Every finding on record at Village Green Health and Rehabilitation

Based on record review and staff interviews, the facility failed to submit a request for a Level II Preadmission Screening and Resident Review (PASRR) evaluation for a resident who was admitted to the facility with a serious mental health disorder for 1 of 3 residents reviewed for PASRR (Resident #1).Findings included:Resident #1's Hospital Course and Treatment Encounter Note dated 2/21/26 indicated Resident #1's chronic conditions included post-traumatic stress disorder (PTSD) which was monitored during that hospitalization. A PASRR Determination Notification letter dated 2/26/26 revealed Resident #1 had a Level I PASRR with no expiration date.A North Carolina Medicaid FL2 Level of Care Screening Tool (a medical document completed by a physician which certifies a patient's need for a specific level of care in a long-term care facility) signed by the hospital Social Worker on 3/19/26 and submitted to the facility did not include a diagnosis of PTSD. Resident #1 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD) and PTSD. Resident #1's care plan had a care focus area initiated on 3/25/26 that indicated that he was at risk for impairments or complications due to a history of PTSD with the goal for Resident #1 to feel safe and secure in his environment. Interventions included approach in a calm and respectful manner, avoid triggers/actions that can cause relapses or crisis, build a trusting relationship with the resident, obtain psychiatric referral as needed and include resident in decision making regarding care. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was not currently considered by the state Level II PASRR process to have a serious mental illness or intellectual disability. Resident #1's active psychiatric/mood disorder diagnoses included (PTSD). He received an antidepressant medication during the MDS assessment review period. During an interview on 5/5/26 at 3:29 PM with the facility Social Worker (SW), she revealed that she was responsible for submitting requests for Level II PASRR evaluations. She stated that Resident #1 had a diagnosis of PTSD which was not included on the FL2 that was submitted by the hospital. The SW stated that she completed her audits on a quarterly basis where she reviewed the admission paperwork to include hospital records and the MDS to identify the diagnoses that required submission for PSARR evaluations. She reported that she was in the process of completing audits for PASRR screening and was getting ready to submit them including one for Resident #1. An interview was conducted on 5/6/26 at 3:24 PM with the Administrator. She stated that the Social Worker should have submitted a request for a Level II PASRR evaluation for Resident #1 with all the diagnoses to include PTSD when he was admitted to facility. The Administrator explained that the Social Worker was supposed to review the admission diagnoses and those that triggered in the MDS and request a Level II PASRR evaluation within a month of admission or new diagnosis and not on a quarterly basis to ensure requests were submitted in a timely manner.

Based on record review, and interviews with staff and Medical Director the facility failed to ensure the medical record was complete regarding documentation of acute medical symptoms and the administration of an as needed medication. This was for 1 (Resident # 1) of 3 residents reviewed for acute medical needs.The findings included:Resident # 1 was admitted to the facility on [DATE].Nurse # 4 was interviewed on 2/18/26 at 3:19 PM and reported the following information. She did not recall the specific date, but a couple days prior to the date of 2/3/26, Resident # 1 had vomited undigested food. She assisted to help him get cleaned up and gave him some ginger ale and soup for supper. She recalled no further complaints or vomiting after one episode of emesis.Review of the record revealed no documentation of the vomiting incident referenced by Nurse # 4 during her interview on 2/18/26 at 3:19 PM.Nurse # 3 was interviewed on 2/19/26 at 8:16 AM and reported the following information. She had cared for Resident # 1 on the shift which began at 11:00 PM on 2/2/26 and ended at 7:00 AM on 2//3/26. Resident # 1 had complained of having gas and stomach pain. She had administered Milk of Magnesia per an as needed standing order to do so at some point during her shift. She did not recall the specific time. Review of Resident # 1's record revealed no documentation of the administration of Milk of Magnesia on Nurse # 3's shift.The facility Medical Director was interviewed on 2/20/26 at 11:57 AM and reported the following information. Staff should have documented any clinical symptoms of medical problems that Resident # 1 was having and any treatment they had rendered. It was important to document clinical symptoms for any resident that might be experiencing an acute issue because when she and other providers came in to review any acute illness, they reviewed a resident's record as well as talking to staff and the resident while making decisions.The Director of Nursing was interviewed on 2/20/26 at 1:10 PM and reported he would have liked to have seen that Nurse # 4 documented Resident # 1's episode of vomiting in the record. The DON reported the administration of an as needed medication should have been documented in the resident's record. The DON validated that the as needed medication administration had not been documented making the record incomplete.

Based on observation, record review, and interviews with residents, staff, Physician, and Psychiatric Nurse Practitioner, the facility failed to develop and implement individualized person-centered care plan approaches for a resident (Resident # 8) diagnosed with dementia who had a known pattern of verbal behaviors, to include yelling slurs and foul language, specifically targeting Resident # 9. Staff reported that they attempted redirection of Resident #8, but the behaviors had continued and no additional care plan interventions had been developed or implemented that focused on instructing staff on how to manage these verbal behaviors. This deficient practice was for 1 of 1 resident (Resident # 8) sampled for dementia care.The findings included:Resident # 8 was admitted to the facility on [DATE] with diagnoses which included early onset Alzheimer's Disease, dementia, major depressive disorder, and a history of stroke. Resident # 8's annual Minimum Data Set (MDS) assessment, dated 10/15/25 revealed Resident # 8 was moderately cognitively impaired, had no behaviors during the assessment period of the MDS, and used a wheelchair to self-propel himself with supervision. He received antidepressant and anticonvulsant medication.Resident # 8's care plan was updated on 10/30/25 with a new problem area of frequent conflicts with peers and staff, apparently related to mood distress, poor coping skills, and intolerance of others. These conflicts often took the form of complaints about his roommate, cursing/yelling at his roommate, complaints and concerns about other residents/staff, and unprovoked expressions of anger towards staff/ residents. The care plan approaches included staff intervening when inappropriate behaviors were observed and to communicate assertively that the resident must exercise control over his impulses and behaviors; staff to remind the resident to communicate his anger and frustration without offending, being mean, or being verbally aggressive towards others; and staff to refer the resident to the consulting psychiatrist. On 11/18/25 a Mental Health Counselor documented the following notations after seeing Resident # 8 for talk therapy. The staff had noted that Resident # 8 was becoming increasingly agitated and argumentative and she (the Mental Health Counselor) probed the resident to discuss triggering situations. The Mental Health Counselor documented that Resident #8 stated, 'I am not agitated. I am tired of being here. The resident indicated that he wanted to go somewhere like a movie or retail store. The resident stated that he wanted to do different things sometimes as he always played games and watched TV. He went on to explain that he wished they had more ice cream socials and that he liked when the preacher/pastor came from the church to have bible study and prayer. The resident reported that he liked his roommate, but the roommate didn't talk; and that he wished he could talk with his family more, but they are living their own lives. Resident #8 verbalized that deep breathing didn't work for him and meditation was ok but sometimes he couldn't focus.On 12/30/25 the Mental Health Counselor documented she saw Resident # 8 who reported he was alright, a new year was coming, and he was hoping that good things would come to him and everyone else. The resident also reported he did not expect much from his family because they had their own lives.On 1/8/26 the Psychiatric Nurse Practitioner (NP) noted she was seeing Resident # 1 for Alzheimer's disease, neurocognitive disorder due to the Alzheimer's disease, and depressive disorder. The resident's dementia was classified as moderate. The Psychiatric NP noted the resident's behavioral disturbances were at his baseline and there had been no reports of inappropriate behaviors from the staff. Resident # 8 was currently receiving the mood stabilizing medication Depakote (an anticonvulsant medication that acts as a mood stabilizer) 250 mg (milligrams) twice per day for mood support and Zoloft 100 mg for depressive disorder. On 2/6/26 at 8:52 AM Nurse # 1 entered a nursing progress note into Resident # 8's record that indicated a Nurse Aide reported she could overhear Resident # 8 cursing and yelling at a resident in another room (Resident # 9) and that Resident # 8 was redirected to move away from Resident # 9's doorway. Resident # 9, who was being cursed at from his doorway, reported the incident was unprovoked and Resident # 8 had a history of this type of behavior towards him. Resident # 9 reported Resident # 8 just started yelling faggot bitch into his room that morning.Resident #9's quarterly MDS assessment dated [DATE] indicated his cognition was intact and he had no behaviors. Review of Resident # 8's nursing and social service progress notes for January and February 2026 revealed no other documentation of any additional behaviors by Resident # 8 towards Resident # 9.Nurse # 1 was interviewed on 2/20/26 at 2:00 PM and reported the following information. Nurse Aide # 1 had reported on 2/6/26 that she heard Resident #8 calling Resident # 9 a faggot and a bitch. On 2/6/26 she (Nurse #1) had talked to Resident # 9 who reported Resident # 8 had not come into his room but had yelled the remarks into the room while sitting in the middle of the hallway outside his door. Resident # 9 reported he did not respond to Resident # 8 on that day or other times. She (Nurse # 1) had worked on Resident # 8's unit during orientation for only about a week. After a week of orientation, she moved to another unit and therefore was not aware of any ongoing behaviors exhibited by Resident # 8. On the day the incident of derogatory name calling had occurred (2/6/26), she had talked to Resident # 8 also who appeared pleasant to her and not confused.Nurse Aide # 1 was interviewed on 2/20/26 at 3:00 PM and reported the following information. Resident # 8's room was in close proximity to Resident # 9's room. Resident # 8 was outside of Resident # 9's room calling him a faggot and telling him to do a particular sexual act on 2/6/26. She stated that it appeared to her that Resident # 9 had been upset about the incident. She did not explain what made her think Resident # 9 was upset. This was the only time she had witnessed the behavior from Resident # 8. When Nurse Aide # 1 was asked whether Resident # 9 had provoked Resident # 8 in any way to say the things he did she responded that Resident # 9 had not done so. Nurse Aide # 1 reported that was not even in [Resident #9's] character at all. Nurse Aide # 1 was interviewed regarding what she did about the behavior and reported that she had redirected Resident # 8 to the dayroom and away from Resident # 9's door. Resident # 9 was interviewed on 2/20/26 at 9:00 AM and reported the following information. When he (Resident # 9) first arrived at the facility (2/24/25), he thought Resident # 8 was cool. Then for no reason, Resident # 8 started calling him derogatory names and every time Resident # 8 now saw Resident # 9 he would call him derogatory names. He did not indicate when this behavior first took place. This happened in the dining/activity room with other residents around. Resident # 8 would also come to his door where he resided, stare in, and call him names. Resident # 8 did not enter the room but yelled from the hallway. He would say things such as You ole faggot. You ole bitch. You need to suck my . I am going to f. you. Resident # 8's behaviors toward him were happening almost on a daily basis while he was outside of his room. The current week, Resident # 8 had said such derogatory things to him Monday, Tuesday, and Wednesday while they were both outside of their rooms. The incidents where Resident # 8 would come to the doorway and yell in his room derogatory remarks occurred about two to three times a month. He wanted it to stop, and he had talked to the Social Worker and the Director of Nursing about the problem. It was his understanding that the staff were supposed to move Resident # 8 out of the dining/activity room when he (Resident #9) was in the dining/ activity room. He did not specify who informed him that staff were supposed to move Resident # 8 out of the dining/activity room when he (Resident # 9) was present. Resident # 9 reported he liked his room and he did not want to move. He wanted to be able to sit in public spaces without being called names. Resident #9 reported, I don't want to hurt him. During the interview, it was observed that Resident # 8's room was across the hallway from Resident # 9's room.Resident # 8 was interviewed on 2/20/26 at 2:30 PM regarding whether he had called another resident derogatory terms. Resident # 8 appeared frustrated by repeating that he just wanted to leave the facility and said he was tired of people saying he did things. He further reported the following information. He had called Resident # 9 a faggot because Resident #9 had called him one. Staff would blame him (Resident # 8) and take him out of the dining room/activity room, and he did not think this was fair. He had told staff this when they had talked to him. Resident # 8 did not report exact dates that name calling had occurred or dates staff had talked to him. He reported he just wanted to leave and not be at the facility. Resident # 1, who was coded as cognitively intact on a 12/11/25 quarterly MDS assessment, was interviewed on 2/19/26 at 1:19 PM. He reported that he (Resident # 1) sat in the dining/activity room at times and witnessed Resident # 8 calling Resident # 9 a faggot for no reason. Resident # 9 never did anything to provoke this type of behavior.Nurse Aide # 2 was interviewed on 2/20/26 at 9:30 AM and reported the following information. She was caring for Resident # 9 that day (2/20/26) and was also familiar with Resident # 8. Resident # 8 was difficult to deal with. She explained that he would call staff derogatory names and was not easily redirected. Resident # 8 would stare at Resident # 9 and Resident # 8 would call Resident # 9 a faggot and tell him he was going to beat his [a**]. Anytime the residents were in the dining/activity room together this tended to happen which according to Nurse Aide # 2 was often. It was hard to redirect Resident # 8 because he would get mad if he was redirected. Resident # 8 used to call another resident a derogatory name, but he no longer did so and was instead directing the derogatory remarks to Resident #9.Nurse # 2 was interviewed on 2/20/26 at 9:46 AM and reported the following information. She had heard Resident # 8 and Resident # 9 have smart remarks between the two of them. Resident # 8 would start it by calling Resident # 9 a faggot and a bitch. It happened sporadically and occurred multiple times per week. When it occurred, Resident # 9 would let staff know. They (the staff) tried to monitor the dining room/activity room, but they had multiple residents and duties and therefore they could not be there all the time to redirect Resident # 8. For a while, Resident # 8 was on one-on-one supervision a couple months ago, but that stopped and she was not sure why he had been on one on one or why the monitoring stopped. She knew that the derogatory remarks upset Resident # 9. She explained that Resident # 9 would made remarks such as if Resident # 8 kept making the derogatory remarks to him then he was going to do something about it. She indicated she just thought that was Resident # 9 talking and that Resident # 9 would not really hurt Resident # 8.Resident # 8's active care plan revealed that the most recent care plan conference was on 2/9/26. There was no information on Resident # 8's active care plan related to the known pattern of targeted derogatory name calling and foul language directed towards Resident # 9. The care plan interventions related to the problem area of conflicts with peers continued to include interventions developed on 10/30/25 that were ineffective with managing Resident # 8's verbal behaviors directed toward Resident # 9. No new interventions had been developed that instructed staff on how to manage these known verbal behaviors.The Social Worker and the Care Plan Nurse were interviewed on 2/20/26 at 1:17 PM. The Social Worker reported the following information. Resident # 9 had reported to her that Resident # 8 would stare at him and say negative things to him. Resident # 9 reported he did not know why it was happening and he had not provoked the behavior. She recalled Resident # 9 mentioning that Resident # 8 was making sexual remarks but did not recall if he had mentioned specifically being called a faggot. She followed up weekly and thought there had been small incidents and lately that things had been okay. She thought Resident # 9 had come to her at the end of 2025 or sometime in January 2026 about the issue. She had not made a note about it to reference the date. She had talked to Resident # 8 who denied the whole situation. The Nurse Aides were supposed to be redirecting Resident # 8 and keeping the residents separated. She thought Resident # 8 was easy to redirect. The Social Worker was interviewed about Nurse Aide # 2's comments about Resident # 8 being difficult to redirect. The Social Worker reported that it was how you did the redirection that mattered as well as the approach to the situation. The Care Plan Nurse reported the following information. When she revised the care plan, she reviewed the documentation in the record. She explained that if she saw nursing notes, then she would incorporate any documented behaviors in the care plan. She indicated the care plan for Resident # 8 had been reviewed related to behaviors, but they (the facility) had not included a plan specifically to deal with Resident # 8 targeting Resident # 9 in public and in his room with derogatory comments.The Director of Nursing was interviewed on 2/20/26 at 1:10 PM and reported the following information. He had been the acting DON since the former DON left in October 2025. He saw Resident # 9 sitting in a corridor area almost every day and the resident had not brought up specifically the concern with Resident # 8. It was his understanding that Resident # 8 and Resident # 9 sometimes got along and other times they did not like each other, but he was not aware of specific details of why. He indicated he knew that the Psychiatric NP spoke to the facility Social Worker about any type of behavioral problems residents were displaying so that the behaviors could be addressed. The Psychiatric NP was interviewed on 2/20/26 at 3:38 PM and reported the following information. She saw Resident # 8 again on 2/9/26 following her 1/8/26 visit. She saw only one incident noted in the record since her January notation about Resident # 8 having behaviors and that was the note on 2/6/26 (related to Resident # 8 cursing and yelling at Resident # 9). It had not been made clear to her that Resident # 8 was using derogatory language more frequently than what was charted. She was familiar with Resident # 9 and had evaluated Resident # 9 when he was initially admitted in order to conduct depression screening, but Resident # 9 had no mental illness, no behavioral problems, and there was no further need to provide services to him after she conducted her screening process. Resident # 8's dementia did contribute to confusion and like any resident with dementia, he would wax and wane regarding his confusion. When she talked to him, he would say he just wanted to go home. She knew he had had arguments in the dining room/activity room but did not know they involved any specific resident. When she asked him (Resident # 8) if he had any arguments, he would always say no. The Psychiatric NP indicated that the Social Worker was usually very good at discussing with her any behavioral issues. She did not recall specifically discussing the incident of Resident # 8 calling Resident # 9 derogatory names on a repetitive basis, but the Social Worker probably did mention it to her. She did not realize it was a big problem for Resident # 8. It was her opinion that any targeted behavior by Resident # 8 of calling Resident # 9 derogatory names was stemming from his dementia diagnosis.The Medical Director was interviewed on 2/20/26 at 11:57 AM and reported the following information. She was not aware of any targeted derogatory remarks by Resident # 8 to another resident. There was a psychiatric provider for the facility, and the staff should be talking to the psychiatric provider about behavioral issues.The Administrator was interviewed on 2/20/26 at 10:35 AM and reported the following information. Resident # 8 was cognitively impaired and did not want to be at the facility and wished to reside elsewhere, but he did have behavioral problems which made it difficult to find an alternate facility to accept him when they saw that he had behaviors. During a follow up interview with the Administrator on 2/20/26 at 5:17 PM, the Administrator was interviewed regarding any type of behaviors that Resident # 9 had which might provoke Resident # 8 to target him and whether Resident # 9 also called Resident # 8 a faggot as Resident # 8 alleged. The Administrator reported there had been one documented incident when Resident # 9 had been admitted and was adjusting to residing at the facility and roomed with an older resident. He called his former roommate a creepy old man, and then after an adjustment period Resident # 9 never had any further behavior problems that were documented or of which she was aware. She indicated she talked to her staff (she did not specify which staff) on the date of this interview (2/20/26) and no one had reported that Resident # 9 called Resident # 8 a faggot.

Based on observations and staff interviews, the facility failed to date opened food items and seal leftover frozen food stored in 1 of 1 reach-in freezer, 1 of 1 walk-in freezer, 1 of 1 dry goods storage area and failed to remove a bowl being used as a scoop observed nested in breadcrumbs in one of the dry ingredient storage bins in the kitchen. This practice had the potential to affect foods served to the residents. The findings included: On 02/16/25 at 11:28 A.M., an observation of the kitchen revealed the following: a. Reach-in freezer: - A plastic bag containing slider buns (this item had a label with 8/20/24 written in the shelf life spot on the label and 11/20/24 written in the use by spot on the label) - A zippered type of plastic storage bag containing pork loin with no date on it - A zippered type of plastic storage bag containing pulled chicken with no date on it b. Walk-in freezer: - A box of pre-cooked egg patties - the egg product was in the manufacturer's box and contained inside the box in a plastic bag; both the box and the plastic bag were left open to air and there was no date on it. c. Dry storage area: - An opened package of devil's food cake mix in a plastic package with no date on it. d. On 02/18/25 at 8:42 A.M., an observation of the kitchen revealed one of the white 3-bin dry ingredient storage bins contained a black bowl. The bowl had been left inside the bin and was observed in contact with the breadcrumbs being stored in the bin. The Dietary Manager, who was present during this observation, stated that she thought staff were using the bowl as a scoop and that it should not be stored inside the bin. An interview was conducted with the Dietary Manager (DM) on 02/18/25 at 11:28 A.M. The DM stated she thought staff were moving too fast as a possible reason why opened food items were not labeled or dated. When asked to explain what she meant, the DM gave an example of staff being busy on the line at mealtimes and had to run get an item for a resident and then forgot to go back after the busy period to properly label the food item that had been opened in a hurry. The DM stated it was her expectation that dietary staff seal opened food items appropriately and to label the items with the name of the item, the date it was opened and the expiration date of the item. An interview was conducted with the Administrator on 02/18/25 at 10:16 A.M. The Administrator stated it was her expectation that dietary and nursing staff label opened food items with the date opened and a use-by date. The Administrator also stated that if the opened food item cannot be packaged for storage appropriately, it should be discarded.

Based on observations, record review and staff and family interviews the facility failed to implement an activity intervention on the comprehensive care plan for 1 of 22 residents (Resident #29). The findings included: Resident #29 was admitted into the facility on [DATE] with a diagnosis of dementia. A review of Resident #29's significant change Minimum Data Set assessment dated [DATE] revealed that she was severely cognitively impaired, had trouble falling or staying asleep, or sleeping too much for 12-14 days, trouble concentrating on things for 12-14 days, was sometimes understood and sometimes understood by others and had impaired vision. She had no behaviors and noted it was very important to have her family be part of the discussions regarding her care. A review of Resident #29's comprehensive care plan updated 12/19/24 revealed a problem of a need for daily stimulation by having her television and lights on daily in the morning. The goal and intervention to the problem included she would have her television and lights on by 10:00 AM each day. An interview was conducted with Resident #29's family member on 2/16/25 at 12:35 PM who indicated a concern of Resident #29 not receiving any type of mental, tactile, or visual stimulation that the family member was aware of. The family member stated they visited the resident at different times during the week and that when they visited they always had to turn on the television and open the window blinds. An observation of Resident #29's room on 2/16/25 at 12:30 PM noted the television and lights were not on, and the window blinds were closed. The resident was lying in bed with her eyes open. Observations of Resident #29's room on 2/17/25 at 11:00 AM and 1:00 PM noted the television and lights were not on, and the window blinds were closed. Resident #29 was lying in bed with her eyes open. An observation of Resident #29's room on 2/18/25 at 10:30 AM noted the blinds were open but the lights and television were not on. Resident #29 was lying in bed with her eyes open. An interview conducted on 2/18/25 at 10:25 AM with Nurse Assistant #1, who was working on Resident #29's hall, revealed that if a resident had a daily task that needed to be completed it was placed on the resident care card at the desk. Nurse Assistant #1 was not aware of any resident's care cards that had a notation of the lights or television turned on by a certain time. An interview conducted on 2/18/25 at 10:30 AM with Nurse Assistant #2, who was working on Resident #29's hall, indicated that any special tasks were on the resident care cards at the desk. She further indicated that she was not aware of any residents that had a certain time for the lights or television to be on. A review of Resident #29's care card did not reveal instructions for the lights and television to be on by 10:00 AM each day. An interview with the Activity Director on 2/18/25 at 12:38 PM revealed that she was not aware the care plan had the problem of the resident need for stimulation by having the lights and television on by 10:00 AM and stated she had not created that care plan, the former Social Service Worker had, and that the former Social Service Worker should have put that on Resident #29's care card so the nursing assistants were aware. She further stated that the activity department provided one-on-one visits to Resident #29 on Tuesdays and Thursdays. A telephone interview with the Administrator on 2/20/25 at 9:44 AM indicated that the Activity Director should have been aware of the care plan problem regarding the lights and television on by 10:00 AM and the information should have been placed on Resident #29's care card so that the nursing assistants were aware.

Based on record review, staff and family interviews the facility failed to provide a written summary of the baseline care plan to the resident or resident representative in 3 out of 3 sampled residents (Resident # 6, Resident # 75, and Resident #84). Findings included: A. Resident #6 was admitted to the facility on [DATE] with diagnoses including: multiple sclerosis, and vascular dementia. A review of Resident 6's admission Minimum Data Set (MDS) dated [DATE] revealed the resident's cognition was intact. A review of Resident #6's medical record revealed that a 48- hour interim(baseline) care plan was completed on 12/15/2023 by Admission Nurse. A review of Resident # 6's medical records indicated a care plan meeting was held on 12/15/2023 and included Resident #6's resident representative, Discharge Planner, Assistant Director of Nursing, and Director of Rehabilitation Services. An interview conducted on 01/16/2024 at 11:25 AM with Resident#6's resident representative indicated she had not received a copy or a summary of the base line care plan. An interview conducted on 01/16/2024 at 11:27 AM with Resident #6 revealed she did not receive a copy of or a summary of the baseline care plan. An interview with the Admission Nurse on 01/17/24 at 1:52 PM revealed she reviewed with the resident representative and Resident#6's baseline care plan on 12/15/2023 and she indicated that she did not give a summary or a copy of the baseline care plan to the resident or resident's representative. An interview with the Director of Nursing conducted on 01/19/24 at 11:15 AM revealed the Admission Nurse went over the baseline care plan verbally with the resident and/or resident representative and she did not provide a copy or summary of the baseline care plan to the resident representative and/or resident. An interview with the Administrator was conducted on 01/19/24 at 11: 16 AM and revealed she was aware that the Admission Nurse went over the baseline care plan verbally with the resident and/or resident representative. She further revealed the facility did not provide a copy or summary of the baseline care plan to the resident representative and/or resident. She indicated she was not aware that the copy or summary needed to be provided to the resident and/ or resident representative. 48007 Based on record review, resident, staff and resident representative interviews the facility failed to provide a written summary of the baseline care plan to the resident or family in 3 out of 3 residents (Resident # 6, Resident # 75, and Resident # 84). Findings included: B. Resident #75 was admitted to the facility on [DATE] with diagnoses including: diabetes and cancer. A review of Resident #75's admission Minimum Data Set, dated dated dated [DATE] revealed the resident's cognition was intact. A review of Resident #75's medical record revealed that a 48-hour interim (baseline) care plan was completed on 11/3/23 by the Admission Nurse. A review of Resident # 75's facility records indicated a baseline care plan meeting was held on 11/6/2023 and included Resident #75, Resident #75's Representative, and facility staff consisting of the Discharge Planner, Social Services, Assistant Director of Nursing, Admission Nurse, and Director of Rehabilitation Services. An interview conducted on 1/16/24 at 1:30 PM with Resident #75 indicated that she had not received a copy or summary of the base line care plan. An interview was attempted with Resident #75's resident representative but she was unavailable. C. Resident #84 was admitted to the facility on [DATE] with diagnoses including: malnutrition and arthritis. A review of Resident 84's admission Minimum Data Set, dated dated dated [DATE] revealed the resident's cognition was moderately impaired. A review of Resident 84's facility medical records indicated a baseline care plan meeting was held on 11/17/2023 and included Resident #84 and facility staff consisting of the Discharge Planner, Social Services, Assistant Director of Nursing, Admission Nurse, and Director of Rehabilitation Services A review of Resident #84's facility medical record revealed that a 48-hour interim (baseline) care plan was completed on 11/18/23 by the Admission Nurse. An interview conducted on 1/17/24 at 11:00 AM indicated that Resident #84 had not received a copy or a summary of the base line care plan. An interview with the Admission Nurse on 01/17/24 at 1:52 PM revealed she verbally goes over the resident's baseline care plan with the resident and/or family but she did not provide a summary or a copy of the baseline care plan. An interview with the Director of Nursing conducted on 01/19/24 at 11:15 AM revealed the Admission Nurse went over the baseline care plan verbally with the resident and/or family and they did not provide a copy or summary of the baseline care plan to the family and/or resident. An interview with the Administrator was conducted on 01/19/24 at 11: 16 AM and revealed she was aware that the Admission Nurse went over the baseline care plan verbally with the resident and/or their family. She further revealed they did not provide a copy or summary of the baseline care plan to the family and/or resident. The administrator stated she did not know that a written summary needed to be provided to the resident and/or family.

Based on record review and resident, family, staff, and Regional Ombudsman interviews the facility failed to assure a resident (Resident # 1) was treated respectfully during a meeting held with staff members to discuss her care and concerns. This was for one of one sampled resident who met with administrative staff during a formal meeting. The findings included: Resident # 1 was admitted to the facility on [DATE] for rehabilitation after being hospitalized for a respiratory illness. Resident # 1's admission Minimum Data set assessment, dated 1/16/23, coded Resident # 1 as cognitively intact. Resident # 1 was not coded as displaying any behaviors during the assessment period. Resident # 1's care plan, updated on 2/20/23, noted Resident # 1 suffered from chronic pain. The care plan also addressed that she also displayed manipulative behavior/ attention seeking behaviors. Although not all inclusive, some of the interventions to address behaviors on the care plan were as follows. Staff were directed to determine the reason for any behaviors, approach her in a calm manner, praise for desired behavior, and provide support as needed. Resident # 1 was interviewed on 2/25/23 at 9:40 AM and reported the following. She and two of her family members had a meeting within the past week with administrative staff members to discuss her care and concerns that she and her family had. One of the resident ' s main concerns, which was discussed, was pain management and getting her pain medication timely. The resident also reported that she had concerns that she heard staff talking about her from her room while they were in the hallway, and she did not appreciate that. Prior to the meeting, Nurse # 1 had informed Resident # 1 that upon her initial admission, Resident # 1 acted as if staff should drop everything and attend to her. According to Resident # 1, Nurse # 1 was a direct care nurse and had not been at the meeting. Resident # 1 did not recall anything specifically she had done to give staff this impression, and acknowledged that when she first came, she may not have remembered everything as clearly as she did currently. During the meeting with administrative staff, she stated she spoke up and apologized for anything she had done to upset facility staff. She told the administrative staff that she wanted everyone to get along. During the meeting she recalled the business office manager rolling her eyes during the meeting. She also recalled the social worker sat as if she had a chip on her shoulder and would not look at her. The resident stated it made her feel as if I was beneath them and a nobody to them. Resident # 1's family member was interviewed on 2/24/23 at 10:40 AM and reported the following. Resident #1, another family member, and she had met with several administrative staff members within the past week to discuss Resident # 1's care and concerns they had. The Regional Ombudsman was also present for the meeting. The family member reported the staff members looked down rather than at the resident and rolled their eyes during the meeting. The Regional Ombudsman was interviewed on 2/24/23 at 12:53 PM AM and reported the following. He had been in attendance during the meeting with Resident #1, two family members, and several administrative staff members within the past week. The administrative staff members who were present were the Rehabilitation Director, the Director of Nursing, the Social Worker, and the business officer manager. The Administrator was not physically present and had called in on the speaker phone. The Physician Assistant (PA) came for the first few minutes of the meeting and stepped out after discussing pain management. After the PA left, they further discussed concerns that the resident felt she had waited for care and pain medications, that the resident felt staff were talking about the resident in the hallway when she was not present, discharge planning, and the amount of assistance the resident needed to walk to the bathroom. The Regional Ombudsman corroborated that during the meeting he witnessed the social worker rolling her eyes as Resident # 1 was speaking. He also corroborated some of the administrative staff members would not look at the resident and looked down. The Regional Ombudsman reported Resident # 1 spoke up and said she was not asking for special treatment, but only to be treated the way they would treat their own family member. According to the Regional Ombudsman, none of the staff members spoke up when this was said by the resident. Following the meeting, the Regional Ombudsman stated he had spoken to the Administrator about how the staff had acted during the meeting. The Regional Ombudsman was interviewed again on 2/27/23 at 10:35 AM. The Regional Ombudsman reported the meeting with Resident # 1 and the family lasted approximately one hour and 15 minutes. They had also discussed what the social worker's role was during the meeting. He did see the social worker go up to the resident after the meeting had been concluded and as people were leaving. According to the Regional Ombudsman, as people were leaving the SW told Resident # 1 she cared. The Administrator was interviewed on 2/24/23 at 5:25 PM and again on 2/25/23 at 3:45 PM and reported the following. She had been out of town when the meeting was held. It would have been her preference to have been physically present during the meeting, but she had not wanted to delay the meeting for her return. This was because she wanted any concerns Resident # 1 and her family had to be resolved. Therefore, she had called in by speaker phone and she could not see how her staff were acting nor always hear every detail. Since the meeting, she had followed up with her staff who reported that after the meeting the social worker had tried to reinforce that they cared about Resident # 1.

Based on record review and interviews with staff and Nurse Practitioner, the facility failed to provide care in a safe manner for 1 of 4 residents reviewed for supervision to prevent accidents (Resident #293). The resident rolled off the bed during care which resulted in a laceration above the left eye and fracture of the left 7th and 8th ribs. The findings included: Resident #293 was admitted to the facility on [DATE]. His diagnoses included cognitive communication deficit, dementia without behavioral disturbance and generalized muscle weakness. The most recent comprehensive Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #293 was severely impaired and required extensive assistance to accomplish activities of daily living (ADL) to include bed mobility, personal hygiene, dressing, and toileting. He was coded for one person assist. The Care Area Assessment (CAA) summary indicated Resident #293 was at risk for falls due to weakness, debility, and poor safety awareness secondary to severe cognitive decline. Nursing note dated 4/3/2022 at 3:15 am indicated Nurse #3 was called to Resident #293's room by Nursing Assistant #1 (NA #1). He was informed by NA #1 that Resident #293 fell out of bed during patient care. Resident #293 was lying on his left side on the floor at the left side of bed. He complained of pain on left side of head, upon inspection found ½ -inch laceration above left eye just below eyebrow. Cleansed site and applied clean dry dressing. Resident #293 denied neck injury and stated he had pain on entire left side of body upon questioning but showed no change in baseline with range of motion to extremities or hip. He was repositioned back to bed with assistance from nursing assistants. Unit manager and physician were notified of the fall and Emergency Medical Services (EMS) were contacted to transfer Resident to the emergency room (ER). Nursing Assistant #1 (NA #1) statement dated 4/3/22 indicated NA #1 was performing patient care for Resident #293 when he rolled over too far. NA #1 attempted to catch Resident #293, but she was unsuccessful. During an interview on 7/27/22 11:48 am, Nursing Assistant #1 (NA #1) indicated she was changing resident #293's linen when he fell off the bed. She stated she had raised the bed to hip level, pulled resident #293 to the middle of the bed and turned him away from her so that she could tuck the dirty linen under him, he rolled too far and fell off the bed hitting his left side. She tried to hold onto Resident #293, but he slipped and hit the floor. She noticed Resident #293 had a skin tear above the left eye and she went to the doorway to call Nurse #3 who came in to assess Resident #293. Nurse #3 cleaned the skin tear, applied a bandage, and contacted Emergency Services to transport Resident #293 to the emergency room . An interview on 7/26/22 at 2:21 pm with Nurse #3 revealed he was the primary nurse for Resident #293 when he fell off the bed on 4/3/22. He indicated he became aware of the fall after Nursing Assistant #1 (NA #1) called for assistance from Resident #293's doorway. When he walked into the room Resident #293 was on lying on his left side on the floor, he had a laceration above left eye and complained of pain on entire left side of body. Nurse #3 cleaned the site, applied a dressing then transferred Resident #293 back to bed. He notified physician of the fall and contacted EMS to come transfer Resident #293 to the ER for evaluation. Nursing note dated 4/3/2022 at 3:45 am indicated Nurse #3 assisted EMS staff with transferring Resident #293 onto stretcher for transfer to the ER. emergency room (ER) progress notes dated 4/3/22 indicated Resident #293 was seen at the ER for a fall and laceration in left eyebrow. The laceration measured 2 centimeters in length by 1 millimeter in depth and was repaired with 2 sutures. Computerized tomography (CT) of head and cervical spine revealed no acute [CONDITION(S)] or acute cervical spine fracture. Resident #293 was transferred back to the facility on [DATE] after the ER visit. During an interview on 7/26/22 at 12:15 pm with the Director of Nursing (DON), she indicated Resident #293 fell during patient care while being positioned in bed. NA #1 was changing Resident #293's bed linen when he rolled out of bed. The DON stated NA #1 should have turned Resident #293 toward her instead of away from her. She stated NA #1 had been trained to turn the resident toward the staff instead of away from the staff when utilizing one-person physical assist. The DON indicated Resident #293 was initially coded as requiring 1-person physical assist and his care plan was updated after the fall on 4/3/22 to include 2-person assist during ADLs. A nursing note dated 4/5/22 at 10:57 am indicated Resident #293 complained of pain/discomfort to left ribs. A nursing note dated 4/5/22 at 2:25 pm indicated new orders were received for [MEDICATION(S)] and [MEDICATION(S)] gel for pain for Resident #293. A nursing note dated 4/5/2022 11:12 pm indicated an order was received for [MEDICATION(S)] patch 4% on for 12 hours and off 12 hours for Resident #293. Nurse Practitioner (NP) progress note dated 4/5/22 indicated Resident #293 reported recent onset of left rib pain, since fall and a 2-view x- ray was ordered to rule out any fractures or injuries. A physician's order dated 4/5/22 indicated an x-ray of left ribs status post fall with pain. Review of X-ray results dated 4/5/22 revealed Resident #293 had acute left 7th and 8th rib fractures. An interview was conducted with facility Nurse Practitioner (NP) on 7/27/22 at 10:31 am. The NP stated Resident #293 was send out to ER for fall on 4/3/22. The hospital sutured the laceration above left eye and completed a CT to head/neck. A chest x-ray or CT was not ordered at the hospital. When Resident #293 returned to the facility, he complained of rib pain and the NP ordered a chest x-ray on 4/5/22. The chest x-ray revealed acute left 7th and 8th rib fractures. The NP verbalized she gave an order for [MEDICATION(S)] patch for Resident #293 for rib pain for 14 days. An interview was conducted on 7/27/22 at 2:00 pm with the Administrator. She stated NA #1 should have turned Resident #293 toward her because she was providing care by herself. She stated all the nursing staff were retrained, after Resident #293's fall, on turning residents toward staff if utilizing one-person physical assist. The Administrator indicated the facility had completed a plan of correction related to the fall. The facility's corrective actions implemented after the accident to prevent a reoccurrence included the following: 1. Resident #293's care plan and Care card was reviewed, and appropriate changes were made as needed. 2. All residents were reviewed to ensure the following areas had been appropriately addressed by the Nursing Administration Team and was to be completed by 4/4/2022: a) Number of staff members needed to provide care; b) Bed surface to ensure sufficient room for turning and repositioning; c) Whether or not the resident had a physical impairment or behaviors that needed to be considered; and d) Any resident that could not assist with turning or repositioning. 3. Effective 4/3/2022, all Certified Nursing Assistants were re-educated on the locations of the resident Care Card, where on the Care Card to find the information needed to ensure appropriate care was provided to the resident. 4. Effective 4/3/2022, Certified Nursing Assistants were educated related to proper technique for turning and repositioning residents (+1/+2 staff assist). 5. No Certified Nursing Assistant would be allowed to work without the education. Education was completed by 4/4/2022. 6. All Current residents Care Card were reviewed, and changes were made as needed. This was completed 4/4/2022. The care plans were updated with any changes as needed by 4/4/2022 7. Effective 4/4/2022, the ADON added to orientation specific education regarding the Care Card to include the purpose of the Care Card and a detailed review of the information on the Care Card. 8. Effective 4/4/2022, the DON/designee conducted audits to ensure that care was being provided according to the resident care plan and Care Card. The audits were to be conducted daily for 14 days various shifts then weekly for 2 weeks. These audits would be conducted on all shifts. 9. Effective 4/4/2022, DON was to report findings of this monitoring process to the facility Quality Assurance and Performance Improvement Committee for any additional monitoring or modification of the plan monthly x 2 months, or until the pattern of compliance was maintained. The QAPI committee could modify the plan to ensure the facility remained in substantial compliance. Alleged Compliance Date: 4/4/2022 On 7/27/22 the facility's Plan of correction was validated by the following: Audits conducted by the facility were reviewed and were found to be completed according to the plan of correction. All nurses and nursing assistants were educated on turning and repositioning. The training topic was proper positioning when providing ADLs in bed to prevent Resident from falling content included: 1. Roll resident toward person giving care 2. If resident requires extensive care or is not able to assist with care, utilize 2-person assist for ADLs. Director of Nursing (DON) completed initial training for all staff and DON/Designee was responsible for ensuring all staff were trained on proper positioning to prevent falls. The validation confirmed the facility was still implementing steps of their corrective action plan on 4/4/22. The corrective action plan was validated to be completed as of 4/5/22.

Based on observation, staff interviews, and record reviews, the facility failed to provide a resident's tube feeding in accordance with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included: Resident #55 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Care Plan dated 6/29/22 focused on tube feeding included a goal for Resident #55 to receive the appropriate number of calories from her tube feeding to maintain weight and hydration. Interventions included provide tube feeding as ordered and notify dietitian, doctor, and family of any weight changes. Resident #55's admission Minimum Data Set (MDS) dated [DATE] indicated a moderate cognitive impairment. She received greater than 51% of her calories and fluid from her TF. An observation was made on 7/25/22 at 12:45 PM of Resident #55 in bed with TF formula running at 60 ml per hour through her feeding tube. During an interview on 7/25/22 at 12:50 PM, Nurse #1 confirmed the TF was ordered for 55 ml per hour. She indicated that it was running at 60 ml per hour when she took over Resident #55's care from night shift and it had been changed by the night shift nurse. She revealed she had checked the TF that morning but was not aware it was not the correct rate. During an interview on 7/26/22 at 1:15 PM, the Director of Nursing (DON) indicated that the nurses should check the order when they start a new bottle of tube feeding formula. The nurses on each shift should confirm the TF was running as ordered. During an interview on 7/26/22 at 3:00 PM, the Administrator revealed TF should run as ordered by a physician. The nurse should have reviewed the order when she changed out the TF bottle.

Based on record review, observations, staff and physician interviews, the facility failed to obtain a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings included: Resident #214 was admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent comprehensive Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #214 was cognitively impaired and received oxygen therapy. Review of Resident #214's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During observation on 07/25/22 09:33 AM Resident #214 was observed with the oxygen nasal canula. Resident #214's oxygen regulator on the concentrator was set at 3 liters/minute when viewed horizontally at eye level. During observation on 07/26/22 09:16 AM Resident #214 was observed with the oxygen nasal canula. Resident #214's oxygen regulator on the concentrator was set at 3 liters/minute when viewed horizontally at eye level. During observation on 07/26/22 11:15 AM Resident #214 was observed with the oxygen nasal canula. Resident #214's oxygen regulator on the concentrator was set at 3 liters/minute when viewed horizontally at eye level. Resident #214's oxygen regulator was verified with Medication Aide #2 to be set at 3 liters/minute. During an interview on 07/26/22 at 11:15 AM with Medication Aide #2, she stated she thought Resident #214 was supposed to be on oxygen at 2 liters/minute via nasal cannula, but she could not locate the order. Medication Aide #2 stated the order would be documented under physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 07/26/22 at 11:22 AM with Nurse #2, she stated there was no order for Resident #214's oxygen administration under physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] An interview was conducted on 07/26/22 12:15 PM with the Director of Nursing (DON). She stated there should have been a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON further stated when the facility utilized standing orders, the standing order would be activated and documented under physician orders. During an interview on 07/26/22 at 12:32 PM with the facility Administrator, she stated she expected nursing staff to obtain a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted on 07/27/22 08:38 AM with the facility Physician. He stated he could not recall if the facility had contacted him for an order to administer oxygen to Resident #214. He further stated if the facility had contacted him for an order, it would be documented under physician orders. The Physician stated he expected nursing staff to administer oxygen with an order and to contact him if there was need for oxygen administration or oxygen titration for any resident in the facility.

Based on record review and staff interviews, the facility failed to refer a resident with a newly evident diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings Included: Resident #72 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident #72's Significant Change Minimum Data Set (MDS), dated [DATE], indicated Resident #72 was not currently considered by the State Level II Preadmission Screening and Resident Review (PASRR) process to have a serious mental illness. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS also indicated Resident #72 had received antipsychotic medication on a routine basis only. A review of Resident #72's medical doctor's progress notes revealed she was diagnosed with [CONDITION(S)] with hallucinations due to known physiological condition on 04/28/22. In the Plan of Care in the progress note, the medical doctor (MD) indicated Resident #72 was to continue taking her antipsychotic medication daily. On 06/10/22, Resident #72's MD note specified, she has refused treatment and baseline has significant dementia with agitation .will also continue [MEDICATION(S)] (an antipsychotic medication) for [CONDITION(S)] and [MEDICATION(S)] (an antidepressant medication) for depression and behaviors. During an interview with the Social Worker (SW) on 07/26/22 at 3:39 p.m., the SW stated she was the person responsible for referring residents with a newly evident diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The SW explained she had been unaware Resident #72 had been diagnosed with [CONDITION(S)] with hallucinations due to known physiological condition. The SW was unsure whether [CONDITION(S)] had been erroneously checked on the MDS assessment or not. An interview was held with the MDS Coordinator on 07/26/22 at 4:22 p.m. The MDS Coordinator explained she had indicated Resident #72 had a [CONDITION(S)] on the significant change MDS after reading the new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A second interview was held with the SW on 07/27/11 at 11:11 a.m. The SW explained the process she followed for making a PASRR Level II screen on new residents and on established residents. For established residents, she stated she would run a report on all residents which included their diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She further explained that residents on the report with newly evident mental illness diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During the survey, the SW discovered Resident #72's new mental illness diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with the Administrator on 07/28/22 at 12:08 p.m., the Administrator stated after discussion with her interdisciplinary team (IDT), Resident #72 was not referred for a PASRR Level II screen because her newly evident mental illness diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observations, record review and staff interviews, the facility failed to implement the facility policy for unvaccinated employees when 2 of 12 unvaccinated (with exemptions) staff members were observed wearing KN95 masks instead of N95 masks as an additional precaution for unvaccinated staff members (Patient Care Attendant #1 and Laundry Aide #1). Additionally, the facility failed to track and document the COVID-19 vaccination status for 1 of 2 staff members documented as partially vaccinated (Nursing Assistant #2). The failures occurred when the facility was in COVID-19 outbreak status. Findings included: 1.The facility's COVID-19 Vaccination Policy dated January 2022 indicated additional precautions for staff with COVID-19 vaccination exemption which included, source control by use of the N95 respirator and physical distancing. As requested, on 07/27/22 the Administrator provided a list of unvaccinated employees that included Patient Care Attendant (PCA) #1 and Laundry Aide #1. 1a. An observation of PCA #1, an unvaccinated staff member (with an exemption), was made on 07/25/22 at 08:55 AM. She was observed wearing a KN95 mask while talking to Resident #33 in her room and was within 6 feet of Resident #33. An interview with PCA #1 on 07/25/22 at 09:00 AM revealed she had a COVID-19 vaccination exemption and was aware she was supposed to wear an N95 mask at all times while in the facility but the KN95 mask felt more comfortable for her. She stated she was assigned to pass ice and answer call lights in the 200 hallways. 1b. An observation of Laundry Aide #1, an unvaccinated staff member (with an exemption), was made on 07/26/22 at 11:50 AM. She was observed wearing a KN95 mask while folding laundry in the laundry room within 6 feet of other laundry department employees. During an interview with Laundry Aide #1 on 07/26/22 at 11:50 AM, she indicated she had a COVID-19 vaccination exemption. She stated she was not aware she was required to wear an N95 as an additional precaution while working in the building. She also stated she worked in the laundry room and transported linen to different halls. During an interview with the facility Infection Preventionist (IP) on 07/26/22 at 01:50 PM, she stated all unvaccinated staff members were aware of the requirement to wear an N95 mask at all times while in the facility. She stated all the staff that had been granted a COVID-19 vaccination exemption had signed an acknowledgement of the policy with additional mandated precautions to include donning an N95 mask at all times while working in the facility. During an interview with the facility Administrator on 07/26/22 at 01:55 PM, the Administrator stated unvaccinated staff members were made aware of the requirement to use an N95 mask and signatures were obtained from staff indicating they had been made aware of the policy. 2. The facility's COVID-19 Vaccination Policy dated January 2022 indicated the facility would use a tracker to document employees' date of first vaccine, second vaccine as well as date of additional booster vaccine and securely document the information in employee medical file. As requested, the Administrator provided a list of partially unvaccinated employees that included Nursing Assistant (NA) #2 on 07/27/22. The facility records indicated NA #2 received her 1st vaccination dose of a multi-dose vaccine on 6/16/21. The COVID-19 staff vaccination matrix provided by the facility indicated NA #2 was partially vaccinated. On 08/03/22, the Administrator provided NA #2's COVID-19 Vaccination card which indicated she had received her 1st vaccination dose on 6/16/21 and her 2nd vaccination dose on 7/21/21. During a follow up interview with the Administrator on 08/03/2022 at 09:15 AM, she stated NA #2 had received both doses of a multi-dose COVID-19 vaccine, but the facility failed to track and document it correctly which resulted in NA #2 being documented as partially vaccinated. The Administrator stated the facility should have ensured all staff COVID-19 vaccinations were documented correctly.

Based on staff interview and record review, the facility failed to obtain a Level II Preadmission Screening and Resident Review (PASARR) for a resident with an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings included: Resident #76 was admitted to the facility on [DATE] after hospitalization . Review of the PASRR Level I application dated 07/10/18 revealed no mental health diagnosis. Review of the PASRR Level I Determination Notification letter dated 07/10/18 revealed that no further PASRR screening is required unless a significant change occurs with the individual's status that suggest a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #76's Annual Minimum Data Set (MDS) dated [DATE] revealed Resident #76 current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 04/28/21 at 10:31 AM with the Social Worker (SW), she stated when a resident was newly diagnosed with a mental illness the resident needed to be evaluated for a Level II PASRR. The SW stated she was not in the current position when the evaluation should have been completed, she did not know what had happened or why the evaluation was not done. She stated she would make the corrections and she shared the monitoring sheet the facility was currently using for PASRR tracking. An interview was conducted with the facility's Administrator on 04/28/2021 at 03:28 PM, she expressed the PASARR information is expected to be updated immediately and follow up documentation sent for evaluation as appropriate to the interdisciplinary team. She expressed all residents should be reviewed and screened for any needed Level II PASRR assessments when changes occur.

Based on record review and staff interviews, facility failed to obtain a consent from the Responsible Party (RP) before giving a COVID-19 vaccine for 1 of 3 sampled residents. (Resident #244). The findings included: Resident # 244 was admitted to the facility on [DATE]. She was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Minimum Data Set (MDS) dated [DATE] indicated she was severely cognitively impaired. she required limited assistance with bed mobility, extensive assistance with dressing, independent with eating, limited assistance with toileting and limited assistant with personal hygiene. Resident # 244 was care planned for the following areas: complications for fatigue, weakness, and confusion related to dx of [CONDITION(S)], require assist with ADL's due to impaired mobility, at risk for falls due to an unsteady gait and a hx of falls Review of the form Informed Consent for Vaccination in Long Term Care Facility dated 03/10/2021 revealed no signature or verbal consent provided by the Responsible Party (RP). During the phone interview on 04/27/202 at 10:00 AM, the Responsible Party indicated she did not give permission for a COVID-19 vaccine to be given to Resident # 244. During the interview on 04/27/2021 at 11:00 AM, Nurse # 1 stated she did not document that the RP gave verbal consent for Resident # 244 to receive a vaccine on the COVID-19 vaccination form. Nurse # 1 also stated she understands the resident was cognitively impaired and that was the reason it was important to get consent from the Responsible Party. The Director of Nursing stated during the interview on 04/27/2021 at 11:07 AM that she was not sure why Nurse # 1 failed to document she called the Responsible Party on the phone for verbal consent before giving the COVID-19 vaccine to Resident # 244. She stated her expectation was for Nurse # 1 to have called RP and document the verbal consent on the vaccination consent form before giving COVID-19 vaccine to Resident # 244.

Based on observation, record review, a test tray, resident and staff interviews the facility failed to serve palatable food according to their preferred temperature for 2 out of 2 residents (Resident #3 and Resident #4) sampled for palatable food. Findings included: The meal policy revised July 2017 in part read: Hot foods shall be held at a temperature of 136 degrees or above until served Nursing and Dietary Services will establish procedures such that delivery of food to serving areas accommodates this requirement. A lunch meal pass and test tray on 02/06/2021 was observed on Unit 2B at 12:10 PM with the Dietary Supervisor (DS). The cart arrived on the hall with ten trays. Nurse #1 walked to the cart and removed a tray and walked away with the cart door open. Two Nursing Assistants then came and passed the remaining trays out and left two trays, one being the test tray. The DS took the tray out of the cart at 12:22 PM and stated her thermometer was calibrated and proceeded to test the lunch. The menu consisted of: meatloaf, potatoes and mixed vegetables. The meatloaf was 122 degrees, the potatoes were 130 degrees and the mixed vegetables were 124 degrees. During an interview with Resident #3 on 02/06/2021 at 12:33 PM, Resident #3 stated his lunch was warm and would like to have hot food. Resident #3 also stated the temperature has gotten better in the last couple of weeks because his food used to be cold most of the time. Resident #3 further stated he also received cold breakfasts and doesn't ask to reheat it because once it is cold it would not taste right after it is reheated. During an interview with Resident #4 on 02/06/2021 at 12:37 PM, Resident #4 stated his lunch was not hot, it was warm, and his breakfasts are also cold. Resident #4 also stated he would like to give them a list of his likes and don't likes and have them follow the list. During an interview with Nurse #1 on 02/06/2021 at 12:13 PM, Nurse #1 stated she didn't know why she left the cart door open and she was just helping the Nursing Assistants. Nurse #1 also stated she did have complaints of cold food from the residents and she would ask if they wanted it heated up but has not reported it to anyone. During an interview with Nursing Assistant (NA) #1 on 02/06/2021 at 12:51 PM, NA #1 stated she had had complaints of cold food. She asked residents if they wanted their food heated and she would get it warmed for them. NA #1 also stated she has reported it to the Nurses and Dietary Supervisor. During an interview with NA #2 on 02/06/2021 at 12:53 PM, NA #2 stated she had received complaints of cold food and she would warm it up if they wanted. NA #2 also stated she had not reported it to the nurse because it happened frequently. During an interview with the DS on 02/08/2021 at 1:29 PM, the DS stated she has not had any complaints of cold food. The DS also stated the hot temperatures are supposed to be 136 degrees when served to residents. During an interview with the Administrator on 02/08/2021 at 3:56 PM, the Administrator stated she expected the temperature of meals to be served according to facility policy.

Based on observation, record review and staff interviews, the facility failed to implement their policies and procedures related to personal protective equipment (PPE) and hand hygiene when entering and exiting resident rooms for 2 of 5 sampled residents (Resident #1 and Resident #2) who resided on the facility ' s quarantine hallway and were on enhanced droplet isolation precautions. These failures occurred during COVID-19 pandemic. The findings included: Record review of facility policy and procedure titled Personal Protective Equipment for COVID-19 or Suspected COVID-19 Residents revised April 2020 revealed personnel were to use hand sanitizer or soap and water before and after entering isolation precaution setting. It further revealed staff were to wear full personal protective equipment when working with individuals with known or suspected COVID-19. On 02/06/21 at 12:30 PM, an observation was made of Nurse Aide (NA) #1 entering Resident #2 ' s room that was located on the facility ' s 100 hall quarantine unit. She picked up a meal tray and she was not wearing gloves and a gown. NA# 1 was observed to exit the room after picking up the lunch tray and did not perform hand hygiene. Droplet precaution signage was observed posted beside the door to Resident #2 ' s room which specified staff were required to wash hands when entering and leaving room, wear mask. If contact with secretions likely, they were to use gown, gloves and facial shields. On 02/06/21 at 12:32 PM, NA #1 was observed entering Resident # 1 ' s room after exiting Resident #2 ' s room. Resident #1 ' s room was also located on the facility ' s 100 hall quarantine unit. NA #1 did not don a gown and gloves or wash her hands before entering Resident # 1 ' s room. She picked up Resident #1 ' s tray. NA # 1 also did not wash her hands or use a hand sanitizer after she exited the resident's room. Enhanced Droplet precaution signage was observed posted beside the door to Resident #1 ' s room which specified staff were required to wash hands when entering and leaving room, wear mask. If contact with secretions likely, they were to use gown, gloves and facial shields. During an interview on 02/06/21 at 12:35 PM, NA #1 revealed she had been trained regarding infection control practices, hand hygiene and use of PPE when entering isolation rooms. She indicated she was aware that she should have performed hand hygiene and don PPE according to the signage posted but missed to do it when she entered and exited Resident #1's and Resident # 2 ' s rooms. An interview with Nurse #1 on 02/06/21 at 12:40 PM revealed Resident #1 and Resident # 2 were on 14 days isolation. Nurse #1 indicated residents placed on isolation had a signage and PPE supplies outside their doors for staff to utilize prior to entering the room. He indicated nursing staff had been trained on hand hygiene and the use of PPE when caring for residents in isolation to prevent infection transmission. He indicated he always donned PPE prior to entering the room and performed hand hygiene when entering and exiting residents' rooms. An interview with Director of Nursing (DON) on 02/06/21 at 1:45 PM revealed she was also the Infection Prevention Nurse (IPN). She indicated all staff had been trained regarding infection control practices, policies and procedures including enhanced droplet precaution requirements. She stated staff were to perform hand hygiene before and after every resident encounter as well as don PPE as per signage on the resident's door. She indicated Resident #1 and Resident #2 were on 14 days isolation after being admitted to the facility from the hospital. The residents had an enhanced droplet isolation signage as well as PPE supply outside their doors that staff were required to use prior to entering the rooms. An interview with the Administrator on 02/08/21 at 10:25 AM revealed all staff were to perform hand hygiene and don PPE as per signage on the door prior to entering the room of residents on isolation

Based on record review and staff interviews the facility failed to provide pain medication according to physician's order for 1 of 1 resident reviewed for pain management. (Resident#2) Findings included: The facilities policy for medication administration dated 12/2020 read, in part: Medications must be administered in accordance with the orders, including any required time frame .The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones. Resident #2 was admitted [DATE] with [DIAGNOSES REDACTED]. The admissions Minimum Data Set ((MDS) dated [DATE] had Resident#2 coded as cognitively intact needing extensive assistance with toilet use, personal hygiene, limited assistance with bed mobility, transfer and dressing, and supervision with eating. Resident #2 had experienced pain 4 out 5 times during the last look back period. The December 2020 and January 2021 Medication Administration Record (MAR) did not have the following medications documented as administered: [MEDICATION NAME] 100 MG capsule for Diabetic [MEDICAL CONDITION], three times a day, January 6th, [MEDICATION NAME]-[MEDICATION NAME]-Schedule II, 10-325 MG tablet for pain, every eight hours, three times a day, and for a pain assessment every shift was missed for second shift on December 30th, first shift on January 2nd, 3rd and 4th, second shift on January 21st, first shift January 22nd, 23rd, 24th, 25th, and 26th. January 25th also missed second shift documentation. During a telephone interview with Nurse #2 on 02/08/2021 at 1:57 PM, Nurse #2 stated there were documentation errors but did give medications on the days the MAR wasn't signed, and the MAR was supposed to be signed after every medication administration. Nurse #2 also stated she realized she didn't sign the MAR the next day but the matrix will not let her go back in to fix it and she did not put a note in the system because the unit was very busy on those days. Nurse #2 further stated Resident #2 never complained of pain when she worked with him. During a telephone interview with the Physician Assistant (PA) on 02/08/2021 at 3:41 PM, the PA stated there should be documentation for all medication administrations to assure medications were administered and he expected the medication orders to followed. The PA also stated the pain assessments were needed because Resident #2 had chronic pain and was on medication to control his pain prior to being admitted to the facility and he wanted to make sure his pain medication regimen was controlling his pain. During a telephone interview with the Administrator on 02/08/2021 at 3:56 PM, the Administrator stated documentation for medications should be documented and Physician orders should be followed as prescribed.

Based on record review and staff interviews the facility failed to assure 1 of 1 resident (Resident #2) was free of medication errors when medications were not documented as being administered. Findings included: The facilities policy for Medication Administration dated 12/2020 read in part: Medications must be administered in accordance with the orders, including any required time frame .The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones. Resident #2 was admitted [DATE] with [DIAGNOSES REDACTED]. The admissions Minimum Data Set ((MDS) dated [DATE] had Resident#2 coded as cognitively intact needing extensive assistance with toilet use, personal hygiene, limited assistance with bed mobility, transfer and dressing, and supervision with eating. Resident #2 had experienced pain 4 out 5 times during the last look back period. The care plan dated 01/04/2021 had focuses of needed assistance with activities of daily living (ADL) related to (R/T) impaired mobility, at risk for skin breakdown R/T impaired bed mobility, at risk for pain R/T acute/chronic illnesses, at risk for alteration of skin integrity R/T fragile skin. The December 2020 and January 2021 Medication Administration Record (MAR) did not have the following medications documented as administered: December 30th, [MEDICATION NAME] 40 MG tablet, twice a day, January 1st, [MEDICATION NAME] 40 MG tablet, twice a day, January 25th, [MEDICATION NAME] 40 MG tablet, twice a day, January 1st, [MEDICATION NAME] 100 MG capsule, three times a day, January 6th, [MEDICATION NAME]-[MEDICATION NAME]-Schedule II, 10-325 MG tablet, every eight hours, three times a day, and for a pain assessment every shift was missed for second shift on December 30th, first shift on January 2nd, 3rd and 4th, second shift on January 21st, first shift January 22nd, 23rd, 24th, 25th, and 26th. January 25th also missed second shift documentation. During a telephone interview with Nurse #2 on 02/08/2021 at 1:57 PM, Nurse #2 stated there were documentation errors but did give medications on the days the MAR wasn't signed, and the MAR was supposed to be signed after every medication administration. Nurse #2 also stated after both days of missed documentation, she realized she didn't sign the MAR but the matrix would not let her go back in to correct it and she did not put a note in Resident #2's chart because the unit was very busy on those days. During a telephone interview with Med Aid#1 on 02/08/2021 at 2:54 PM, Med Aide #1 stated Resident #2 never had c/o pain. The Med Aides are supposed to report any complaints from the residents to the nurses and the pain assessments are completed by the nurses. During a telephone interview with Nurse #4 on 02/08/2021 at 3:49 PM, Nurse #4 stated all medications are to be signed as they are administered and the pain assessments are to be completed by the nurses. During a telephone interview with the Physician Assistant (PA) on 02/08/2021 at 3:41 PM, the PA stated there should be documentation for all medication administrations to assure medications were administered and he expected the medication orders to followed. The PA also stated the pain assessments were needed because Resident #2 had chronic pain and was on medication to control his pain prior to being admitted to the facility and he wanted to make sure his pain medication regimen was controlling his pain. During a telephone interview with the Administrator on 02/08/2021 at 3:56 PM, the Administrator stated medications should be documented and Physician orders [REDACTED].

Based on medical record review and staff interviews, the facility failed to provide an ongoing activities program for 1 of 1 sampled resident. (Residents # 4) The findings include: Review of chart revealed Resident # 4 was admitted to the facility on [DATE] was discharged on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of the admission minimum data set ((MDS) dated [DATE] coded brief interview of mental status (BIMS) as intact, he required supervision with bed mobility and eating, limited assist with transfer, dressing and toileting. Care plan dated 12/29/2019 revealed the Resident # 4 was care planned to discharge home when rehab is completed, and he was at risk for falls. The goals were measurable, and the approach were appropriate. Resident # 6's admissions Activity Assessment/ History dated 7/14/2009 documented Resident #'s activity pursuit patterns was reading. Review of the resident's activities attendance record revealed the facility staff provided the activities to Resident # 4 only 5 times for the month of December 2019. Further review of the attendance record revealed the staff provided activities only 4 times for the month of January 2020. Resident # 4 was no longer at the facility, so no observation of the resident was completed. Other residents were observed in their rooms due to covid-19 social distancing. During an interview with the Activity Director (AD) on 08/12/2020 at 11:45 AM, she revealed Resident # 4 remained in her room most of the day and very rarely the staff took her out of the room for out of the room activities. AD further stated she provided 1:1 in room activities to the resident 4 times in the month of January 2020. During an interview on 08/12/2020 at 1:04 PM, the Administrator stated her expectation was for the Activity department to provide activities that would engage the resident both in room and outside his room. The administrator further indicated the AD was expected to document each time they invited the resident or offered an activity to a resident. They were expected to document any of the resident's refusal to participate in the activity.

Based on record reviews and family and staff interviews, the facility failed to provide incontinence care for 1 of 3 dependent residents reviewed for the provision of activity of daily living (ADL) care (Resident # 1) for dependent residents. Findings included: Resident # 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 was cognitively intact and required extensive assistance for her Activities of Daily Living (ADL) and was frequently incontinent of bowels and bladder. A review of Resident #1 Care Plan last updated 3/12/20 indicated Resident #1 was frequently incontinent of bowel and bladder and required assist with ADL ' s related to impaired mobility. Approaches for problem areas included provide incontinence care during routine rounds and as needed in a timely manner. During a telephone interview with the Responsible Party (RP) on 8/13/20 at 8:52 AM, she explained informed the facility of her concerns of Resident #1 not being toileted through the facility ' s grievance system named Grasshopper on 2/14/20. The RP explained on the previous night (2/13/20), Resident #1 had not been toileted and there was urine still floating in the bed upon her early morning arrival to the facility for a visit. An email correspondence dated 2/14/20 at 9:21 AM from Grasshopper (the electronic grievance system) revealed the RP had identified concerns about Resident #1 care. Review of the Sanstone Inservice Training Report dated 2/14/20 all shifts, it is both C.N.A (Certified Nursing Assistants) and nurse responsibility to answer call lights in a timely manner, to help assist with residents care. When staff is on break or away from the floor, notify your floor nurse/C.N.A so your section can be covered in your absence. Residents should also be routinely asked if they need help toileting as this promotes increase in independence and dignity for our residents. In-services were conducted by the Assistant Director of Nursing. Response to the RP through Grasshopper dated 2/14/20 at 10:05 AM stated the issue is night shift CNAs didn ' t change her appropriately last night. The Director of Nursing investigated and corrective action and retraining to the CNAs was completed. Attempts were made during the survey to contact the Nurse Assistance and the Director of Nursing involved; but they no longer worked at the facility and failed to return calls. In an interview with the former ADON on 8/13/20 at 1:30 pm, she remembered Resident #1; but, did not recall the incidence. She remembered training but could not remember when or why. She explained staff would have been trained and the incident would have been noted in the staffs ' files. In an interview on 8/14/20 at 2:00 PM, the current Director of Nursing stated she expected incontinence rounds to be completed every two hours and as needed on all shifts. She indicated she would not expect aides to leave residents floating in urine. A follow-up telephone interview with the Administrator on 8/14/20 at 3:30 PM, she expressed the incident did occur. She stated all residents should be toileted timely and routinely checked on all shifts.

Based on physician interview, staff interview, and record review the facility failed to collect urine for a urinalysis for ten days and failed to initiate antibiotic treatment as ordered by the physican for fifteen days after nursing faxed the physician describing painful signs and symptoms for 1 of 1 sampled residents (Resident #287) who experienced a urinary tract infection [MEDICAL CONDITION]. Findings included: Resident #287 was admitted to the facility on [DATE], readmitted to the facility on [DATE], and discharged to the hospital on [DATE]. The resident's documented [DIAGNOSES REDACTED]. On 06/24/14 the resident's care plan identified, I have occasional episodes of incontinence as a problem. The resident's care plan was last reviewed on 03/23/15, and there were no revisions regarding this problem. Interventions to this problem included, Observe me for acute behavioral changes that may indicate UTI. The resident's 03/16/15 quarterly minimum data set (MDS) documented her cognition was severely impaired, there were no signs of [MEDICAL CONDITION], the resident was having trouble sleeping, the resident was feeling tired, the resident was experiencing poor appetite, the resident was having trouble concentrating, there was no evidence of [MEDICAL CONDITION], the resident exhibited no behaviors, the resident did not reject care, and the resident was not wandering. The resident required extensive assist with her activities of daily living except she was totally dependent on staff for bathing. The resident was frequently incontinent of bowel and bladder, and had two or more falls since her last MDS with one resulting in non-major injury. A 04/09/15 (Sunday) physician progress notes [REDACTED].#287's health status. The note documented a routine visit with the resident being alert, but not oriented to time or place. [MEDICAL CONDITION] was noted in the hands and feet, the resident was unable to follow commands, there was evidence of advancing multi-infarct dementia with recent TIA ([MEDICAL CONDITION]), the resident was continuing a DNR (do not resuscitate) status, and there was to be a continuation of comfort measures. A 04/21/15 fax to Resident #287's primary physician from Nurse #1 documented, Rsdt (resident) had 2 falls on 11 - 7 shift last night. Rsdt is being very combative, hallucinating. Urine is cloudy with (symbol used) gray tint. Strong odor & c/o (and complaints of) pain when urinating. Family is present @ (at) current & request she gets a UA/C & S ASAP (urinalysis/culture and sensitivity as soon as possible). Current symptoms before & had UTI. Please advise! The fax documented the resident's 04/21/15 10: 00 AM vital signs were blood pressure of 144/86, pulse 78, respirations 18, temperature 98.1, and oxygen saturation 95% on room air. Also handwritten on the facility's copy was, Temp (temperature) 99.9 urine collected.: This handwritten entry was undated. On 04/21/15 Combative behavior during care AEB (as evidenced by) striking out at and pulling away from staff; at risk of injury to self/others and undue stress r/t (in regard to) increased confusion was newly identified as a problem in the resident's care plan. Interventions to this problem included, monitor and document my behavior Q (every) shift, report significant changes to physician, administer medications as ordered by physician, monitor effectiveness of resident drug regime. On 05/01/15 the primary physician faxed a reply which documented, If still symptomatic (i.e. having dysuria), obtain in and out cath for U/A, C & S only if pyuria. 05/02/15 vital signs documented Resident #287's temperature was 99.9 degrees Fahrenheit (with all prior temperatures in April 2015 on 04/06/15, 04/13/15, 04/20/15, and 04/27/15 being within normal range). Lab results documented urine was collected on 05/02/15 with the C & S available on 05/04/15 which showed greater than 100,000 colony-forming units (CFU) of Escherichia coli bacteria. A 05/05/15 4:44 PM progress note documented, Rsdt slept majority of the day and consumed 0% of food and about 60 cc (cubic centimeters) of liquids throughout the day. Family also stated resdt was in pain and PRN (as needed) pain medication administered and had minimal effect A 05/05/15 physician order [REDACTED]. A 05/06/15 fax to Resident #287's primary physician by Nurse #1 documented, Rsdt family requesting a CBC & BMP (complete blood count and basic metabolic panel) on rsdt. Rsdt currently not consuming food or liquids. A 05/06/15 physician order [REDACTED]. A 05/06/15 12:42 AM progress note documented, Resident remained in bed throughout 3 - 11 shift. Respirations even and unlabored. Skin warm and dry to touch. Total care provided by staff, resident fed by staff member consuming 100% of dinner intake. ABT (antibiotic in progress for UTI, no adverse reactions note. No complaints voiced, no distress noted. Resident #287's Medication Administration Record [REDACTED]. A 05/07/15 12:11 AM progress note documented, Resident in bed resting entire shift with family members at bedside most of shift. Received total care, fed by family members, appetite good consuming greater than 75% of dinner intake. The resident's MAR indicated [REDACTED]. A 05/07/15 12:09 PM progress note documented, Resdt in bed all morning very lethargic with family @ bedside. Did not consume any breakfast, scant amounts of liquids .ABT in progress with no adverse reactions noted. A 05/08/15 1:57 PM progress note documented the resident's blood pressure was 126/82, pulse was 92, respirations were 20, temperature was 97.7, and oxygen saturation was 95% on room air. A 05/08/15 physician order [REDACTED]. The resident's MAR indicated [REDACTED]. A 05/08/15 hospital history and physical documented, .was brought in from nursing home for evaluation of change in mentation. The patient is lethargic. She opens her eyes spontaneously to verbal commands. She tries to communicate, but no meaningful information can be obtained Apparently the patient has complaints of abdominal pain and was diagnosed with [REDACTED]. She was started on [MEDICATION NAME], but the patient continued to get worse. The patient can usually talk and answer questions, but for the last 2 days, the ___ (family member designation) states the patient has not been able to communicate at all. Also, the patient's intake has decreased significantly, which has complicated things. She also states the patient's urine has smelled very foul and is very dark in color. The patient apparently used to use a wheelchair to ambulate, but for the last few weeks the patient's functional status has also declined tremendously. No report of fever, chills, nausea, vomiting, diarrhea, chest pain, shortness of breath, lightheadedness, dizziness, or rash Results from the CBC were faxed to the facility on [DATE] with the white blood cells elevated at 22.8 (the normal range being 4.5 - 12.5). A hospital final summary documented Resident #287 passed away in the hospital on [DATE]. Death [DIAGNOSES REDACTED]. At 2:25 PM on 11/18/15 Nurse #1 stated she personally observed the signs and symptoms Resident #287 was experiencing when she faxed the physician on 04/21/15. She also reported the resident's family informed her that they recognized these as the signs and symptoms experienced by the resident when she had UTIs in the past. According to Nurse #1, the resident continued to experience all these signs and symptoms, and she placed three follow-up phone calls to the physician's office on multiple days (there was no documentation of these phone calls in the resident's medical record). She commented she was not able to talk to the physician during these follow-up calls, but his nurses told her that the physician was aware of her concerns about Resident #287 and he would be back in touch. Nurse #1 stated this lag in physician response was not an isolated incident, reporting it was not uncommon to have to wait a week or longer for feedback and orders from Resident #287's physician. At 2:50 PM on 11/18/15 nursing assistant (NA) #5 stated for a couple of weeks before Resident #287 went out to hospital on [DATE] the resident had some hallucinations, moaned, reported she wanted to get out of the facility, and more frequently tried to do unsafe things like get up unassisted. During this same time period the NA commented the resident would say she had to go to the bathroom, and then be unable to urinate, complaining of feeling pressure. According to the NA, she also recalled the resident having brown/gray stains in her brief for a couple of weeks, but she felt this might not have been unusual for the resident. The NA also reported she thought she remembered the resident having cloudy urine, an isolated elevation in temperature, and some complaints of abdominal pain 2 - 5 day before the 05/08/15 hospitalization . She commented she was told by family members that the resident had a past history of UTIs, and her family was concerned that she was going through the same thing again. At 4:30 PM on 11/18/15 Nurse #5 stated for a couple of weeks before her 05/08/15 hospitalization Resident #287 seemed more confused, was less able to do things for herself, and was falling more frequently. She reported she was unsure about any changes in the resident's urination during this time period. However, she commented she recalled the family having concerns saying they thought the resident was exhibiting signs and symptoms of a UTI, and they were getting more aggravated because the resident's doctor was not responding. Nurse #5 commented delays of a week or longer were not uncommon after faxing physicians about changes in resident condition or about concerns with resident health. She explained that about all you could do about the delay was call the physician office and talk to nurses who would say they had already passed the information on to the physician. At 3:06 PM on 11/19/15 NA #6 stated because the resident was last in the facility so long ago about all she could remember was in her last couple of weeks in the facility Resident #287 seemed more weak, was more confused, and the resident was able to go to the bathroom less. She reported Resident #287 did not have frequent UTIs, but had enough in the past that the family stated they could tell when the resident had a UTI from the symptoms she exhibited. At 3:35 PM on 11/19/15 the director of nursing (DON) stated there were two ways to communicate changes in resident condition to the primary physician. She explained if the change seemed urgent nurses could page physicians or physician assistants, and if the change was not urgent and a reply within 1 - 2 days was acceptable then a communication form could be faxed or placed in the physician communication book. She reported staff usually called Resident #287's primary physician since he only had 2 or 3 residents in the building. She commented he was not in the building much more than once a month when he attended quality assurance (QA) meetings. According to the DON, there was a folder at the nurse's station where communication forms that had been faxed to physicians were kept. She stated she expected the nursing staff to check the folder the next day after the initial fax to make sure a response had been obtained. If there was no response, she reported the nurse was supposed to call the physician office. If the nurse was unable to get a response from the physician after the phone call, then the nurse was supposed to take the matter to the unit or clinical coordinator who would then take over the responsibility of obtaining a response. The DON stated waiting almost two weeks to get antibiotic orders for someone exhibiting definitive symptoms of a UTI was too long. She commented in that amount of time the resident should have already completed antibiotic therapy and been free of painful UTI symptoms. At 8:42 AM on 11/20/15, during a telephone conversation with Resident #287's primary physician, he stated when residents experienced changes in condition the best way the nursing staff could reach him was on his cellular phone. He commenting faxing was acceptable also if the problem was not urgent. The physician reported he had some conversations with the former DON before 05/01/15, and they did not think Resident #287 was exhibiting definitive signs and symptoms of a UTI until the resident had an elevated temperature on 05/02/15. (However, there was no documentation of such conversations in the resident's paper or electronic medical record). He stated definitive signs and symptoms of a UTI included elevated temperature, pelvic/abdominal/flank pain, and painful urination. According to the physician, he also stopped by to see Resident #287 while visiting two other residents in the facility on 05/03/15 (Sunday), and Resident #287 seemed at baseline and in no acute distress. (However, there was not a physician progress notes [REDACTED].

Based on policy review, record review as well as interviews with a private sitter, security guard and staff, the facility failed to prevent 1 (Resident #5) of 3 cognitively impaired residents, from leaving the facility as well as sustaining an injury, requiring hospitalization . The facility failed to implement their elopement policy to identify residents with a history of wandering for elopement risk assessment and monitoring schedules to be developed. The facility failed to monitor to prevent an unsupervised exit from the facility. The immediate jeopardy began on Resident #5 on [DATE] and was abated on [DATE]. The facility remained out of compliance at the lower scope and severity level, an isolated deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy, (D). The facility was in the process of implementing their corrective actions on training and monitoring for residents at risk of elopement. The findings include: The facility's policy and procedures, dated [DATE] on Resident Elopement was reviewed. It read, "It is the policy of the facility to make every effort to prevent Elopement episodes while maintaining the least restrictive environment for residents who are risk for elopement. Please note that elopement differs from wandering in that a dependent resident leaves the facility without nursing observation or known knowledge of their departure. Residents at risk for elopement include those who have: delusions, hallucinations, Alzheimer's disease or other dementia, anxiety disorder, manic depression, schizophrenia and history of wandering." "Documentation/Assessments: Elopement Risk Assessment, Elopement Risk Tracking Log, Documentation of Elopement episodes in nurse's notes and implementation of monitoring schedule. " "Elopement Prevention: assess, communicate, ensure resident safety, document, investigate and QA (quality assurance) monitoring." "Procedures: The nursing unit will assess all residents who are risk for harm because of elopement. The resident's current MDS (Minimum Data Set) will be reviewed to determine what changes have occurred that would trigger elopement episodes. The resident's care plan will be modified to indicate the resident is at risk for elopement episodes. If a resident repeatedly wanders off the unit, a monitoring schedule will be implemented to ensure the resident ' s safety." Resident #5 was admitted to the facility on [DATE] then re-admitted on [DATE]. He had the following cumulative Diagnoses: [REDACTED]. On [DATE], Resident #5 was assessed using the Minimum Data Set (MDS), which determined that he had moderate cognitive impairments. He also exhibited wandering behaviors 4 to 6 days of the 7 days look back assessment, but less then daily. He was not care planned for wandering or exit seeking behaviors. On the most recent quarterly MDS dated [DATE], Resident #5 was assessed with [REDACTED]. It was also noted that he wandered 4 to 6 days of the 7 days look back assessment, but less then daily. Resident #5 was not care planned for wandering or exit seeking behaviors. Resident #5 did not have an additional quarterly MDS in August, because he was discharged to the hospital and was not available for review. A review of the nurse's notes revealed the following history. On [DATE], Nurse #1 recorded that "Resident #5 was very agitated throughout the day. Very angry that he had to get up for restorative. He yelled "Why" constantly throughout the morning. He continued to go into other resident's rooms and disturb them. He would not refrain from doing this. Then he attempted to leave the facility via the front doors 2x (twice). He went over to Unit 1 while Nurse #1 was in another patient's room and went in several rooms and disturbed residents there as well. Risperdone (an anti-psychotic medication) not effective at all for his agitation. Physician contacted several times already previously by this nurse and fully aware of these issues. Will continue to monitor. Oncoming nurse made aware of behavior " On [DATE], Nurse #1 recorded in the nurse's notes that Resident #5 was agitated and yelling out sporadically at times. "Resident went down to Unit 2B station self propelled in wheelchair and attempted to open alarm door at end of hall and fell out of wheelchair. RN Supervisor present to observe incident. RN Supervisor assessed resident, no injuries observed. RN Supervisor completed incident report, resident observed throughout day. Oncoming nurse (7pm-7am shift) made aware, will continue to monitor." On [DATE], during the 7am-7pm shift, Nurse #1 documented in his nurse's notes that Resident #5 yelled throughout the day and frequently went into other residents' rooms disturbing them. He wrote, "He attempted to leave the facility via the alarm door and set off the alarm." On [DATE], during the 7pm-7am shift, Nurse #2 recorded that Resident #5 continued to go in and out of other residents' rooms and tried to get out of the emergency door. Resident #5 was unable to be redirected and was given Xanax; however it was found to be ineffective. It was recorded that he made five attempts to go out of the exit doors. Nurse #2 wrote that she monitored him closely. Nurse #2 was unavailable for interview during the survey. A copy of the incident report was requested for this event and the Director of Nursing stated on [DATE] that she did not have a copy. The resident's mental health consultation, dated [DATE] assessed him to have vascular dementia with delusions. It was noted that he had off and on agitation and appear to be Sundown in nature. Staff had relayed that he was manageable when redirected and current medications. An Incident/Accident Report, dated [DATE] at 5:00pm, documented that Resident #5 tipped over in his wheelchair and sustained a small cut to his left arm below the elbow and to his left forehead above the eyebrow. Bruising was noted. His personal alarm was in place. Resident #5 was observed by a visitor, who notified the nurse. Nurse Aide #1 assisted the nurse with placing the resident back in his wheelchair. His physician was notified on [DATE] at 5:30pm. The resident was sub sequentially transported to the emergency room . The facility's Exit Door Alarms document was viewed. It documented that the maintenance supervisor last checked the functioning of Unit 2 A door on [DATE]. On [DATE] at 5:00pm the Maintenance Director was interviewed. He shared that prior to Resident #5's accident; he would check 10 exterior doors in the facility which had alarms, once a month. He would document the audit on a log. The door alarms he stated always functioned. He had not discovered any alarm turned off. In between his monthly visits, he indicated that a security guard would do evening rounds and check all doors. Since the incident on [DATE] he stated he has begun to check the doors weekly. The log indicated that he checked all exit doors on [DATE] and [DATE]. He relayed there were no problems with the alarms during these checks. The maintenance supervisor mentioned that the facility has electronic gates at their exits. The visitor parking lot has a gate which can be electronically opened when needed by the receptionist from 8:00am until 8:00pm. The employee parking lot's electronic gate remained open until 6:00pm when it gets shut, in order to secure the premises. The employee parking lot gate was out of site and a considerable distance from the facility's corridors. On [DATE] at 8:40am, upon arrival at the facility, the exit side of the electronic visitor's lot gate was open. There was no car at the gate. On [DATE] at 8:30am and 8:45am, the exit side of the electronic visitor's lot gate remained open. There was no car at the gate. The main street adjacent to the gate served a mixed residential -commercial area with the posted speed limit of 35mph. The gate was positioned less then 30 feet from the street. On [DATE] at 10:05am, an exterior tour was conducted of the facility's grounds. The visitor parking lot gates were now closed, however it was noted that on the parameter of the small parking lot, there was a small grassy area with full shrubbery and trees that had a significant drop to the ground, with a pond at the bottom. At the rear of the building, was the employee parking lot. It had moderate traffic activity with staff coming and going, as well as deliveries being made. To the left of Unit 2 B, near the restorative dining room was a steep stairwell, leading to the basement. The stairwell's entrance was available for entry. The door that Resident #5 exited on Unit 2A faced the visitor parking lot. Once outside the door, there was a small ramp, leading to the parking lot, approximately 20 feet from the door. To the right of the doorway, was a narrow winding sidewalk, which led to the entrance of the lobby doors. It was also parallel to the drop off area for vehicles. To the left of the door on Unit 2A was a narrow sidewalk which led to Unit 3. The area was not visible from the lot and had a narrow grassy area, East of the sidewalk, with a steep drop to the ground. The abundance of shrubs and trees prevented a safe evaluation of the bottom. A review of the facility's Continuation Sheet, documented that the security guard made rounds on [DATE] at 8:00pm. The guard wrote that when he performed his rounds in the rehabilitation center, "All the exit doors alarm. All secure." On [DATE] at 11:55am, an interview was held with the security guard. He stated that he completed the Continuation Sheet form on [DATE] and that when he was on duty, he checked every door. He emphasized that if the alarm doesn't sound when I check, then I am expected to reset it. The doors always made a sound when he checked. To his knowledge, he had never discovered a door with the alarm turned off. The alarms can only be operated with a key. The Fall Investigation dated [DATE] stated that Resident #5 was last toileted 10 minutes prior to the accident. The investigation determined that Resident #5 was not left unattended inappropriately. However, in a written statement, dated [DATE] at approximately 4:05pm which was attached to the Fall Investigation, Nurse Aide #1 stated that she was attending to another resident on the Unit when she received a page to come to the lobby. She discovered that Resident #5 had fallen on the ground. Resident #5's hospital records were contained within his chart. It revealed that on [DATE] he was sent to the emergency room and was diagnosed with [REDACTED]. It was compared to a previous CT scan that Resident #5 had on [DATE] after his stroke. It found that he still had severe atrophy with old left cerebral infarct in the frontal lobe with some degree of encephalomalacia. The condition was a stable mild distention of lateral ventricles. He had no acute bleed; no acute intracranial hemorrhage, midline shift, or mass lesion. When Resident #5 returned to the facility on [DATE], he had significant changes to his health. A review of nurse's notes on [DATE] and [DATE] relayed that he was more lethargic, ran a fever and had a decrease in appetite and fluids. He was re-hospitalized on [DATE] for altered mental status and a urinary tract infection. On [DATE], he returned to the facility with orders for comfort care measures. On [DATE], Resident #5 expired at the facility. On [DATE] at 2:10pm, Nurse Aide #2 was interviewed. She worked with Resident #5 on 1st shift, [DATE]. She stated that Resident #5 was very confused that day and kept going in another resident's room, near the exit door on Unit 2 A and was imagining seeing a bug in the room. He became difficult to redirect, so she summoned help from Nurse #1. On [DATE] at 11:28am, during a follow up interview, Nurse Aide #2 relayed each time she redirected Resident #5 on [DATE] she would place him at the nurse ' s station. She stated that staff were present, including herself, because "We know how he likes to wander." She stated that he remained at the station with her, while she charted. She shared that nurse aides do not check the alarms on the door, that task was left for the maintenance department. However, she stated she had never seen Resident #5 open the doors on her shift. At 3pm, she positioned Resident #5 at the Unit 2 A nurse's station and found him to be drowsy. She did not report to Nurse Aide #1, coming on duty, that she felt Resident #5 to be more confused then usual, however, she did express her concerns with Nurse #1. Nurse Aide #1 was interviewed on [DATE] at 3:45pm. She stated that she worked 2nd shift on [DATE] and was assigned to Resident #5. She commented that he liked to roam around the building but always came back to his area. He would visit the cafe and the other nurse's stations. She stated that she had never witnessed him trying to leave the building on her shift. As well as she never considered him an elopement risk, because she could always calm him. She did mention that he would tell her that he wanted to go home. She recalled that on [DATE] she had changed Resident #5 then placed him at Unit 2 A nurse's station, ten minutes before she was paged to the lobby, to be alerted that he had fallen outside. She stated that at the time of his fall, she was in another resident's room, diagonal from the nurse's station, performing personal care. When she helped to bring him back into the facility, she stated that she noticed that he had blood on his forehead and cleaned him up. Nurse Aide #2 stated that all of the doors have alarms on them but the one that Resident #5 exited, did not sound. She continued by saying that the nurses are supposed to check them, but she does not witness them checking the alarms. At night when she worked, she would see the security guard making rounds and checking the alarms. She stated that the alarm was set the night before. A follow up interview was held with Nurse Aide #1 on [DATE] at 1:23pm. She stated that on [DATE] she did not receive a report from Nurse Aide #2 that Resident #5's behavior was out of the ordinary. During her shift, she recalled having to bring him back to the nurse's station while she worked, a few times. He was known to wander into female resident's rooms, according to her, and would mess with their belongings. Whenever he roamed, he always found his way back to his room. She remembered that after his fall on [DATE] she was told by some of the staff that he had tried to get out on 1st shift and the alarm went off. They were able to stop him from exiting, but it was reported that he pushed the door and it sounded. The nurse would have to reset the door alarms, she commented. On 2nd shift, she relayed that Resident #5 usually visited others and participated in activities. He would stay in his room, watching TV or go to the halls. Sometimes he would go sit by the doors and soak up the sunshine. She did share that in general, he was confused more on 2nd shift then when she worked with him at other times of day. He would tell her that he wanted to go home or would ask for his wife, who lived at his former residence. She would always explain to him that he was at the facility now and he would calm down. She would then give him a snack. She shared that another way, they monitored him was to have him follow Nurse #3 while she passed medications since he responded positively to her. If Nurse Aide #1 was busy, then perhaps another aide from another station would come over to Unit 2 A and watch him. Nurse Aide #1 did note that on Sundays, there were no planned activities after 2:30pm. He would normally sit in the hallway or roam the facility until dinner time at 5:25pm. The day of his accident, she stated that "He wasn't acting weird. I was never told to keep a close eye on him." In fact she recalled that Nurse #1 told her that he was in a good mood and did not share that he had tried to open doors earlier his shift. On [DATE] at 3:55pm, Nurse #1 was interviewed. He worked with the resident on weekends from 7:00am until 7:00pm. On [DATE] he was on duty and stated that the resident's routine was to wheel himself around the facility, visiting nurse's stations and activities. He witnessed him wandering into other resident's rooms on this day as well as on previous occasions, getting into others' belongings. Nurse #1 also stated that he has needed to intervene before when Resident #5 opened exit doors. He was aware that he had previously opened doors at the front lobby, on Unit 2 A and Unit 2 B. Each time he intervened, he recalled Resident #5 would resist coming back into the building, stating "Why do I have to go back?" Each time the door alarmed and Nurse Aide #2 helped to retrieve the resident who was only a few feet outside the door. On [DATE] he described the resident exhibiting exit seeking behavior. He stated that during 1st shift (7:00am to 3:00pm), Resident #5 opened a door and again on 2nd shift (3:00pm to 11:00pm) before succeeding from exiting the building at 5:00pm. With each earlier attempt, Nurse #1 stated that they would bring Resident #5 to the nurse ' s station to help keep an eye on him. On [DATE], Nurse #1 said the alarm did not go off on Unit 2 A, he only heard a beeping sound. Nurse #1 became aware of the elopement, after a sitter of another resident, saw Resident #5 outside of the facility, tipped over in his wheelchair and reported it at the nurse's station. He stated that along with maintenance and the security guard, nurses have keys to the alarms After the incident on [DATE], Nurse #1 stated he got a doctor's order to send Resident #5 to the hospital since he hit his head and was on Coumadin (a blood thinner). On [DATE] at 11:30am, a follow up interview was conducted with Nurse #1. He indicated that Resident #5 had several documented elopement attempts in February and he sought interventions through his physician for medication management. He recalled that the doctor told him that he would re-assess Resident #5 later in the week and that he didn't want to adjust his medications until then. He was told that Resident #5's agitation was within normal limits. He continued to express his concerns about Resident #5' s to his unit supervisor and the on-coming nurse. Nurse #1 continued by saying that once Resident #5's medication was adjusted he saw improvements in his behaviors, so there wasn't much to document. He never shared his concerns with the Director of Nursing because he stated that she wasn't in the building on weekends. Then he recalled an incident in July, 2011 when Resident #5 opened an alarmed door. He placed both of his hands inside the door well, with the alarm sounding, but did not go out of the building. They were able to hear the alarm and redirect him. Nurse #1 stated that he might have forgotten to document this incident in his nurse's notes. The morning of [DATE], Nurse #1 stated that Resident #5 kept going into a room next to the exit door on Unit 2 A. He would be brought back to the nurse's station and given a snack or he would converse with another resident. Nurse #1 said that he remained at the station to do his charting. Then after lunch, he recalled that Resident #5 was heading toward the exit door again and Nurse Aide #1 had to redirect him. Nurse #1 stated that he did not feel that Resident #5 exhibited increased confusion on [DATE]; however felt that his overall confusion was more of a factor then the resident trying to exit the facility. Nurse #1 shared that a few days before the elopement on [DATE], Resident #5 said that he wanted to go home and would ask him, "Why Am I here?" Nurse #1 shared that it was never his practice to check the door alarms on his unit and that he did not check the door on Unit 2 A on [DATE]. The security guards made rounds at night and checked all the doors. He couldn't recall unlocking the doors, not even to allow the release of a resident's body, within the last 30 days. He stated that visitors would accidentally open the door, because it faced the parking lot and they wouldn't read the sign that it was alarmed. The private duty sitter was interviewed on [DATE] at 9:30am. She stated that on [DATE], during the afternoon, she was in the room of another resident, when the resident remarked that she saw a man lying on the ground outside of the facility. She stated that when she approached the window, she could see an elderly man tipped over in his wheelchair on the sidewalk. At that point, she left the room and went to the nurse's station to tell someone. On [DATE] at 11:45am the Nurse Supervisor was interviewed. She stated that she worked on weekends and often had interactions with Resident #5. On [DATE] she worked from 6:00am until 11:00pm. She commented that earlier that day, Resident #5 traveled here and there around the building, into other resident's rooms and other nurse's stations. She stated that he was a "free agent and was a busy, busy guy". He was vocal and she always knew what he was up to. She did not witness any exit seeking behavior from him that day and did not receive any reports of him trying to leave the building before he succeeded. He did not appear agitated or more confused then usual. She stated that she didn't see anything different about him. The Nurse Supervisor shared that on [DATE], she was paged to the nurse's station. She went outside with Nurse #1, to assess Resident #5 who had fallen out of his wheelchair. Resident #5 had traveled a short distance from the doorway and was around the corner on the sidewalk, positioned between the exterior rooms of 201 and 203. His head had hit the pavement and he had almost fallen off of the sidewalk onto the pavement where cars drove. The incident report, dated [DATE], stated that the fall occurred at 5:00pm. She later discovered that the door on Unit 2 A did not have its alarm turned on. Every night, security was responsible for checking the light on the doors to make sure the alarm was turned on. She indicated that she did not check the alarms when she began her shift, because it was not expected or part of her routine, however, since the incident, she had checked the door and documented this on a log. She stated that "we never had a problem like this before." To her knowledge, staff did not tamper with the alarms and only nurses had keys to the alarm. In the event that a visitor exits from a door with an alarm, staff was expected to stand by and reset the alarm. Had she known that he was exhibiting exit seeking behavior she stated she would expect her staff to evaluate if he had a change in his condition, like behaviors or a urinary tract infection. Also staff should try to determine what ' s going with him, was he hungry, wet, thirsty? She would expect staff to ensure his safety by double checking the doors and keep him close the station or the cart, to supervise him. On [DATE] at 1:42pm, Nurse Aide #3 was interviewed. She shared that Resident #5 often came on Unit 3 when he attended activities, then he would proceed to travel around the facility. She recalled that he would try to get out the doors on the hallway and they would catch him before he got out. They would redirect him and take him to a safer location. Twice she recalled he roamed to Unit 1. On [DATE] at 5:45pm the evening receptionist was interviewed. She stated that she worked the reception desk in the lobby from 4 to 8pm. She commented that Resident #5 was one of the residents that she would keep her eye on if he came into the area. She shared that he liked to sit in his wheelchair in front of the door and watch the fountain. One day she remembered that he opened the lobby door and she went over to him, she turned him back around. Then she reported the incident to the nurse on duty. She stated that there hasn't been an incident in months. On [DATE] at 1:00pm, the Social Worker was interviewed. She was responsible for completing the behavior section on his [DATE] MDS and had stated that he exhibited wandering. The Social Worker acknowledged that she did often see Resident #5 roam through the building, visit the front lobby and go into other's rooms, however, she never viewed him as an elopement risk. She would return him to his unit because it didn't appear to her that he was oriented enough to return there by himself. She shared that had he been an elopement risk, the facility would have discussed with his family, the option of exploring a locked unit to keep him safe. She commented, "We would be negligent if we didn't keep him safe and he was at risk as an elopement." The MDS Nurse was interviewed on [DATE] at 12:05pm. She stated that she had difficulty assessing Resident #5 because he was Aphasic but she did not feel that he was cognitively intact. She shared that she was aware that we wandered around the building but she had never known him to try to get out, in fact, there were times when staff tried to lead him outside to the courtyard, and he would resist, planting his feet firmly on the ground. She further stated that no one had ever reported to her that Resident #5 had tried to leave the building or opened doors. The MDS Nurse stated that if she was aware of those behaviors, she would have care planned him for wandering and she would have advocated for a placement in a locked unit, stating that it would be too dangerous to have those behaviors here. Other interventions that she might have recommended would have been to keep the fire doors closed on his unit to prevent wandering. She stated that she had reviewed the Social Worker's comments about Resident #5 ' s wandering, but she never considered it to mean that he was an elopement risk. On [DATE] at 3:30pm, the Patient Care Coordinator was interviewed about in-servicing staff on securing the doors. She provided documentation which captured the names of staff, as well as material presented on [DATE] on the new requirement for nursing staff to check the alarmed doors daily and to document in on a log in their narcotic book. Nurses are now expected to check the doors prior to starting their Med Pass. Other staffs responsible for checking the doors are maintenance and security. The facility does not use security devices on residents, since there are no " locked down " units. On [DATE] at 10:30am, the Director of Nursing (DON) was interviewed. She stated that only nurses, maintenance and security have keys to access the alarms. She demonstrated how the alarms work and how staff should check the doors to make sure the alarms are turned on. She had not received any reports of staff de-activating the alarms to avoid the noise. At 2:05pm, the discussion continued with the DON. She was asked to define exit seeking behavior. She replied that it meant anytime a resident tried to get out of the building, through physical attempts to go through the door. She had never considered Resident's #5 an elopement risk due to roaming about the facility, nor was she informed of his prior successful attempts in opening the doors When a resident displayed wandering, she expected the staff to document the incidents on ADL (activities of daily living) behavior sheets, the pharmacy provided documentation of behavior forms or in the nurse's notes. She relayed that it has always been her expectation for the nurses to check the alarms on the door, each shift. The DON produced a document, titled "Finger Tip" Reminders from the Personnel Policy Manual, dated July, 2009. In the document, in number 29, it read, "Nurses are to check alarm doors each shift." In the past, the facility did not require for the nurses to sign off that the doors were checked but still had the expectation that the task would be done. The DON stated that once a resident showed exit seeking behavior, staff should keep the resident in close supervision and attempt to discuss with their family if another placement, to a locked unit, should be pursued. She emphasized that Nurse #1 had never discussed any of Resident #5's behaviors with her and stated that he had the opportunity because sometimes he would be in the building, during weekdays. On [DATE] at 2:33pm, the Administrator was interviewed. She was on medical leave [DATE] to [DATE] and was not available for interview. The Administrator shared that she regularly meets with the nurses and did rounds on the floors. No one had ever discussed that Resident #5 had tried to open the doors before the incident on [DATE]. She stated that she was aware that he roamed the building, and they motivated him to ambulate freely; due to this being very social for him. She stated that his roaming did not raise the concern for her to inquire if he also exhibited exit seeking behaviors because she never saw him try to touch any of the doors. She also did not recall him expressing that he wanted to leave the facility. Some residents would say that they wanted to leave, and then she would view them as elopement risks. The Administrator could not ascertain how the alarm became turned off on Unit 2a on [DATE]. She said that their investigation could not determine who was responsible. The Administrator produced copies of her security guard rounds from [DATE] to [DATE], there were no incidents, when the guard found the doors unarmed. She shared, that she had already expected the nurses to check the alarms on the door, each shift. She has also conveyed to her Maintenance Supervisor, that he needed to ensure that the electronic gates to the visitor parking lot remained closed when not used, and quickly repaired, if they became inoperable. On [DATE] at 5:38pm, the Administrator was informed of the Immediate Jeopardy involving Resident #5. On [DATE] at 5:30pm, the facility had provided an acceptable credible allegation. A. Address how corrective action will be accomplished for each resident found to have been affected by the deficient practice. Resident #5 was discharged on [DATE]. During his stay the facility implemented a personal alarm on his wheelchair, a sensory pad on his bed and in his wheelchair as well as frequent monitoring and supervision by staff. The bed for resident #5 remained in the low position with mats beside the bed when resident was in bed. These interventions were imposed for resident safety. A falls risk assessment is completed upon admission on all residents by the admitting nurse as well as quarterly and when there is a significant change in status noted by any staff utilizing a communication form. All residents identified by nursing staff as high risk for falls have a current fall risk assessment and care plan with fall risk interventions identified. (6 of 79 residents) [DATE] Residents who display exit seeking behaviors are assessed using the 'Potential for Elopement Profile' form and a care plan is initiated by the MDS staff. One new resident was identified with potential exit seeking behaviors on [DATE] making a total of three in facility MDS staff, DON, and nursing supervisor will perform daily rounds to each nursing station for reports on each resident. Information will be discussed daily at stand up meetings and will be acted upon immediately. A communication form will also be distributed to all depts. The care plan will be on the charts and verbally communicated to each unit. The CNA will review the care plan and document as well as the nurse. [DATE] B. Address how corrective action will be accomplished for those residents having potential to be affected by the same deficient practice. The staff provides additional supervision to these residents by involving them more frequently in activities, including them in groups that routinely sit together, and positioning the resident at the nurses' station for closer observation when the nurse or CNA is at the nurses' station. Residents who present a safety risk are moved to a room closer to the nurses' station with the permission of the resident/family. The family/responsible party is included in the care plan meeting to discuss interventions including providing sitters for additional supervision and their option to move

Based on staff interviews and record review, the facility failed to develop a comprehensive care plan for 1(Resident #5) of 3 residents with a history of exit seeking behaviors, which resulted in an elopement. The findings include: The immediate jeopardy began on Resident #5 on 8/21/11 and was removed on 9/17/11. The facility remained out of compliance at the lower scope and severity level, an isolated deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy, (D). The facility was in the process of implementing their corrective actions on training and monitoring for residents at risk of elopement. The findings include: Resident #5 was admitted to the facility on [DATE] then re-admitted on [DATE]. He had the following cumulative Diagnoses: [REDACTED]. On 1/29/11, Resident #5 received a quarterly Minimum Data Set (MDS) assessment, which determined that he had moderate cognitive impairments and exhibited wandering behaviors 4 to 6 days of the 7 days look back assessment, but less then daily. The most recent quarterly Minimum Data Set ((MDS) dated [DATE] assessed him with severe cognitive impairments, needing extensive assistance with ambulation in his room, and determined that he had limitations with his upper extremities. It was also noted that he wandered 4 to 6 days of the 7 days look back assessment, but less then daily. Resident #5 was not care planned for wandering or exit seeking behaviors. Resident #5 did not have an additional quarterly MDS in August, because he was discharged to the hospital and was not available for review. A review of the nurse's notes revealed the following history. On 2/5/11, Nurse #1 recorded that "Resident #5 was very agitated throughout the day. Very angry that he had to get up for restorative. He yelled "Why" constantly throughout the morning. He continued to go into other resident's rooms and disturb them. He would not refrain from doing this. Then he attempted to leave the facility via the front doors 2x (twice). He went over to Unit 1 while Nurse #1 was in another patient's room and went in several rooms and disturbed residents there as well. Risperdone (an anti-psychotic medication) not effective at all for his agitation. Physician contacted several times already previously by this nurse and fully aware of these issues. Will continue to monitor. Oncoming nurse made aware of behavior." On 2/19/11, Nurse #1 recorded in the nurse's notes that Resident #5 was agitated and yelling out sporadically at times. "Resident went down to Unit 2B station self propelled in wheelchair and attempted to open alarm door at end of hall and fell out of wheelchair. RN Supervisor present to observe incident. RN Supervisor assessed resident, no injuries observed. RN Supervisor completed incident report, resident observed throughout day. Oncoming nurse made aware, will continue to monitor." On 2/26/11, Nurse #2 recorded that Resident #5 tried to get out emergency door; was up and down the hallways, in and out of other resident's room. He was unable to be redirected and was given [MEDICATION NAME]. He continued to constantly try to go out exit doors 5x. Will monitor closely. On 9/8/11 at 3:55pm, Nurse #1 was interviewed. He worked with the resident on weekends from 7:00am until 7:00pm. On 8/21/11 he was on duty and stated that the resident's routine was to wheel himself around the facility, visiting nurse ' s stations and activities. He witnessed him wandering into other resident's rooms on this day as well as on previous occasions, getting into others' belongings. Nurse #1 also stated that he has needed to intervene before when Resident #5 opened exit doors. He stated that Resident #5 since his admission, had opened doors at the front lobby, on Unit 2 A and Unit 2 B. Each time he intervened, he recalled Resident #5 would resist coming back into the building, stating "Why do I have to go back?" Each time the door alarmed, either Nurse Aide #1 or Nurse Aide #2 helped to retrieve the resident who was only a few feet outside the door. On 8/21/11 Nurse #1 described the Resident #5 exhibiting exit seeking behavior. He stated that during 1st shift (7:00am to 3:00pm), Resident #5 opened a door and again on 2nd shift (3:00pm to 11:00pm) before succeeding from exiting the building at 5:00pm. With each earlier attempt, Nurse #1 stated that they would bring Resident #5 to the nurse's station to help keep an eye on him. On 8/21/11, Nurse #1 said that he became aware of Resident #5 eloping, after a sitter of another resident, saw him outside of the facility, tipped over in his wheelchair and reported it at the nurse's station. The chart review did not reflect that Resident #5 had any revision to his care plan after the 8/21/11 to reflect wandering or exit-seeking behaviors. On 9/17/11 at 11:30am, a follow up interview was conducted with Nurse #1. He indicated that once Resident #5's medication was adjusted he saw improvements in his behaviors, so there wasn't much to document. He never shared his concerns with the Director of Nursing because he stated that she wasn't in the building on weekends. Then he recalled an incident in July, 2011 when Resident #5 opened an alarmed door. He placed both of his hands inside the door well, with the alarm sounding, but did not go out of the building. They were able to hear the alarm and redirect him. Nurse #1 stated that he might have forgotten to document this incident in his nurse's notes. The morning of 8/21/11, Nurse #1 stated that Resident #5 kept going into a room next to the exit door on Unit 2 A. He would be brought back to the nurse's station and given a snack or he would converse with another resident. Nurse #1 said that he remained at the station to do his charting. Then after lunch, he recalled that Resident #5 was heading toward the exit door again and Nurse Aide #1 had to redirect him. Nurse #1 stated that he did not feel that Resident #5 exhibited increased confusion on 8/21/11; however felt that his overall confusion was more of a factor then the resident trying to exit the facility. Nurse #1 shared that a few days before the elopement on 8/21/11, Resident #5 said that he wanted to go home and would ask him, " Why Am I here?" On 9/8/11 at 2:10pm, Nurse Aide #2 was interviewed. She worked with Resident #5 on 1st shift, 8/21/11. She stated that Resident #5 was very confused that day and kept going in another resident's room, near the exit door on Unit 2 A and was imagining seeing a bug in the room. He became difficult to redirect, so she summoned help from Nurse #1. On 9/15/11 at 11:28am, during a follow up interview, Nurse Aide #2 relayed each time she redirected Resident #5 on 8/21/11 she would place him at the nurse ' s station. She stated that staff was present, including herself, because "We know how he likes to wander." She stated that he remained at the station with her, while she charted. Nurse Aide #1 was interviewed on 9/8/11 at 3:45pm. She stated that she worked 2nd shift on 8/21/11 and was assigned to Resident #5. She commented that he liked to roam around the building but always came back to his area. He would visit the cafe and the other nurse's stations. She stated that she had never witnessed him trying to leave the building on her shift. As well as she never considered him an elopement risk, because she could always calm him. She did mention that he would tell her that he wanted to go home. A follow up interview was held with Nurse Aide #1 on 9/15/11 at 1:23pm. She stated that on 8/21/11 she did not receive a report from Nurse Aide #2 that Resident #5 ' s behavior was out of the ordinary. During her shift, she recalled having to bring him back to the nurse's station while she worked, a few times. He was known to wander into female resident's rooms, according to her, and would mess with their belongings. Whenever he roamed, he always found his way back to his room. On 2nd shift, she relayed that Resident #5 usually visited others and participated in activities. He would stay in his room, watching TV or go to the halls. Sometimes he would go sit by the doors and soak up the sunshine. She did share that in general, he was confused more on 2nd shift then when she worked with him at other times of day. On 9/8/11 at 5:45pm the evening receptionist was interviewed. She stated that she worked the reception desk in the lobby from 4 to 8pm. She commented that Resident #5 was one of the residents that she would keep her eye on if he came into the area. She shared that he liked to sit in his wheelchair in front of the door and watch the fountain. One day she remembered that he opened the lobby door and she went over to him, she turned him back around. Then she reported the incident to the nurse on duty. She stated that there hasn't been an incident in months. On 9/15/11 at 1:00pm, the Social Worker was interviewed. She was responsible for completing the behavior section on his 5/24/11 MDS and had stated that he exhibited wandering. The Social Worker acknowledged that she did often see Resident #5 roam through the building, visit the front lobby and go into other's rooms, however, she never viewed him as an elopement risk. She would return him to his unit because it didn't appear to her that he was oriented enough to return there by himself. She shared that had he been an elopement risk, the facility would have discussed with his family, the option of exploring a locked unit to keep him safe. She commented, "We would be negligent if we didn't keep him safe and he was at risk as an elopement." The MDS Nurse was interviewed on 9/15/11 at 12:05pm. She stated that she had difficulty assessing Resident #5 because he was Aphasic but she did not feel that he was cognitively intact. She shared that she was aware that we wandered around the building but she had never known him to try to get out, in fact, there were times when staff tried to lead him outside to the courtyard, and he would resist, planting his feet firmly on the ground. She further stated that no one had ever reported to her that Resident #5 had tried to leave the building or opened doors. The MDS Nurse stated that if she was aware of those behaviors, she would have care planned him for wandering and she would have advocated for a placement in a locked unit, stating that it would be too dangerous to have those behaviors here. She stated that she had reviewed the Social Worker's comments about Resident #5's wandering, but she never considered it to mean that he was an elopement risk. At 2:05pm, the discussion continued with the DON. She was asked to define exit seeking behavior. She replied that it meant anytime a resident tried to get out of the building, through physical attempts to go through the door. She had never considered Resident's #5 an elopement risk due to roaming about the facility, nor was she informed of his prior successful attempts in opening the doors The DON stated that once a resident showed exit seeking behavior, staff should keep the resident in close supervision and attempt to discuss with their family if another placement, to a locked unit, should be pursued. She emphasized that Nurse #1 had never discussed any of Resident #5's behaviors with her and stated that he had the opportunity because sometimes he would be in the building, during weekdays. On 9/15/11 at 2:33pm, the Administrator was interviewed. She was on medical leave 9/7/11 to 9/9/11 and was not available for interview. The Administrator shared that she regularly meets with the nurses and did rounds on the floors. No one had ever discussed that Resident #5 had tried to open the doors before the incident on 8/21/11. She stated that she was aware that he roamed the building, and they motivated him to ambulate freely; due to this being very social for him. She stated that his roaming did not raise the concern for her to inquire if he also exhibited exit seeking behaviors because she never saw him try to touch any of the doors. She also did not recall him expressing that he wanted to leave the facility. Some residents would say that they wanted to leave, and then she would view them as elopement risks. The Administrator commented that if she knew that Resident #5 was at risk for an elopement she would have expected for him to be care planned for elopement. Lastly, she would have spoke to family members about considering another placement for him, where he could be safe on a locked unit. On 9/15/11 at 5:38pm, the Administrator was informed of the Immediate Jeopardy involving Resident #5. On 9/17/11 at 5:30pm, the facility had provided an acceptable credible allegation. A. Address how corrective action will be accomplished for each resident found to have been affected by the deficient practice. Resident #5 was discharged from the facility on 9/4/2011. Residents with a [DIAGNOSES REDACTED]. Also all comprehensive assessments completed in the past 30 were reviewed on 9/15/2011. Care plans for these residents have been updated by the care plan team to reflect current condition of residents' functional and cognitive status. One resident was identified prior to 9/15/2011. No other residents were identified on this date. The MDS staff were in-serviced on 9/15/11 and were instructed to review the guidelines for accurate timely assessment and care plan. MDS staff will now manually update care plans in charts as well as electronically. The assessment and comprehensive plan of care is updated quarterly and in the event of a change in status of the residents' mental or physical condition. 9/15/2011 B. Address how corrective action will be accomplished for those residents having potential to be affected by the same deficient practice. Residents who have experienced a change in condition or a change in behaviors has been re-assessed and care planned by the care plan team. A communication form will be initiated by the unit nurse when there is a change in status of the resident and distributed to all dept. managers. Residents are discussed in our daily stand-up meeting to ensure communication between depts. Pictures of residents who have the potential to wander or have exit seeking behaviors are posted at the front desk and at every nurse's station. Staff is made aware of potential behaviors through our communication form and face to face conversation 9/15-16/2011 C. Address what measures will be put in place or systemic changes made to ensure that the deficient practice will not occur. Care plans are updated on at least a quarterly basis by the interdisciplinary care plan team. Care plans are also revised for each resident when there is a change of status of the residents' mental or physical condition, or when they become a known elopement risk by the care plan team. Additional monitoring tools (30 minute checks for residents identified as elopement risks and completed documented behaviors forms) are contained on the nurses' cart to assist with care plan objectives. D. Indicate how the facility will monitor to make sure that the solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. The plan must be implemented and corrective action evaluated for its effectiveness. The POC must be integrated into the QA system of the facility. Include dates when corrective action will be taken. The corrective dates must be acceptable to the State. Care plans will be monitored during monthly chart audits by the nursing department. A chart audit tool has been developed to ensure compliance. The audits are a part of the monthly QA process and are presented during the monthly QA meeting along with an action plan as needed by the DON. On 9/17/11 at 5:30pm, validation of the credible allegation was done. Residents identified as potential elopement risks were photographed with their photographs placed behind the nurse's stations for easy recognition. Residents identified as potential elopement risks, were placed on a 30 minute monitoring schedule, which went into effect on 9/17/11. Both nurse aides and nurses are responsible for knowing the resident's exact whereabouts. The nurse recorded the resident's location on a log, which was kept on the nurse's cart. Residents identified as potential elopement risks, were care planned by the MDS department staff with interventions outlined to prevent unsupervised exits from the facility. On 9/17/11, each care plan was reviewed and verified that they were placed on the resident's medical chart, for quick access by all staff and measurable goals for preventing an unsupervised exit from the facility. As of 3:00pm on 9/17/11, 55% of the staff was in-serviced on Elopement and how to document behaviors. The remaining staff will be in-serviced on the material, before they can return to the floor. The MDS nurse was interviewed and was able to explain the criteria used to identify residents with cognitive impairments, who either have a history of wandering or expressed desire to leave the facility, as well as how they are now identified as potential elopement risks, for care plan assessments. The Staff Development Nurse was interviewed, and the course material was reviewed for in-services on Elopement and Behavior Monitoring. The attendance record for the 9/17/11 in-services was reviewed. Nurse Aides that began their shift at 3:00pm were instructed to complete new training (elopement and documentation of behavior) before beginning their assignments. The Director of Nursing and Administrator were interviewed and expressed satisfaction in the manner, staff has implemented the new policies and procedures to help identify residents at risk for elopement, who need comprehensive care plan assessments.