#5 was suspended pending investigation and never returned to work. - Interviews with staff verified that staff were educated and were able to articulate who to report abuse to and when to report abuse.- Facility-provided records of residents who were interviewable and were interviewed about abuse that they did not report to the social worker. - Facility records revealed that non-interviewable residents had head-to-toe assessments for injury by the DON with the nursing staff. - Facility records revealed nursing, dietary, housekeeping, activity and maintenance departments were reeducated by the DON on the abuse policy, with an emphasis on reporting. - The facility provided evidence they had conducted audits with two random staff members to verify who to report abuse to and when to report abuse by the DON or designee. - Documents were prepared to continue with future audits of residents for unreported abuse.- The QAPI IDT team was to discuss compliance with reporting abuse by the DON, verified with documents. The corrective action plan compliance date of 6/28/25 was validated.

Based on record review and staff interviews, the facility failed to protect a severely cognitively impaired resident's right to be free from physical and verbal abuse. During care on 6/26/2025 Nursing Assistant (NA) #5 held the resident's arms down on the bed, told him to shut up, and put her gloved hand over Resident #4's mouth while assisting with incontinence care. This deficient practice occurred for 1 of 2 residents reviewed for abuse (Resident #4).The findings included: Resident #4 was admitted on [DATE] with the diagnosis of non-Alzheimer's dementia. The quarterly Minimum Data Set, dated [DATE] revealed Resident #4 was severely cognitively impaired and was dependent on staff to turn in bed, with activities of daily living and incontinence care. Resident #4 did not refuse care and had no behavior towards staff. The most recent care plan, revised 3/7/2025, revealed Resident #4 had cognitive loss related to dementia. The goal was to provide positive experiences in his daily routine without overly demanding tasks and to avoid causing stress by anticipating and meeting Resident #4's needs. He was incontinent of bowel and bladder. The goal was that Resident #4 would not experience complications related to his incontinence. The interventions were for the nursing staff to assist with toileting, hygiene, and transfers as needed. A telephone interview was completed on 7/8/2025 at 3:37 PM with NA #7. NA #7 explained on the night of 6/26/2025 she arrived at work at 11:00 PM and took over NA #5's resident assignments. NA #5 voiced to NA 7 that she had done her incontinent care at 8:00 PM. During the rounds, NA #7 stated residents assigned to NA #5 were either wet or soiled. NA #7 further explained that she instructed NA #5 to provide incontinence care for Resident #4 before clocking out. NA #5 was agitated and instructed NA #6 to assist her in providing care to Resident #4. NA #7 observed that NA #6 was tearful at the nursing station, but she did not know the reason. NA #5 did not mention any abuse. During a telephone interview on 7/9/2025 at 8:31 AM, NA #8 stated that NA #5 left residents wet or soiled at the change of shift at 11:00PM. NA #7 went to check the residents assigned to NA #5 and found them to be soiled or wet. NA #7 instructed NA #5 to provide incontinent care for Resident #4 before she clocked out. NA #5 was talking under her breath and rolling her eyes. She took NA #6 and completed the incontinent care for Resident #4. After the care was completed, NA #5 was at the nursing station, and she was angry and speaking loudly. NA #6 was crying and did not say that NA #5 had abused Resident #4. A telephone interview on 7/8/2025 at 1:05 PM with NA # 6 revealed that she was working with NA #5 on 6/26/2025 during second shift (3:00 PM -11:00 PM). NA #7 and NA #8 arrived at work for the third shift (11:00 PM - 7:00 AM), and during the rounds, NA #7 stated that there were residents who were not dry. NA #7 instructed NA #5 to provide incontinence care for Resident #4. NA #6 stated that she and NA #5 and went to Resident #4's room to provide incontinent care. NA #6 indicated NA# 5 held Resident #4's arms down because he flailed his arms during care. NA #6 recalled NA #5 voiced, Sometimes you have to be aggressive with them. Resident #4 growled, and NA #5 told him to Shut up. NA #6 stated that Resident #4 was lying on his side, and she had turned her back to retrieve a washcloth from the nightstand. When she turned around, NA #5 quickly removed her gloved hand from over Resident #4's mouth, and they finished his care and covered him with a blanket. NA #5 did not know if Resident #4's mouth was touched. NA #6 stated she was shocked by NA #5's behavior. Review of a facility submitted investigation report 6/27/2025 specified an allegation of abuse for Resident #4 that occurred on 6/26/2025. The allegation was reported by NA #6 to the facility Administrator on 6/27/25. Nurse Aide #5's handwritten note dated 6/30/2025 indicated that she held Resident #4's arms down due to the resident being combative and trying to hit. NA #5 denied that she put her hand over his mouth. During a telephone interview on 7/11/2025 at 9:13 AM, NA #5 stated that on 6/26/2025, she was behind on her incontinent rounds and had not completed Resident #4's incontinent care. She worked on the same hall as NA #6, and they provided care for Resident #4. NA #5 stated that Resident #4 didn't like to have incontinent care, and he hit and scratched during care. NA #5 stated she tried to explain to Resident #4 that she was going to change him. NA #5 stated she gently held his arms to the bed while he was lying on his back. NA #6 pulled the incontinent product from under him and Resident #4 had completely saturated the bed. NA #5 stated that he was soaked because she couldn't get to him earlier in the shift because she helped NA #6 with her assignment. She denied that she told Resident #4 to shut up or that she put her hand over his face. NA #5 indicated she usually did rounds after dinner and at 10:30 PM. During a telephone interview on 7/8/2025 at 2:29 PM Nurse #7 stated he was the nurse during the evening shift on 6/26/2025 and was not told about the abuse by NA #6. He did not observe any behavior from NA #6 that gave him an indication that she had observed abuse. Nurse #7 indicated he did not observe behavior from NA #5 that was out of the ordinary, it was a normal evening shift. He had not heard any residents cry out while NA #5 was providing care. An interview with the Director of Nursing (DON) on 7/8/2025 at 12:23 PM stated that nursing assistants from the third shift (11:00 PM to 7:00 AM) had complained that NA #5 did not like to do rounds and that she had left residents soiled who needed incontinence care at the beginning of the shift. The DON recalled that she had provided NA #5 with reeducation for not providing care but was not sure. NA #6 reported to the DON on 6/27/2025 around 3:40 PM that she had observed NA #5 physically and verbally abusing Resident #4 on 6/26/25 and that NA #5 held her hand over Resident #4's mouth. NA #6 also reported NA #5 told Resident #4 to shut up during care. NA #5 was immediately suspended and never returned to work at the facility. Resident #4 was not interviewable and had a head-to-toe body assessment, and there were no injuries. There was no change in Resident #4's behavior. The facility started an investigation 6/27/2025. A skin assessment was conducted by Nurse #4 on 6/27/2025 at 3:27 PM with Resident #4 after an allegation of abuse. No injury was noted. An interview on 7/8/2025 at 11:10 AM with Nurse #4 was completed. Nurse #4 stated on 6/27/2025 that she assessed Resident #4 head to toe for new injuries. Resident #4 was at his baseline and had no injuries. During an interview on 7/8/2025 at 11:15 AM, NA #8 revealed that Resident #4 did not hit staff during incontinence care; he verbally objected. On 7/8/2025 at 4:21 PM, the Administrator stated that the investigation they conducted was unsubstantiated for abuse because they did not find any proof of abuse. The facility provided the following corrective action plan with a compliance date 6/28/25.How will corrective action be accomplished for those residents found to have been affected by the deficient practice? On 6/27/2025 Certified Nursing Assistant (CNA) #6 reported allegation of abuse to the Director of Nursing (DON). The Director of Nursing notified the Administrator. The Director of Nursing called CNA # 5 (the accused staff member), suspended her, and took her statement regarding incident. The Nursing Home Administrator (NHA) notified the Police Department, Adult Protective Services and submitted an initial allegation to the Department of Health Services Regulation. The DON started abuse education for staff who were present in the facility to include dealing with behaviors exhibited by the resident in question. Nurse #4 performed head- to-toe assessment of Resident #4 with no negative findings noted. Nurse #4 notified the Provider with no new orders and notified Resident #4's responsible party. The Administrator interviewed CNA #5 and obtained her statement. CNA #6 was educated on the Abuse Policy and reporting by the DON on 6/27/2025. NHA provided emotional support for Resident #4 who was calm and had no recollection of any incident How will the facility identify other residents having the potential to be affected by the same deficient practice? To identify like residents that have the potential to be affected the Director of Nursing/Designee completed skin checks on residents with BIMS less than 12 for any signs and symptoms of abuse. No negative findings noted. The NHA/Designee interviewed residents with BIMS of 12 or above if they are aware of or have experienced any abuse. No negative findings noted. These interviews and observations were completed by 6/27/2025. On 6/27/25 the Interdisciplinary Team (IDT), which consists of the Director of Nursing, Administrator, Nurse Managers, Social Worker (SW), Dietary Manager, and Minimum Data Set Coordinator, reviewed residents with behaviors during their resident review meeting. Any resident identified with behaviors making them more at risk for abuse were reviewed by the interdisciplinary team and interventions were updated on the resident care plan and staff are informed of new interventions during pre-shift huddles. What measures will be put into place or systemic changes be made to ensure that the deficient practice will not occur? To prevent this from happening again on 6/27/25 the DON/Designee was notified by the Administrator to educate all current staff on the abuse policy and reporting. Education included recognizing signs of burn-out, frustration, stress and appropriate interventions to deal with aggressive residents. If staff recognized burn out, they are to report to their supervisor. Staff will be educated annually to prevent abuse and also periodically throughout their employment. Any staff not working received the education prior to working their first shift. Agency staff will be educated upon first shift working. Newly hired staff will be educated with the onboarding procedure. The Director of Nursing is responsible for ensuring all current staff are educated on the abuse and neglect policy and the Social Worker is responsible for ensuring new hired staff are educated during the onboarding process, the Scheduler is responsible for ensuring all agency staff receive the education. Previous to 6/27/25, the Payroll Coordinator was only verifying dates of employment with previous employers. On 6/27/25 the Administrator educated the Payroll Coordinator to obtain reference checks and request additional performance information. How will the facility monitor its corrective actions to ensure the deficient practice will not recur? The Administrator and Director of Nursing discussed Resident #4 and the allegation of abuse on 6/27/2025 and determined to have ADHOC Quality Assurance Process Improvement (QAPI) meeting. ADHOC QAPI was held on 6/27/2025 with the Interdisciplinary team to discuss the incident with Resident #4 and educate the team on the interventions that were put into place to prevent further incidents. The Medical Director was notified by the Director of Nursing via phone on 6/27/2025 regarding the abuse allegation and what interventions that were put in place for Resident #4 and the plan of correction to prevent abuse. The Director of Nursing implemented the plan of correction to prevent abuse on 6/27/2025.To monitor and maintain ongoing compliance the SW/Designee will interview 2 residents with BIMS of 12 weekly, if they are aware of any concerning behavior of staff that may lead to abuse. DON/Designee will observe 2 staff on rotating shifts performing care for any signs of abuse weekly. Audits will continue for 12 weeks. Any negative findings will be followed by the Administrator. The Interdisciplinary team will review and provide recommendations on the audit results provided by the Director of Nursing and or Designee during the QAPI meeting for the next 3 months to ensure sustained compliance. If noncompliance is identified during these three months, immediate correction, re-education to staff members and an ADHOC QAPI meeting will be held to address the noncompliance and make recommendations for adjustments to the plan. The Administrator and Director of Nursing will ensure the corrective action plan is implemented. Alleged Date of Compliance 6/28/2025 The facility's corrective action plan was validated on 7/7/2025 by validating the following:- NA#5 was suspended pending investigation and never returned to work. - Interviews with staff in all departments verified they were educated and were able to articulate abuse policy, abuse prevention, and recognizing signs of burn-out, frustration, stress and appropriate interventions to deal with aggressive residents. In addition, staff stated if they recognized burn-out in themselves or another staff member they would report it to their supervisor.- Facility provided records of residents who were interviewed to determine if they were aware of or had experienced any abuse. - Review of facility records revealed all residents with a BIMS score of 12 or less had a head-to-toe assessment for injury by the DON with the nursing staff. - The facility provided evidence they had conducted audits of staff providing care and the SW/Designee completed interviews with residents with a BIMS score of 12 or greater as specified in the corrective action plan. - Inclusion in QAPI was verified. The corrective action plan compliance date of 6/28/25 was validated.

Based on record review, and resident and staff interviews, the facility failed to provide care in a safe manner for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #1). On 10/22/24 Resident #1 was lifted manually by Nursing Assistant (NA) #1 from the shower chair to the bed, causing Resident #1 right leg to hit the shower chair, get caught in between the shower chair and the bed, causing severe pain and swelling. An x-ray completed on 10/24/24 confirmed Resident #1 sustained an acute distal tibia/fibula (the two long bones in the lower leg) fracture. Findings included: Resident #1 was admitted to the facility on [DATE] with diagnosis that included right hand contracture, spondylolisthesis (a condition where a vertebra in the spine slips out of place and onto the bone below it), spinal stenosis (narrowing of the spinal canal that occurs over time), and hypertension. Resident #1's quarterly Minimum Data Set (MDS) dated [DATE] revealed she was cognitively intact, with no behaviors and weighed 104 pounds. The quarterly assessment further indicated Resident #1 had impaired functional limitation in range of motion to both sides of her upper extremity (shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle, foot) and required a wheelchair for mobility. The quarterly assessment also indicated Resident #1 was dependent (Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with transferring from chair/bed-to-chair transfer (the ability to transfer to and from a bed to a chair [or wheelchair]) and was unable to walk. An interview with the Regional Nurse Consultant was conducted on 01/09/25 at 2:18 pm. The Regional Nurse Consultant indicated that she could not provide the printed and updated manual care plan for Resident #1, because the Care Plan books for all residents were missing. The Regional Nurse Consultant provided a care plan for Resident #1 which was revised after the incident on 10/22/24. Interview with the Rehabilitation Director was conducted on 01/10/25 at 10:29 am. The Rehabilitation Director stated Resident #1 could not walk or bear any weight to her extremities prior to the incident that occurred. The Rehabilitation Director further stated Resident #1's last transfer status, assessed by the therapy department, indicated Resident #1 transfer status as maximum assistance (staff does more than half the effort) with 2 people with sliding board. The Rehabilitation Director indicated Resident #1 was non weight bearing and was supposed to be transferred using a sliding board due to the fact that her lower extremities were contracted, and she could not stand. The Rehabilitation Director noted that therapy does not instruct any staff to lift residents manually. The Rehabilitation Director added that if a resident is not able to bear weight, they recommend that staff use sliding board or mechanical lift. The Rehabilitation Director indicated that as far as she knew, Resident #1 was always maximum assistance of one to two persons using a sliding board for transfers, prior to 10/24/24. The Point of Care History report for What appliances or assistive devices were used for transferring? dated 10/01/24 -10/31/24 was reviewed. The report indicated that NA #3 documented on 10/02/24 at 4:40 pm lifted manually. A telephone interview was conducted with NA #3 on 01/09/25 at 2:39 pm. NA #3 indicated that she had cared for Resident #1 and that Resident #1 needed extensive assistance with transfers and did not recall Resident #1 using mechanical lift for transfers prior to her incident on 10/22/24. The Point of Care History report for Type of bath? dated 10/01/24 -10/31/24 was reviewed. The report indicated that NA #2 documented on 10/22/24 at 11:57 am that Resident #1 had received a shower. The Point of Care History report for How did resident transfer? dated 10/01/24 -10/31/24 was reviewed. The report indicated that NA #2 documented on 10/22/24 at 11:57 am that Resident #1 was total dependence. The Point of Care History report for Staff support provided for transferring? dated 10/01/24 -10/31/24 was reviewed. The report indicated that NA #2 documented on 10/22/24 at 11:57 am that Resident #1 required 1-person physical assist. The Point of Care History report for What appliances or assistive devices were used for transferring? dated 10/01/24 -10/31/24 was reviewed. The report indicated that NA #2 documented on 10/22/24 at 11:57 am that transfer aid. An interview was conducted with Resident #1 on 01/08/25 at 1:15 pm. Resident #1 indicated that she recalled when her right leg got hurt. Resident #1 indicated that NA #1 had just finished giving her a shower and had returned Resident #1 to the room. Resident #1 indicated that she was on the shower chair, when NA #1 lifted her manually to transfer her back to bed. Resident #1 indicated that NA #1 transferred her by using NA #1's two arms underneath Resident #1's underarms and lifting her off the shower chair onto the bed. Resident #1 indicated that she could not stand or walk. Resident #1 indicated that NA #1 did not use a mechanical lift for the transfer, and no staff, Nurse or NA, ever used a mechanical lift to transfer her prior to that incident. Resident #1 indicated that majority of the time staff lifted her manually and a couple of times staff used a sliding board to transfer her. Resident #1 indicated that sometimes it would be one staff member lifting her manually during a transfer or two staff lifting her manually, but no one ever used a mechanical lift to transfer her. Resident #1 indicated that when NA #1 lifted her manually from the shower chair to the bed, Resident #1's right leg hit the chair and got stuck between the shower chair and bed. Resident #1 indicated that she informed NA #1 that she was hurting. Resident #1 indicated that NA #1 proceeded with lifting her manually during the transfer, even after informing her that her leg was in severe pain of a 10/10 (with 0 being the least pain and 10 being the worst pain imaginable). Resident #1 indicated NA #1 completed the transfer and placed her in bed and she did not fall during the transfer. Resident #1 indicated that NA #1 did not have another NA assist her during the transfer from the shower chair to the bed. Resident #1 indicated that no nurse came in to assess her after she had reported to NA #1 that her leg was in severe pain. Resident #1 indicated that days later, the pain got worse, and she could not bear it. Resident #1 indicated that she informed another NA (Resident could not recall name) about her pain getting worse. Resident #1 indicated at that time, Nurse #5 came in to assess her and that Nurse #5 was the only nurse who assessed her right leg. Resident #1 indicated that her pain was 10/10. Resident #1 indicated that Nurse #5 notified the provider, who ordered an x-ray that revealed she had fracture. Resident #1 indicated that she refused to go to the hospital and opted to be seen by an orthopedic doctor. Resident #1 indicated that she received new orders for additional pain medication for the severe pain in her right leg. Resident #1 indicated that facility staff initiated using a mechanical lift for transfer only after x-ray results showed she had a fracture to her right leg. Written statement from NA #1, with no date indicated, was reviewed. The statement stated, I NA #1 gave Resident #1 a shower and transferred her to bed with another NA in the room. At this time and Resident #1 said she hurt but proceeded to tell NA#1 that she (Resident#1) was ok and not to worry. Resident #1 was fine, and NA#1 did report it to the nurse. A telephone interview was conducted with NA #1 on 01/10/25 at 9:08 am. NA #1 indicated that she worked from 7:00 am to 3:00 pm on 10/22/24 and provided care to Resident #1. NA #1 stated on 10/22/24, Resident #1 had a shower scheduled. NA #1 indicated that Resident #1 was in bed and needed to be transferred from the bed to the shower chair. NA #1 stated that she asked NA #2 to assist her during the transfer. NA #1 indicated that NA #2 held onto the shower chair so that Resident #1 could be transferred. NA #1 revealed that, while NA #2 was holding onto the shower chair, she lifted Resident #1 manually because Resident #1 was not able to put her feet on the floor because they (Resident #1's legs) were contracted. NA #1 confirmed that Resident #1's feet never touched the floor, while she lifted her manually from the bed onto the shower chair. NA #1 indicated Resident #1 was not able to bear her own weight on both lower extremities and Resident #1 was not able to walk. NA #1 stated that there was no emergency situation occurring that would have required for her to lift Resident #1 manually, and that she was just transferring Resident #1 per care plan. NA #1 indicated that Resident #1 did not have any concerns during the shower. NA #1 indicated, after she completed the shower, she took Resident #1 back to her room, to transfer her back to bed at around 11:00 am. NA #1 indicated that during this transfer (from shower chair to bed) she did not have any other staff to assist. NA #1 indicated that she transferred Resident #1 from the shower chair to the bed, by lifting her manually, with Resident #1 feet not touching the floor. NA #1 indicated that she placed Resident #1 on the bed. NA #1 stated that Resident #1 did not fall during transfer. NA #1 further stated, she could not recall if Resident #1 hit her leg or foot on anything during transfer. NA #1 revealed she did not recall if Resident #1's foot got stuck between the shower chair and the bed during transfer. NA #1 indicated that after completion of the transfer and Resident #1 was in bed, Resident #1 verbalized that her leg was hurting but she was fine. NA #1 indicated that she reported to Nurse #1 that Resident #1 complained that her leg was hurting. NA #1 indicated that Nurse #1 did not go to assess Resident #1 or ask Resident #1 about the pain. NA #1 indicated that after this day (10/22/24), she worked again from 7:00 am to about 3:00 pm on 10/24/24 and provided care to Resident #1. NA #1 indicated that Regional Nurse Consultant informed her that she would be suspended for breaking Resident #1's leg due to not transferring her using a total mechanical lift. NA #1 indicated that Resident #1 did not have a care plan to transfer Resident #1 using a total mechanical lift. NA #1 indicated that the care plan indicated that Resident #1 required extensive assistance of one person to transfer. NA #1 indicated that on 10/24/24, she was informed by Nurse #5 that Resident #1 was supposed to be a mechanical lift. NA #1 indicated that when she looked for the care plan books with Nurse #5 at the nursing station, the care plan books were missing. NA #1 indicated that Resident #1 never had a care plan to use a mechanical lift and that all staff lifted Resident #1 manually during all transfers. Written statement from NA#2, dated 10/24/24 was reviewed. NA #2 indicated, On 10/24/24 I received a call from facility on behalf of Resident #1 and informed me that Resident #1 leg was broken. 10/22/24 Resident #1 shower day, I witnessed another transfer Resident #1 to shower chair. NA pick Resident #1 up and put Resident #1 in shower chair. Also, on 10/24/24 facility informed that Resident #1 is a mechanical lift. I only witness the transfer from bed to shower chair. I did not make any contact with Resident #1. Multiple attempts made to reach NA #2 for an interview were unsuccessful. A progress note dated 10/24/24 at 10:41 am written by Nurse #5 revealed that during morning medication pass author noted new medication for lidocaine patch to right leg. Author asked Resident #1 what happened to her leg that she is now needing that. Resident #1 stated on Tuesday (10/22/24) her leg got caught when being transferred and her leg has been hurting on/off since. Author asked Resident #1 how her pain has been, and Resident stated it hurt last night but once she got her pain medication she felt better and was able to rest and this morning she is having trouble flexing her toes to right leg. Author removed cover, right ankle noted, swollen, discolored. Author asked resident to wiggle toes and is able to do so slightly. Pedal pulses present. Nurse Practitioner (NP) made aware, ok for x-ray to site. Power of Attorney (POA) made aware. Resident #1 made aware of order. Foot elevated as tolerated and cold compress applied. Resident #1 stated that felt good. Call bell within reach. On 10/24/24 at 10:41 am, order for right ankle x-ray 2 view was obtained by Nurse #5. X-ray results received on 10/24/24 at 3:46 pm that revealed acute appearing distal tibia/fibula fracture. A progress note dated 10/25/24 written by the NP indicated [AGE] year-old female patient is being seen today for right tibia/fib fracture. Contacted yesterday about increased swelling and pain to right ankle and x-ray was ordered demonstrating fracture. Patient is refusing the hospital however she is okay with a stat orthopedic referral. Asked physical therapy for boot to be placed and it is present. Patient is thankful for pain medications. Resident stated on Tuesday (10/22/24) her leg got caught when being transferred and her leg has been hurting on/off since but that it was an accident. Oriented X 3. Boot applied to right leg. Assessment and Plan for fracture of tibia and fibula: Norco (hydrocodone-acetaminophen) 5/325 milligrams (mg) give 1 tablet by mouth every 6 hours as needed. Continue scheduled tramadol, start ortho referral and continue wearing boot to right leg until further recommendations from ortho. Multiple attempts were made to reach NP for an interview were unsuccessful. Review of Medication Administration Record (MAR) for 10/01/24 - 10/31/24 was reviewed. MAR indicated new order initiated on 10/24/24 of hydrocodone-acetaminophen (Norco) 5/325mg, give 1 table by mouth every six hours pain. New order initiated on 10/23/24 for Lidocaine adhesive 5% patch, applied once a day to right leg for pain, with first dose administered on 10/24/24. Review of Resident #1's orthopedic consultation dated 10/29/24 revealed tender to palpitation distal tibia over fracture site on right. Mildly tender to palpation distal fibula, mild swelling. Gentle ankle range of motion. Pain with inversion and eversion Diagnosis: nondisplaced right distal tibia fracture. Recommendations to include non-weight bearing to right lower extremity, continue fracture boot. Avoid non-steroidal anti-inflammatory drugs (NSAIDs) as they delay bone healing. Interview with MDS Nurse #1 was conducted on 01/09/25 at 12:35 pm. MDS Nurse #1 indicated that she did not recall anything about Resident #1's incident with transfers being discussed or reviewed by the interdisciplinary team. MDS Nurse #1 indicated that Resident #1 could not walk or bear her own weight. An interview with Regional Nurse Consultant was conducted on 01/09/25 at 2:18 pm. The Regional Nurse Consultant indicated that Nurse #5 was the first nurse to notify the previous Director of Nursing (DON) and herself on 10/24/24 that Resident #1 had x-ray results indicating she had a right tibia fracture. The Regional Nurse Consultant stated at that point in time staff were questioned and it was revealed that Resident #1 had an incident during a transfer with NA #1 on 10/22/24. The Regional Nurse Consultant further indicated that NA #1 transferred Resident #1 from a shower chair to the bed with NA #2. The Regional Nurse Consultant further stated Resident #1 was supposed to be transferred using a mechanical lift because she could not stand. Regional Nurse Consultant indicated NA #1 stated that she transferred Resident #1 using stand and pivot technique. Regional Nurse Consultant revealed that NA #1 took Resident #1 back to her room after completing a shower, and while in room, transferred Resident #1 from shower chair to bed. The Regional Nurse Consultant stated during interview Resident #1 indicated that during the transfer her leg got caught in the wheelchair and Resident #1 verbalized pain. Regional Nurse Consultant indicated that NA #1 did not verbalize or report that there was an issue with the transfer when interviewed on 10/24/24. An interview was conducted with the Administrator on 01/10/25 at 11:30 am. The Administrator indicated that all residents should have their needs met per plan of care.

Based on record review, and resident, staff, and Medical Director interviews, the facility failed to notify the physician of a change in condition for 1 of 3 residents (Resident #1) reviewed for notification of changes. On 10/22/24 Resident #1 was lifted manually by Nursing Assistant (NA) #1 from the shower chair to the bed, causing Resident #1's right leg to hit the shower chair, get caught in between the shower chair and the bed, causing severe pain and swelling. On 10/22/24 Nurse #1, was notified by NA #1 that Resident #1 complained of pain. Nurse #1 did not notify the physician. On 10/22/24, Nurse #2, was informed by Resident #1 of her right leg hurting, and did not notify the physician. On 10/23/24, Nurse #3, who worked from 11:00 pm (10/22/24) to 7:00 am (10/23/24), was notified by NA (Unknown) that resident complained of pain, and did not notify the physician. On 10/23/24, Nurse #4, who worked from 7:00 am to 11:00 pm, was notified by NA (Unknown) that resident complained of pain. Nurse #4 did not notify the physician. Findings included: Resident #1 was admitted to the facility on [DATE] with diagnosis that included right hand contracture, spondylolisthesis (a condition where a vertebra in the spine slips out of place and onto the bone below it), spinal stenosis (narrowing of the spinal canal that occurs over time), and hypertension (HTN). Resident #1's quarterly Minimum Data Set (MDS) dated [DATE] revealed she was cognitively intact. An interview was conducted with Resident #1 on 01/08/25 at 1:15 pm. Resident #1 indicated that she recalled when her right leg got hurt. Resident #1 indicated that NA #1 had just finished giving her a shower and had returned Resident #1 to the room. Resident #1 indicated that she was on the shower chair, when NA #1 lifted her manually to transfer her back to bed. Resident #1 indicated that NA #1 transferred her by using NA #1's two arms underneath Resident #1's underarms and lifting her off the shower chair onto the bed. Resident #1 indicated that she could not stand or walk. Resident #1 indicated that when NA #1 lifted her manually from the shower chair to the bed, Resident #1's right leg hit the chair and got stuck between the shower chair and bed. Resident #1 indicated that she informed NA #1 that she was hurting. Resident #1 indicated that NA #1 proceeded with lifting her manually during the transfer, even after informing her that her leg was in severe pain of a 10/10 (with 0 being the least pain and 10 being the worst pain imaginable). Resident #1 indicated NA #1 completed the transfer and placed her in bed and she did not fall during the transfer. Resident #1 indicated that no nurse came in to assess her after she had reported to NA #1 that her leg was in severe pain. Resident #1 indicated that 2 days later, the pain got worse, and she could not bear it. Resident #1 indicated that she informed another NA (Resident could not recall name) about her pain getting worse. Resident #1 indicated at that time, Nurse #5 came in to assess her and that Nurse #5 was the only nurse who assessed her right leg. Resident #1 indicated that her pain was 10/10. Resident #1 indicated that Nurse #5 notified the provider, who ordered an x-ray that revealed she had fracture. Resident #1 indicated that she refused to go to the hospital and opted to be seen by an orthopedic doctor. Resident #1 indicated that she received new orders for additional pain medication for the severe pain in her right leg. A telephone interview was conducted with NA #1 on 01/10/25 at 9:08 am. NA #1 indicated that she worked from 7:00 am to 3:00 pm on 10/22/24 and provided care to Resident #1. NA #1 stated on 10/22/24, Resident #1 had a shower scheduled. NA #1 indicated, after she completed the shower, she took Resident #1 back to her room, to transfer her back to bed at around 11am. NA #1 indicated that she transferred Resident #1 from the shower chair to the bed, by lifting her manually, with Resident #1's feet not touching the floor. NA #1 indicated that she placed Resident #1 on the bed. NA #1 indicated that after completion of the transfer and Resident #1 was in bed, Resident #1 verbalized that her leg was hurting but she was fine. NA #1 indicated that she reported to Nurse #1 that Resident #1 complained that her leg was hurting. NA #1 indicated that Nurse #1 did not go to assess Resident #1 or ask Resident #1 about the pain. An interview was conducted with Nurse #1 on 01/09/25 at 12:11 am. Nurse #1 indicated that on 10/22/24 NA #1 reported that while giving Resident #1 a shower, Resident #1 stated her leg was hurting. Nurse #1 further stated that he went to Resident #1's room and asked if she was in pain, for which Resident #1 stated no. Nurse #1 indicated he did not assess Resident #1 because he did not see any reason to do anything further, when Resident #1 had stated she was not in pain. Nurse #1 indicated that he did not notify the physician because he did not assess Resident #1. A telephone interview with Nurse #2 was conducted on 01/09/25 at 2:44 pm. Nurse #2 confirmed she worked on 10/22/24 between 3:00 pm to 11:00 pm and was assigned to Resident #1. Nurse #2 indicated Resident #1 reported to her that when the NA that gave her a shower was putting her to bed Resident #1's right leg got caught in the wheelchair and the bed and her right leg was hurting. Nurse #2 did not report the incident to the administration because she did not have a way of notifying them. Nurse #2 stated she put Resident #1's name on the medical director's book for them to follow up the next day (10/23/24). Nurse #2 indicated that she did assess Resident #1 and that she did not see any bruising or swelling. Nurse #2 could not recall which leg she assessed for Resident #1 or what she had written in the medical director's book. Progress note dated written by Nurse #3 on 10/23/24 at 3:04 am indicated that NA called this nurse to the room, resident complained of pain to right leg. Resident #1 had taken Tramadol 30 minutes prior. Applied ice and elevated. Call light in reach. Bed in lowest position. Will continue to monitor. Multiple attempts made to reach Nurse #3 for an interview were unsuccessful. Review of progress note dated 10/23/24 at 4:04 pm, written by Nurse #4, indicated that Resident #1 has no complaints of pain at this time, will continue to monitor. A telephone interview with Nurse #4 was conducted on 01/09/25 at 12:29 pm. Nurse #4 indicated that she recalled an NA notified her on 10/23/23, that Resident #1's ankle was hurting. Nurse #4 stated that she went in to ask Resident #1 if she was having pain, and Resident #1 stated she felt pretty good. Nurse #4 indicated that she did not assess the leg and did not notify the physician because she did not have anything to report or notify about Resident #1. A progress note dated 10/24/24 at 10:41 am written by Nurse #5 revealed that during morning medication pass author noted new medication for lidocaine patch to right leg. Author asked Resident #1 what happened to her leg that she is now needing that. Resident #1 stated on Tuesday (10/22/24) her leg got caught when being transferred and her leg has been hurting on/off since. Author asked Resident #1 how her pain has been, and Resident stated it hurt last night but once she got her pain medication she felt better and was able to rest and this morning she is having trouble flexing her toes to right leg. Author removed cover, right ankle noted, swollen, discolored. Author asked resident to wiggle toes and is able to do so slightly. Pedal pulses present. Nurse Practitioner (NP) made aware, ok for x-ray to site. Power of Attorney (POA) made aware. Resident #1 made aware of order. Foot elevated as tolerated and cold compress applied. Resident #1 stated that felt good. Call bell within reach. On 10/24/24 at 10:41 am, order for right ankle x-ray 2 view was obtained by Nurse #5. X-ray results received on 10/24/24 at 3:46 pm that revealed acute appearing distal tibia/fibula fracture. A progress note dated 10/25/24 written by the NP indicated [AGE] year-old female patient is being seen today for right tibia/fib fracture. Contacted yesterday (10/24/24) about increased swelling and pain to right ankle and x-ray was ordered demonstrating fracture. Patient is refusing the hospital however she is okay with a stat orthopedic referral. Asked physical therapy for boot to be placed and it is present. Patient is thankful for pain medications. Resident stated on Tuesday (10/22/24) her leg got caught when being transferred and her leg has been hurting on/off since but that it was an accident. Multiple attempts were made to reach NP for an interview were unsuccessful. On 1/9/25 at 11:00 am the Medical Director was interviewed about Resident #1. The Medical Director indicated that he did not assess Resident #1 at the time of the fracture but had reviewed the NP's assessment that was done on 10/25/24. The Medical Director stated he was not notified about the Resident #1 complaints of right leg pain on 10/22/24 but was aware that notification was made on 10/24/24. The Medical Director indicated that he would have expected staff to notify the physician with a change of condition. An interview with Regional Nurse Consultant was conducted on 01/09/25 at 2:18 pm. The Regional Nurse Consultant indicated that Nurse #5 was the first nurse to notify the previous Director of Nursing (DON) and herself on 10/24/24 that Resident #1 had x-ray results indicating she had a right tibia fracture. The Regional Nurse Consultant stated Nurse #1, Nurse #2, Nurse #3 and Nurse #4 did not notify the physician. The Regional Nurse Consultant further stated they did not have any record of Nurse #2 or any other nurse notifying the physician or documenting in the medical director's book about Resident #1's complaints of pain. The Regional Nurse Consultant indicated that notification to the physician in reference to Resident #1's change of condition was initially made by Nurse #5 on 10/24/24. An interview was conducted with the Administrator on 01/10/25 at 11:30 am. The Administrator indicated that all residents should have their needs met and that she required for the physician to be notified with resident change of condition. The facility provided the following corrective action plan. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 10/22/24 the nurse aide transferred Resident #1 using stand and pivot of one assist, the resident's leg got caught in shower chair, and the resident reported pain to the nurse aide. The nurse aide did not notify the nurse that the resident was transferred stand and pivot and did not notify the nurse that the resident's leg was caught in the shower chair and the resident reported pain. The licensed nurse on the following shift noted the new pain and treated the resident's pain with ice but did not notify the provider since the event did not happen on their shift. On 10/23/24 the licensed nurse noted that the resident reported pain to their leg and was treated with a prior existing as needed Tramadol order, but did not notify the provider of any change in condition. There was no documentation in the chart that the provider was notified until 10/24/24. On 10/24/24 the medical provider was notified of the change in condition with the transfer resulting in leg pain. New orders were obtained for an x-ray of the right leg. On 10/24/24 the provider was notified of the results of the x-ray which revealed a right distal tibia/fibula fracture. The resident declined to go to the hospital and a follow-up orthopedic appointment was made for 10/29/24. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: On 10/24/24 the Administrator or designee interviewed all alert and oriented residents if they have been transferred appropriately by staff and if they have any unreported injuries or changes in condition. On 10/24/24 the Director of Nursing or designee assessed all non-alert residents for new unreported injuries or changes in condition. No other issues were identified. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: On 10/24/24 the Director of Nursing or Designee educated all facility licensed nurses and certified nurse aides and all agency licensed nurses and certified nurse aides on change of condition notification to the nurse and timely change of condition notification to the provider. Education was provided verbally and in writing. Nurses were educated to check the resident record for documentation of notification to the provider and if there is no documentation to notify the provider and document the notification. Nurse aides were educated to notify the nurse as soon as a new change of condition was identified. For example as soon as new pain is identified the aide should immediately inform the nurse and inform the nurse if there was a situation to cause the new pain, like an issue with a transfer. Staff will not be able to work until they receive this education. All new and agency licensed nurses and certified nurse aides will receive this same education during orientation. The Scheduler will track that newly hired staff and agency staff have been educated. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: A Quality Assurance and Performance Improvement (QAPI) meeting was held with the Administrator, Minimum Data Set Coordinator, Therapy Director, Business Office Director, Medical Records, Director of Nursing, Housekeeping, Maintenance, Admissions, and Payroll on 10/28/24 to review the plan of correction and the decision was made to continue audits for 8 weeks. Beginning 10/28/24 the Director of Nursing or designee will complete a head-to-toe assessment on 3 residents per week for unreported injuries or changes in condition. Audits will continue for 8 weeks. Results of the audits will be reviewed by the QAPI committee and the plan of correction will be edited as needed. Alleged Compliance date: 10/29/24 The facility's corrective action plan was validated by the following: On 01/10/25 the facility's plan of correction was validated upon review of the sign-in sheets for in-service education provided to all licensed nurses and certified nurse aides on change of condition notification to the nurse and timely change of condition notification to the provider. Review of the monitoring audits revealed no concerns identified. Interviews conducted with licensed nurses and certified nurse aides revealed they had received education on the change of condition notification to the nurse and timely change of condition notification to the provider. In addition, the plan of correction was validated upon review of the sign-in sheets for in-service education provided to all licensed nurses and certified nurse aides on notification of change in condition policy. Record review of sampled residents who recently had changes in condition revealed no concerns. The compliance date of 10/29/24 for the corrective action plan was validated.

Based on record review, and resident, staff and Medical Director interviews, the facility failed to complete and document ongoing comprehensive assessments after Resident #1 reported leg pain which delayed medical treatment and interventions for 1 of 3 residents (Resident #1) reviewed for assessments. On 10/22/24 Resident #1 was lifted manually by Nursing Assistant (NA) #1 from the shower chair to the bed, causing Resident #1 right leg to hit the shower chair, get caught in between the shower chair and the bed, causing pain and swelling. On 10/22/24, between 11:00 am and 11:30 am, Nurse #1 was notified by NA #1 that Resident #1 complained of pain and Nurse #1 did not complete an assessment. Nurse #2 was assigned to Resident #1 on 10/22/24 from 3:00 pm to 11:00 pm and did not complete a comprehensive assessment and only documented she did not observe any bruising or open area. Nurse #3 (assigned to Resident #1 on 10/22/24 at 11:00 pm to 7:00 am on 10/23/24) and Nurse #4 (assigned to Resident #1 10/24/24 from 7:00 am to 11:00 pm) were notified by an NA that Resident #1 was in pain and did not document assessments of Resident #1's right leg. On 10/24/24, Resident #1 reported right leg pain to Nurse #5 who assessed the resident and noted Resident #1's leg was swollen and discolored and notified the physician. Findings included: Resident #1 was admitted to the facility on [DATE] with diagnosis that included right hand contracture, spondylolisthesis (a condition where a vertebra in the spine slips out of place and onto the bone below it), spinal stenosis (narrowing of the spinal canal that occurs over time), and hypertension (HTN). Review of physician orders revealed on 4/01/24 Resident #1was prescribed Tramadol 50mg (milligrams) three times a day for pain. Resident #1's quarterly Minimum Data Set (MDS) dated [DATE] revealed she was cognitively intact. An interview was conducted with Resident #1 on 01/08/25 at 1:15 pm. Resident #1 indicated that she recalled when her right leg got hurt. Resident #1 indicated that NA #1 had just finished giving her a shower and had returned Resident #1 to the room. Resident #1 indicated that she was on the shower chair, when NA #1 lifted her manually to transfer her back to bed. Resident #1 indicated that NA #1 transferred her by using NA #1's two arms underneath Resident #1's underarms and lifting her off the shower chair onto the bed. Resident #1 indicated that she could not stand or walk. Resident #1 indicated that when NA #1 lifted her manually from the shower chair to the bed, Resident #1's right leg hit the chair and got stuck between the shower chair and bed. Resident #1 indicated that she informed NA #1 that she was hurting. Resident #1 indicated that NA #1 proceeded with lifting her manually during the transfer, even after informing her that her leg was in severe pain of a 10/10 (with 0 being the least pain and 10 being the worst pain imaginable). Resident #1 indicated NA #1 completed the transfer and placed her in bed and she did not fall during the transfer. Resident #1 indicated that no nurse came in to assess her after she had reported to NA #1 that her leg was in severe pain. Resident #1 indicated that days later, the pain got worse, and she could not bear it. Resident #1 indicated that she informed another NA (Resident could not recall name) about her pain getting worse. Resident #1 indicated at that time, Nurse #5 came in to assess her and that Nurse #5 was the only nurse who assessed her right leg. Resident #1 indicated that her pain was 10/10. Resident #1 indicated that Nurse #5 notified the provider, who ordered an x-ray that revealed she had fracture. Resident #1 indicated that she refused to go to the hospital and opted to be seen by an orthopedic doctor. Resident #1 indicated that she received new orders for additional pain medication for the severe pain in her right leg. Written statement from NA #1, with no date indicated, was reviewed. The statement stated, I NA #1 gave Resident #1 a shower and transferred her to bed with another NA in the room. At this time and Resident #1 said she hurt but proceeded to tell NA#1 that she (Resident#1) was ok and not to worry. Resident #1 was fine, and NA#1 did report it to the nurse. A telephone interview was conducted with NA #1 on 01/10/25 at 9:08 am. NA #1 indicated that she worked from 7:00 am to 3:00 pm on 10/22/24 and provided care to Resident #1. NA #1 stated on 10/22/24, Resident #1 had a shower scheduled. NA #1 indicated, after she completed the shower, she took Resident #1 back to her room, to transfer her back to bed at around 11:00 am. NA #1 indicated that she transferred Resident #1 from the shower chair to the bed, by lifting her manually, with Resident #1's feet not touching the floor. NA #1 indicated that she placed Resident #1 on the bed. NA #1 indicated that after completion of the transfer and Resident #1 was in bed, Resident #1 verbalized that her leg was hurting but she was fine. NA #1 indicated that she reported to Nurse #1 that Resident #1 complained that her leg was hurting. NA #1 indicated that Nurse #1 did not go to assess Resident #1 or ask Resident #1 about the pain. NA #1 indicated that she could not recall if she had informed Nurse #1 she transferred Resident #1 from shower chair to bed, by lifting Resident #1 manually. NA #1 stated that Resident #1 did not fall during transfer. NA #1 further stated, she could not recall if Resident #1 hit her leg or foot on anything during transfer. NA #1 revealed she did not recall if Resident #1's foot got stuck between the shower chair and the bed during transfer. Written statement from Nurse #1, dated 10/25/24, was reviewed. Nurse #1 stated On 10/22/24 NA reported to me that Resident #1 moaned while receiving care but was now okay. Upon administering medication to Resident #1, I asked Resident #1 if she was in pain/discomfort as I had heard that Resident #1 expressed a groan upon being repositioned. Resident #1 stated she was fine. I asked Resident #1 for a number on 1-10 pain scale, and she reported none. I was not aware that Resident #1 had been transferred and more importantly transferred inappropriately at that time, as that was not reported to me by the aide. An interview was conducted with Nurse #1 on 01/09/25 at 12:11 am. Nurse #1 indicated that on 10/22/24 NA #1 reported that while giving Resident #1 a shower, Resident #1 stated her leg was hurting. Nurse #1 further stated that he went to Resident #1's room and asked if she was in pain, for which Resident #1 stated no. Nurse #1 indicated he did not assess Resident #1 because he did not see any reason to do anything further, when Resident #1 had stated she was not in pain. Nurse #1 also revealed that he did not ask Resident #1 what happened. Nurse #1 could not recall if he reported to the oncoming nurse about Resident #1's complaint of pain. Review of progress note dated 10/22/24 at 11:31 pm, written by Nurse #2, indicated that patient stated to nurse that the NA that gave her a shower, while putting her to bed, patients right leg got caught in the wheelchair and the bed. She stated that her right leg was hurting and wanted to put some ice on it, which nurse did. No bruising or open area on leg. Will have medical doctor follow up. A telephone interview with Nurse #2 was conducted on 01/09/25 at 2:44 pm. Nurse #2 confirmed she worked on 10/22/24 between 3:00 pm to 11:00 pm and was assigned to Resident #1. Nurse #2 indicated Resident #1 reported to her that when the NA that gave her a shower was putting her to bed Resident #1's right leg got caught in the wheelchair and the bed and her right leg was hurting. Nurse #2 did not report the incident to the administration because she did not have a way of notifying them. Nurse #2 stated she put Resident #1's name on the medical director's book for them to follow up the next day (10/23/24). Nurse #2 indicated that she did assess Resident #1 and that she did not see any bruising or swelling. Nurse #2 could not recall which leg she assessed for Resident #1 or what she had written in the medical director's book. Review of the medical record revealed Nurse #2 did not document an assessment of Resident #1's leg on 10/22/24. Progress note dated written by Nurse #3 on 10/23/24 at 3:04 am indicated that NA called this nurse to the room, resident complained of pain to right leg. Resident #1 had taken Tramadol 30 minutes prior. Applied ice and elevated. Call light in reach. Bed in lowest position. Will continue to monitor. Multiple attempts made to reach Nurse #3 for an interview were unsuccessful. Review of progress note dated 10/23/24 at 4:04 pm, written by Nurse #4, indicated that Resident #1 has no complaints of pain at this time, will continue to monitor. The progress noted did not include an assessment of Resident #1's right leg. A telephone interview with Nurse #4 was conducted on 01/09/25 at 12:29 pm. Nurse #4 indicated that she worked 10/23/24 from 7:00 am to 11:00 pm and recalled that an NA notified her on 10/23/24, that Resident #1's ankle was hurting. Nurse #4 stated that she went in to ask Resident #1 if she was having pain, and Resident #1 stated she felt pretty good. Nurse #4 indicated that she did not assess the leg and did not notify the provider. Nurse #4 indicated that she did not assess Resident #1 leg because, Resident #1 had reported that she felt good. Nurse #4 indicated that she did not recall reporting to the oncoming nurse about Resident #1's ankle hurting. Physician order initiated 10/23/24 for Lidocaine adhesive 5% patch, applied once a day to right leg for pain with first dose administered on 10/24/24. A progress note dated 10/24/24 at 10:41 am written by Nurse #5 revealed that during morning med (medication) pass author noted new medication for lidocaine patch to right leg. Author asked Resident #1 what happened to her leg that she is now needing that. Resident #1 stated on Tuesday (10/22/24) her leg got caught when being transferred and her leg has been hurting on/off since. Author asked Resident #1 how her pain has been, and Resident stated it hurt last night but once she got her pain medication she felt better and was able to rest and this morning she is having trouble flexing her toes to right leg. Author removed cover, right ankle noted, swollen, discolored. Author asked resident to wiggle toes and is able to do so slightly. Pedal pulses present. Nurse Practitioner (NP) made aware, ok for x-ray to site. Power of Attorney (POA) made aware. Resident #1 made aware of order. Foot elevated as tolerated and cold compress applied. Resident #1 stated that felt good. Call bell within reach. A phone interview with Nurse #5 was conducted on 1/9/25 at 1:45 pm. Nurse #5 indicated that on 10/24/24 she worked from 7:00 am to 3:00 pm. Nurse #5 indicated that on 10/24/24, Resident #1 informed her she was in pain. Nurse #5 revealed that it was not normal for Resident #1 to complain of pain especially because she was already on scheduled pain medication. Nurse #5 further stated that she asked Resident #1 what was hurting her, even with her having received scheduled pain medication. Nurse #5 indicated that Resident #1 stated that her right leg was hurting. Nurse #5 indicated that she then assessed Resident #1's leg and noted that it was swollen and discolored. Nurse #5 indicated that she then notified the physician, who ordered x-ray's to be done. On 10/24/24 at 10:41 am, order for right ankle x-ray 2 view was obtained by Nurse #5. X-ray results received on 10/24/24 at 3:46 pm that revealed acute appearing distal tibia/fibula fracture. A progress note dated 10/25/24 written by the NP indicated [AGE] year-old female patient is being seen today for right tibia/fib (fibula) fracture. Contacted yesterday about increased swelling and pain to right ankle and x-ray was ordered demonstrating fracture. Patient is refusing the hospital however she is okay with a stat orthopedic referral. Asked physical therapy for boot to be placed and it is present. Patient is thankful for pain medications. Resident stated on Tuesday (10/22/24) her leg got caught when being transferred and her leg has been hurting on/off since but that it was an accident. Oriented X 3. Boot applied to right leg. Assessment and Plan for fracture of tibia and fibula: Norco (hydrocodone-acetaminophen) 5/325 milligrams (mg) give 1 tablet by mouth every 6 hours as needed. Continue scheduled tramadol, start ortho referral and continue wearing boot to right leg until further recommendations from ortho. Multiple attempts made to reach NP for an interview were unsuccessful. A physician order dated 10/24/24 prescribed hydrocodone-acetaminophen (Norco) 5/325mg, give 1 tablet by mouth every six hours for Resident #1. Review of Resident #1's orthopedic consultation dated 10/29/24 revealed tender to palpitation distal tibia over fracture site on right. Mildly tender to palpation distal fibula, mild swelling. Gentle ankle range of motion. Pain with inversion and eversion Diagnosis: nondisplaced right distal tibia fracture. Recommendations to include non-weight bearing to right lower extremity, continue fracture boot. Avoid non-steroidal anti-inflammatory drugs (NSAIDs) as they delay bone healing. An interview with Regional Nurse Consultant was conducted on 01/09/25 at 2:18 pm. The Regional Nurse Consultant indicated that Nurse #5 was the first nurse to notify the previous Director of Nursing (DON) and herself on 10/24/24 that Resident #1 had x-ray results indicating she had a right tibia fracture. The Regional Nurse Consultant stated at that point in time staff were questioned and it was revealed that Resident #1 had an incident during a transfer with NA #1 on 10/22/24. Regional Nurse Consultant further stated per Resident #1's interview, that during transfer, Resident #1's leg got caught in wheelchair and resident verbalized pain. The Regional Nurse Consultant also indicated that during facility investigation it was discovered Nurse #5 was the only nurse who assessed Resident #1, and this did not occur until 10/24/24. The Regional Nurse Consultant indicated that Resident #1 was not assessed on 10/22/24 or 10/23/24 by a nurse. The interview further revealed that the Regional Nurse Consultant expected that nurses would document resident assessment for each change of condition. On 1/9/25 at 11:00 am the Medical Director was interviewed about Resident #1. The Medical Director indicated that he did not assess Resident #1 at the time of the fracture but had reviewed the NP's assessment that was done on 10/25/24. The Medical Director stated he was not notified about the Resident #1 complaints of right leg pain on 10/22/24 but was aware that notification was made on 10/24/24. The Medical Director indicated that he would have expected staff to assess any resident who had a change of condition. An interview was conducted with the Administrator on 01/10/25 at 11:30 am. The Administrator indicated that all residents should have their needs met and she would require nursing staff to assess residents with a change of condition.

Based on record review, resident, ombudsman, family, friend, staff, the Home Health Nurse, and Adult Protective Services Social Workers interviews the facility failed to develop and implement an effective discharge planning process for 1 of 3 residents, Resident #1, by not assessing the home environment which was described as not safe by the resident and family, discharging the resident to home where the resident did not have a functional phone to contact people or 911 in the event of an emergency and arranging for individuals who would be able to obtain the resident's prescription medications and assist with basic Activities of Daily Living (ADLs) such as transfer from the couch to a wheelchair, toileting, peri-care, meal preparation, and bathing. The facility failed to realize the risk the resident was being placed at by being discharged to home without on-site assistance despite adult protective services being involved with the resident, family members stating the resident would be unable to care for himself, the resident not being able to function independently at the facility, and the resident stating he was not comfortable with being discharged to home by himself. Resident #1 lacked community resources and a dedicated support network to provide at-home support and was without assistance except for a friend delivering a meal from the time the facility dropped him off until Adult Protective Services (APS) arrived in the evening of 2/27/24. APS contacted emergency transport services to send Resident #1 to the hospital emergency department. Upon admission, Resident #1 was noted with bedbugs, weakness, lower extremity edema and high blood pressure. Resident #1 described feeling worried, humiliated, isolated, and helpless. Immediate jeopardy began on 2/27/24 when Resident #1 was discharged to his residence without caregiver support. The immediate jeopardy was removed on 03/22/24 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with a potential for minimal harm that is not Immediate Jeopardy) to ensure monitoring of systems are put in place and to complete employee in-service training. The findings included: Resident #1 was admitted to the facility on [DATE] after a hospitalization for continuation of intravenous antibiotics for an infection following a surgical procedure. Resident #1's care plan dated 01/16/24 revealed a focused area for discharge to the community, with a goal that the resident would have a safe discharge back to the community. Interventions for the focused area included to involve specialized home health care agencies, and appropriate community support services, provide resident and family with written instructions upon discharge, periodically reevaluate resident's capabilities to return to the community, and upon discharge resident and family will receive written discharge instructions to enable a safe return to the community. A facility social worker (SW) progress notes dated 01/18/24 at 9:04 PM revealed a care plan meeting was held, and the resident's plan was to return home. The SW documented the Resident had not had home health in the past and had no equipment at home. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was cognitively intact with diagnoses that included infection following a procedure, hypertension, heart disease, muscle weakness, peripheral vascular disease, and presence of coronary angioplasty implant and graft (A stent graft is a small metal coil or mesh tube that is placed in an artery thickened with a buildup of plaque which has decreased the flow of blood and oxygen to the heart). The MDS indicated he had a discharge plan and the local contact agency had not been contacted. A review of the SW progress notes revealed she documented that she issued four Notice of Medicare Non-Coverage (NOMNC) with the last dates of care as 02/05/24, 02/08/24, 02/18/24, and 02/22/24. On 02/02/24 at 6:16 PM the SW documented that she and the Business Office Manager (BOM) spoke with the resident's family member. The family member stated he would not take the resident home to his house in his condition. The family member explained he could not take care of the resident. The SW documented the family member stated if the facility discharged the resident to his house, he would call adult protective services. The SW documented the resident was stand by assist (SBA) and contact guard assist (CGA - The person can do the transfer or self-care task with the caregiver providing a light touch (hence the term contact guard) for safety). The SW documented the resident was SBA to CGA in therapy as that time. The SW's note stated the resident's family member voiced he was going to do an appeal. On 02/06/24 at 10:39 AM The SW documented a NOMNC was issued with the last covered day of 02/08/24. The note revealed the resident did not want to go back to his house due to it not being safe. The note further revealed the family member was in the process of trying to find a facility closer to him where they could take the resident. The SW documented Medicaid pending. On 02/15/24 at 4:09 PM the SW documented a NOMNC was issued with the last covered day of 02/18/24. The resident's family member was notified as well. The resident was given contact information to KEPRO, the organization responsible for beneficiary review and skilled service termination appeals and a copy of NOMNC as well. On 02/20/24 at 12:53 PM the SW documented a NOMNC was issued with the last covered day of 02/22/24. The note read that the SW left a voicemail for the resident's family member. The note stated the resident, and his family member were informed that placement had not been found. The SW note further indicated the facilities she had contacted or left voicemails for the facility and the facility had declined admission, or she had not received a response from them. The SW note included she had given the resident and his family member information regarding the care patrol (a senior care advisory organization that help families find senior care solutions for their family member when living at home alone is no longer a safe option following hospitalization , a change in health, or due to the natural aging process) to help with placement. A review of the Physician's Order written on 02/26/24 at 4:16 PM revealed Resident #1 was to be discharged on [DATE] with Physical Therapy/Occupational Therapy evaluation and therapy as indicated, Home Health Agency to help with personal care as needed, Skilled Nurse for medication management/wound care, and a Social Worker for possible treatments/needs. On 02/26/24 at 5:08 PM the SW documented she received fax notification on the resident's reconsideration from KEPRO and the resident lost. The Resident was informed of this notification and was also told that starting on 02/23/24 he was considered as private pay. SW documented she called the resident's family member and his friend to inform them as well. The note revealed the resident, his family member, and his friend were aware he would be discharged on [DATE] with a transport time of 10:30 AM. The SW notes she spoke with the resident's friend about the copays that needed to be paid before his wheelchair and walker would be delivered. The note stated the friend voiced she would make the copay since she was the one who managed his money. The SW noted she would continue with discharge planning. On 03/18/24 at 10:28 AM an interview was conducted with the Adult Protective Services (APS) SW #1. She stated APS had received a report of self-harm due to Resident #1 living in an unsafe dwelling prior to admission to the facility and the facility's plan to discharge the resident back to that environment. She was informed Resident #1 resided in the facility and she entered the facility on 02/09/24 at 3:15 PM. She stated she announced herself at the front desk and she was wearing her APS SW badge. She stated she went to the nurses station where there were multiple staff at the nurse's station and was pointed in the direction of Resident #1's room. She said Resident #1 told her he wanted to go to a long-term care facility near his family. He said they had been doing therapy on his legs and it was helping but he was still very weak. The APS SW #1 stated at that time Resident #1 did not have a set discharge date . She stated multiple attempts to inform the facility SW of the open APS case by phone and voice mail were unsuccessful. The APS SW had not visited Resident #1 in his home. A review of the medication review report dated 02/26/24 at 4:25 PM revealed Resident #1 was prescribed the following medications upon discharge: -Acetaminophen ER Oral Tablet Extended Release 650 MG Give 1300 mg by mouth every 24 hours as needed for pain - Albuterol Sulfate HFA Inhalation Aerosol Solution108 Oral (90 Base) MCG/ACT (Albuterol Sulfate) 2 puffs inhaled orally every 6 hours as needed for chronic obstructive pulmonary disease - Amlodipine Besylate Oral Tablet 2.5 MG Give 1 tablet by mouth one time a day for hypertension - Aspirin Oral Tablet Delayed Release 81 MG Give 81 mg by mouth one time a day for heart health - Atorvastatin Calcium Oral Tablet 40 MG Give 40 mg by mouth at bedtime for hyperlipidemia - Bisacodyl Suppository Insert 10 mg rectally as needed for constipation - Docusate Sodium Oral Capsule 100 MG Give 1 capsule by mouth every 12 hours as needed for constipation - Sodium Phosphates enema Insert 1 application rectally as needed for constipation - Hydralazine HCI Oral Tablet 25 MG Give 25 mg by mouth three times a day for hypertension - Lasix Oral Tablet 20 MG Give 1 tablet by mouth every 24 hours as needed for edema - Metoprolol Succinate Oral Capsule ER 24 Hour Give 1 capsule by mouth one time a day for hypertension - Milk of Magnesia Suspension 400 MG/5ML Give 2400 mg by mouth as needed for constipation - Mirtazapine Oral Tablet 15 MG Give 15 mg by mouth at bedtime for sleep - Omeprazole 20mg Capsule Give 1 capsule by mouth one time a day for gastroesophageal reflux disease - Trazodone HCI Oral Tablet 100 MG Give 100 mg by mouth at bedtime for sleep On 02/26/24 at 5:36 PM the SW's Social Service Summary revealed the resident was discharged in stable condition with home health and his primary care physician follow-up appointment was scheduled for 03/06/24 at 2:00 PM. The note indicated the resident was also set up with a social worker through home health to be able to help him at home with further services. Resident #1's Discharge Instruction Form dated 02/26/24 at 5:36 PM indicated in Section II under the Pharmacy heading written prescriptions were provided to the Resident, no prescriptions were called in to a pharmacy. Additionally, under the Nursing heading Resident #1 had a bilateral groin wound which required a dry dressing. The Therapy heading of the Discharge Instruction Form revealed a home evaluation was not completed and a wheelchair and walker were ordered by the SW. The Rehab heading indicated Resident #1 needed continued therapy with bathing, dressing, toileting, transfers, and stairs. On 02/27/24 at 3:00 AM Physician's Assistant Note read the resident was seen for their discharge summary. The note revealed the resident had remained at the facility since 1/15/24 and appealed discharge several times. He received and completed intravenous antibiotics for a groin infection. The resident was followed by infectious disease. His pain control continued to be an ongoing issue, but narcotics had been able to be deescalated to a non-narcotic pain reliever. The note further revealed Resident #1 received physical therapy and occupational therapy. He continued to have concerns about functioning at home on his own but would have his brother and home health. On 03/17/24 at 1:40 PM an interview was conducted with the Director of Therapy, and she stated Resident #1 often verbalized to her he wanted to go back to his own home, and he had a neighbor friend who helped him out. The Resident's family member was made aware of his wish to return to his own home. She further stated Resident #1 was alert and oriented and was his own responsible person. She stated Resident #1's family member voiced concerns about the resident's safety and was interested in taking resident to his house. She stated she offered opportunities to train the family on assisting the Resident with hygiene care since Resident #1 did need some assistance with bathing and hygiene after toileting. She stated the family declined and told her they were not skilled to provide that level of care to Resident #1. She stated she told the family member home health would be available for the first couple weeks after discharge. The Director of Therapy stated the Resident was able to walk with a walker independently and transfer independently. She stated it was very difficult to get the resident and the family member to commit to a discharge plan because of their wish to appeal the discharge. They won several appeals but when their last appeal was denied. The facility offered Resident #1 a private pay room, but the Resident declined and said he was going to go back to his own home. She stated she did not conduct a home assessment. On 03/18/24 at 4:51 PM an interview was conducted with Resident #1's family member and he stated the Resident had been admitted to the facility after having a couple of surgeries on his legs which had become infected. He stated he tried to get the Business Office Manager to help file for Medicaid and she said, Oh, we can't do that and the Social Worker said she could not help either. He stated Resident #1 was discharged from the facility to home and unfortunately, he was living in a terrible living environment. The family member stated Resident#1's home environment was not good due to rotting floors, holes in the floor, and an infestation of bed bugs. He stated Resident #1's trailer was falling apart. He stated that he thinks Resident #1's wounds initially got infected because of the bed bugs. The family member said that is why the Resident went back to the hospital and was then admitted to the facility. He added that before Resident #1 went to the hospital he had fallen and was unable to get up for a couple of days. The family member said Resident #1 was in the hospital for 34 days. He stated Resident #1 had an infection in his blood and they started him on intravenous antibiotics. The family member said Resident #1 was sent to the facility to finish his antibiotic regimen and for physical therapy and occupational therapy. He stated when he was discharged from the hospital, the hospital only requested rehabilitation to Medicare for the 23 remaining days and his antibiotics were not considered rehab. The family member said he repeatedly appealed each time the facility tried to discharge Resident #1. He said he ran out of appeals at the 4th level, but it did gain the Resident about two more weeks of therapy. Resident #1's family member stated that the Resident was up walking with a walker with the help of PT. The family member stated Resident #1 could not change his own brief when he was incontinent. The family member stated he was out of town when the resident received the third discharge notice, and they discharged Resident #1 home. The family member stated that resident #1 told the facility that his home was unsafe for him, and he told them he did not want to go there. The family member stated that facility staff transported Resident #1 to his home, wheeled him into home. set him on the couch, and just left him there. He stated Resident #1 was unable to get up and go to the bathroom, unable to prepare a meal for himself, and could not make any phone calls. The family member stated Resident #1's phone had started malfunctioning while he was hospitalized and had stopped working completely by the time he was admitted to the facility. He stated Resident #1 used the facility phone when he wanted to make a call. The family member stated a neighbor called him and told him Resident #1 had been dropped off at his home and had not been able to get up off the couch. He stated he told the neighbor to call APS for assistance. He stated APS tried to find Resident #1 emergency placement in a safe environment but there were none available, so she called an ambulance to take him to the hospital. He stated the resident was covered in bed bugs again. He stated the facility should never have dropped his brother off at his home. It was not a safe discharge to take him to his home. He stated Resident #1 said he had had his brief changed that morning but by the time he got to the hospital he had urinated in that brief about six times. On 03/18/24 at 5:10 PM an interview was conducted with Resident #1's friend who was also his neighbor in the mobile home park. She stated she visited the Resident about every week. She stated on 02/05/24 she fell and could not visit the resident as often. She said she went to a care plan meeting in February for Resident #1 to talk about his discharge plan. She stated an appeal was filed because they were going to send him to an unsafe home. She stated at that discharge care plan meeting she told them the resident had nowhere to go because his home was not safe. She said she showed the SW pictures of the condition of the home. She stated there were holes in the floor, black mold in the bathroom and the ceiling was falling down in the bathroom. She said she told the SW Resident #1 couldn't go to his family member's home because he said Resident #1 had to be self-sufficient and the SW said Well, we'll have to discharge him back to his own home then. The friend stated she informed the SW that she nor the Resident's family member would provide transportation back home for Resident #1. She stated they left him on his couch, unable to get up and walk for himself, go to the bathroom or anything else. She added that unfortunately, when she turned the heat back on and the place heated up, the bed bugs came out. She stated he sat on the couch, unable to get up, and covered in bed bugs. She stated she took him a plate of food that evening. The friend stated, I was hot when I saw him sitting there, even with a walker he couldn't have maneuvered in there the way the floors were rotted out and the boards on the floor. She stated Resident #1's trailer park manager came to visit him in hospital, and the Resident signed his trailer over to him. She stated Resident #1 did not have a home phone and his cell phone had not worked since he was admitted to the hospital in December. An interview was conducted on 3/17/24 at 1:03 PM with the Administrator and she stated Resident #1 was able to transfer and walk independently with wheelchair. She stated he had been admitted to the facility for short term rehabilitation due to a wound that required intravenous antibiotics through a peripherally inserted central catheter (PICC line). 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. She further stated Resident #1 was only supposed to be in the facility for the duration of the antibiotic therapy. The Administrator explained Resident #1 filed an appeal for each NOMNC he received to the higher level until it was denied for the last time. She added Resident #1 had no skilled needs and was given a 30-day notice. The Administrator stated Resident #1's family member initially said they were willing to allow the Resident to discharge to their home. The Administrator stated later the family member changed his mind and said the Resident could not discharge to their home because Resident #1 required assistance with hygiene. The Administrator stated she told the SW they needed to talk to the Ombudsman to make sure they were doing the right thing. The Administrator relayed the Ombudsman confirmed discharging the resident home was appropriate. She stated the Ombudsman said the facility was not responsible for repairing the Resident's home if that was the condition it was in prior to his admission. The Administrator said it was explained to Resident #1's family that he would have home health services when he was discharged . She added referrals were made to other facilities, but they declined Resident #1 due to his payor source. The Administrator stated a home assessment and review for barriers to a successful discharge was not conducted. The Administrator stated they felt the need to contact the Ombudsman because the SW had put so much time and effort into researching available resources for this resident. She said the Ombudsman told the SW that the resident is alert and oriented and the facility is not a prison. The Administrator stated Resident #1, or his family member never voiced concerns that the Resident's house was not safe to live in or that there was any type of insect infestation. Record review revealed no evidence a 30-day discharge notice was issued. An interview was conducted with the Transportation Aide on 03/17/24 at 1:30 PM and she stated she had only transported one resident into their home and that was Resident #1 02/27/24 at 10:45 AM. She further stated she was accompanied by Nurse #1. She explained she wheeled Resident #1 up the ramp in a facility wheelchair and through the unlocked door of his mobile home. She said the living room was at the entrance and Resident #1 transferred himself independently from the wheelchair onto the couch. She stated she folded the wheelchair up and pushed it out the door. She added the nurse who had accompanied her in the transportation van brought two boxes of Resident #1's personal items into the home. She stated the Resident asked the nurse to set one box on the television tray table by couch and one on the island between the living room and kitchen. She stated she did not go any further beyond the living room into the home. She stated his phone was on the table beside him and she thought it worked. She further stated it was not plugged into a charger. An interview was conducted on 03/17/24 at 2:10 PM with Nurse #1 who accompanied the Transportation Aide during Resident #1's discharge home. She stated the Transportation Aide pushed Resident #1 up the ramp in a wheelchair and went in the unlocked mobile home. She stated Resident #1 transferred himself from the wheelchair to the couch. Nurse #1 explained she brought in two boxes of the Resident's belongings. She said he asked to place the box that contained soft drinks on the table beside him and told her to place the other box on the counter between the kitchen and living room. She stated the box which she put on the counter contained his written prescriptions. Nurse #1 added the trailer was warm, cluttered, and smelled of old cigarette smoke. She added as she walked from the living room to the kitchen counter, she did not feel any weak spots or holes in the floor. She stated she did not see any rodents or insects. Nurse #1 said Resident took his cell phone from his pocket and put it on the tray table. She stated she assumed the phone worked but did not check it and did not see a charging cord. Nurse #1 added while in the facility she observed Resident #1 ambulate with a walker and a wheelchair. She stated he only needed some assistance with hygiene. She did not observe Resident #1 get up and ambulate after he sat down on the couch. On 3/17/24 at 4:26 PM an interview was conducted with the facility Social Worker, and she stated Resident #1's discharge process began on his admission to the facility. She explained a form called Your Path was used which allowed for input from the Minimum Data Sets (MDS) Nurse, Therapy, Nursing, SW and Business Office Manager input. Each discipline had a piece of the Your Path form to fill out that assessed the Resident's needs so they could be addressed. She stated the Your Path form provided a baseline to work from. Nursing for education, Therapy for physical/occupational needs and for SW to know where the resident came from, where he planned to discharge to and any equipment or services he may need. She explained Resident #1 was ordered home health, physical and occupational therapy, a home health aide, and skilled nursing for medication management. She stated home health usually visited within 24 to 48 hours after discharge. The SW stated the only concern voiced about the Resident #1's home environment was from the Resident's family member who said the floor had areas without carpet. She stated on 02/06/24 she called the Ombudsman to make sure the facility was doing the right thing because Resident #1's family member was concerned about the flooring in Resident #1's home. The SW stated the Ombudsman told her if the Resident lived in his home prior to admission then could be discharged back to his home from the facility. The SW added the Ombudsman stated it was not the facility's responsibility to fix anything that was wrong with Resident#1's home. The SW stated the Ombudsman said if the facility set up Resident #1 with a home health aide, a skilled nurse and a social worker, discharge was appropriate. The SW stated Resident #1's neighbor told her she would be responsible for getting Resident #1's prescriptions filled and assisting him in his home. She stated the Home Health Agency would provide a Home Health Aide to assist Resident #1 with his needs for a period of time. The SW stated she would not send a resident to an unsafe environment and that is why she called the Ombudsman for clarification. On 03/18/24 at 9:15 AM an interview was conducted with the Ombudsman, and she stated the facility SW said Resident #1's family member had said he was going to take the Resident home with them but then declined. The Ombudsman stated the SW said that Resident #1's family member had voiced concerns regarding the flooring in the Resident's home. The Ombudsman said she spoke with her colleagues, and they advised that if the Resident's home was in the condition he left it then he could return to it. She stated she relayed that information to the facility social worker. She stated she told the SW that if the Resident was to be discharged back to his home, to make sure he had home health services and a social worker. An interview was conducted on 03/18/24 at 7:34 AM with the Home Health Nurse and she stated she received the referral for Resident #1 on 02/27/24. She explained she called his number on the evening of 02/27/24 to set up a time to visit him. She stated the phone number did not work. She said she tried the family member's and friend's number listed in his file and didn't get an answer, so she went out on 02/28/24 to check on the Resident. She said she drove out to his house and knocked for several minutes and couldn't get an answer. She stated she was able to finally reach Resident #1's friend by telephone who informed her Adult Protective Services had been called the evening prior and the Resident was sent by ambulance to the hospital. On 03/18/24 at 10:39 AM an interview was conducted with the APS SW #2, and she stated she called the facility SW on 02/27/24 and did not get an answer, left a voicemail but did not receive a call back from the SW. She stated she called and spoke with Resident #1's family member on the 2/27/24. She stated the family member was very frustrated with the facility. She said Resident #1's family member had filed an appeal three times and it had been approved those three times for the Resident to have an extended stay for therapy. He said that the facility told him Resident #1 needed an assisted living level of care. The APS SW #2 stated the Resident's family member told her Resident #1 was unable to use a wheelchair or walker due to his physical limitations and the poor condition of his home. The family member told APS SW #2 the Resident was incontinent and he needed help with dressing, bathing, grooming, meal prep, and medication assistance. He reported to the APS SW #2 that the facility said Resident #1 needed 24-hour care however there's no one in Resident #1's home to provide that care. The APS SW #2 stated she called the facility SW multiple times and left multiple messages which were unanswered. An interview was conducted with Resident #1 on 03/18/24 at 10:45 AM from his hospital room phone and he stated he was at the facility on 1/15/24 to continue antibiotic therapy for a wound he had. He stated he also received PT and OT. He stated that the final appeal was not granted, and he was going to be discharged . He stated he told the facility SW his house was not safe. He stated he told them that the floors had holes in them and that it was infested with bedbugs. He stated after being in the hospital for a month in December 2023 his health had declined, and his muscles had weakened to the point he needed physical therapy at the nursing home to help him get enough strength back to walk with a walker. He stated prior to going in the hospital in December he could walk to the store, or his friend would take him to get whatever he needed from town. He stated they told him that if he stayed at the facility, he would be private pay. Resident #1 stated he could not afford $500 a day so he felt his only choice was to be discharged back to his unsafe home. He stated he did not apply for Medicaid in the facility. Resident #1 said the facility transportation aide and a nurse took him to his house, they rolled him up the wheelchair ramp into the house and he transferred himself onto the couch. He stated the nurse put a box of soft drinks next to him on the table and a box with his prescriptions in it on the island between the kitchen and living room. Resident #1 stated he urinated on himself about six times because he could not pull himself up to the walker to go to the bathroom. He stated he did not have a working phone to call anyone to help him. He stated he felt worried, humiliated, isolated, and helpless. Resident #1 stated his neighbor stopped by to visit him, saw the condition he was left in and called his family member. She called APS and they came to his home and sent him to the hospital. Resident stated he was unable to call anyone because his phone had not worked since his admission to the hospital in December. He added when he wanted to make a phone call he used the room phone. On 03/18/24 at 12:22 PM an interview was conducted with APS SW #3, and she stated APS received a phone call on 2/27/24 at 4:45 PM Related to Resident #1 discharge to an unsafe home. She stated the call was from a neighbor who was very concerned about Resident #1 being left alone in an unsafe home. She stated she walked into the house, and he was sitting on his couch by the door with a plate of food that his neighbor had brought him. She stated she asked him if he could get up and he said he wasn't able to stand on his own. She stated she asked him if he felt safe in his home, and he stated he did not feel safe in his home. She said she asked if he had moved since he had been dropped off at his home and he stated he was not able to move from the couch on his own. She stated she asked him how he had been going to the bathroom and he said that he had on an adult diaper the whole time and he had used it three or four times. Resident #1 also advised the APS SW #3 that there had been no one at the home to help him until the friend came by to check on him. APS SW #3 stated that Resident #1 had hundreds of bed bugs crawling on him. She stated they were very visible, and he was spraying some kind of chemical on him every time one would bite him. She stated the mobile home had a horrible smell of chemicals related to Resident #1 spraying himself. She stated his walker was in reach, but he was unable to stand to use it. She stated there was a wheelchair on the other side of the room folded closed. She stated she called the emergency medical services (EMS) to transport Resident #1 to the hospital. She said the EMS team had to assist Resident #1 to stand because his legs were like wobbly sticks. The APS SW #3 had Resident #1 transported to the hospital by (EMS) for evaluation. The neighbor stated Resident #1 had a cell phone, but it had not worked since he had been admitted to the hos

Based on record review and staff and family member interviews, the facility failed to provide the resident a notification of discharge and did not send a copy of the notice to the Ombudsman for 1 of 1 residents (Resident #1) reviewed for discharge. Findings included: Resident # 1 was admitted to the facility on [DATE]. A review of the medical record review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact. A record review revealed Resident #1 was his own responsible person. An interview on 03/18/24 at 10:45 AM with Resident #1 revealed he was aware he was to be discharged on [DATE] but he did not receive a written notification of his discharge. An interview on 03/19/24 at 10:20 AM the facility Social Worker (SW) revealed the facility did not send a written notice of transfer/discharge with Resident #1 or send a copy of the written notices to the Ombudsman. She stated Resident #1 was an insurance-initiated discharge and she was not required to provide one. An interview was conducted on 03/18/24 at 5:30 PM with the Administrator and she stated Resident #1 was an insurance-initiated discharged . No written notice of transfer/discharge was provided because he was insurance cut. On 03/19/24 at 9:00 AM an interview was conducted with the regional director of clinical services, and she stated the facility did not issue a 30 written discharge/transfer notice. She stated the insurance-initiated discharge was because Resident #1's insurance issued a cut off notice that they were no longer going to pay. She stated the SW issued a Notice of Medicare Non-Coverage (NOMNC) that was generated from the insurance. She said the only time the facility issued a 30-day notice was if the resident was a danger to other residents or for non-payment. She stated for non-payment the resident had to have stayed 30 days and not paid for the 30 days.

Based on resident and family member interviewa, staff interviews and record review the facility failed to provide a resident with information regarding application for Medicaid for 1 of 1 resident reviewed for discharge (Resident #1). Findings included: Resident #1 was admitted to the facility from the hospital on 01/15/24. Resident #1's last date of skilled nursing services ended on 02/22/24 and he was discharged to his home on 02/27/24. During an interview with Resident #1 on 03/18/24 at 10:45 AM he stated the Social Worker (SW) and the Business Office Manager (BOM) told him and his Family Member the facility did not do the Medicaid application. The SW told them they would have to apply for community Medicaid on their own. An interview was conducted with Resident #1's Family Member on 03/18/24 at 4:51 PM. He stated he tried to get the BOM to help file for Medicaid and she said Oh, we can't do that and the Social Worker said she could not help either. During an interview with the Social Worker on 03/19/24 at 10:20 AM, she stated she did not assist Resident #1 with a Medicaid application. She further stated the BOM was responsible for Medicaid applications. On 03/19/24 at 12:08 PM an interview was conducted with the BOM. She stated she helped residents who were going to stay in the facility for long term care or if they were going to stay at the facility an extended period. She said she did not typically just help a resident apply for Medicaid. She stated she could fax in a Medicaid application, but it would be for the community. The BOM said when Resident #1's Family Member asked her and the SW about Medicaid, she explained Medicaid was based on monetary amounts that they must be under to qualify. She said she told the Family Member he could apply but he said Resident #1 made too much money. The BOM stated the day the Family Member asked about Medicaid the facility had already issued the anticipated discharge date . The BOM stated she recommended Resident #1 get in touch with the Department of Social Services to find available programs because she did not deal with community Medicaid. An Interview with the Administrator on 03/19/24 at 4:05 PM revealed she was not aware Resident #1, or his Family Member had asked the SW or BOM about Medicaid. She added Resident #1 wanted to go home so he would have needed to apply for community Medicaid.

Based on staff interviews and record review, the facility failed to complete a discharge summary for 1 of 1 resident (Resident #1) reviewed for planned discharge to the community. Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included, in part, infection following a procedure, hypertension, heart disease, muscle weakness, and peripheral vascular disease. A review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact and discharge planning was in place as Resident #1 expected to be discharged to the community. A review of the medical record revealed a discharge instruction sheet dated 02/26/24 was provided to the resident on the day of discharge. The discharge instruction sheet included information on home health services and a list of medications. A review of the medical record revealed no discharge summary was completed prior to or after Resident #1 discharged home. Resident #1's care plan dated 01/16/24 revealed a focused area for discharge to the community, with a goal that the resident would have a safe discharge back to the community. Interventions for the focused area included to involve specialized home health care agencies, and appropriate community support services, provide resident and family with written instructions upon discharge, periodically reevaluate resident's capabilities to return to the community, and upon discharge resident and family will receive written discharge instructions to enable a safe return to the community. Resident #1 discharged home on 02/27/24. On 03/19/24 at 4:05 PM an interview was completed with the Administrator. She stated she was not aware Resident #1 had requested assistance with Medicaid to remain in the facility. She stated she thought he wanted to apply for community Medicaid because he wanted to go home. She stated discharge instructions were provided. She was not aware the Resident did not receive a discharge summary. She stated a discharge summary should have been sent with resident.

Based on observation, record review and interview of staff, physician, resident, the facility failed to protect Resident #1 from rolling out of bed during the provision of personal care. Resident #1 fell from her bed to the floor. Resident #1 was sent to the emergency room and was diagnosed with a distal femur fracture (fractures of the thighbone that occur just above the knee joint) of both legs. The fractures resulted in hospitalization , treatment with Heparin (blood thinner) to prevent blood clots in the lower legs and Fentanyl (a controlled substance used to treat severe pain) for pain. The resident had to wear knee braces to both legs for stability until healed which can cause skin breakdown and significantly limit her ability to move/transfer during care, dialysis, or simple shifting herself in the bed. This deficient practice affected one of two sampled residents (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses of a history of falling, and muscle and right-sided weakness, diabetes, neuropathy, and renal failure. Resident #1 had a quarterly Minimum Data Set (MDS) dated [DATE] that documented she had severely impaired cognition. The resident required one-person physical assistance with bed mobility. The active diagnoses were end-stage renal disease dependent on hemodialysis, diabetes, cognitive communication deficit, dementia, and muscle weakness. The resident had scheduled and as needed pain medication. Her pain was occasional and mild. She was not coded for anticoagulant and coded no falls since the prior assessment. Resident #1's care plan dated 10/7/23 documented she had an activity of daily living deficit and required assistance with hygiene by one staff, impaired mobility, pain, and was at risk for falls. On 1/10/24 at 12:20 pm an interview of Resident #1 was completed. The resident was alert and oriented to self and situation. She remembered falling from her bed by herself. She did not remember staff being present. The resident stated that she had very bad pain when the staff tried to move her after the fall (does not remember how many days after). The pain with movement was a 10 (scale of 1 to 10, with 10 being the worst), the worst she ever had. The resident had no pain at this time and no other concerns. A review of Resident #1's Medication Administration Record for December 2023 which documented the resident was assessed for pain each shift. Her pain level was none or below a 4 from 12/1/23 to 12/8/23. On 12/9/23 the pain level had increased to a 10 (the resident was sent to the Emergency Department). A nurses' note dated 12/7/23 at 7:36 am by Nurse #2 (night shift) documented she was called to Resident #1's room by Nursing Assistant (NA) #1. NA #1 informed Nurse #2 that during peri care, the NA rolled the resident over onto her right side and the resident rolled out of bed. According to NA #1, the resident will sometimes continue to roll when being turned for peri care but not out of bed. The resident was assessed, and her range of motion did not change per the resident's baseline, and she had no pain. The resident was known to moan and groan often, but no injuries were noted at this time. There was no swelling, deformity, discolorations, or redness noted. The resident's vital signs were unchanged from her normal baseline. The resident was assisted back up and into bed. The bed was elevated for care when the resident fell out of the bed. A message was left for the on-call medical service. The call bell was within reach and bed was in low position. On 1/10/24 at 4:11 pm Nurse #2 was interviewed. Nurse #2 stated NA #1 informed her Resident #1 had fallen out of the bed when the NA was changing her on night shift 12/6/23. The accident occurred close to the end of shift. The NA rolled the resident to the right side in the center of the bed and the resident held onto the quarter rail as usual, but she rolled out of bed. Nurse #2 stated she and NA #1 had taken care of the resident before and had no problems. The resident's right side was weaker, and the resident rolled over from time to time but not out of the bed. Nurse #2 stated she assessed the resident and there were no injuries, and the resident had no pain. The resident's extremities were moved and checked with no change. There was no head injury. Resident #1 informed Nurse #2 she fell out of bed. Nurse #2 stated she assisted the resident off the floor and put her back in the bed using a mechanical lift. There was no redness, swelling, or deformity of the extremities. There was a fall committee (date unknown) that evaluated the incident. The resident was changed to a larger/wider bed for safer rolling. NA #1 was called and left a detailed message to return the call on 1/10/24 at 3:50 pm and again on 1/11/24 at 10:30 am. The NA was unable to be contacted. On 1/11/24 at 10:30 am an interview was attempted with NA #3 but was unsuccessful. NA #3 was assigned to Resident #1 on 12/7/23 day shift. A nurses' note dated 12/7/23 at 3:51 pm written by Nurse #5 documented follow up for Resident #1's fall. The blood pressure was 131/69 position was lying taken on the left arm. The pulse was 75 and regular, respirations were 19, temperature was 98.1 taken on the forehead, and oxygen saturation was 97.0 %. The resident was oriented to room location and was pleasant. Neurological checks were within normal limits. The resident had no complaint of pain. The pain level was 0 (pain score 0 to 10 with 10 being the worst). The resident's skin tone was normal, warm, and dry. The respirations were unlabored and lung sounds were clear. The resident had no edema, and pedal pulses were present. The resident required two-person physical assistance with transfers and bed mobility after the fall. On 1/10/23 at 2:40 pm an interview was conducted with NA #2. NA #2 stated she was assigned to Resident #1 on day shift 12/7/23, 12/8/23, and 12/9/23. She stated the resident had no pain on 12/7/23 or 12/8/23 during care or assistance with her meals. On 12/9/23 the resident complained of acute pain in her left leg when moved and Nurse #1 was informed. Nurse #1 called the doctor and an x-ray was ordered. When she returned to work and was assigned to Resident #1 days later, she had been to the hospital and was wearing splints to both her legs and had no pain during care. On 1/10/24 at 4:30 pm an interview was conducted with Nurse #5. Nurse #5 stated she was familiar with Resident #1. The resident had an accident on 12/7/23 and had no pain until 12/9/23. The resident had an x-ray and was sent out to the Emergency Department. The resident was able to inform staff if she had pain. The resident had an assessment on each shift twice a day for two days and on the third day after the accident she had pain and was sent out. The resident had neurological assessments each shift. The resident had gone to dialysis on Friday 12/8/23, the date she completed the head-to-toe form (assessment of the resident's body) after the resident returned. She had no pain, and her neuro check was negative. A facility Head to Toe Evaluation form was completed by Nurse #2 dated 12/8/23. Nurse #2 documented Resident #1 had no swelling, discolorations, or redness noted on her body. The resident's vital signs were taken and at her baseline. The resident was assessed for pain and had none, score of a 0. Nurses' note dated 12/8/23 at 5:44 pm written by Nurse #1 documented Resident #1's blood pressure was 117/62, pulse was 77 and regular, respirations 20 and non-labored, temperature was 97.8, and oxygen saturation was 98%. Neurological check was within normal limits for the resident. The resident had no complaints of pain, and the skin tone was normal. The staff will continue to monitor the resident. Nurses' note dated 12/9/23 written by Nurse #1 documented Resident #1 had new onset pain to the left knee and the physician was called and tramadol 50 milligrams one time only for pain was ordered and administered. Resident #1's Medication Administration Record documented on 12/9/23 her pain score level was 10. Resident #1 had a medication order dated 12/9/23 for Tramadol 50 milligrams one time only for pain and for radiographs of the left knee, leg, and hip. Resident #1 had a medication order dated 12/9/23 for Tylenol 650 milligrams every 6 hours as needed for pain. Resident #1's radiograph reading of the left knee, leg, and hip dated 12/10/23 reported a left acute distal femur fracture that was comminuted (more than 2 breaks) and closed. The bony structures appear osteopenic (weak bones) . The knee and hip joints were in place and unaffected. Resident #1's hospital discharge summary dated 12/14/23 documented the resident was seen in the Emergency Department on 12/10/23 for a history of falling and knee pain and radiographs were completed. The resident was admitted for fractures. The resident's radiographs reported she had closed bilateral (both legs) closed distal femur fractures that were managed non-surgically. The resident was to be non-weight bearing with knee immobilizers. Heparin (blood thinner) was added to prevent deep vein thrombosis (clots of the lower legs). The resident was evaluated by an orthopedic physician and pain management medication and immobilizers were initiated for the fractures. Resident #1 had a new pain medication order upon return from the hospital dated 12/14/23 for Norco 5-325 milligrams every 6 hours as needed for pain for 7 days. On 1/10/24 at 12:00 pm an interview was conducted with Nurse #1. Nurse #1 stated she was assigned to the resident for a 12-hour day shift on 12/9/23 after the fall that occurred on night shift 12/6/23. It was on Sunday morning and the resident complained of left leg pain, score level of 10 when staff moved her for care. This was the first time the resident had complained of leg pain that Nurse #1 was aware of. The on-call medical practitioner was called and he ordered an immediate x-ray of the leg which was taken at the facility and pain medication. The x-ray result reported a distal fracture of the left femur on 12/10/23. There was no deformity, bruising, or edema of the legs or knees at this time (12/9/23). The resident was sent to the Emergency Department for evaluation on 12/10/23. Nurse #1 stated she readmitted the resident on 12/14/23 and the Emergency Department diagnosis was distal fracture of bilateral femurs. The resident was ordered a Fentanyl patch on 12/20/23 (a controlled substance used to treat severe pain) for pain because she attended hemodialysis. With the patch, pain would be more continuously controlled with dialysis and pain was under control. Nurse #1 stated the resident required one person assist for in bed care and was able to hold the quarter mobility rail for care and had no prior history of not being able to hold the rail and falling from the bed before the accident. On 1/14/24 the resident was changed to a two-person bed mobility assist to prevent falls. Nurse #1 also stated she thought the resident was now unable to hold the rail and balance when rolled was a change. Nurse #1 stated the resident now had knee immobilizers and was unable to bend her knees and move freely in her bed and the immobilizers had to be removed to check for skin breakdown. The immobilizers placed the resident at risk for skin breakdown. The resident was non-weight bearing and had to be transferred using a mechanical lift after the accident. Nurse #1 stated she was not aware of any other incidence where a resident rolled out of bed onto the floor. Resident #1 had a change in pain medication dated 12/20/23 from Norco to Fentanyl transdermal (through the skin) patch 12 micrograms/hour change every 72 hours due to uncontrolled pain. On 1/10/24 at 12:20 pm an observation of Resident #1 was completed. The resident was lying in a pressure reduction air mattress bed that was wider than the traditional foam mattress she was on prior to the fall. She had knee imobilizers in place to both legs. On 1/10/24 at 1:10 pm an interview was conducted with the Administrator and Director of Nursing (DON). The accident was investigated, and the outcome determined was the resident had a large bottom and abdomen in comparison to the extremities which slid off the bed from the center when turned/rolled during care and hit her knees to the floor. The resident was still holding on to the bed mobility rail when she fell . There was a full investigation, education, and plan of correction. The Quality Assurance Committee was involved, and the Medical Director was informed. After the accident, NA #1 was observed to provide bed mobility for Resident #1 by the Administrator and Physical Therapist. No concerns were identified with the technique at this time. On 1/10/24 at 3:00 pm an interview was conducted with the Physician. The Physician stated on 12/7/23 he examined Resident #1 in the late morning of the day she fell previously on night shift, approximately 2:00 am. The resident was fully examined and there was no deformity, edema, redness, or pain. The resident had been able to verbalize pain or concerns in the past and on 12/7/23 during the exam the resident had no pain or concerns. The Physician stated the resident had normal vital signs (within her usual range) and no facial grimace or body language that would show pain. The Physician further stated Resident #1 had diabetes, neuropathy, and renal failure usually have decreased sensation and the diagnoses contribute to osteoporosis. The resident had no bone scan to diagnose osteoporosis, it was suspected. The Physician stated that the pain showing two days later was not unusual and the nursing staff had documented an assessment each shift of no pain or changes. The Physician stated that pain would cause increased vital signs and the resident's vital signs were normal and at her baseline until 48 hours later when the resident verbalized pain. The resident went to dialysis during the two days after the fall before she had experienced pain. The Physician stated the fall was an accident, the staff handled the situation appropriately, it was investigated, and shared at QA (quality assurance). The clinical staff also participated in education for bed mobility and falls. On 1/10/24 at 3:40 pm an interview was conducted with the Physical Therapist (PT) Director who investigated Resident #1's fall. The PT volunteered to be a subject in the bed and evaluated the width and determined the root cause of the accident, observed NA #1 complete bed mobility with the PT as the resident, and provided education with return demonstration to all clinical staff, including therapy. The PT stated the morning of Resident #1's fall, the risk management morning meeting included the fall/incident, and the staff reviewed the plan of intervention for recurrence. The resident was handled by NA #1 and the resident fell out of the bed while being rolled to her right side for incontinence care. The resident had no pain until two days later, on the weekend. PT and the Administrator interviewed NA #1 and she provided a demonstration of bed mobility that was used for Resident #1 with the PT as the resident in the bed. It was determined the root cause for the accident was the resident was rolled from the center of the bed, held the mobility rail and was stable on one side but not the other. The second rollover of the resident to the right side was a weaker side and the resident could not hold her core muscles and leaned over and rolled out of bed. The NA overestimated the space and ability of the resident to remain on her side in the center of the bed, which had not occurred in the past. The resident was provided a wider bed for bed mobility and to prevent any further accident. Resident #1 was initially evaluated upon admission for use of the mobility rail by PT staff and then entrapment evaluation by nursing staff. PT stated this incident was isolated to one NA. There had not been this type of accident before or after the 12/7/23 accident. The NA took the proper steps after the fall and was forthcoming. All clinical staff, including therapy, were educated with return demonstration. The resident had a communication deficit and dementia. The fracture pain seemed to have shown when the swelling increased post injury two days later. The resident required maximal assistance for transfer. Resident #1's PT note dated 12/15/23 documented the resident had minor generalized pain with movement before the fall at a level of 4 and had a level of 10 after the fall. The resident was sit to stand transfer before the fall and non-weight bearing after the fall which required maximum assistance for transfer. The 12/20/23 significant change MDS assessment revealed that sit to stand, chair to bed, toilet and shower transfers were not attempted due to medical condition or safety concerns. The Administrator was notified of immediate jeopardy on 1/17/24 at 4:20 PM. The facility provided the following corrective action plan with a completion date of 12/19/23: F689 1.Corrective action for resident(s) affected by the alleged deficient practice: On 12/10/23 the Resident was transferred to the hospital for evaluation and treatment. She returned to the facility on [DATE] with bilateral knee immobilizers. 2. Corrective action for residents with the potential to be affected by the alleged deficient practice: One on one education with the staff member identified in the incident was provided on 12/11/23 by the facility Rehab Director. To identify other residents with this same issue on 12/18/23 the Director or Nursing or Designee audited all residents who have had a fall in the last 7 days for issues related to bed mobility and for injuries related to the fall. No other issues were identified. 3. Measures/Systemic changes to prevent reoccurrence of alleged deficient practice: To prevent this from recurring on 12/18/23 the Director of Nursing, Assistant Director of Nursing and Rehab Director designee educated all licensed nurse, certified nurse aides and therapists on resident handling with bed mobility. As the training was being completed, the facility rehab director made unannounced in room visits while resident care was being provided by staff to observe for any safety concerns. None were observed. All agency and new licensed nurses, certified nurse aides and therapist will receive this same education prior to working with residents. 4. Monitoring Procedure to ensure that the plan of correction is effective, and that specific deficiency cited remains corrected and/or in compliance with regulatory requirements. To monitor and maintain ongoing compliance beginning 12/25/23 the Director of Nursing or designee will audit 3 residents per week with falls for injuries and issues related with bed mobility, and will observe 3 staff providing care with bed mobility x 12 weeks. Compliance Date: 12/19/23 Validation of the corrective action plan was completed on 1/10/24: There was a signed roster of 120 clinical staff who received in-service for the fall incident of a resident who rolled out of bed onto the floor during care. 97 staff members were educated onsite and 23 staff were educated by telephone completed by 12/19/23. There were 81 staff who signed a check off procedure for return demonstration of proper bed mobility of a resident to include rolling a resident during care. There was documentation of on-going monitoring of random bed mobility observation for 3 clinical staff per week for the past 2 weeks (1/10/24) as part of the quality assurance plan. On 1/10/24 Nurses #1, #2, and #5 and NAs #2 and #5, the Director of Nursing, Physical Therapy Director, and the Physician were all interviewed during validation and were able to state nursing and therapy staff received education for resident safety, care, and bed mobility. The Director of Nursing provided documentation of the on-going audits of staff provide care and bed mobility. The completion date of 12/19/23 was validated.

Based on staff interviews and medical record review, the facility failed to provide a CMS-10055 (Centers for Medicare and Medicaid Services) Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) prior to discharge from Medicare part A services to one of three residents (Resident #77) reviewed for SNF Beneficiary Protection Notification Review. Findings included: Resident #77 was admitted to the facility on [DATE]. Medicare part A services began on the date of admission. The medical record revealed a CMS-10123 Notice of Medicare Non-Coverage letter (NOMNC) was signed by Resident #77 on 3/21/23. The notice indicated that Medicare coverage for skilled services was to end 3/23/23. Resident #77 remained in the facility when Medicare coverage ended for an additional four weeks, and discharged home on 4/24/23. The medical record further revealed a CMS-10055 SNF ABN was not provided to the resident or resident representative. A telephone interview was conducted with the Social Worker Director on 5/11/23 at 1:59 PM. She shared staff (included Social Work, Business Office Manager, Therapy Director and Minimum Data Set Nurse) met weekly and discussed each resident who received services under Medicare part A. She explained the team discussed the anticipated last covered day of Medicare services and she completed the NOMNC form and ABN form (if resident planned to remain in the facility) and provided it to the resident or resident representative. The Social Worker Director explained that she was not employed at the facility during the time Resident #77 received care. During a telephone interview with the former Social Worker on 5/11/23 at 2:12 PM, she stated Resident #77's discharge goal was to return home after completion of therapy. She had provided the NOMNC notice to the resident and the family appealed the notice, but the appeal was denied. The former Social Worker explained after the appeal was denied, Resident #77's family made arrangements for the resident to remain in the facility until they finalized arrangements for a safe discharge home and the payor status became private pay. The former Social Worker stated she reviewed information with the family about the costs of paying privately but had not issued the written ABN to Resident #77 or her representative. The Administrator was interviewed by telephone on 5/11/23 at 2:50 PM. She thought the former Social Worker gave verbal information to Resident #77's family about facility charges after the Medicare services ended but was unable to locate the ABN form.

Based on record review, staff interviews, and physician interview the facility failed to have a nurse assess one (Resident #1) of three residents reviewed for assessment after injury. Resident #1 had her right leg pinched between the bed and the sit to stand lift during a transfer to the shower chair. Before reporting the injury to the nurse, Resident #1 was transferred to a shower chair, received a shower, and was transferred back to bed. Resident #1 experienced pain and was transferred to the hospital where she expired from complications with a traumatic right calf hematoma. Immediate Jeopardy began on [DATE] when Nurse aide (NA #8) was transferring Resident #1 and pinched her leg between the bed and the sit to stand lift causing pain. Prior to notification of the nurse of the injury, Resident #1 was transferred with the sit to stand lift onto the shower chair, given a shower, and then transferred onto the bed without the use of a lift. The immediate jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation for Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level of a D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems and education put into place are effective. Findings included: Resident #1 was admitted to the facility on [DATE] for rehabilitative services. Resident #1 had multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Documentation on the quarterly Minimum Data Set assessment dated [DATE] did not assess Resident #1 for her cognition. Resident #1 was coded as having highly impaired hearing and impaired vision but was able to be understood and understood others. Resident #1 was coded on the same assessment as being able to transfer with the extensive assistance of one person and as not being steady with surface to surface transfers. Resident #1 was coded as having range of motion impairment on both sides of her lower extremities. In addition, Resident #1 was coded as receiving an anticoagulant on 7 days of the assessment period. Documentation on the care plan, last revised on [DATE], revealed a focus area for a self-care deficit for Resident #1 relative to weakness, pain, and stiffness in bilateral knees with decreased range of motion. One of the interventions was to transfer Resident #1 with one staff assist. Documentation on the same care plan was a focus area, initiated on [DATE], for Resident #1's use of anticoagulant therapy. Interventions included administration of medications as ordered, avoidance of activities that may cause injury, and monitoring of signs and symptoms of bleeding. Documentation in a physician's progress note for Resident #1 written by MD #1 dated [DATE] revealed in the assessment and plan portion of the note, Hematoma - This appears to be a hematoma in the subcutaneous fat layer. The fat it ruptured and bled for 2 days after it was first noted suggested that she might be over anticoagulated. Perhaps there is some venous malformation in this area that makes her prone to do this. She is on [MEDICATION(S)] for stroke prevention. I am hoping that if we put a dressing on it that applies some pressure, stop her [MEDICATION(S)] for 24 hours, and then started at a reduced dose that the leak will clot and then heal. I am afraid that if we stop it for too long, she may become transiently hypercoagulable and that this would put her at risk for stroke or [[CONDITION(S)]]. Documentation in the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #1 was receiving 10 milligrams of [MEDICATION(S)] (blood thinner) as one tablet given by mouth one time a day for [CONDITION(S)]. Documentation in the nursing notes written by Nurse #5 for Resident #1 revealed on [DATE] in a late entry for 9:00 PM stated, This nurse was notified that this resident had a hematoma on right lower leg. Assessment done. Skin was intact but there was a large blister type of hematoma on lower lateral side of shin. Notified [Doctor] and received orders to apply [MEDICATION(S)] to area. Resident was intolerant of any touching of wound. [As needed] pain [medication] given on request. Hematoma was approximately 4 1/2 inch in length, 2 1/2 inches in width and ,d+[DATE] inches high. Hematoma continued to increase in size and resident continued to complain. Now approximately 45 minutes later hematoma had increased in size to extend from the ankle and up to bottom of knee and expanded across [front] of calf of leg, and approximately ,d+[DATE] inches high. Resident request to go to hospital, notified [Doctor], received orders to transfer to hospital, [family] notified, Administrator notified, transported to hospital approximately [10:30 PM]. NA #8 was interviewed on [DATE] at 11:15 AM. NA #8 revealed on [DATE] she went into the room of Resident #1 at approximately 8:00 PM to give her a shower. NA #8 explained how she set up the sit to stand lift and positioned the resident on the side of the bed with her feet on the lift. NA #8 stated that as she lifted Resident #1 with the sit to stand lift and turned the lift toward the shower chair when the foot of Resident #1 slipped and was pinched between the bed and the lift. NA #8 expressed pain, so she lowered Resident #1 back onto the bed with the sit to stand lift. NA #8 indicated she asked Resident #1 if she was okay to which Resident #1 replied she was fine. NA #8 stated she did not notify the nurse at this point because she thought the resident was not injured. NA #8 again transferred Resident #1 from the bed to the shower chair using the sit to stand lift. NA #8 took Resident #1 to the shower room in the shower chair and gave her a shower. NA #8 noticed while she was in the shower room that there was a bruise on the right leg of Resident #1. NA #8 took Resident #1 back to her room and requested the help of NA #4 and NA #10. NA #4 and NA #10 put Resident #1 back into the bed and then they went to get a nurse. NA #8 stated she did not think the bruise was that bad, so she went back to work to give another shower. NA #4 was interviewed on [DATE] at 3:45 PM. NA #4 revealed he was assigned to care for Resident #1 on the 3:00 PM to 11:00 PM shift. NA #4 said he was doing incontinent care rounds with the help of NA #10 on the hallway which Resident #1 resided on [DATE]. NA #4 revealed NA #8 did not ask NA #4 for help in transferring Resident #1 to the shower chair. NA #4 indicated he was in a resident room when, NA #8 came to the room asking for help transferring Resident #1 because she had hit her leg. NA #4 stated when he got to the room of Resident #1, he could not believe the size of the bump on her right leg. NA #4 described it as, really big. NA #4 stated NA #8 had not told the nurse about the injury at that point. NA #4 indicated he did not want to use the sit to stand lift so, NA #4 and NA #10 strong armed and pivoted Resident #1 into the bed. NA #4 went to get Nurse #3 after they got her in the bed. Nurse #3 came in and saw the leg and then went to get pain medication for Resident #1 because she was in a lot of pain. Nurse #3 was interviewed on [DATE] at 4:24 PM. Nurse #3 stated she did not see NA #8 take Resident #1 to the shower. Nurse #3 revealed she was coming back onto the hall and she knew something was wrong as NA #8 and NA #4 approached her. Nurse #3 stated she went to the room of Resident #1 and observed she was in the bed. Nurse #3 revealed she saw a hematoma on the right leg of Resident #8 the size of an orange. Resident #1 did not want anyone to touch the hematoma and was in a lot of pain. Nurse #3 went to get pain medication for Resident #1 as NA #4, NA #10, and NA #8 were in the room with Resident #1. Nurse #3 indicated, about 5 minutes later, she gave the pain medication to Resident #1. Nurse #3 stated she thought Resident #1 was overreacting and the large hematoma was as big as it was going to get. Nurse #3 went to get Nurse #5, to help assess the area and contact the nurse practitioner. Nurse #3 stated she did not know how Resident #1 acquired the hematoma, but she assumed it happened prior her getting a shower. Nurse #3 revealed she was not thinking about Resident #1 being on [MEDICATION(S)] at the time of the incident to communicate this to the nurse practitioner. Nurse #5 was interviewed on [DATE] at 2:59 PM. Nurse #5 stated she was on another hallway when Nurse #3 approached her on [DATE] and asked her to come look at a big bruise on the leg of Resident #1. Nurse #5 explained that it did not seem to her that anybody knew how the injury had occurred. Nurse #5 explained that at the time, all she knew was that Resident #1 was taken for a shower and put back to bed with a bruise on her right leg. Nurse #5 stated she went to the room of Resident #1 and saw she had a blood blister under the skin that was 3 to 4 inches long on the right lower leg, above the ankle and below the calf, with 2 inches rounded on top. Nurse #5 explained how the nurse practitioner was contacted, continued monitoring by nursing staff, and ultimately Resident #1 was sent to the hospital. An interview was conducted with the facility Administrator on [DATE] at 12:07 PM. The Administrator confirmed NA #8 told her the leg of Resident #1 was pinched between the bed and the sit to stand lift when NA #8 turned the lift to position the resident on the shower chair. The Administrator stated she was not aware Nurse #3 was not notified immediately by NA #8 when the leg of Resident #1 was pinched. The Director of Nursing (DON) was interviewed on [DATE] at 11:17 AM. The DON revealed she was not in the position of DON on [DATE]. The DON stated she would not have expected a nurse aide to notify a nurse of a transfer where a resident expressed generalized pain but it would be her expectation if a resident had an injury and expresed pain, a nurse should be notified for an assessment. An interview was conducted with the Medical Director and physician (MD #1) for Resident #1 on [DATE] at 3:23 PM. MD #1 stated he was made aware of Resident #1 being sent to the hospital for a pinched lateral leg that developed into a bruise and kept growing. MD #1 felt the occurrence was very unusual and the facility staff could not have had any way of predicting the hematoma would grow larger necessitating her being sent to the hospital any sooner than she was. Documentation on the discharge summary from the hospital dated [DATE] revealed in the history of present injury stated in part, Patient presented from skilled facility after receiving a trauma to her right lower extremity causing a development of very large hematoma. After she arrived at the hospital the hematoma erupted with significant blood loss per [emergency department] provider. Documentation in the hospital course revealed Resident #1 had hemorrhagic shock secondary to ruptured hematoma of her right lower extremity. Ultimately Resident #1 had respiratory failure, her left lung collapsed, transitioned to Hospice care, and expired on [DATE]. Documentation on the death certificate for Resident #1, dated as signed on [DATE], listed the immediate cause of death as complications traumatic right calf hematoma. Under the description of how the injury occurred the death certificate stated, traumatic injury to right calf while using lift to transfer patient. The Administrator was notified of the immediate jeopardy on [DATE] at 10:15 AM. The facility provided the following credible allegation: F 684 o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; Resident #1 was not assessed after an injury during a transfer with a sit to stand lift. She was then transferred several times. NA #8 was transferring Resident #1 with the sit to stand lift to a shower chair. Resident #1's right leg shifted and was pinched between the bed and the lift. Resident #1 expressed pain. NA #8 transferred Resident #1 back to the bed and did not notify the nurse. NA #8 transferred Resident #1 to the shower chair and then to the shower room. After the shower NA #8 noticed a bruise on the right leg of Resident #1 but did not notify the nurse. NA #8 took Resident #1 back to her room and notified NA #4 and NA #10 of an injury to the leg of Resident #1. NA #4 and NA #10 transferred Resident #1 from the shower chair to the bed without the use of a lift. Nurse #3 was then notified by NA #8 of an injury to the right leg of Resident #1 for assessment. There has been a 30-day lookback of incidents to identify any where a lift was involved. There were no incidents involving lifts. o Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. Current nursing staff will be reeducated concerning when to notify the nurse prior to moving a resident when there is any change of condition. This will specify any change of condition of a resident whether medical changes (including physical changes of condition such as changes in breathing, ability to move as before, vital sign changes, verbal, or nonverbal signs of pain), mental changes (including change in level of consciousness, behavioral changes, or increased confusion) or if there has been an incident or accident involving the resident. The staff must get a nurse to assess the resident prior to moving the resident. Specific focus during the reeducation will be that any time a resident expresses pain, whether verbally or non-verbally, during a transfer, the transfer must be stopped, and the resident assessed by a nurse before the any further movement of the resident. At any time, there is a need for assessment by a nurse, the staff member must stay with the resident, put the call bell on, and yell out to get assistance. This reeducation was provided by the Director of Nursing, the Assistant Director of Nursing, or the Unit Manager on [DATE] for nursing staff and nursing agency staff able to come to the facility. For any nursing staff and nursing agency staff members who were not able to come to the facility on [DATE], a nurse that has been reeducated will be assigned to meet each oncoming shift to complete the reeducation before they take the next assignment. The Director of Nursing has begun and will continue to track the reeducation until completion of training of all current nursing staff and nursing agency staff. [DATE] is the alleged date of immediate jeopardy removal. The credible allegation was validated on [DATE] as evidenced by: Surveyor was present on [DATE] to review the evidence to removal of the IJ for F 684. During this visit, interviews with alert residents indicated no issues. Interviews were conducted with several staff from each hall who revealed knowledge of the training on lift skill and education training. All staff had been trained and education provided by [DATE] on notifying a nurse prior to moving a resident when there is a change in condition.

Based on record review, staff interviews, and a Physician interview the facility failed to safely transfer from the bed to the shower chair one (Resident #1) of three residents reviewed for supervision during transfers. Resident #1 experienced pain and was transferred to the hospital where she expired from complications with a traumatic right calf hematoma. Immediate Jeopardy began on [DATE] when Nurse aide (NA #8) transferred Resident #1 from the bed to the shower chair pinching her leg between the bed and the sit to stand lift. NA #8 then sat Resident #1 back down on the bed using the sit to stand lift when the resident expressed pain. NA #8 used the sit to stand lift to transfer Resident #1 to the shower chair, gave her a shower, and returned her to her room. NA #4 and NA #10 lifted Resident #1 from the shower chair onto the bed without the use of a lift prior to notifying the nurse of an injury to the leg of Resident #1. The immediate jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation for Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level of a D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems and education put into place are effective. Findings included: Resident #1 was admitted to the facility on [DATE] for rehabilitative services. Resident #1 had multiple diagnoses some of which included Type 2 Diabetes Mellitus, [CONDITION(S)], [CONDITION(S)], and heart failure. Documentation on the quarterly Minimum Data Set assessment dated [DATE] did not assess Resident #1 for her cognition. Resident #1 was coded as having highly impaired hearing and impaired vision but was able to be understood and understood others. Resident #1 was coded on the same assessment as being able to transfer with the extensive assistance of one person and as not being steady with surface to surface transfers. Resident #1 was coded as having range of motion impairment on both sides of her lower extremities. In addition, Resident #1 was coded as receiving an anticoagulant on 7 days of the assessment period. Documentation on the care plan, last revised on [DATE], revealed a focus area for a self-care deficit for Resident #1 relative to weakness, pain, and stiffness in bilateral knees with decreased range of motion. One of the interventions was to transfer Resident #1 with one staff assist. Documentation on the same care plan was a focus area for Resident #1's use of anticoagulant therapy. Interventions included administration of medications as ordered and avoidance of activities that may cause injury. Documentation in a physician's progress note for Resident #1 written by MD #1 dated [DATE] revealed in the assessment and plan portion of the note, Hematoma - This appears to be a hematoma in the subcutaneous fat layer. The fat it ruptured and bled for 2 days after it was first noted suggested that she might be over anticoagulated. Perhaps there is some venous malformation in this area that makes her prone to do this. She is on [MEDICATION(S)] for stroke prevention. I am hoping that if we put a dressing on it that applies some pressure, stop her [MEDICATION(S)] for 24 hours, and then started at a reduced dose that the leak will clot and then heal. I am afraid that if we stop it for too long, she may become transiently hypercoagulable and that this would put her at risk for stroke or [[CONDITION(S)]]. Documentation in the physician orders dated as initiated on [DATE] revealed Resident #1 was receiving 10 milligrams of [MEDICATION(S)] (anticoagulant) as one tablet given by mouth one time a day for [CONDITION(S)]. Documentation in the nursing notes for Resident #1 revealed on [DATE] in a late entry for 9:00 PM stated, This nurse was notified that this resident had a hematoma on right lower leg. Assessment done. Skin was intact but there was a large blister type of hematoma on lower lateral side of shin. Notified [Doctor] and received orders to apply [MEDICATION(S)] to area. Resident was intolerant of any touching of wound. [As needed] pain [medication] given on request. Hematoma was approximately 4 1/2 inch in length, 2 1/2 inches in width and ,d+[DATE] inches high. Hematoma continued to increase in size and resident continued to complain. Now approximately 45 minutes later hematoma had increased in size to extend from the ankle and up to bottom of knee and expanded across [front] of calf of leg, and approximately ,d+[DATE] inches high. Resident request to go to hospital, notified [Doctor], received orders to transfer to hospital, [family] notified, Administrator notified, transported to hospital approximately [10:30 PM]. NA #8 was interviewed on [DATE] at 11:15 AM. NA #8 explained she knew Resident #1 well and had transferred her previously with a sit to stand lift quite a few times. NA #8 described the following events of [DATE]. NA #8 stated she arrived on the hall Resident #1 resided at approximately 8:00 PM and went to her room to prepare Resident #1 for a shower. Resident #1 agreed to have a shower. NA #8 set up the sit to stand lift and positioned the resident on the side of the bed with her feet on the lift. NA #8 stated that as she lifted Resident #1 with the sit to stand lift and turned the lift toward the shower chair the foot of Resident #1 slipped and was pinched between the bed and the lift. Resident #1 cried out and said, Ow! NA #8 lowered Resident #1 back onto the bed with the sit to stand lift. NA #8 asked Resident #1 if she was okay to which she replied that she was fine. NA #8 again transferred Resident #1 from the bed to the shower chair using the sit to stand lift. NA #8 took Resident #1 to the shower room in the shower chair and gave her a shower. NA #8 noticed while she was in the shower room that there was a bruise on the right leg of Resident #1. NA #8 took Resident #1 back to her room and requested the help of NA #4 and NA #10. NA #4 and NA #10 put Resident #1 back into the bed by lifting her up under the arms and then they went to get a nurse. NA #8 stated she did not think the bruise was that bad, so she went back to work to give another shower. NA #4 was interviewed on [DATE] at 3:45 PM. NA #4 revealed he was assigned to care for Resident #1 on the 3:00 PM to 11:00 PM shift on [DATE]. NA #4 explained Resident #1 was a bed bound resident who he had never transferred out of the bed. NA #4 described the following events as occurring on [DATE]. NA #4 said he was doing incontinent care rounds with the help of NA #10 on the hallway which Resident #1 resided. NA #8 did not ask NA #4 for help in transferring Resident #1 to the shower chair. When NA #4 and NA #10 were on the last person they needed to provide incontinent care, NA #8 came to the room and asked for help transferring Resident #1 because she had hit her leg. NA #4 stated when he got to the room of Resident #1, he could not believe the size of the bump on her leg. NA #4 described it as, really big. NA #4 did not want to use the sit to stand lift so, NA #4 and NA #10 strong armed and pivoted Resident #1 into the bed. NA #4 went to get Nurse #3 after they got her in the bed. Nurse #3 came in and saw the leg and then went to get pain medication for Resident #1 because she was in a lot of pain. NA #4, NA #10, and NA #8 attempted to get Resident #1 comfortable in the bed while Nurse #3 went for the pain medication. NA #4 revealed he kept checking on Resident #1 but within half an hour the area increased from around her ankle up to her knee. Nurse #3 was interviewed on [DATE] at 4:24 PM. Nurse #3 described the following events as happening on [DATE]. Nurse #3 did not see NA #8 take Resident #1 to the shower. Nurse #3 revealed she was coming back onto the hall and she knew something was wrong as NA #8 and NA #4 approached her. Nurse #3 stated she went to the room of Resident #1 and observed she was in the bed. Nurse #3 revealed she saw a hematoma on the right leg of Resident #8 that was the size of an orange. Resident #1 did not want anyone to touch the hematoma and was in a lot of pain. Nurse #3 went to get pain medication for Resident #1 as NA #4, NA #10, and NA #8 were in the room with Resident #1. Nurse #3, about 5 minutes later, gave the pain medication to Resident #1. Nurse #3 went to get Nurse #5 to assist in the assessment of Resident #1. The nurse practitioner was contacted, and instruction was given to put [MEDICATION(S)] on the hematoma and ice. Nurse #3 went to check on Resident #1 again approximately half an hour later and realized the hematoma was increasing in size. Nurse #3 revealed she called the Nurse Practitioner, the family of Resident #1, and Emergency Medical Services so, Resident #1 could be sent to the emergency room . Nurse #3 stated she did not know how Resident #1 acquired the hematoma, but she assumed it happened prior her getting a shower. Nurse #3 revealed she was not thinking about Resident #1 being on [MEDICATION(S)] at the time of the incident to communicate this to the nurse practitioner. Resident #1 had a physician's order initiated on [DATE] for a [MEDICATION(S)] tablet ,d+[DATE] milligrams (mg) ([MEDICATION(S)]-Acetaminophen) to be administered as 1 tablet by mouth every 12 hours as needed for pain. Documentation on the Controlled Medication Utilization Record for the administration of [MEDICATION(S)]-Acetaminophen ,d+[DATE] mg ([MEDICATION(S)]) tablets revealed Resident #1 was administered one tablet of [MEDICATION(S)] on [DATE] at 9:20 PM. Nurse #5 was interviewed on [DATE] at 2:59 PM. Nurse #5 stated she was on another hallway when Nurse #3 approached her on [DATE] and asked her to come look at a big bruise on the leg of Resident #1. Nurse #5 explained that it did not seem to her that anybody knew how the injury had occurred. Nurse #5 explained that at the time all she knew was that Resident #1 was taken for a shower and put back to bed with a bruise on her right leg. Nurse #5 stated she went to the room of Resident #1 and saw she had a blood blister under the skin that was 3 to 4 inches long on the right lower leg, above the ankle and below the calf, with 2 inches rounded on top. Nurse #5 stated she was afraid if the blister was wrapped with gauze it would have popped and Resident #1 did not want them to touch it. Nurse #5 revealed Resident #1 complained about her leg hurting. Nurse #5 stated she called the Nurse Practitioner to ask her what to do and was advised to apply [MEDICATION(S)] and ice. Nurse #5 stated they did put [MEDICATION(S)] on it but Resident #1 did not tolerate ice. Nurse #5 revealed about 20 minutes later Nurse #3 came to get her on the other hallway again because the hematoma was getting bigger on Resident #1. Nurse #5 said she saw at this point the hematoma had increased in size up to the knee of Resident #1 and she knew she had to be sent to the hospital. Nurse #5 stated the Nurse Practitioner was contacted again and permission was given to send Resident #1 to the hospital. An interview was conducted with the Medical Director and physician (MD #1) for Resident #1 on [DATE] at 3:23 PM. MD #1 stated he was made aware of Resident #1 being sent to the hospital for a pinched lateral leg that developed into a bruise and kept growing. MD #1 explained that he had decreased the [MEDICATION(S)] (anticoagulant) for Resident #1 from 15 milligrams per day to 10 milligrams per day on [DATE]. MD #1 further explained Resident #1 had a blood blister on her left buttock that had ruptured and bled for two days causing him to initially put her [MEDICATION(S)] on hold and then decreasing the dose of the anticoagulant to 10 milligrams. MD #1 stated usually a hematoma will stop growing but in this very unusual case the hematoma for Resident #1 did not stop growing necessitating her to be sent out. An interview was conducted with the facility Administrator on [DATE] at 12:07 PM. The Administrator revealed she was notified on [DATE] in the early morning hours Resident #1 being sent to the hospital. The Administrator stated she began her investigation into what happened on [DATE] which included contacting NA #8. The Administrator revealed she spoke with the family of Resident #1 and the events as told to the family by Resident #1 in the hospital concurred with the events of [DATE] as described by NA #8. The Administrator confirmed NA #8 told her the leg of Resident #1 was pinched between the bed and the sit to stand lift when NA #8 turned the lift to position the resident on the shower chair. The Administrator revealed she gave additional instruction to NA #8 on how to use the sit to stand lift. The Administrator stated she was not aware Nurse #3 was not notified immediately by NA #8 when the leg of Resident #1 was pinched. Documentation on the discharge summary from the hospital dated [DATE] revealed in the history of present injury stated in part, Patient presented from skilled facility after receiving a trauma to her right lower extremity causing a development of very large hematoma. After she arrived at the hospital the hematoma erupted with significant blood loss per [emergency department] provider. Documentation in the hospital course revealed Resident #1 had hemorrhagic shock secondary to ruptured hematoma of her right lower extremity. Ultimately Resident #1 had respiratory failure, her left lung collapsed, transitioned to Hospice care, and expired on [DATE]. Documentation on the death certificate for Resident #1, dated as signed on [DATE], listed the immediate cause of death as complications traumatic right calf hematoma. Under the description of how the injury occurred the death certificate stated, traumatic injury to right calf while using lift to transfer patient. The Administrator was notified of the immediate jeopardy on [DATE] at 10:15 AM. The facility provided the following credible allegation: F 689 o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. Resident #1 was receiving the anticoagulant [MEDICATION(S)] 10 milligrams daily. Nurse aide (NA #8) transferred Resident #1 from the bed to the shower chair pinching her leg between the bed and the sit to stand lift. NA #8 then sat Resident #1 back down on the bed when she expressed pain. NA #8 used the sit to stand lift to transfer the resident to the shower chair. NA #8 gave Resident #1 a shower and then noticed a bruise on the right leg of Resident #1. NA #8 returned Resident #1 to her room. NA #8 sought help from NA #4 and NA #10. NA #4 and NA #10 then lifted Resident #1 from the shower chair onto the bed without the use of a lift. NA #4 went to notify Nurse #3 of a large, raised blister on the leg of Resident #1. Resident #1 later died , and this injury was listed on her death certificate as a contributing factor. All residents who require assistance with transfers are at risk for this issue. There has been a 30-day look back of incidents to identify any where a lift was involved. There were no incidents involving lists. The current residents have been reviewed and assessments have been completed as need to determine the appropriate transfer status. This review was done by the Director of Rehabilitation and completed [DATE] Care plans have been reviewed and any change identified by the Director of Rehabilitation has been updated in the resident care plan by the nurses that perform the Minimum Data Set assessments. The transfer information was placed into the care plans in instructive language of either stand pivot with either an assist of 1 or assist of 2, sit to stand lift, or full lift. This information was triggered to the Kardex for nursing staff that do not have access to the care plans. The number of staff required for the different types of lifts is in the policy and training that the staff have completed. This process was completed on [DATE]. o Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. The facility will reeducate nursing and therapy staff who assist with transfers of residents concerning safe transfer processes. Part of their training was to stop a transfer if there were any difficulties and seek help and nursing assessment once the resident is safe. If the resident has had noticeable decline prior to the transfer that makes the current transfer status unsafe, the staff member will notify a nurse for assessment and follow the nurse's guidance to use a total lift for any transfers unless changed by therapy after an evaluation. The transfer status is found in the care plan or Kardex that is accessible by nursing staff and therapists. The stand pivot transfer must use a gait belt and the number of staff members designated in the resident's transfer status. The sit to stand lift process includes how to apply the straps of the lift pad and the lift and work the lift to elevate the resident, then how to move the lift to safely transfer to the next surface, and then lower the resident with the lift to a seated position. The full lift process includes that there must be two staff members at all times during the lifting process. How to place the lift pad, attach the pad to the lift, to lift the resident off the surface and successfully pivot the lift to place the resident onto the next surface. There will be a return demonstration using each of the transfer types with the reeducation. The reeducation has been completed for all nursing and therapy staff who are in the building on [DATE] and will be completed ongoing as nursing staff arrive for work. This includes facility staff and agency staff. No one will take an assignment prior to training. The Director of Nursing began tracking the education and return demonstration for staff as soon as it began. She will be reviewing the upcoming assignment sheets to ensure that the training is completed before the staff take their next assignment. Any new hired staff will receive this training during orientation prior to working with any resident. The transfer status for each resident will be completed on admission, quarterly, or with a change of condition. This is the responsibility of the Director of the Rehabilitation department on admission, staff nurse in the identification of a change of condition, and the Director of the Rehabilitation department during the quarterly review of the resident. Care plans will be updated by the MDS nurses or administration nurses as changes are made. [DATE] is the date of the immediate jeopardy removal. The credible allegation was validated on [DATE] as evidenced by: Surveyor was present on [DATE] to review the evidence for removal of the IJ for F 689 during this visit. Interviews with alert residents indicated no issues. Interviews were conducted with several staff from each hall who revealed knowledge of the training on lift skill and education training. All staff had been trained and educated by [DATE]. Observations of staff using the sit to stand lift to transfer residents revealed no issues were identified.

Based on staff interviews and record review, the facility failed to accurately code Special Treatments and Programs on the Minimum Data Set (MDS) assessment for 1 of 23 residents (Resident #10) reviewed for MDS accuracy. Findings included: Resident #10 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The quarterly MDS assessment dated [DATE] specified Resident #10 received [CONDITION(S)] care, was on a mechanical ventilator, and received [CONDITION(S)] and Hospice services during the 14 day lookback period. Resident #10's medical record was reviewed and revealed the resident did not have a [CONDITION(S)] and had not been on a ventilator. Further review indicated Resident #10 was not on [CONDITION(S)] or Hospice services. During an interview with MDS Nurse #1 on 2/10/22 at 9:09 AM, she reported she completed Resident #10's quarterly MDS assessment. She explained when she coded the special treatments and programs section, she reviewed the medical record and identified any special treatments, programs or procedures the resident received at the facility. She stated Resident #10 did not have a [CONDITION(S)], was not on a ventilator and had not received [CONDITION(S)] or Hospice services. MDS Nurse #1 thought she probably clicked on the incorrect column when she went through the list of special treatments and services on the assessment. She added she would immediately complete a modification MDS assessment to correct her error. On 2/10/22 at 1:36 PM an interview was completed with the Administrator. She confirmed Resident #10 had not received [CONDITION(S)] care, ventilator, [CONDITION(S)] or Hospice services at the facility. She added the corporate office periodically reviewed MDS assessments for accuracy and provided education to staff as needed.

Based on record review and staff interviews, the facility failed to submit information for Preadmission Screening and Resident Review (PASSR) for a level 2 re-evaluation for 1 of 2 residents reviewed for PASSR (Resident #41). The findings included: The facility admitted Resident #41 to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] An annual Minimum Data Set assessment dated [DATE] revealed no review for a Level 2 PASRR. A review of a hospital history and physical dated 12/6/2020 indicated Resident #41 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set, dated dated dated [DATE] revealed Resident #41 received antipsychotic medication 7 out of 7 days of the look back period. A review of the care plan revealed a focus area of risk for altered behaviors and/or mood related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Behaviors included episodes of medication and treatment refusals, periods of hallucinating, increased confusion, misplacing items, urinating on self or floor when displeased with new roommates, will site naked in wheelchair in full view of roommate/hallway. On 02/10/2022 at 11:15 AM, an interview was conducted with the facility ' s Social Worker who stated Resident #41 was initially admitted to the facility on [DATE], discharged home and was readmitted on [DATE]. The resident was diagnosed with [CONDITION(S)] in October of 2017 and at that time, there was another Social Worker at the facility, and she did not submit the application for a level 2 PASSR after the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review and staff interviews, the facility failed to ensure a Medication Regimen Review (MRR) was conducted monthly for 1 of 5 residents (Resident #230) reviewed for unnecessary medications. The findings included: Resident #230 was admitted to the facility on [DATE] with diagnoses to include [CONDITION(S)], dementia with behavioral disturbance, right humerus fracture and [CONDITION(S)]. An admission Minimum Data Set assessment dated [DATE] revealed Resident #230 had severely impaired cognition and had behaviors of care rejection 1-3 days of the look back period. Resident #230 received antipsychotic, antianxiety, antidepressant and opiod medications during the assessments look back period. A pharmacy consultation summary report for the period of 01/02/2022 through 01/04/2022 did not indicate a MRR was conducted for Resident #230. A comprehensive medical record review did not include a MRR for January 2022 for Resident #230. An interview was attempted with the facility ' s Pharmacy Consultant on 02/10/2022 at 12:45 PM and on 02/10/2022 at 1:44 PM. Messages were left with no return call by the end of the survey. On 02/10/2022 at 1:55 PM, the pharmacy was called, and a message left for the pharmacy consultant to return the call; no return call was received by the end of the survey. On 02/10/2022 at 3:30 PM, the concern regarding a MRR not conducted in January 2022 was brought to the attention of the Director of Nursing and the Corporate Nurse Consultant. The Corporate Nurse Consultant stated she believed the MRR for January 2022 was not conducted because Resident #230 was admitted on [DATE].

Based on observation, record review and staff interviews, the facility failed to provide monitoring and modification of interventions to ensure a cognitively impaired resident, who had been identified as a wanderer, did not wander outside unsupervised from the facility for 1 of 3 residents (Resident #137) reviewed for accidents. On 4/22/15 the resident was found in the median of U.S. Highway 52 (a 4-lane highway) and assisted back across the highway toward the facility by an unidentified motorist. Immediate jeopardy began on 4/22/15 and was removed on 6/4/15 when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy (D). Findings included: Resident #137 ' s Hospital Physical Therapy note dated 4/6/15 at 8:47 am stated, Spoke with family who report (Resident #137) has been up most of the night walking halls. Has now been asleep 1 hour. Hold (therapy) per family request. The Physician note, from the hospital record review, dated 4/6/15 at 3:31pm stated, (Resident #137) with ongoing agitation. Behavioral problems at night. (Resident #137) noted to be walking the hallway at night. Resident #137 was admitted to the facility on [DATE] from a hospital and was discharged from the facility on 5/6/15. Her [DIAGNOSES REDACTED]. She was admitted to room 411 and remained in that room until her discharge. Record review of the Admission Nursing assessment dated [DATE] indicated Resident #137 was alert and oriented to person, was confused always, needed cueing/re-directing, had a memory problem, and needed staff assistance with transfers/walking. Record review of the Care Plan dated 4/8/15 indicated the following care areas: · Elopement risk. Intervention: Do elopement assessment · Safety needs. Intervention: Admission protocols are considered part of the initial care plan for 10 days. Record review of the facility Elopement Risk assessment dated [DATE] indicated Resident #137 was fully ambulatory, disoriented, did not wander, and had no history of elopement. The Assessment further stated, Resident is not considered an elopement risk. Record review of the nurse ' s note dated 4/9/15 revealed Resident #137 was alert, confused and uncooperative with care. Record review of the nurse ' s note dated 4/12/15 at 1:28 am revealed Resident #137 was up walking the hall that shift, was very confused , and was assisted back to her bed. The note further stated the resident wandered the hall and goes into other (residents ' ) rooms. Record review of the nurse ' s note dated 4/13/15 at 1:30 am revealed Resident #137 has been up wandering into other rooms and was redirected back to her room. Record review of the nurse ' s note dated 4/13/15 at 11:04 pm revealed Resident #137 ambulated out of her room and down the hall into other resident ' s room, staff attempted redirection, and Resident #137 raised her voice at the redirection attempt. Resident #137 continued walking up and down the hallway, was placed back in her bed where she slept for 1 hour and then repeated the same process. The Admission Minimum Data Set ((MDS) dated [DATE] indicated Resident #137 was severely cognitively impaired, exhibited wandering behavior on 4-6 of 7 days, her wandering placed her at significant risk of getting to a potentially dangerous place, and her wandering significantly intruded on the privacy or activities of others. She required limited assistance with walking. The Event Investigation dated 4/16/15 at 11:00 am stated, Resident had attended activity in dining room and walked out with volunteers, redirected and brought back in. (A wandering prevention system) placed on resident. (Family member) aware. The witness on the report was Activity Assistant #1. The report further stated the incident was avoidable. Record review of the nurse ' s note dated 4/16/15 at 1:23 pm indicated Resident #137 had attended an activity in the dining room and wandered out the front door with volunteers. She was easily redirected and a wandering prevention system was placed. Record review of the nurse ' s note dated 4/16/15 at 3:11 pm stated, (Resident #137) out 400 hall door, redirected. The Physician order [REDACTED]. Record review of the Care Plan dated 4/17/15 indicated the following updated care area: · Elopement risk - (Wandering prevention system) to left ankle. Intervention: (A wandering prevention system) bracelet on to left ankle at all times. Check for proper functioning (every) shift. The activity note dated 4/20/15 at 9:58 am stated, (Resident #137) up daily in (wheelchair). She will get up out of (wheelchair) and walk off and leave (wheelchair) behind. She attended music program and when it was over (I) was taking another (resident) back to their room and by the time I got back she was gone and (wheelchair) was left at table. She had walked outside with our volunteer. She came back in and (I) went to her nurse and told her what had happened. Record review of the Care Plan dated 4/21/15 indicated the following updated care area: · Elopement risk - Needs cueing, supervision/oversight, re-directing/distracting, (wandering prevention system) bracelet related to wandering, cognitive impairment, poor safety awareness. (Wandering prevention system) to left ankle. The Event Investigation dated 4/22/15 at 8:00 pm stated, Saw (Resident #137) standing in the median of US (Highway) 52. (Resident) was assisted across the road by a motorist and nursing staff assisted resident to room. (Family member) came to facility and stayed with resident until she fell asleep. No injuries noted. Staff will continue to monitor location frequently. Follow up necessary: 15 minute watches. Staff reported resident noted to be agitated and restless. The witness on the report was Nurse Aide (NA) #1. The report further stated the incident was avoidable. The report indicated frequent re-direction from staff / increase visual checks as an intervention. Record review of Nurse #1 ' s note dated 4/22/15 at 11:24 pm stated, (Resident) very agitated and wandering. At (8 pm) was noted to be out of the building. Administrator, (Staff Development), husband and doctor were notified. No injuries were noted. New orders were received. During an interview with NA #1 on 6/4/15 at 2:52 pm, regarding Resident #137 ' s elopement on 4/22/15, NA #1 stated, I was on the hall that night and knew (Resident #137) had a (wandering prevention system). I was entering room 414 to do care. There was also an aide, NA #2, doing baths and she walked in and said where ' s (Resident #137)? (NA #2) said she had just looked for her. We looked out of the 414 window and could see traffic backed up on Ingram (the 2-lane street in front of the facility). We looked out the door (outside door at the end of the 400 hallway) and looked toward the highway past Ingram and (the resident) had gotten out. (Resident #137) was in the median and a motorist was standing with her. He made it back across the highway with her. We ran out there to get to her. We took (the resident) under the arms and escorted her back to the building. We got (Resident #137) back in her wheelchair and reattached her shirt alarm. She was able to and would un-attach her own (personal body alarm) and had had it on before she left the building that night. (Resident #137) was very steady on her feet and walked very briskly. The nurse was already made aware before we went out the door that the resident was gone. We called the administrator and he came to the building. I did not hear the door alarm go off that night. I had been in the 414 room, the (television) was on and I didn ' t hear (the 400 door) alarm. You really couldn ' t hear (the door alarm) if you were in a room. NA #1 indicated the personal body alarm had been placed on the resident to alert staff when she would get out of her wheelchair to. She further indicated the resident would pull her clothing around and detach the personal body alarm clip from her clothing. During an interview with NA #2 on 6/4/15 at 5:57 pm, regarding Resident #137 ' s elopement on 4/22/15, she stated, I was in the tub room and had gone down the hall to get (Resident #137) for her shower and she wasn ' t in (her room). Her wheelchair was there but she wasn ' t in it. I walked to find (NA #1) to ask where she was. We started looking for her and we looked out the 400 door and saw cars backed up on Ingram then we saw her in the median in between the north and southbound lanes (of U.S. Highway 52). There was a man out there with her. We yelled for the nurse and went out to get her. I did not hear (the door alarm) go off. We assisted her back into the building. The Event Investigation dated 4/24/15 at 8:00 pm stated, Resident was wandering up and down 400 hallway, (Nurse aide) stepped out into hallway to see resident opening door. Resident stepped out onto sidewalk and then came back in to hallway as staff got to her. Resident stated, ' I just wanted to know what was out there. ' The witness on the report was Nurse Aide (NA) #1. The report further stated the incident was avoidable. The report indicated interventions were frequent re-direction from staff, increase visual checks, and the resident was brought to the nursing station for one on one observation to promote safety. Review of the nurse ' s note dated 4/24/15 at 8:00 pm revealed Resident #137 had exited the building to the outside sidewalk through the 400 hall door. Staff heard the alarm sound and the resident was coming back into the building as staff got to door. The physician order [REDACTED]. Alarm to alert staff if (resident) transfers without assist. Record review of the Care Plan dated 4/24/15 indicated the following updated care area: · Safety needs - personal alarm to resident to alert staff if resident transfers without assistance to promote safety. Intervention: check personal alarm (every) shift continuous. During an interview with NA #1 on 6/4/15 at 3:02pm, regarding Resident #137 ' s exiting of the building on 4/24/15, she stated, The nurse told me the door alarm was ringing. I was about half way down the hall and it was very faint ringing. (Resident #137) had just made it out the door. She would get very anxious when we would try to redirect her and so we walked with her back in through the front door. Review of the nurse ' s note dated 4/25/15 at 12:19 am indicated Resident #137 was sitting with staff at the nurses ' desk. She continued to wander up and down the hall and was redirected with no success. The Event Investigation dated 4/25/15 at 2:40 am stated, Resident stated she wasn ' t staying here and needed to go and she was going to drive herself home. The report indicated the nurse supervisor observed Resident #137 walking towards the 400 hall door, went down the hall to redirect the resident and the resident opened the door and walked out onto the sidewalk. Staff redirected the resident back into the building and the resident was attempting to push staff away. The report further stated the incident was avoidable. The report indicated interventions were frequent re-direction from staff, increase visual checks, and the resident was brought to nurses ' station for one-on-one observation. Review of the nurse ' s note dated 4/25/15 at 2:46 am indicated Resident #137 continued to wander up and down the halls, attempting to go outdoors. Staff attempted to re-direct her with little success. The resident began to get combative with staff when being redirected. The nurse supervisor noted Resident #137 walking out into the hallway on 400 hall, heading toward (exit) door and went outside onto the sidewalk. Staff redirected the resident back into the building. The Event Investigation dated 4/28/15 at 10:45 pm indicated Resident #137 opened the 300 hall (exit) door, opened the 400 hall (exit) door and walked approximately 15 feet into the yard. She became combative when nursing staff assisted her back into the building. The witness on the report was Nurse #2. The report further stated the incident was avoidable. The report indicated a bed alarm, chair alarm, frequent re-direction from staff, monitoring the resident ' s location every 30 minutes and increased visual checks were interventions. Nurse #1 ' s note dated 4/28/15 at 11:04 pm stated, (Resident #137) exhibited wandering behavior. Opened 300 hall door and 400 hall door and walked (approximately) 15 (feet) into yard. During an interview with Nurse #2 on 6/4/15 at 3:10pm, regarding Resident #137 ' s exiting of the building on 4/28/15, she stated, We could not keep her in the room. I was the nurse on 300 that night and (Nurse #1) was the nurse on 400. I put (Resident #137) at the nurses ' station. I put a chair next to (Nurse #1) at the station so she could keep an eye on (the resident). The aide was talking to me and noticed (Resident #137) was not there. The aide and I ran down the hall to get her. She was outside on the sidewalk walking away from the building. We were trying to get her back in and she was slapping at us, elbowing us. She was so quick. I don ' t remember hearing the door alarm that night. Sometimes we heard the alarm, but once you are down the hall you couldn ' t hear it. I would never have been able to hear the alarm if I was in a resident room. We talked about that among the nurses and mentioned it to maintenance. (The facility) would always say, ' They go off at the nurses ' station so you should be able to hear when a door is opened ' but you couldn ' t hear them. We don ' t just sit at the nurses ' station and couldn ' t hear them if we were in a room. (Resident #137) wore a personal alarm but knew how to take it off. We would try to move her personal alarm but she was able to get it off herself. She would just come walking down the hall with the alarm in her hands. During an interview with the Maintenance Director on 6/1/15 at 11:12 am he indicated the facility ' s 4 resident halls were formed in the shape of an H with exit doors at the end of each hall and a nurses ' station at the midpoint of each hall. He indicated the resident halls were the vertical lines of the H and the 2 nurses ' stations were located where the horizontal line met the vertical lines. He further stated, On the 300 hall people can come and go (through the exit door at the end of the hallway) throughout the day. It is locked at 9pm at night. At 9pm if the door is opened then it will alarm and it will alarm at any time of the day with a resident who has a (wandering prevention system). The laundry and the front doors are the same. Door alarms are checked every morning by maintenance using the tester. There are testers on the medication carts that are used by the nurses to check the residents who have (wandering prevention systems). The Maintenance Director further clarified the 300 hall exit door, laundry door, and front door were the doors that are monitored with the (wandering prevention system) and the alarm sounds at those doors. The 100 hall, 200 hall, and 400 hall doors were not monitored with the (wandering prevention system) but alarmed at the nurses ' station when those doors were opened by anyone. On 6/1/15 at 11:45 am an observation was made as the Maintenance Director tested the (wandering prevention systems) functioning of the 300 hall exit door, laundry door, and front door of the facility. The doors each alarmed, at the door, with a sound sufficiently loud enough to alert staff and others in the immediate area who turned toward the loud alarming. During an interview on 6/1/15 at 12:20 pm with the Administrator he indicated Resident #137 had been discharged from the facility to a locked assisted living facility due to her numerous attempts at exiting the building and her ability to ambulate very quickly. He stated, (The resident) got out of the building multiple times and was wearing a (wandering prevention systems) that worked. The furthest she got was out of the building to the parking lot and she was not injured. That elopement was in the evening and (Resident #137) left out of the door on 400 hall that alarms at all times when it is opened. On 6/1/15 at 12:50 pm an observation was made as Maintenance #1 opened the 100 hall exit door. There was no alarm heard. When asked why there was no alarm sounding, Maintenance #1 indicated the alarm only sounded at the nurse ' s station. Upon turning toward the nurse ' s station, there was a very faint beeping that Maintenance #1 indicated was the alarm. He further stated, The 100, 200, and 400 doors alarm only at the nurse ' s station and if they go off (the nurses) will come and get whoever is going out the door. During an interview on 6/1/15 at 3:10 pm the Administrator stated, When a door alarm goes off, the instrument panel at the nurse ' s station lights up. It shows any (alarmed) door in the facility. You should be able to hear the alarm even if you are on the hallway, but it sounds the loudest at the nurse ' s station. There is always someone sitting at the nurse ' s station who would hear the alarm and see which door had been exited. An observation on 6/1/15 at 4:50 pm revealed there were no staff present at the nurse ' s station between 100 and 200 halls. On 6/2/15 at 9:30 am an observation was made as the Administrator opened the 100 hall exit door. A very faint beeping was heard while standing in the hallway, but the beeping was unable to be heard when this surveyor stepped into several resident rooms. The administrator indicated he also could not hear the alarm beeping when he stepped into a resident ' s room. On 6/2/15 from 1:15 - 1:20 pm a continuous observation was made of the 100 hall/200 hall nurse ' s station. There was a call bell ringing at the nurse ' s station and there were no staff present at the station. On 6/2/15 at 5:00 pm an observation was made of Room 411. The room door was located 29 feet from the exit door at the end of hall 400. It was the last resident room on the right side of the hallway going from the nurse ' s station to the outside of the facility. On 6/2/15 at 5:05 pm an observation was made of the Maintenance Director opening the alarm door at the end of 400 hall. A faint, barely audible, beeping was heard at the nurse ' s station. Upon entering a resident room the Maintenance Director confirmed he was no longer able to hear the exit door alarm that continued beeping at the nurse ' s station. On 6/2/15 from 5:17 - 5:22 pm a continuous observation was made of the 300 hall/400 hall nurse ' s station. There were no staff present at the station. During an interview on 6/3/15 at 9:51 am with the Administrator he stated, After the elopement on 4/22 we in-serviced all staff on the alarm to make sure they could hear them. The resident ' s family was staying all day, and we began attempting a discharge to a locked location. When (Resident #137) was agitated, two nurses would watch her at the nurse ' s station. Knowing there are alarms on the doors and the family would sit with her during the day, we felt she was being monitored. The nurse who worked the hall that night is no longer here, (Nurse #1). She indicated to me that night (4/22/15) that she was not sure she even heard the alarm go off. When I came in right after the elopement I checked the alarms and they worked. She had been in-serviced on the alarms, but I am not sure she understood how they worked. The lights can be confusing. During an interview on 6/3/15 9:58 am the Director of Nursing (DON) stated, I was (out of town) when the elopement occurred on 4/22. Staff called the (Assistant Director of Nursing) and the Administrator. They had a family conference on that Friday after the incident occurred, an aide stayed with (the resident) until the family came the day of the elopement. (Staff) put a personal alarm on her when she was in her bed and wheelchair. My expectation is that the facility put steps in place to ensure (the resident ' s) safety. One thing we discussed with the family was that we did not feel this was an appropriate environment for her. She was a high elopement risk. Her room was the last resident room on the right before the exit on the hall. It is not a (wandering prevention systems) door. During a subsequent interview on 6/3/15 at 11:10 am with the DON she indicated she was not notified of the elopement until she returned to work from training on 4/24/15, the family and the administrator were having a conference about the elopement and she was instructed by the administrator that she was not needed in the meeting. She further indicated that more could have been done to ensure the safety of this resident, including moving her room closer to the nurse ' s station or providing continuous one-on-one until placement in a more appropriate facility could be arranged. During an interview on 6/4/15 at 4:37 pm with the MDS Nurse she indicated an elopement risk assessment was done on 4/8/15 for Resident #137 and there were no more done. She further stated, Whoever identified and investigated the elopement should have done another risk assessment. On 6/4/15 at 6:00 pm an observation was made of the distance between the exit door on 400 hall, across the 2-lane road in front of the facility, to the median of the 4-lane divided highway where Resident #137 was found by a motorist. The distance was approximately 240 feet (80 yards). Nurse #1 was no longer an employee of the facility and was not interviewed. The Administrator was notified of the Immediate Jeopardy on 6/2/15 at 6:20 pm. The facility presented a credible allegation of compliance on 6/4/15 at 2:30pm which included: Please accept this Credible Allegation of Compliance as of 06/04/2015 A. Corrective action was accomplished for resident #137 as follows: 1. Resident # 137 admitted to the facility 04/08/2015. [DIAGNOSES REDACTED]. 2. On admission day to facility of 04/08/15 this resident was assessed by the licensed nurse using the electronic healthcare record elopement questionnaire and was not identified to be an elopement risk at the time of admission. 3. Resident #137 had a wander guard placed on 04/16/2015 when identified to be an elopement risk. This intervention was care planned and placed on the care guide, as well as orders written by the nurse to check wander guard placement each shift 4. Resident #137 was assessed on the 14 day MDS 04/20/2015 section E0900 coded as 2 for wandering with in the facility based on documentation in the resident record during the look back period in the electronic record. 5. Resident #137 eloped from facility on 04/22/15. Nursing staff were in-serviced by the maintenance supervisor for Door alarm operation. Although not documented the nurse specified in writing on the event report every 15 minute checks as new intervention. Also a chair alarm was applied to resident wheelchair. The social worker began to seek alternate placement in a secured unit on 04/23/15 after meeting with the family. 6. Resident #137 did not experience any harm or negative outcomes related to the elopement. 7. Resident # 137 discharged from the facility to a secured unit on 05/06/15. B. To identify other residents with the potential to be affected by the deficient practice, the facility performed the following audits. Utilizing the 672 Census and Condition electronic health care record report, specifically focusing on behaviors triggered from current MDS a total of 9 residents were identified as having the potential to be affected by this deficient practice. This audit began by the MDS nurse and Regional Nurse Consultant 6/2/15 and completed 06/3/15. Audit results revealed these 9 residents all have current interventions in place per care plan, care guide, and orders scheduled in the electronic healthcare record for the licensed nurse to check placement of the safety devices each shift. None of these residents were identified as having any elopement attempts or having any compliance issues since this immediate jeopardy was identified during the current state survey. C. Corrective action completed 06/03/15. 1. On 6/2/15 and 6/3/15 The MDS nurses, DON, ADON, began reeducating all staff in all departments on the Wandering/missing resident policy and procedure. 2. No staff members will be allowed to work their scheduled work day until receiving mandatory reeducation for the wandering/missing resident policy and procedure. Reeducation of the wandering/missing resident policy and procedures includes: · Protocol/guidelines when door alarm sounds. · Facility full search procedure · What to do when resident has not been located by the room search. · High risk missing resident protocol 3. All new employees receive in-service education on Village care of King ' s wandering/missing resident policy. 4. An audit tool has been incorporated to monitor compliance for wandering/missing residents identified by assessment to be at risk. 5. The 100 hall, 200 hall and 400 hall exit doors are not protected with the wander guard alert system, but have a low audible tone alarm, therefore new door alarms with louder, audible sounding tones were applied to these doors on 6/3/15 by the maintenance supervisor. 6. Any residents identified with risk potential to elope from facility will be placed in a room with closer proximity to the nurse ' s station and further distance from exit doors. D. New Monitoring systems/ interventions have been placed in effect to prevent recurrence 1. Within 15 days after admission the MDS nurse will complete a follow up (2nd) elopement assessment to ensure residents are identified for risk 2. A thorough investigation for any elopement event will be completed by the DON or other designated administrative staff member under the supervision of the DON. · Investigation will include: · Document means of egress where resident exited facility · What was direct care staff doing when elopement occurred? · Where was resident located? · Ask and document what resident states trying to do. · Who returned resident to facility? · Was resident experiencing behaviors? · Document immediate intervention/s placed to maintain resident safety (guidelines/suggestions) staff member stay with resident one on one, 15 minute checks, inform MD and Responsible party, inform Administrator and Director of nursing immediately for additional suggestions, nurse placing the interventions edits care plan and care guides 3. Residents identified will have the following completed by the MDS nurse: · Update and revise Care plan to address elopement risk · Update Care guide with risk for wandering/elopement · Order scheduled in electronic healthcare record for nursing to check the wander guard placement each shift to better ensure resident safety. Immediate Jeopardy was removed on 6/4/15 at 7:00 pm when interviews with nursing staff confirmed they had received in-service training on the Wandering/Missing Resident Policy and Procedure. Record reviews confirmed 9 residents were identified by the facility as having the potential to be affected by the deficient practice and an audit tool was in place to identify residents with an elopement risk upon admission and to ensure a 2nd evaluation for elopement at 15 days. Two residents were identified as having a high risk of elopement and were being moved closer to the nurse ' s station. Observations confirmed alarms were placed on the 100, 200, and 400 hall exit doors. The alarms were tested by the Maintenance Director and revealed loud alarms that were audible in resident rooms with the doors closed. The alarms were able to be heard with the doors closed even in rooms with televisions on, oxygen on, and residents conversing.