Every finding on record at Waverly Hills Post Acute

Based on policy review, medical record review, facility investigation review, Emergency Medical Services, Police Department Incident Narrative, and interview, the facility failed to ensure safety interventions were implemented and failed to ensure an environment free of accident hazards for 1 of 3 (Resident #4) sampled resident reviewed for accidents, resulting in significant injury and death to Resident #4 . On 1/9/2026, Resident #4, who was moderately cognitively impaired and required staff assistance with transfers, was found unresponsive by Certified Nursing Assistant (CNA) A and lying supine (lying on back with face upward) on the floor with the bed control cord stretched across her body and neck area and pinned under her back near her left shoulder. Resident #4's head and torso were partially under the bed, with the bed resting on the Resident's head and chest. The facility's failure to ensure care plan safety interventions to keep the bed in low position were followed, resulted in immediate jeopardy when Resident #4 sustained serious injury that resulted in death. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator, the Director of Nursing (DON) and Assistant Regional Director Clinical Nurse were notified of the Immediate Jeopardy on 4/13/2026 at 5:29 PM, in the Day Room. The facility was cited Immediate Jeopardy at F-689. The facility was cited at F-689 at a scope and severity of J, which is Substandard Quality of Care. The IJ began on 1/9/2026 and continued through 4/14/2026. The IJ was removed on 4/15/2026 when the facility implemented a corrective action plan. The corrective actions were validated by the surveyor on 4/15/2026. A partial extended survey was conducted from 4/14/2026 through 4/15/2026. The facility's noncompliance at F689 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the facility policy titled, .Safety and Supervision of Resident, with a revision date of 7/2025, revealed .Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility - wide priorities.Implementing interventions to reduce accident risks and hazards shall include the following.Communication specific interventions to all relevant staff.Providing training.Ensuring that interventions are implemented. 2. Review of the closed medical record revealed resident #4 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Peripheral Vascular Disease, Convulsions, Repeated Falls, Psychotic Disorder with Delusions, Dementia, Obsessive-Compulsive Behavior, and Anxiety. Review of the Care Plan revised on 5/2/2025, revealed .Convulsions .has a diagnosis of seizure disorder and is at risk for complications manifested by Falling .Monitor for change in level of consciousness .Monitor for seizure activity . revised on 5/7/2025.is at risk for falls.r/t [related to] unstable balance, decreased safety awareness.impaired decision making skills, lack of coordination.Keep bed in low position with brakes locked. Review of the Nurse's Note dated 8/29/2025 at 7:27 AM, revealed .Resident found laying [lying] on back in the floor beside residents [resident's] bed. Alert and oriented x [times]1. No visible injuries.resident back to bed with 2 person assist.bed at lowest position. Review of the Care Plan revealed the Care Plan was revised on 8/29/2025 to provide a fall mat to left side of bed. There was no documentation the Care Plan had been revised with safety interventions implemented to prevent falls from the bed. Review of the FALL RISK OBSERVATION/ASSESSTMENT dated 10/23/2025, revealed Resident #4 had a fall risk score of 16, which indicated the Resident was high risk for falls. Review of the Nurse's Note for Resident #4 dated 10/23/2025 at 4:53 PM, revealed .CNA notified nurse of fall. Resident found lying in floor beside bed. Assisted into sitting position. Laceration noted to LLE [left lower leg].resident to ER [Emergency Room] for further evaluation.EMTs [Emergency Medical Technicians] arrived to get patient. Review of the Nurse's Note for Resident #4 dated 10/23/2025 at 9:30 PM, revealed .Resident returned from the ER [emergency room].via [by way] stretcher. Returned with N.O. [new order] for Keflex [an antibiotic used to treat infections] 500 mg [milligram] 3x [3 times] a day for 5 days.remove sutures [from left lower leg] in 2 weeks. Review of the Care Plan revealed the Care plan was revised on 10/23/2025 for staff to provide incontinent care prior to meals. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #4 scored a 10 on the Brief Interview for Mental Status (BIMS) assessment, which indicated the Resident was moderately cognitively impaired, dependent on staff for activities of daily living and had one fall with injury during the review period. Review of the medical record dated 1/6/2026 revealed Resident #4 weighed 210.8 pounds. Review of the facility's fall investigation dated 1/9/2026 at 4:55 AM, revealed .FALL.UNWITNESSED.Residents Room [Resident #4] .CNA alerted nurse.How was the Resident positioned when you observed them.on back on floor.What time did you last see the Resident before the occurrence.0340 AM [3:40 AM]. Review of the Nurse's Note for Resident #4 dated 1/9/2026 at 5:32 AM, revealed .CNA notified nurse of patient being on floor and appearing unresponsive. Nurse entered room and witnessed CNA providing chest compressions. Immediately assisted with CPR [Cardiopulmonary Resuscitation] while other nurse contacted 911. EMTs arrived and transported resident to ER. Review of the Witness Statement dated and signed by CNA A on 1/9/2026, revealed I was rounding on my patients for last round when I entered [Named Resident #4's] room .I found patient [Resident #4] laying [lying] on her back partially underneath the bed. The bed was in the lowest position with the cord to the controller [bed control] wrapped across her [Resident #4] neck and the end with the buttons was under back/shoulder area. I immediately pulled the remote from underneath her and elevated the entire bed so that it no longer pinned against the patient's chest. I ran out to the hallway to notify and get a nurse .the nurses from both stations and myself began CPR immediately until EMS arrived. I rounded on the hall and [Named Resident #4] was changed at 3:40-3:45 am [AM]. Patient was alive and fine in bed when I left her. The time that I found [Named Resident #4] was around 4:50-4:55ish [AM]. Review of the Witness Statement dated and signed by CNA B on 1/9/2026, revealed [Named CNA A] Came out of [Resident #4's room] .4:55 am [AM] .yelling where is the nurse I asked why he said Patient [Resident #4's room] was underneath bed with .the bed on top of her head and body I .Ran in the Room took the Cord Away from her head and bed off of her checked her pulse and started performing CPR until the nurse Came in. Review of the Emergency Medical Services (EMS) Prehospital Patient Care Report dated 1/9/2026, revealed EMS arrived at the facility at 5:04 AM, .cpr in progress .Staff relates they do not know how long pt [patient/Resident #4] was trapped/pinned by her bed. Staff relates the beds corded control remote was found wrapped around pt with the control buttons underneat. Staff relates they had to move pt to access the bed's control to raise the bed before they could get the bed raised off of pt and slide pt out from underneath the bed frame. Staff relates they found pt to be unresponsive, apneic [not breathing], and pulseless .they [facility staff] started CPR .Staff relates pt hx [history] of falls and dementia .Upon arrival . [Resident #4] [was found] laying supine [lying on back] on the floor next to a bed with CPR being performed .upon assessment with visibly cyanotic/blue coloration to her face and a mark across her chest possibly from the bed she was pinned beneath. Pt has no other visible signs of trauma noted at time of initial assessment .full Code [provide full resuscitation] .possibly secondary to traumatic asphyxiation .Pt care taken over and CPR resumed by [EMS] .4th rhythm check performed finding pts rhythm Asystole [no heart rate]. With CPR performed prior to our arrival and multiple rounds of CPR with ACLS [Advanced Cardiovascular Life Support provides advanced techniques for critical care providers to stabilize patients after cardiac arrest] drugs given with no change in pt vitals or rhythm, on line medical control was contacted by phone at [Named local hospital] to discontinue resuscitation efforts. ED [Emergency Department] MD [Medical Doctor] on duty relayed orders to discontinue efforts .MD .local medical examiner performed a brief exam and gave time of death 0530 [5:30 AM] .deceased transported to .[Named] county morgue . Review of the Police Department Incident Narrative by the responding Officer revealed, .On 01-09-2026 approximately 0500 hours [5:00 AM] I, Officer .was dispatched [Named Long Term Care Facility] .I arrived on scene at 0503 [5:03 AM] .Upon entering room [Resident #4's room] .I observed a .female laying on her back in the floor .Two Nursing Home staff members were performing CPR .0505 [5:00 AM] .EMS .arrived .and took over CPR .at which time I left the room to speak with staff .I made contact with [Named CNA A] .he stated found [Named Resident #4] around 04:40-04:45 [AM] hours. He stated she was trapped by the bed and all of her upper body was underneath the bed .stated he raised the remotely control [controlled] bed off of the victim [Resident #4] and then ran and located a nurse to help him with the victim .He went on to state he and the nurse pulled the Victim from underneath the bed and immediately started CPR while someone else place a call to 911 .[Named CNA A] later said the victim had the remote for the bed under her body. He stated he pulled the remote out from under her while getting the Victim pulled from underneath the bed. He stated the cord on the remote was laying across her chest and over the left shoulder with the controller under her back. He did state the cord was not wrapped around her neck but only laid against her neck. After EMS cleared the room I .inspected the body .and did observe bruising and compression marks on her lower torso and between her breast consistent with the underpinning of the mechanical bed. The victim also had a compression mark on the left side of her face in the same direction as the marks on her lower torso . Review of the Police Department Incident Narrative by the Detective revealed, .On 01-09-2026 at approximately 0550 [5:50 AM] hours I, Detective.received a call.in reference to a deceased person at [Named Long Term Care Facility].upon arrival I spoke to [the] Officer.stated he arrived on scene to find [Named Resident #4] deceased , lying in the floor of her room.While examining the body.I noticed multiple marks across her [Resident #4's] chest and face consistent with the frame of the bed. The marks began on her stomach and went up across her chest and across the left side of her face. These marks appeared to be the same size and shape of the frame of the bed. There was [were] also smaller marks on her chest that appeared to be the same size and shape of the piston on the bed used for raising and lowering it. I noticed a chunk of hair lodged in the bolt of the bed on the lower frame where [Named Resident #4] was stated to have been found. It appeared that [Named Resident #4] attempted to get out of bed or fell out of bed and in doing so knocked the bed remote under the bed and fell on it. This caused the bed to lower onto her chest and head. While examining the bed and room I also noticed there was a fall alert system attached to the bed rail. Upon examining the alert system I noticed it was not plugged in to anything and was not set up to make any type of alerts if [Named Resident #4] were to get out of bed or fall. I also noticed the call button.was tucked behind her nightstand and would not have been accessible for her to call the nurse's station. I did pull the call button from behind the nightstand and pushed the button.a staff member reported to [the] room.in response to the call. This confirmed to me that the call button did work. While speaking to her [staff member] about the call button I inquired about the fall alert system on the bed. She [staff member] told me [she] would have to go and check to see if [Named Resident #4] was still using that or not. She reported back and told me that according to [Named Resident #4's] chart she no longer needed the fall alert system. I later spoke to multiple staff members who stated [Named Resident #4] was unable to walk on her own and was constantly falling.Staff members told me that due to [Named Resident #4's] dementia she would often times holler for help even when nothing was wrong . Review of the facility's Physician Discharge summary dated [DATE], revealed .Date of discharge 1/9/2026.Resident was initially admitted in April of 2021.She has declined physically throughout stay and mentally. Bedbound with severe psychiatric issues. During a telephone interview on 4/8/2026 at 2:56 PM, CNA A was asked about the incident regarding Resident #4 on 1/9/2026. CNA A stated, .she was pinned underneath her bed.remote was pinned underneath her.it was evident she had already passed away.the moment I open the door.I knew she was gone.she had the indentures on her face.of the actually [actual] bedframe on her face.I went to go get help. CNA A stated he had not initiated CPR and stated, . went to get help.I think [Named Licensed Practical Nurse (LPN) D] started CPR. During a telephone interview on 4/8/2026 at 3:22 PM, Registered Nurse (RN) H stated, .when I arrived in the room [Resident #4's room].the contract CNA [referring to CNA B] she was pushing the bed to the side.and patient [Resident #4] was laying out on the floor.it was very obvious that she [Resident #4] had not been passed long.still soft.warm around neck.cool face and lips.she wasn't my patient.I could walk down the hall and hear her call out till she went to sleep.that's the only interaction that I had. During a telephone interview on 4/8/2026 at 3:09 PM, LPN D stated, .she [referring to CNA B] was the only one performing CPR.but there was another CNA [referring to CNA A] in the room at the time.when I came in the room.I could tell she [Resident #4] was gone.she was warmish cold.she hadn't been gone very long.she felt like she had been uncovered from a blanket.from the time I had worked there.she couldn't get up and walk if she wanted to.she had been on therapy.at least one incident.she had surgery on her leg where she had attempted to get out of bed.it wasn't a regular occurrence for her to try to get out of bed.the way it [the incident] happened it was messed up.you could see the indentures [of the bed frame] on her. During an interview on 4/13/2026 at 9:05 AM, the Director of Nursing (DON) stated Resident #4's fall care plan included the current interventions of bed in the lowest position and fall mat on her left side. During an interview on 4/13/2026 at 9:08 AM, the MDS Coordinator was shown Resident #4's care plan for falls and was asked if she developed the care plan. The MDS Coordinator stated, I did. The MDS Coordinator was asked what interventions were in place for falls. The MDS Coordinator stated, .fall mat to left side of bed.keep bed in low position and brakes locked.call light within reach. The MDS Coordinator confirmed Resident #4 could not walk or turn herself side to side in bed without staff assistance. During an interview on 4/13/2026 at 10:03 AM, the Occupational Therapist (OT) stated, I was very sad and distraught when I heard she [Resident #4] left us.last time she received therapy was September 2025.from 9/3- 9/30 [2025].she had just got a new wheelchair.custom seating.tilt and space.had a fall. The OT stated Resident #4 was not mobile and stated, .she was two person assist.we always recommended two person assist. The OT stated that when she would see Resident #4, the Resident's bed would be in low position. The OT was asked how Resident #4 had progressed in therapy. The OT stated,.often our therapy was to teach care givers.usually in training teach the CNA's to raise the bed while doing their care.they did implement at one point fall mat.on the side of her bed just because she was a risk.she had long history of decline. The OT was asked if Resident #4 was totally dependent on staff for bed position and care. The OT stated, Yes. The OT was asked did you ever see Resident #4 have a seizure. The OT stated, I have not .I knew it was in her records.she had functioning of alertness.somedays she would talk out and other days she was asleep.if she was in need of care.she would say please God please.there were times she would sing hymns. The OT stated she never saw Resident #4 use her call light or bed remote and the Resident lacked the physical ability to pull herself up from the floor into a sitting position. The OT stated, .I'm not for sure what happened.I was surprised.you go through your whole career.it's distressing.I just know it was an unfortunate event. During a telephone interview on 4/13/2026 at 11:27 AM, CNA B stated, It was [a] horrible sight.took care of her [Resident #4] plenty of times. CNA B was asked was Resident #4 totally dependent on staff for bed position and care. CNA B stated, Yes ma'am, no way she could walk. CNA B was asked did you ever see Resident #4 have a seizure. CNA B stated, I have never seen her have seizure. CNA B was asked did you see a fall mat beside the Resident's bed. CNA B stated, I didn't. CNA B was asked what a low position bed means. CNA stated, .it's as low as it could go.her [Resident #4] bed is always low. CNA B confirmed Resident #4's bed should have been lowered all the way to the floor. CNA B was asked how do you think Resident #4 got underneath the bed. CNA B stated, I don't know.I have never seen her with the remote.something happened.and [Resident #4] couldn't yell.she never moves.she can't do things for herself.she was heavy. CNA B was asked what did you do when you went into Resident #4's room. CNA B stated, .I raised the bed.and I took the cord [from] around her [Resident #4] neck.and I pulled her away from the bed.he [referring to CNA A] was screaming and hollering.saying where is the nurses.and I was thinking why didn't he pull her away from here.I don't understand why he [CNA A] left the bed on top of her.[the bed] was still on her.and the cord was around her neck. CNA B was asked had CNA A raised the bed off her. CNA B stated, No ma'am.it was like the bed was a tattoo on her. CNA B was asked did she [Resident #4] have a fall mat. CNA B stated, I didn't see a fall mat.she was on the left side [referring to the left side of the bed]. CNA B confirmed she had initiated CPR and stated, .it was horrible.I was sitting at the front desk.he [CNA A] come running out of the room.and he said the bed is on her [Resident #4].he showed me the room.I told him to go get them [referring to the nurses ].I started chest compression.they came in a few minutes.I stopped CPR when the nurse came in.and took over.EMS.didn't get a pulse at all.[Resident #4] started to feel cold a little bit.and starting to turn blue.she [Resident #4] never calls you.I have never seen her use the call light.I don't think it [referring to the bed position] was to the floor [in the lowest position]. During an interview on 4/13/2026 at 12:12 PM, LPN E was asked was Resident #4 able to walk. LPN E stated, No, she couldn't walk.she thought she could so when she would get out of bed.she would fall. LPN E was asked was she [Resident #4] totally dependent on staff for bed position and care. LPN E stated, Yes. LPN E was asked was she a two person assist. LPN E stated, .at the end 2 [used to be a one person assist but was presently a 2-person assist] . LPN E was asked what position was Resident #4's bed supposed to be in. LPN E stated, The lowest position because she was a fall risk. LPN E was asked was Resident #4 able to use the bed remote and call light. LPN E stated, No.she would holler at night.please Lord please.say it two or three times. LPN E was asked if the Resident's bed had been in low position, could that have made a difference for the Resident being unable to get under the bed. LPN E stated, .if it was on the lowest position don't see how she could get under it.they go all the way down so if they fall they don't get hurt as bad. During a telephone interview on 4/13/2026 at 12:39 PM, CNA A was asked could Resident #4 walk. CNA A stated, No.she couldn't.I have seen her trying to get out of bed.get her feet out and one time seen her have both legs off the bed.and I readjusted her, didn't have any more trouble. CNA A was asked was the Resident totally dependent on staff for bed position and care. CNA #1 stated, Yes, I believe so. CNA A was asked if he had ever seen Resident #4 use the call light or bed remote. CNA A stated, I want to say she used her call light.but not her bed remote. CNA A was asked what position was the Resident's bed in the last time he saw her at 3:40 AM. CNA #1 stated, .I believe it was waist high.that's typically where it's at all the time. CNA A was asked did you see a fall mat beside the Resident's bed. CNA stated, No, she didn't have one. During an interview on 4/13/2026 at 1:08 PM, the Administrator verified that he was the Administrator in training on 1/9/2026. The Administrator was asked who notified you about Resident #4's incident on 1/9/2026. The Administrator stated, .[Named the Previous Administrator]. The Administrator was asked what the facility decided was the cause of Resident #4 ending up pinned underneath the bed. The Administrator stated, .while I was training.I was limited to understanding.I was involved to an extent.there are topics that I was not fully involved in.can't say for certain what was included or how she made her way under [the bed]. The Administrator was asked why was this not given to the surveyor when the facility was asked for any usual investigation or anything about a death that had been investigated. The Administrator stated, When you first came in, I wasn't sure of the time frame.I came in the end of January.when you said unusual thought it was the time I was here.even for this it's a freak accident.thought everything had been verified for the story.I thought the investigation was complete.and there was reasonable explanation.I can't tell you the explanation. During an interview on 4/13/2026 at 1:34 PM, CNA C confirmed she was Resident #4's restorative aide and stated, .her [Resident #4] upper body was more active than the lower body.when I first meet her 4 years ago she could walk.she had [a] full decline process.the last couple of weeks was using a [name of mechanical lift] lift to move. CNA C was asked was Resident #4 able to walk. CNA C stated, No. CNA C was asked was Resident #4 able to turn side to side. CNA C stated, No, we turned her.she did have a custom wheelchair.she could not self-propel her chair. CNA C was asked was the Resident totally dependent on staff for bed position and care. CNA C stated, Yes, she was.night shift would turn her at night and day shift would do the same if she wasn't in her chair. CNA C was asked did you ever see the Resident have a seizure. CNA C stated, Yes.when I worked the night shift.I know she had them.I would deal with her seizures at night.a year ago [last time this CNA recalled the Resident experiencing a seizure]. CNA C was asked what position the bed was in when she worked with Resident #4. CNA C stated, Low to the floor.I would never put her bed above my knee.I kept her bed in low position.you just never know. CNA C was asked would Resident #4 been able to get underneath the bed if it was positioned at knee height. CNA C stated, I wouldn't think so. CNA C stated she had worked with Resident #4 the day before the bed was found on top of Resident #4 and stated, .[Resident #4] was up in chair and was in my office. We were sorting building blocks.could feed herself finger foods. CNA C was asked was Resident #4 able to use the bed remote and call light. CNA C stated, She could but she was notorious for yelling.would tell you what she needed if you asked her.she was alert and oriented to herself. During an interview on 4/13/2026 at 3:13 PM, the DON was asked who had informed her about Resident #4 on 1/9/2026. The DON stated, [Named LPN F].told me they were doing CPR.had found [Named Resident #4] underneath her bed unresponsive.and had called 911.had her repeat it to me again.and she repeated it to me again.told her to continue with her [Resident #4] and I am going to reach out to [Named previous Administrator].called and woke him up.we came up.when I got here [Named Medical Examiner] was up here.investigator.two or 3 cops [at the facility].and [Named Quality Assurance (QA) Nurse].was here.I had called her [QA Nurse].once we got here.we talked to [Named Medical Examiner] he told us what he observed, the marks on her [Resident #4] chest and abdomen.he wasn't here long.had all staff still here.talked to the investigator.we interviewed everybody that was here.they wrote statements.[Named CNA A and CNA B].we called them back due to the discrepancy [referring to who had removed the bed remote to raise the bed and who started the CPR].one that said he started and the other said she started it. The DON confirmed both CNAs were agency staff. The DON was asked what they had determined as to how Resident #4 got underneath the bed. The DON stated, We were trying to figure it out.when she started moving around, the remote had to come down with her.looked like it went across her left shoulder.and as far if the bed was down like it was supposed to be and if she wiggled, moving her upper body around.depending on the location of the button.did it raise it up and then bring it down.when it [the bed] got on top of her [Resident #4] it continued to press down on her. The DON confirmed the bed should have been all the way down to the floor and stated, Everything we were told it [the bed] was not up in the air [in a high position] . The DON confirmed she had never seen Resident #4 have a seizure and stated, .we tossed that idea [referring to the Resident having a seizure] and wonder if that was the cause.when I came in 2024.she wasn't walking anymore.she could tell you what she wanted.so many thoughts came into my head.why didn't she [Resident #4] yell.said she was yelling around 2 [referring to 1/9/2026 at 2:00 AM].he [CNA A] changed her and she quit yelling.between 3 and 4 [3:00 AM and 4:00 AM] checked on her. The DON was asked was Resident #4 having to be checked more frequent since it was just 1 hour since the CNA had last check on her. The DON stated, .he was just walking down the hall doing a spot check and that's when he saw her. During a telephone interview on 4/14/2026 at 10:32 AM, the Detective stated, .I remember the call light being tucked behind the nightstand and [Resident #4] couldn't reach. During a telephone interview on 4/14/2026 at 2:14 PM, the Previous Administrator was asked what happened on 1/9/2026 with Resident #4. The Previous Administrator stated, .I got a call around 5 am [5:00 AM].DON.told me had been incident and that they had called EMS.I got ready came on in.they had already left with her [Resident #4], by the time I got here they [referring to EMS] had already left.[Named the Medical Examiner] was here.he basically told me that he would do his report.sent off autopsy and he did say that would take a long time.he indicated there were no foul play.no concerns just a horrible accident.and then also meet with the police investigator and told me basically the same thing.he indicated the same .he didn't have any concerns of foul play.appeared to be an accident.from there we dove into the investigation.pulled everyone in got witness statements from everyone involved. The Previous Administrator was asked do you know when Resident #4 last had a seizure. The Previous Administrator stated, I do not. The Previous Administrator was asked what the root cause of the Resident's fall was. The Previous Administrator stated, .she [Resident #4] worked herself out of the bed.rolled tried to crawl.ended up out bed on her own.behavior related . The Previous Administrator was asked if the Resident's bed had been in the lowest position could the Resident had gotten underneath the bed. The Previous Administrator stated, .through our investigation the statements and conversation we had don't remember that being an issue. The Previous Administrator was asked if he had reported this unusual incident to any state agencies and stated, .didn't report to any department [State Survey Agency]. The Previous Administrator was asked about the discrepancies related to CNA A and CNA B's statements. The Previous Administrator stated, .we called them both back in.we determined that either statement was accurate.he [referring to CNA A] had done a little bit of the moving [referring to moving of the bed partially off Resident #4]. During a telephone interview on 4/15/2026 at 11:12 AM, the Physician said he provided care to Resident #4 and stated, .something like that [Resident #4 being pinned underneath her bed and dying as a result], I was shocked.she [Resident #4] was mainly bed ridden.police were involved.she [Resident #4] was paranoid.she had been my patient for years. The Physician was asked when the last time was you saw Resident #4. The Physician stated .I went every month.She had declined.when she first got there, she was mobile.then wheelchair [dependent].you could see the steady decline. The Physician was asked do you know when she had her last seizure. The Physician stated, .a couple of years.she had [a] diagnosis of Alzheimer's.she had quite a few behaviors. The Physician was asked should staff follow care plan interventions. The Physician stated, Yes. The Physician was asked if Resident #4's bed had been in the low position as care planned could the Resident have gotten underneath the bed. The Physician stated, .that would be hard.usually there is a mat.it would be difficult for her to get under the bed.she would yell out.I'm not g

Based on policy review, review of the facility's Infection Control Program documents, medical record review, observation and interview, the facility failed to follow Infection Control practices when they failed to track pathogens in the Monthly Surveillance Report, when facility staff left a contaminated ice scoop in the ice chest for 1 of 2 (300 and 400 hall) nourishment rooms and when the facility failed to use enhanced barrier precautions for 1 of 3 (Resident #8) residents reviewed for pressure ulcers. The findings include: 1. Review of the facility policy titled, Antibiotic Stewardship- Review and Surveillance of Antibiotic Use and Outcomes, dated 12/2016, revealed .Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility -wide antibiotic stewardship .All resident antibiotic regimens will be documented on the facility -approved antibiotic surveillance tracking form. The information gathered will include .date symptoms appeared .name of antibiotic .pathogen identified .site of infection .date of culture . Review of the facility's policy titled, Enhanced Barrier Precautions, revised 12/2024, revealed .Enhanced barrier precautions (EBP) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents .Enhanced barrier precautions apply when .A resident is NOT known to be infected or colonized with any MDRO, has a wound or indwelling medical device, and does not have secretions or excretions that are unable to be covered or contained; and .EBPs employ targeted gown and gloves use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply .Gloved [Gloves] and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room) . Review of the facility policy titled, Ice Machines and Ice Storage Chests, dated 1/2025, revealed .Ice machines and ice storage/distribution containers will be used and maintained to assure a safe and sanitary supply of ice .To help prevent contamination of .ice storage chests .Keep the ice scoop/bin in a covered container when not in use . 2. Review of the .Monthly Infection Surveillance Report, dated 3/2025, 4/2025, and 5/2025, revealed .Unit/Room .Infection Onset .Infection .Signs and Symptoms .Status .Pharmacy Order .Comments. There was no column to document on the .Monthly Infection Surveillance Report, form that named the organism that was being tracked. During an interview on 6/18/2025 at 11:27 AM, the Infection Preventionist (IP) /Assistant Director of Nursing (ADON) confirmed that she does not track the organisms in the Monthly Infection Surveillance Report. IP/ADON was unable to provide documentation that infection organisms were being tracked. 3. During observation and interview on 6/17/2025 at 3:50 PM, in the 300/400 hall nourishment room the ice storage/distribution container revealed the ice scoop laying inside the ice storage/distribution container halfway submerged in half melted ice and half ice. Certified Nursing Assistant (CNA) C confirmed the ice scoop should not be lying inside the ice storage/distribution container and should be inside a covered container. During an interview on 6/17/2025 at 4:17 PM, the Director of Nursing (DON) confirmed the ice scoop should not be lying inside the ice storage/distribution container and should be inside a covered container. 4. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Protein-Calorie Malnutrition, Muscle Weakness. Review of the Care Plan revised 5/12/205, revealed . Enhanced Barrier Precautions: [Resident #8] requires enhanced barrier precaution during high-contact resident care activities due to the present of: Wound .Enhanced barrier precautions will be followed during high-contact resident care activities . Review of a Physician's Order dated 6/12/2025, revealed .Enhanced barrier precautions every shift for wound . Observation in the Resident's room on 6/18/2025 at 3:12 PM, revealed the Wound Care Nurse entered the room, performed hand hygiene, donned gloves, rolled the Resident #8 towards her, and unfastened the Resident's adult brief so the wound could be visualized. The Wound Care Nurse failed to put on an isolation gown prior to direct resident care. During an interview on 6/18/2025 at 3:36 PM, the Wound Care Nurse confirmed Resident #8 was in enhanced barrier precautions and an isolation gown should have been worn during patient contact.

Based on facility policy review, Quarterly Payroll Based Journal (PBJ) review, and interview, the facility failed to submit accurate staffing data for 1 of 4 (Quarter 2, January 1-March 31, 2025) quarters reviewed. The findings include: Review of the facility policy titled, Reporting Direct Care Staffing Information (Payroll-Based Journal), with a revision date of August 2022, revealed .Complete and accurate direct care staffing information is reported electronically to CMS [Centers for Medicare and Medicaid Services] through the Payroll-Based Journal (PBJ) system in a uniform format specified by CMS .Direct care staffing information includes staff hired directly by the facility, those hired through an agency, and contract employees . Review of the PBJ Staffing Data Report for Quarter 2 of 2025 (January 1- March 31) revealed one star staffing rating and excessively low weekend staffing. During an interview on 6/18/2205 at 10:54 AM, the Administrator stated, .None of the agency staff hours rolled into the system .The agency staff has to be manually put it into the system. The Administrator confirmed that agency staffing hours had not been included in the report for Quarter 2 of 2025 resulting in inaccurate reporting.

Based on facility policy review, medical record review, observation, and interview the facility failed to follow Physician's Orders and provide care and services regarding oxygen therapy for 3 of 6 (Resident #57, #257, and #308) residents reviewed for oxygen therapy. The findings include: 1. Review of the facility policy titled, Oxygen Administration, dated 10/2024, revealed .The purpose of this procedure is to provide guidelines for safe oxygen administration .Verify that there is a physician's order for this procedure .Review the resident's care plan to assess for any special needs of the resident . 2. Review of the medical record revealed that Resident #57 was admitted to the facility on [DATE], with diagnoses including Acute and Chronic Respiratory Failure, Chronic Obstructive Pulmonary Disease (COPD), Pneumonia, and Dependence on Supplemental Oxygen. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #57 was cognitively intact. Additional information included Resident #57 had shortness of breath or trouble breathing when lying flat and received oxygen therapy. Review of the Physician's Orders dated 6/4/2025, revealed .Elevate HOB [head of bed] .for shortness of breath while lying flat . Review of the care plan dated 6/13/2025, revealed .receives the use of oxygen .continuous .related to, acute respiratory failure, Chronic Obstructive Pulmonary Disease (COPD), Dyspnea .Maintain head of bed elevated .to promote oxygenation .Position with HOB elevated to prevent episodes of shortness of breath while lying flat . Observation on 6/16/2025 at 11:01 AM and 1:46 PM, revealed Resident #57 was lying in the bed and the HOB was flat. Observation on 6/17/2025 at 7:53 AM, revealed Resident #57 was lying in the bed and the HOB was flat. During observation and interview on 6/17/2025 at 5:00 PM, Resident #57's HOB was flat, and Licensed Practical Nurse (LPN) B confirmed the HOB should be raised at least to a 30-degree angle. Observation in the Resident's room on 6/18/2025 at 10:39 AM, revealed Resident #57 was lying in the bed and the HOB was flat. During an interview on 6/18/2025 at 1:59 PM, the DON confirmed the HOB should be elevated at least 30 degrees when ordered by a Physician. 3. Review of the medical record revealed Resident #257 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease and Chronic Diastolic (Congestive) Heart Failure. Review of the Care Plan dated 6/12/2025, revealed Resident #257 was not care planned for oxygen. Review of the Physician Orders for June 2025, revealed no order for oxygen. Review of the Medication Administration Record (MAR) for June 2025, revealed oxygen was not listed. Observation in the hallway on 6/16/2025 at 9:25 AM, revealed Resident #257 was up in the wheelchair, wearing oxygen via (by way of) binasal cannula (BNC) to oxygen tank secured to wheelchair. During an observation and interview in the Resident's room on 6/16/2025 at 4:08 PM, Resident #257 was wearing oxygen at 1 liter/minute (L/min) via BNC. Resident stated, .I wear oxygen all the time . Observation in the Resident's room on 6/17/2025 at 1:01 PM, revealed Resident #257 was up in wheelchair, with oxygen at 1 L/min via BNC. During an interview on 6/16/2025 at 5:21 PM, LPN A was asked if Resident #257 had an order for oxygen therapy. LPN A stated that Resident #257 should have an order for oxygen at 4-5 L/min via BNC. During an interview on 6/17/2025 at 1:42 PM, LPN A confirmed Resident #257 did not have an order for oxygen therapy. 4. Review of the medical record revealed that Resident #308 was admitted to the facility on [DATE], with diagnoses including Subluxation of Left Shoulder Joint, Hyperlipidemia, Hypertension, Anxiety, Morbid Obesity, and Dysphasia. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 15 which indicated that Resident #308 was cognitively intact with no shortness of breath and did not receive oxygen therapy. Review of the Care Plan revised on 6/13/2025, revealed no documentation of oxygen therapy. Review of the Physician's Orders dated 5/29/2025 through 6/17/2025, revealed no order for oxygen therapy. Observation in the Resident's room on 6/16/2025 at 9:31 AM, 2:32 PM, and 6/17/2025 at 7:55 AM revealed Resident #308 was receiving oxygen BNC at 3.5 L/min. During observation in the Resident's room and interview on 6/17/2025 at 5:05 PM, Resident #308 was receiving oxygen via BNC at 3.5 L/min. LPN B confirmed there was no order for oxygen therapy in Resident #308's medical record. During an interview on 6/18/2025 at 10:33 AM, the Director of Nursing (DON) confirmed a resident receiving oxygen therapy should have a Physician's Order for Oxygen.

Based on the facility policy review, medical record review, observation, and interview the facility failed to ensure the environment was free of accident hazards when unsecured sharps were observed in resident's room for 1 of 57 (Resident #37) residents reviewed for accidents. Observations during survey revealed no wandering residents on Resident #37's hall. The findings included: 1. Review of the facility policy titled, Sharps Disposal, with a revised date of January 2012, revealed .The facility shall discard contaminated sharps into designated container . 2. Review of the medical record revealed Resident #37 was admitted to the facility on [DATE], with diagnoses including Bipolar Disorder, Mild Cognitive Impairment, Delusional Disorders, Dementia, and Cognitive Communication Deficient. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 11 which indicated Resident #37 had moderately impaired cognition and required supervision and assistance with Activities of Daily Living (ADLs). Review of the Care Plan dated 8/27/2024, revealed a focus on Activities of Daily Living (ADL)/ mobility decline, cognitive loss related to dementia, and resident behaviors. Observation in Resident #37's restroom on 6/16/2025 at 9:34 AM and 11:43 AM, revealed 2 blue uncapped disposable razors on the back of the sink in a red cup unsecured and unattended. During an observation and interview in Resident #37's restroom on 6/16/2025 at 11:55 AM, Licensed Practical Nurse (LPN) A was asked if razors should be left out accessible to the Resident. LPN A stated, No, I will remove them right now. During an interview on 6/18/2025 at 10:25 AM, the Director of Nursing (DON) confirmed that razors should be stored in a secure location, inaccessible to residents, and should not be left unsecured and unattended in resident rooms or restrooms.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure a safe, sanitary, and comfortable environment for 6 of 60 (Resident #6, #21, #22, #35, #36, and #45) resident shared bathrooms observed. The findings include: 1. Review of the facility's policy titled, Infection Prevention and Control Program, dated 11/20/2023, revealed, .All reusable items and equipment requiring .cleaning .or disinfection shall be cleaned in accordance with our current procedures governing the cleaning and disinfection of soiled or contaminated equipment .The reusable equipment shall be decontaminated using a germicidal detergent prior to storing for reuse . Review of the facility's undated cleaning list titled, ENVIRONMENTAL CLEANING INFECTION CONTROL COMPLIANCE LOG, revealed, .ITEM TO BE CLEANED .HOYERS .FREQUENCY .AFTER USE .METHOD OF CLEANIG .DISINFECTANT WIPES .RESPONSIBLE .CNA'S . 2. Review of the medical record revealed Resident #21 was admitted on [DATE], with diagnoses including Traumatic Brain Injury, Depression, Gastrostomy, Aphasia, and Impulse Disorder. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #21 was severely cognitively impaired, dependent on staff for showering/bathing, toileting, and incontinent of both bowel and bladder. Review of the medical record revealed Resident #45 was admitted on [DATE], with diagnoses including Traumatic Brain Compression, Hydrocephalus, Aphasia, Bipolar Disorder, and Impulse Disorder. Review of the quarterly MDS assessment dated [DATE], revealed the resident was moderately cognitively impaired, dependent on staff for toileting hygiene, showering/bathing, and incontinent of both bowel and bladder. Observation in Resident #21 and Resident #45's shared bathroom on 7/15/24 at 10:17 AM, 2:35 PM, and on 7/16/2024 at 7:53 AM, revealed 3 gray wash basins, 1 gray bedpan stacked inside of each other sitting on top of the lid of a potty chair, unlabeled and uncontained. During an interview and observation in Resident #21 and Resident #45's shared bathroom on 7/16/24 8:00 AM, Certified Nurse Assistant (CNA) D was asked how residents' personal items such as wash basins and bed pans should be stored in a shared resident bathroom. CNA D confirmed that resident personal items should be labeled and stored in plastic bags. 3. Review of the medical record revealed Resident #22 was admitted to the facility 8/9/2019, with diagnoses including Muscle Weakness, Unsteadiness on Feet, Anemia, Difficulty Walking, and Dementia. Review of the quarterly MDS dated [DATE], revealed Resident #22 was cognitively intact and required set up or clean up assisting for toileting hygiene and eating. Review of the medical record revealed Resident #36 was admitted to the facility 5/4/2022, with diagnoses including Heart Failure, Muscle Weakness, Unsteadiness on Feet, Obesity, Rheumatoid Arthritis, and Abnormality of Gait and Mobility. Review of quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #36 was cognitively intact, required set up or cleanup assistance for eating. Observation in Resident #22 and Resident #36's shared bathroom on 7/15/2024 at 10:23 AM, 11:50 AM, and at 3:51 PM, revealed 1 plastic medication cup, 2 clear plastic dietary drinking glasses, 1 plastic maroon dietary bowl, and 1 white dietary bowl, sitting on the ledge of the bathroom mirror all stacked inside each other. During an interview and observation in Resident #22 and Resident #36's shared bathroom on 7/16/2024 at 8:00 AM, revealed 1 plastic medication cup, 2 clear plastic dietary drinking glasses, 1 plastic maroon dietary bowl, and 1 white dietary bowl, sitting on the ledge of the bathroom mirror all stacked inside each other. CNA D was shown the soiled dietary items in Resident #22 and Resident #36's shared bathroom and was asked where these items should be. CNA D stated, They should be in dietary. 4. Review of medical record revealed Resident #6 was admitted on [DATE], with diagnoses including Cerebral Palsy, Depression, and Anxiety. Review of admission MDS dated [DATE], revealed Resident #6 was moderately cognitively impaired and required maximal for oral hygiene and dependent on staff for personal hygiene including oral care. Medical record review revealed Resident #35 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Anxiety, Depression, and Hypertension. Review of admission MDS dated [DATE], revealed cognitively intact and required supervision for oral hygiene and moderate assistance for personal hygiene. Observation in Resident #6 and Resident #35's shared bathroom on 7/15/24 at 10:20 AM, 2:55 PM, and on 7/16/2024 at 4:39 PM, revealed a tube of toothpaste and a toothbrush on the sink behind the faucet unlabeled and uncontained, a plastic denture cup upside down in the corner on the floor unlabeled and uncontained, a soiled adult brief on the floor beside the commode, beside the trash can. 5. During an interview with on 7/18/24 at 11:17 AM, the Administrator was asked how often trash should be emptied. The Administrator confirmed that the trash should be emptied at a minimum of one time daily or more often if needed. The Administrator confirmed that all trash should be contained in the trash receptacles and no trash overflowing or on the floor, around the base of the receptacles. The Administrator was asked how should wash basins and bedpans be stored in a shared resident bathroom. The Administrator confirmed wash basins and bedpans should be labeled with the resident's name and in a plastic bag when not in use. The Administrator confirmed the soiled dietary serving items should not be in resident's bathrooms and should be in the dietary department. The Administrator was asked how resident toothbrushes should be stored in a shared bathroom. The Administrator confirmed toothbrushes should be stored in a holder and labeled and denture cups should be stored upright and labeled.

Based on policy review, observation, and interview the facility failed to ensure food was stored, prepared, and served under sanitary conditions related to unlabeled, undated, food items, expired foods, and dirty metal carts, food containers, food carts, floors, and nourishment refrigerators. The finding include: 1. Review of the facility's policy titled, Dietary: Food Storage, dated [DATE], revealed .Food shall be stored in accordance with professional standards for food service .staple items such as flour, sugar, and cornmeal should be stored in clean, closed containers .All stored items should have an expiration date or a purchase/delivery date .Open Date .ready- to-eat .food .shall be clearly marked at the time the original container is opened . Review of the facility's policy titled, Dietary: Cleaning, dated [DATE], revealed .Adequate cleaning and sanitizing shall minimize the risk of food born illnesses . 2. Observation in the kitchen on [DATE] at 8:48 AM, revealed: A 4-tier metal cart with food particles and a dried dark brown substance on the cart. On the top shelf of the 4-tier metal cart was 2 loaves of undated bread, 8 packages of undated hamburger buns, 1 opened pack of hamburgers containing 2 buns, and 1 open package of hoagie buns containing 4 hoagies. On the second shelf of the 4-tier metal cart was a pack of garlic bread containing 15 slices of bread with a use by date of [DATE]. The kitchen cornmeal, flour, and sugar containers had old food particles around the opening of the containers, and dark brown areas to these containers. Meal delivery carts #2, #3, #4, and #5 had food particles and old dried spillage noted to bottom and sides of cart. Standing water, grease, dirt, and food particles on the kitchen floors. 3. Observation in the ,d+[DATE] hall Employee Break Room on [DATE] at 8:00AM, of the Resident nourishment mini refrigerator revealed: a. An undated glass of orange juice that was fermented. b. Spilled liquids in the inside and shelving areas. c. Review of the The Med Room Refrigerator/Freezer Temp Log, dated [DATE], revealed no temperature documentation for [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. During an interview on [DATE] at 8:06 AM, the Interim Director of Nursing confirmed, the nourishment refrigerators should be kept clean, food and liquids should be dated, and the temperature logs should be completed daily. During an interview on [DATE] at 11:02 AM, the Certified Dietary Manager and the Registered Dietician confirmed all foods should be labeled and dated, no food or liquids should be expired, kitchen should be clean and maintained, and the resident nourishment mini refrigerator should be clean.

Based on facility policy, medical record review, and interview the facility failed to follow Physician Order for 2 of 5 (Resident #23 and #213) sampled residents reviewed. The findings include: 1. Review of the facility's titled, [Named Pharmacy] Delivery Services, dated 11/2021, revealed .Night delivery is provided to each facility on a pre-set schedule .This delivery consists of medications .the Charge Nurse should compare the medication label and the pharmacy label to the physician order .to identify discrepancies .delivered medications match the orders . Review of the facility's policy titled, Medication Administration, dated 8/4/2023, revealed Medications shall be administered by licensed medical or nursing personnel acting within the scope of their practice and per the Physician's Signed Order. While administering medications the nurse shall observe the 8 Rights of Medication Administration .Right Dose .Right Time .Review the EMAR [Electronic Medication Administration Record] to identify the medication to be administered .Report discrepancy to Nurse Management . Review of the facility's policy titled, Medication Administration: Medication, Controlled and Biological Storage, Night/Emergency Box and Backup Pharmacy, dated 9/5/2023, revealed .[named pharmacy] contracts with a local pharmacy in the community where each facility is located to provide medications .The nurse should check the facility's night box/I-Stat for a starter dose. If medication is not available in the night box, the medication should be ordered from the back-up pharmacy . Review of the facility's order titled, Physician Verbal Order Policy, dated 4/18/2024, revealed .To provide guidance on physician verbal orders .Immediately communicate read-back of the orders to the physician .Follow through with orders by appropriate contact or notifications ( .pharmacy) . 2. Review of the medical record revealed Resident #23 was admitted on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Anxiety, Depression, and Osteoporosis. Review of the Care Plan dated 2/6/2024, revealed Resident #23 had . Anxiety Disorder .Medication as ordered . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #23 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #23 was cognitively intact and received Antianxiety medication. Review of the Physician Order dated 7/12/2024, revealed .Xanax [an antianxiety medication] 0.25 mg[milligram] tablet [1 Tablet] .Oral Two Times Daily . Review of the Medication Administration Record (MAR) revealed the Resident had missed administrations of Xanax 0.25 mg on 7/12/202 thru 7/15/2024. During an interview on 7/15/2024 at 10:25 AM, Resident #23 stated, . the shift key nurses [agency nurses], some of them not pulling all my meds . During an interview on 7/16/2024 at 4:05 PM, the Regional Nurse Consultant (RNC) was asked what the shaded area on the MAR with the nurses initial on it mean. The RNC stated, It means the nurse has acknowledge that the resident did not receive the medication, should be an excuse on the MAR. The RNC confirmed the 7/2024 MAR notes stated the Xanax 0.25 mg was unavailable from 7/12/2024 thru 7/15/2024. During an interview on 7/18/2024 at 8:20 AM the Interim Director of Nurses (DON) was asked to explain why Resident #23 was not receiving Xanax as ordered. The Interim DON stated, If the nurse is not paying attention . those type of meds are ordered for so many days and we believe the provider did not realize 0.25 mg was not what the resident normally gets . The Interim Don was asked what the nurse should have done for the days Resident #23 did not receive her scheduled Xanax dose. The Interim DON stated, I assumed they said to the resident, they do not have an order .They should have called the doctor when the resident asked for the medication. It is very difficult working with agency nurses, hard to educate, it is a headache. The Interim DON was asked should the resident receive her ordered medication on those days. The Interim DON stated, I was not aware, they should have called me. During an interview on 7/18/2024 at 8:31 AM and 9:47 AM, the Interim DON was asked to explain the missed dosages on Xanax on the 7/2024 MAR. The Interim DON presented a copy of a narcotic sheet labeled with Resident #23's name and .Alprazolam tab 0.5mg Take one tab [tablet] two times daily ., with signatures of staff which indicated the resident received the medication once per day on 7/12/2024 thru 7/14/2024. The Interim DON confirmed based on documentation the resident was given Xanax 0.5mg once per day for a Xanax 0.25 mg twice per day physician order. The Interim DON stated I think they were so use to giving the 0.5 mg that they did not look to see that the order had been changed. They should have looked at the order and notified the doctor to get a confirmation whether 0.25 mg or 0.5mg should be administered. The Interim DON confirmed the Physician orders were not followed. 3. Review of the medical record revealed Resident # 213 was admitted to the facility on [DATE], with diagnoses including Osteomyelitis of Vertebra, Intraspinal Abscess and Granuloma, and Discitis. Review of the medical record revealed the MDS was incomplete as the Resident was admitted on [DATE]. Review of the Care Plan dated 7/9/2024, revealed Resident #213 was .At Risk for Infection .Medications as ordered . Review of the signed Physician Order revealed Resident #213 had an order for .Vancomycin 1.5 gram/150 ml [milliliter] in 0.9 % [percent] sodium chloride intravenous Every 12 Hours .Route: Intravenous Piggyback ., dated 7/9/2024. Review of the signed Physician Order revealed Resident #213 had an order for .Cefepime [an antibiotic] 2000 mg[milligram] in NS [Normal Saline] 10 ml IVPB [Intravenous Piggy Back] infuse every 8 hours . dated 7/9/2024. Review of the 7/2024 MAR revealed Resident #213 did not receive the Vancomycin and the Cefepime on 7/11/2024. During an interview on 7/17/2024 at 2:39 PM, the RNC confirmed Resident #213 did not receive the Vancomycin on 7/11/2024. The RNC was asked why the resident did not get the Vancomycin. The RNC stated, .it is under the administration note that the medication was unavailable . The RNC was asked should the medication be available for use. The RNC stated, I am not going to say it was not available. I am going to say the nurse did not know where the medication was located. The RNC was asked should the nurse have known where the antibiotic was located. The RNC stated, Yes. The nurse should have notified the provider if she had a medication that was not available. I do not know if she did not know where the medication was or if it was truly not available .he got the med [medication] on the other shift. The nurse should have notified the provider the medication was not given . The RNC confirmed the resident should have gotten the Vancomycin as ordered and the Physician Order was not followed. During an interview on 7/18/24 at 8:42 AM, The Interim DON confirmed the missed dose of Cefepime 2 gram on 7/11/2024 should have been administered and the Physician Order was not followed.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure medications were properly stored and secured when 1 of 3 staff members (Registered Nurse (RN) A) left the medication cart unlocked, unattended, and out of sight for 1 of 7 (100 Hall medication cart) medication storage areas and when medications were left unsecured and unattended, at the bedside, in Resident #41's and Resident #52's room. The findings include: 1. Review of the facility's policy titled, Medication Administration: Medication, Controlled and Biological Storage, Night/Emergency Box and Backup Pharmacy, dated 9/5/2023, revealed .It is the policy of this facility to ensure all medications housed on our premises shall be stored in the pharmacy and/or medication rooms according to the manufacture's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security .All drugs and biologicals shall be stored in locked compartments [ .medication carts .] .During medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart . 2. Observation on 7/17/2024 7:41 AM revealed 100 Hall medication cart left unlocked, unattended, and out of sight of the staff. During an interview at the 100 Hall medication cart on 7/17/2024 at 7:42 AM, the Administrator confirmed the 100 Hall medication cart should not be left unlocked, unattended, and out of sight of staff. During an interview on 7/17/2024 at 7:43 AM, RN A confirmed she should not have left the 100 Hall medication unlocked, unattended, and out of sight. 3. Review of the medical record revealed Resident #41 was admitted to the facility on [DATE], with diagnoses including Stroke, Gastroesophageal Reflux Disease, Urinary Tract Infection, Anxiety, and Depression. Review of the admission MDS assessment dated [DATE], revealed Resident 41 BIMS score of 14 which indicated cognitively intact and the resident required moderate assistance from staff to perform Activities of Daily Living. Observation in the Resident #41's room on 7/15/2024 at 10:11 AM, revealed a medication cup with one oblong yellow tablet, one round white tablet, one green/glue capsule noted at bedside on dresser. 4. Review of the medical record revealed Resident #52 was admitted to the facility on [DATE], with diagnoses including Malnutrition, Anxiety, Bipolar, and Gastroesophageal Reflux Disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #52 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderately cognitively impairment. Resident #52 required supervision of staff to perform Activities of Daily Living, and received antipsychotic, antianxiety, and opioid medications. Observation in Resident #52's room on 7/15/24 at 9:56 AM, 10:08 AM, and 10:24 AM, revealed one small white tablet and one blue capsule pill inside of a medication cup, on the resident's bedside dresser. During an observation and interview in Resident #52's room on 7/15/2024 at 10:24 AM, Licensed Practical Nurse (LPN B) was asked if the medications should be at bedside. LPN B stated, No, they should not be at bedside. During an interview on 7/15/2024 at 10:28 AM, LPN B was asked about medications being left at resident's bedside. LPN B stated .That was me that left those at his bedside. LPN B was asked if she removed the medications from the resident's room. LPN B stated, The Social Worker brought the medications to me, and I placed them back on the cart because he didn't want to take them. During an interview on 7/18/2024 at 11:09 AM, the Interim DON confirmed that medications should not be left at resident's bedside during medication administration.

Based on policy review, medical record review, observation and interview the facility failed to obtain physician's orders for a resident with dialysis, failed to assess and monitor dialysis sites for thrill, bruit, and infection, and failed to follow/implement individualized care plan for 1 of 1 (Resident #263) sampled residents for dialysis. Findings include: 1. Review of the facility's policy Dialysis dated 10/9/2023, revealed .Residents who have End Stage Renal Disease [ESRD] and receive dialysis shall be provided care consistent with professional standards of practice, the physicians/practitioner's orders, and in accordance with the resident goals and preferences .Vascular Access [is] a connection made between an artery and a vein to provide good blood flow for dialysis. Bruit [is] a constant rumbling sound such as swishing or whoosh sound heard via stethoscope placed on the access .Thrill [is] a steady vibration or rumbling sensation felt at the AV [Arteriovenous] graft/fistula site .Medical conditions shall be monitored and managed to prevent complications .Licensed nurses shall participate in the management of medical conditions by following physicians orders, assessing the resident, and reporting changes in condition or behavior to the physician .Infection control practices shall be followed .Documentation shall include .Skin integrity at the access site [document every shift] .Prescence of thrill and bruit of the AV graft/fistula [document every shift] .Evidence of infection, bleeding, and other complications . 2. Review of the medical record revealed Resident #263 was admitted to the facility on [DATE], with diagnoses including End Stage Renal Disease, Deep Vein Thrombosis of Lower Extremity, Hypertension, Malnutrition, and Dependence on Renal Dialysis. Review of the Dialysis Communication forms dated 7/5/2024, 7/8/2024, 7/10/2024, 7/12/2024, 7/15/2024, and 7/17/2024 had a fax received date and time of 7/17/2024 at 2:29 PM on each communication form from the [named Dialysis clinic]. Review of the Care plan dated 7/8/2024, revealed .Dialysis M-W-F at [named clinic] . Do not take blood pressure on arm with shunt/fistula .Monitor access site for bruit and thrill. Notify MD immediately of absent bruit and/or thrill, with follow-up as indicated .Monitor access site for signs and symptoms of infection or bleeding .Monitor for changes in blood pressure, report abnormal findings to MD with follow up as indicated . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #263 was cognitively intact. Resident was assessed for dialysis. Review of the Physician's Orders dated 7/17/2024 revealed Dialysis Monday, Wednesday, Friday .Monitor Fistula/Graft 2 Times Daily for bleeding .Monitor for thrill and bruit 2 times Daily .Post-Dialysis Weight 3 Times Weekly .Pre Dialysis Weight 3 Times Weekly .Remove Pressure Dressing 3 Times Weekly 2-4 hours after dialysis .Vital Signs T/P/R [Temperature/Pulse/Respiration] and B/P [Blood Pressure] 3 Times Weekly obtain post dialysis vital signs . The facility was unable to provide documentation of Physician's Orders for dialysis assessing and monitoring prior to 7/17/2024. Review of the July 2024 Treatment Administration Record revealed the following treatments with no documentation for dates 7/3/2024 through 7/16/2024: Monitor for thrill and bruit two times daily Post-dialysis Weight three times weekly Pre-dialysis weight three times weekly Remove pressure dressing three times weekly 2-4 hours after dialysis Vital signs T/P/R and B/P [Temperature, Pulse, Respirations, Blood Pressure] Three times weekly obtain post dialysis vital signs The facility was unable to provide documentation of dialysis access sites monitored each shift for thrill, bruit, and infections. Observation in the resident's room on 7/17/2024 3:57 PM, revealed Resident #263 with a permacath [dialysis access site] to right-sided chest wall and dialysis shunt to left upper arm with 2 band aids noted. The facility was unable to provide physician's orders and a care plan to assess and monitor Resident's permacath. During an interview on 7/17/2024 4:08 PM, the Interim Director of Nursing (DON) was asked the process for monitoring Dialysis residents. The Interim DON confirmed that facility staff completes a Dialysis Communication form and sends the form with residents to dialysis. The Interim DON confirmed that the Dialysis Clinic completes and sends the communication form to the facility with the resident or faxes the communication form to the facility. The Interim DON was asked if staff had been assessing and monitoring Resident #263's dialysis sites prior to 7/17/2024. The Interim DON stated, Yes. The Interim DON was asked, where staff should complete documentation of assessment. The Interim DON confirmed that site monitoring should be documented on the Treatment Administration Record (TAR) in the electronic medical record. During an interview on 7/17/2024 at 4:40 PM, the Regional Nurse Consultant confirmed that she is unable to provide any documentation related to assessing and monitoring of dialysis sites related to Resident #263, or any communication to dialysis clinics for dates 7/3/2024 through 7/16/2024.

Based on policy review, observation, and interview, the facility failed to maintain or enhance residents' dignity and respect during dining when 3 of 12 (Certified Nursing Assistance (CNA) A, B, C), failed to knock and/or announce self when entering resident rooms and failed to use courtesy titles when addressing residents during dining. The findings include: 1. Review of the facility's policy titled, Promoting/Maintaining Resident Dignity Policy, dated 11/20/2023 revealed, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality .All staff members are involved in providing care and services to residents to promote and maintain resident dignity and respect resident rights . 2. Observation during dining on the 300 hall on 7/15/24 at 11:44 AM, revealed, CNA A removed a tray from the meal cart, knocked and entered Resident #2's room and stated, I got lunch darling . placed the tray on the over the bed table, exited the room. Then CNA A returned to the meal cart, removed a tray from the meal cart and entered Resident #36's room and stated, I got lunch hun [short for honey] . placed the tray on the over the bed table and then exited the room. 3. Observation during dining on the 300 hall on 7/17/24 at 7:15 AM, revealed CNA B removed a tray from the meal cart, entered Resident #34's room and stated, [Named Resident #34], you ready to eat baby . Resident #34 stated, It is cold in here can you light a fire . CNA B stated, I can't start a fire buddy . CNA B set up the tray and exited Resident #34's room. Observation during dining on the 300 hall on 7/17/2024 at 7:15 AM, revealed CNA B removed a tray from the meal cart, entered Resident #1's room and stated, Hey, buddy . placed the tray on the over the bed table, exited the room and went to the nurse's station. CNA B returned to Resident #1's room and attempted to wake the resident and stated, Hey, buddy . and then exited the room. CNA B failed to knock when entering or reentering the resident's room. Observation during dining on the 300 hall on 7/17/24 at 7:48 AM, revealed, CNA B removed a tray from the meal cart, entered Resident #36's room, set up the meal tray and exited the room. CNA B failed to knock and/or announce herself when entering the resident's room. 4. Observation during dining on 7/17/24 at 7:55 AM, revealed CNA C removed a tray from the meal cart, entered Resident #30's room, placed the tray on the over the bed table, assisted with repositioning the resident in the bed and stated, Stretch your legs out buddy ., set up the meal tray and exited the room. CNA L failed to knock and/or announce herself when entering the resident's room. During an interview with on 7/18/24 at 11:17 AM, the Administrator was asked what staff should do before entering a resident's room. The Administrator confirmed that staff should knock and/or announce themselves before entering a resident's room. The Administrator was asked how should staff address residents when speaking to them. The Administrator confirmed that staff should address residents by their preferred name and should not be addressed by pet names.

Based on policy review, fall investigation review, medical record review, observation, and interview, the facility failed to ensure a safe and secure environment for 6 of 8 residents (Resident #11, #14, #18, #52, #163, and #215) reviewed for falls and accidents. The facility failed to ensure processes were implemented to provide supervision and assistance to ensure the residents' environment was free of accident hazards. The facility failed to conduct appropriate fall investigations to identify all contributing factors (root causes) including the disabling of the courtyard door alarm on the 400 hall and failed to implement appropriate interventions to ensure resident safety. On [DATE] Resident #11, a vulnerable resident with memory impairment and abnormalities of gait and mobility, exited the building unsupervised and without staff knowledge after a staff member disabled the courtyard door alarm on the 400 hall. At approximately 11:15 AM, a staff member was looking out the window of a resident's room and saw Resident #11 outside and sitting on the ground in the courtyard. Resident #11 required 2 staff members to assist her off the ground and back into the building. Resident #11 was found 13 feet and 6 inches from the 400-hall courtyard door threshold. The temperature was documented by weatherspark.com to be 89 degrees Fahrenheit with severe thunderstorms watch in effect for [NAME] County ([NAME], Tennessee). The time span Resident #11 was outside could not be determined. The facility's failure to provide supervision and ensure a safe environment free of accidents hazards resulted in Immediate Jeopardy for Resident #11. Resident #14, a cognitively impaired resident at risk for falls, fell on [DATE], sustained a laceration to the left eye and was transferred to the emergency room for evaluation. The facility failed to complete a fall risk assessment for Resident #14 after the fall on [DATE]. The facility failed to ensure appropriate interventions were initiated, failed to obtain an x-ray, and failed to provide pain medication after Resident #18 fell on [DATE], resulting in a painful wrist fracture. Resident #52 fell on [DATE] and the facility was unable to provide a BIMS score on the event note, failed to complete neurological checks, and complete an updated fall risk assessment for Resident #52's fall on [DATE]. The facility was unable to provide a BIMS score on the event note and failed to complete neurological checks for Resident #52 after a fall on [DATE]. Resident #163, who was identified as at risk for falls, failed to have an appropriate care plan developed and implemented for fall preventions. Resident #163 fell on [DATE], sustained multiple skin tears, lacerations, and a head injury, and was transferred to a hospital, then transferred to a higher level of care hospital, and expired on [DATE] related to aspiration pneumonia. Resident #215 had a previous fall on [DATE], which resulted in a right hip fracture. The facility's investigation revealed Resident #215 had another fall on [DATE], with a root cause being the resident's meal tray was not set up within her reach. The [DATE] fall resulted in a left hip fracture. Residents #18, 163, and 215 had falls which resulted in fractures and a head injury, resulting in actual harm. Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified related to the facility's failure to use its resources effectively to attain and maintain the highest practicable well-being of vulnerable residents, to ensure systems and processes were implemented to provide supervision and assistance to ensure the resident environment was free of accident hazards. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for F-689 during the recertification survey on [DATE] at 4:37 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-689. The facility was cited Immediate Jeopardy at F-689 at a scope and severity of J which is Substandard Quality of Care. The Immediate Jeopardy began on [DATE] - [DATE], with [DATE] being the last day of the IJ. The facility's corrective actions were validated onsite by the surveyors on [DATE] through [DATE]. An acceptable Removal Plan, which removed the immediacy of the Immediate Jeopardy, was received on [DATE] at 10:39 AM with an alleged IJ removal date of [DATE]. The Removal Plan was verified and validated onsite by the surveyors on [DATE] through [DATE] by review of the in-service training records and audits, review of the facility's policy, review of new hire orientation packets, observations, and staff interviews. The last day of the IJ was [DATE]. After the acceptable Removal Plan for F-689 was validated on [DATE], noncompliance remains for F-689 at a scope and severity of G. The findings include: 1. Review of the facility policy titled Comprehensive Care Plan, dated [DATE], revealed .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs .The comprehensive care plan shall describe, at a minimum .The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Review of the facility's policy titled Neurological exam, dated [DATE], revealed .To provide a method to assure a uniform procedure for neurological assessments and to provide guidelines for observation and communication of neurological changes over a period of time .The facility shall initiate a neurological examination for individuals who have or may have experienced trauma to the head in order to capture any changes in a resident's neurological condition .a neurological examination shall be completed any time an individual has trauma to the head, either by a blow to the head or by falling and striking the head, regardless of whether they receive medical attention or not .Neuro assessments shall be performed for 72 hours or as ordered by the MD [Medical Doctor]/NP [Nurse Practitioner] . Review of the undated facility FALL PROCESS, revealed .OPEN EVENT NOTE UNDER PROCESS .OBTAIN WITNESS STATEMENTS .DOCUMENT IN THE EVENT NOTE WHY THEY fell . GET TO THE ROOT CAUSE .ATTACH ALL REQUIRED DOCUMENTS IN THOS [THIS] PACKET .NEURO CHECKS INITIATED .FALL RISK ASSESSMENT UPDATED .MAKE SURE BIMS IS INCLUDED. IF NOT, THEN ADDRESS . Review of the facility's undated process titled EVENT NOTE PROCESS, revealed .MAKE SURE BIMS SCORE IS ON THE EVENT NOTE (SCORE HAS TO BE ,d+[DATE] TO BE ABLE TO EDUCATE THE RESIDENT) DO ROOT CAUSE ANALYSIS TO DETERMINE APPROPRIATE INTERVENTION AND PUT AN INSERVICE OUT WITH INTERVENTION IF NEEDED. COMPLETE FALL RISK - MAKE SURE TO ADD YOUR SCORE AND CALCULATE. START NEURO CHECKS - ON ALL UNOBSERVED FALLS AND THE RESIDENTS BIMS IS LESS THAN 13 OR IF GREATER THAN 13 AND THEY TELL YOU THEY HIT THEIR HEAD AND IF IT IS AN OBSERVED FALL AND THE RESIDENT HIT THEIR HEAD .UPDATE THE RESIDENT CARE NEEDS TO REFLECT THE FALL INTERVENTION IF IT AFFECTS THE C.N.A. CARE OF THE RESIDENT .COMPLETE ALL INVESTIGATION FORMS AND HAND IN TO THE APPOINTED PERSON .ATTACHED TO THE OCCURRENCE INVESTIGATION WORKSHEET OCCURRENCE AUDIT CHECKLIST .COMPLETE 72 HOUR DOCUMENTATION, EACH SHIFT, ON THE EVENT AND REFERENCE THE INTERVENTION. Review of the facility policy titled Fall Risk -- Fall Prevention, dated [DATE], revealed .A Resident that unintentionally comes to rest on the ground, floor or other lower level .when a resident is found on the floor, a fall is considered to have occurred .Each resident shall be assessed for fall risk and shall receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls .1. The fall risk assessment shall be completed by a licensed nurse .After a fall .the fall risk assessment shall contain the following four components: a. Identify environmental hazards and individual risks, including the need for supervision. b. Evaluate and analyze hazards and risks. c. Implement interventions, including adequate supervision, consistent with a Resident 's needs, goals, plan of care and current standards of practice in order to reduce the risk of a fall d. Monitor for effectiveness of the interventions and modify the interventions as necessary in accordance with current standards of practice .An 'At risk for Fall' care plan may need to be created or updated for Residents upon admission/readmission to the facility, after a fall .to address items identified on the fall risk as needed .Resident with a BIMS [Brief Interview of Mental Status] score of 13 or greater may be educated on the use of the call light system and reminded to ask for assistance .intervention for consideration to reduce falls .related to the Residents individual fall risk factor and/or fall occurrence .routine rounding by staff .Placing a bedside mat on the floor next to the Resident's bed .Application of proper footwear .Refer to Residents to therapy department for screening .Assess and treat for pain as warranted . 2. Medical record review for Resident #11 revealed an admitted [DATE], with diagnoses of Chronic ulcer of left ankle, Peripheral Vascular Disease, Alzheimer's Disease, Paranoid Schizophrenia, Hypothyroidism, Anxiety, Obsessive Compulsive Disorder, Insomnia, Abnormality of Gait and history of Repeated falls and Seizures. Resident #11's care plan dated [DATE], documented .has a self-care deficit R/T [related to] ambulation, bathing, bed mobility, dressing, eating, hygiene, locomotion, and transfer with interventions effective date [DATE] .Remind [Resident #11] to call for assistance before ambulation. Walk in room/out of room with assistance/device as needed. Requires SBA [Standby Assist] of 1 staff member for transfer and mobility. Exhibited wandering behavior with intervention to redirect when wandering is observed .provide diversional activities .prompt activity attendance to keep resident occupied . problems .at risk for falls r/t [related to] abnormal posture and gait unstable balance with interventions . Review of the Minimum Data Set (MDS) dated [DATE] and [DATE], revealed Resident #11 had a BIMS score of 14, required extensive assistance with bed mobility, transfer, dressing, toilet use, personal hygiene with 1 person assist, surface-to surface transfer (transfer between bed and chair or wheelchair) was not steady, and was only able to stabilize with staff assistance. Review of Resident #11's Fall Risk assessment dated [DATE], documented a total score of 14 indicating moderate risk for falls. Review of the Physical Therapy (PT) Recertification Progress Note and Updated Therapy Plan beginning [DATE] revealed Resident #11, .lacks insight into condition and risk factors . Review of Resident #11's Fall Risk assessment dated [DATE], documented a total score of 15 indicating moderate risk for falls. Review of the Nurse's Event note for Resident #11 dated [DATE] at 11:15 AM, revealed .Location .courtyard .Unobserved .no apparent injury .unobserved .see clinical note . Review of the facility's Clinical Note dated [DATE], at 14:54 (2:54) revealed, . [Resident #11] was found in the courtyard wandering around when they [staff] got to her resident was lying on the ground red and warm to the touch . Review of the Occurrence Investigation Interview for Resident #11 dated [DATE] at 11:15 AM, revealed, .Fall .courtyard .CNA [certified nursing assistant] saw resident from window . What did the Resident say? Unable to determine .How was the Resident positioned when you observed them? .on bottom .At the time of the occurrence, Resident was/had: (Check all that apply) .confusion, impulsive, Wearing Appropriate Footwear . Review of the facility's undated Interdisciplinary Team Occurrence Investigation Worksheet (provided by the facility related to the [DATE] fall) revealed .The root cause of the occurrence is Inappropriate Footwear .Intervention(s) put in place: encourage resident not wear 'crocs' when going outside .Behaviors that may have contributed to the fall .contributing factors .Agitation . Restlessness .Impulsive behaviors .Physical Function problems that may have contributed to the fall .gait disturbance, muscle weakness and loss of balance .Review the environment for possible contributing factors .Alarm not sound on door [alarm was disabled] .Review factors related to the resident for possible contributing factors .pain and fatigue . Review of the revised care plan for Resident #11 with the revision date of [DATE] revealed, problems .at risk for falls r/t [related to] abnormal posture and gait unstable balance with interventions updated [DATE], Actual fall. no apparent injuries. Review of an undated WITNESS STATEMENT conducted via telephone interview by the facility with CNA #3 regarding Resident #11's [DATE] fall, revealed .Date Incident Occurred [DATE] [[DATE] is the date written, however, the incident occurred on [DATE]] .observed resident [Resident #11] sitting on her bottom .[CNA #3] and another CNA [CNA #4] went outside and assisted the resident back in . A facility telephone interview on [DATE], related to Resident #11's [DATE] fall revealed CNA #4 stated . was in room [ROOM NUMBER] assisting with tray set when she [CNA #4] observed [Resident #11] sitting on her bottom approximately 5 feet from the door to enter the facility from the courtyard .she and another CNA [CNA #3] went outside and assisted the resident back in the facility and notified the nurse who assisted the resident . Review of the facility's WITNESS STATEMENT from the Social Service Director dated [DATE], revealed, .A resident [random resident] asked if he could go outside for some fresh air .I borrowed the alarm key to the courtyard from the nurse .unlocked the door .assisted resident [random resident] back inside .he [random resident] was in a wheelchair .I failed to get the key back from a nurse that triggers the exit alarm . Review of the facility's Addendum Note Clinical Note dated [DATE] at 8:48 AM, revealed, .CNA [CNA #4] saw resident [Resident #11] from the window of another room [room [ROOM NUMBER]] and went to get the resident from the courtyard. When they [CNAs] got to [Resident #11] resident was sitting on the ground, red and warm to the touch . Review of a Physicians Clinical Note dated [DATE], revealed, .apparently patient [Resident #11] fell back on [DATE] while she was out in the courtyard. I was asked to see the patient for a neurological evaluation .she has a history of memory impairment and seizure disorder. She also has peripheral vascular disease, insomnia, schizophrenia, conduct disorder, Alzheimer type dementia .when I saw her today she was awake, alert and slightly slow to respond .needs help walking , does not use walker .Neurological .oriented to place but not time or person .Assessment . History of Memory Loss .dementia .seizure disorder . anxiety .Plan .appears to have memory impairment at least orientation to person and time .appears to be able to stand but need assistance . Review of the NURSE'S EVENT NOTE dated [DATE] at 4:30 AM, revealed .Location Incident Occurred .Patient Room .bathroom .Unobserved Fall .Injury .Abrasion .left side of forehead .called to room by CNA, resident noted laying in the floor of her bathroom on her stomach with head turned to right side. 3 staff to get res [Resident #11] up .had on non skid socks and shoes was trying to get to the toilet and lost balance was incont [incontinent] of urine .STEPS IMPLEMENTED TO PREVENT RECURRENCE .visual sign to use call light for assist to bathroom . Review of the OCCURRENCE INVESTIGATION INTERVIEW dated [DATE] at 4:30 AM, revealed .What did the Resident say happened .I don't know .How was Resident positioned when you observed them? .laying in floor on her stomach with head turned to the right .Other comments: .does not wait or call for assistance . Describe any noncompliance issues or impaired safety awareness of the Resident .getting up by herself w/out [without] assistance . Review of the undated INTERDISCIPLINARY TEAM OCCURRENCE INVESTIGATION WORKSHEET, for the [DATE] fall, revealed .The root cause of the occurrence is: Ambulating to restroom without assistance .Intervention(s) put in place .Visual cue placed in Resident room to call for assistance with toileting . Observations on [DATE] at 11:06 AM, revealed Resident #11 sitting in her room in a recliner chair with eyes closed, fully dressed in socks and croc shoes on her feet. A reddened area was observed above Resident #11's left eye, from a fall she had in the bathroom on [DATE]. During an interview on [DATE] at 4:00 PM the Social Worker Director (SSD) was asked about Resident #11 wandering outside to the courtyard unsupervised on [DATE]. The SSD stated, .it was on a Saturday [[DATE]] .I came in that day and I took another resident outside to the courtyard who was in a wheelchair just to get some fresh air .I unlocked the courtyard door [off the 400 hall] when I brought the resident back in, I cut the door alarm off, took the resident back to his room and was talking with other residents and I forgot to cut the alarm back on .I was in another resident room it was at least 15 min .I was coming down the hall and they were bringing Resident #11 back in from outside .No one else knew that the alarm was dislodged .No one knew she was out there and she was in the courtyard by herself. I forgot to turn the alarm back on and she had wandered outside, and no one knew it . The SSD stated .she [Resident #11] was sitting on her bottom when they found her .It was hot that day. This was reported to the state and was investigated .I felt so bad .I am so glad that they saw her .I felt bad because I forgot to turn that alarm back on .and it was so hot that day . The SSD was asked did she see anyone else in the courtyard when she was bringing another resident back inside the building. The SSD stated no. The SSD was asked if Resident #11 was allowed to go into the courtyard by herself. The SSD stated .no, she is never outside alone .someone is always with her .she loves to be outside .she is never outside in the courtyard by herself, the staff only takes her out because when she goes out she does not want to come back in and she would not let the staff know when she needed to come back in .she would have never been outside unattended because she has a lot of mental diagnoses and cognition not good .I forgot to cut the alarm back on .no one knew until she was found .it was my fault I forgot to engage the door alarm . During an interview on [DATE] at 4:30 PM, CNA #3 was asked about Resident #11 being found in the courtyard unsupervised. CNA #3 stated .I was passing a lunch tray to a resident in room [ROOM NUMBER], as I was placing the tray on the table, the blinds were open, and I noticed Resident #11 was outside in the courtyard sitting on the ground. I ran to get her yelling for assistance from CNA #4 . [Resident #11] was sitting on the ground .I remember it was really hot that day .she [Resident #11] was sweating a lot . CNA #3 was asked if she heard the door alarm sounding. CNA #3 stated .No I did not hear an alarm . CNA #3 was asked if Resident #11 was outside alone. CNA #3 stated .there was no one else outside with [Resident #11] .she was on the ground when I saw her through the window .it took 2 of us to get her up .it was so hot that day .she was anxious, red and flushed .I was not [Resident #11's] CNA that day but have worked with her and she does not go into the courtyard alone .she loves to be outside and we have a hard time bring her back in . CNA #3 was asked if she wrote a statement about Resident #11 being outside on the ground, unsupervised the day the incident occurred. CNA #3 stated .I was thinking I needed to write a statement, but no one asked me until ,d+[DATE] [[DATE]] that Monday [2 days later] I was called, and I gave statement over the phone . CNA #3 was asked if the Administrator came to the building after the incident to take her statement. CNA #3 stated .No .if she did, she did not talk to me I was not called or talk to till Monday . During a telephone interview on [DATE] at 4:00 PM, Licensed Practical Nurse (LPN) #5 was asked about Resident #11 being found in the courtyard on the ground and unsupervised. LPN #5 stated .Resident #11 was my assigned resident. It was my first shift working at the facility on ,d+[DATE] .I saw resident [Resident #11] going down the hall, she was a little unsteady .I asked if she was OK to be walking the halls and the CNA said yes .I was passing my medications when I heard the CNAs yelling that Resident #11 was outside lying on the ground. I don't know how she got outside .I heard that a resident wanted to water the flowers and when he came back in, they forgot to set the alarm back .I'm really not sure. I did not hear a door alarming at all . I did not see her [Resident #11] go out of the door and do not know how long she had been outside .I was called on Monday ,d+[DATE] [[DATE]] and asked if I could come in [to work] on ,d+[DATE] [[DATE]] .the Administrator wanted me to make corrections to the documentation that she [Resident #11] was found on her bottom and not lying on her back .I didn't know [Resident #11] had gone outside. I assisted the 2 CNAs bring her [Resident #11] back in and I took her vital signs and gave her some water at the desk . During a telephone interview on [DATE] at 4:19 PM, CNA #4 was asked about Resident #11 being in the courtyard unsupervised. CNA #4 stated .I was assigned to Resident #11 that day .I was giving a shower [to another resident]. It was close to time for the trays to come out. As I was coming out of the shower room I heard and saw CNA #3 running and shouting [Resident #11] was outside in the courtyard on the ground .I started running with her .it was hot outside .[Resident #11] was on the ground and we had to help her up and we got her inside and sat her at the nursing station for the nurse to check her out because she was flushed .[Resident #11] walks the hall and sits at the nursing station .I don't know who let her out, she does not go by outside by herself never .I did not hear the door alarms .no one knows for sure how long she was outside . During an interview on [DATE] at 5:56 PM, the Administrator was asked about Resident #11 being outside, unsupervised and being found on the ground. The Administrator stated, .the event notes and charting was not completed .I asked the nurse to come and make changes to the documentation .I came up to the facility that day of incident but did not get all the statements . The Administrator was asked what Resident #11 had stated happened. The Administrator stated, .[Resident #11] can recall some things and sometimes cannot tell what happened .[Resident #11] has psychosis, it depends on her mental status that day .[Resident #11] goes out to the courtyard with the Activity Director but [Resident #11] has been out there before by herself she likes the flowers . The Administrator was asked should Resident #11 have been in the courtyard unsupervised at any time. The Administrator stated No. During an interview on [DATE] at 9:51 AM, CNA #3 was asked if the Administrator had requested a demonstration of the incident of Resident #11 being found outside on the ground, unsupervised. CNA #3 stated No, the Administrator did not talk to me the day of the incident. I was called on [DATE]rd about a statement for this incident .I did not demonstrate how she was found to the Administrator . During an interview and observations on [DATE] at 2:55 PM, with Resident #11 and the Director of Nursing (DON) in Resident #11's room, the DON was asked where the visual cue reminder was to remind Resident #11 to use call light for assistance when toileting. The DON looked around the room, opened the bathroom door and a red sign was posted on the inside bathroom door that read, Prior to getting up from toilet Please use call light to call for assistance. Resident #11 was asked, would you know to read the sign on the inside of the door. Resident #11 did not answer. Resident #11 was asked, do you know how to use the call light when you have to use the bathroom? Resident #11 stated, .I don't know . Resident #11 was asked do you know what a call light is? Resident #11 stated .no, I don't know . Resident #11 was asked, did you hurt your head when you fell ? Resident #11 stated .I guess it's right here [pointing to left side of head 1-inch red spot noted above eyebrow] . Resident #11 could not demonstrate the use of the call light and was unable to confirm she knew to call the nurse for assistance when she needed to get up. The DON stated .I did not put the sign up .I wasn't aware it was on the inside of the door .the Administrator put it up . The DON stated .Resident #11 will go to the bathroom on her own and call us if she needs help . The DON was asked if the intervention was appropriate to have visual cues inside the bathroom door. The DON stated, .it's just to remind her to call us .I will put the sign on the outside of the door . During an interview on [DATE] at 9:18 AM, the Director of Rehab was asked about Resident #11's therapy evaluations. The Director of Rehab stated, .[Resident #11] has been on our case load because of treatments to a chronic ulcer to the left ankle .she receives treatment 3 times a week .requires verbal cueing to follow directions and tactile [grab under arm to guide]. I talked with [Resident #11] after the fall, and she did not remember .She needs supervision with ambulation when outside because of her gait .it is very unsteady .she shuffles when she walks and ambulates with very slow movement .[Resident #11] is very high risk for falls because of her gait . The Director of Rehab was asked about Resident #11 wearing crocs being the root cause of the fall on [DATE]. The Director of Rehab stated, .I don't think wearing the crocs shoes had anything to do with the fall being a root cause because [Resident #11] wears crocs everyday .inside or outside she is very unsteady with ambulation because of the shuffling of her feet and unsteady gait .she needs supervision . The Director of Rehab was asked should Resident #11 be outside ambulating unsupervised she stated .definitely not . During a telephone interview on [DATE] at 2:00 PM, the Medical Director stated, . [Resident #11] definitely has some mental impairments with her memory .her walking is very unstable .definitely should not have been outside unsupervised . During an interview on [DATE] at 4:00 PM, the Regional Nurse Consultant (RNC) was asked if Resident #11's fall interventions and root causes for falls on [DATE] and [DATE] were appropriate. The RNC stated .the interventions and root causes are discussed when a fall occurs .we should monitor and follow up to see if the interventions are effective .the root causes are determined when a fall occurs what caused the fall and should be discussed in the fall meetings .I am directing the staff to call me personally when there is a fall so we can implement the appropriate interventions .before now this was not being done and we have some work to do with our falls . The RNC confirmed the root cause .wearing crocs shoes when outside for Resident #11 should have been reevaluated and monitored due to Resident #11 was wearing croc shoes on the [DATE] fall in the bathroom and gait was unsteady. 3. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE], with diagnoses of Parkinson's Disease, Dementia, Anxiety, Hypothyroidism, and Depression. Review of the quarterly MDS dated [DATE], revealed Resident #14 had a BIMS score of 1, which indicated severe cognitive impairment, and required limited assistance from staff for ambulation. Review of the Care Plan dated [DATE], and revised on [DATE], revealed Resident #14 had .Dementia .Interventions .Shoes will have non-skid soles and fit well .Parkinson's .Interventions . Modify environment as needed .Provide rest periods as needed .Observe for lack of coordination .Self care deficit R/T [Related To] ambulation .Remind [Named Resident] to call for assistance before ambulation .At Risk For Falls .Offer to be placed in bed prior to becoming impulsive . Review of an Event Note dated [DATE], revealed Resident #14 had an observed fall on [DATE], sustained a laceration of the left eye, was transferred to the emergency room for evaluation and returned to the facility. The facility failed to conduct a Fall Risk Assessment after Resident #14's fall on [DATE], in accordance with facility policy. During an interview on [DATE] at 4:06 PM, LPN #1 confirmed he was at Nurse's Station #1 on [DATE], and observed Resident #14 walking back and forth down the 400 Hall, walking independently with no difficulty, until she lost her balance and fell , and hit her head and injured her left eye. LPN #1 was asked what his immediate intervention was after the fall. LPN #1 stated, .assessed the resident, completed a neuro check, and called the ambulance. During an interview on [DATE] at 9:52 AM, the Assistant Director of Nursing confirmed a Fall Risk Assessment was not completed after Resident #14's fall on [DATE], and should have been. 4. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE], with diagnoses of Dementia, Malnutrition, Depression, Anxiety, Compression Fracture Lumbar, and Obsessive-Compulsive Disorder. Review of the Clinical Notes Report dated [DATE] at 10:32 PM, revealed Resident was witnessed by this nurse grabbing hand rails on 100 hallway and sat down on the floor using the hand rail for assistance, this nurse asked if she needed any help and she stated yeah get me up from here so I helped her up and walked with her to her room where she laid down, resident did not hit head and denied any pain or discomfort at the time. Review of Resident #18's [DATE] Care Plan revealed, XXX[DATE] Actual Fall .No apparent injury; Intervention: Staff IN-Service to offer frequent rest periods when witnessing ambulation . Review of the Clinical Notes Report dated [DATE] at 4:59 PM, revealed Post fall wound assessment completed. Resident's cognition appears slowed from her baseline. Left side weakness with eyes appearing to not track with equally while following objects. Baseline ROM [range of motion] in BUE [bilateral upper extremities] and BLE [bilateral lower extremities] within resident baseline and no report of pain of [or] tenderness. No wounds noted related to fall. Charge nurse notified of above findings on assessment. Review of the Clinical Notes Report dated [DATE] at 5:01 PM, revealed Resident noted to be leaning while ambulating down hallway. Pain look in her face. Complaining of pain to wrist. Assisted to wheel chair brought to room and assisted to bed. Noted drooping to left side of face. Decreased grips and pedal to left side. Rom to right arm limited. Resident complaints of pain in shoulder, wrist and elbow. MD notified. Order received to obtain x-ray to right shoulder, wrist, and elbow . There was no documentation the Resident was administered any pain me [TRUNCATED]

Based on facility policy, Facility Assessment, employee training records, and interviews, the facility failed to develop, implement, and maintain an effective behavioral health training program for all staff (direct care staff, indirect care staff, contract staff and volunteers, as appropriate to their roles). The findings include: 1. Review of the facility's policy's titled, Behavioral Health Services dated 10/24/2022, revealed .To ensure that residents receive necessary behavioral health services .It is the policy of this facility that all residents receive care and services to assist him or her to reach and maintain the highest level of mental and psychosocial functioning .The facility shall consider .residents with mental disorders, psychosocial disorders, or substance use disorders .with a history of trauma and/or post-traumatic stress disorder .Facility staff shall receive education to ensure appropriate competencies and skills sets for meeting the behavioral health needs of residents .Education shall be on the .needs identified through the facility assessment . 2. Review of the Facility Assessment, dated 6/30/2023, revealed .Our Resident Profile .Diseases/conditions, physical and cognitive disabilities .Common diseases, conditions, physical and cognitive disabilities, or combinations of conditions that required complex medical care and management . Psychiatric/Mood Disorders .include . Schizophrenia, Schizoaffective Disorder, Bipolar Disorder .Staff training, education and competencies are necessary to provide the level and types of support and care needed for the resident population . Staff training/education topics .Behavioral Management .Caring for residents with mental and psychosocial disorders, as well as residents with a history of . post-traumatic stress disorder . 3. Review of the medical record revealed Resident #163 was admitted to the facility on [DATE] with diagnoses of Cirrhosis, Hypothyroidism, Diabetes Mellitus, and Anoxic Brain Damage. Review of the admission MDS dated [DATE] revealed Resident #163 had a BIMS score of 14, which indicated resident was cognitively intact. Review of a progress notes dated 3/6/2023, revealed .3/6/2023 .[named Resident #163] .was up in wheelchair propelling self into other residents' rooms .was informed .that she could not go into other residents' rooms and take their snacks .ignored staff .3/6/2023 .Resident #163 .was up in wheelchair propelling self into other residents' rooms .was informed .that she could not go into other residents' rooms and take their snacks .ignored staff and continued to go into other residents' rooms looking for food .This nurse asked, why are you going in people's rooms uninvited, and then stealing from them . she replied I don't know .Attempted to redirect/educate against this behavior. Staff then assisted her to bed to prevent further escalation of situation . Review of a progress notes dated 3/8/2023, revealed .up in wheelchair .propelled herself in and out of several patients rooms this shift .would start going through others personal belongings as well as helping herself to their food .One specific incident she entered the room of [Named Resident] while he was in his bathroom and began to eat cookies from his bedside table .breaking his cookies and knocking them on the floor .continued to attempt to enter others room . 4. During an interview on 8/14/2023 at 12:19 PM, the Director of Nursing (DON) was asked about Resident #163's behaviors. The DON stated, .she goes in the kitchen and eat condiments .she went into resident room .tried to get .snack . During a telephone interview on 8/14/23 at 12:49 PM, Registered Nurse (RN#1) was asked about Resident #163 behaviors. RN #1 stated, .was in wheelchair and would go into .had problems .spontaneous do things including taking thing out of resident room .she had been banned from several resident room .I redirected her .her attention span is so short .she would even roll up cafeteria .eat the coffee creamer .very impulsive probably the most impulsive person I took care of . During an interview on 08/17/23 02:01 PM, the Administrator confirmed the facility has not provided the staff with behavioral health training specific to/based on what has been identified in the Facility assessment. The facility was unable to provide proof of behavioral health training for all employees based on the facility assessment.

Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored and secured when 1 of 5 staff member (Licensed Practical Nurse (LPN #3)) left the medications unattended, when 2 of 5 staff members (LPN #4 and #LPN #7 ) left the medication cart and treatment cart unlocked and unattended, and when 2 of 7 medication storage areas (Station 2 Medication Room, and Station 2 medication Cart) had expired medications, open undated medications, had externals and internals stored together, and a medication was left at a resident's bedside. The findings include: 1. Review of the facility's policy titled Medication Administration: Medication, Controlled and Biological Storage . dated 9/20/2022, revealed .Eternal Products: Disinfectants and drugs for external use are stored separately from internal and injectable medications .Internal Products: Medications to be administered by mouth are stored separately from other formulation .Opening Medications: whenever a seal of a multidose vial is broken it must be initialed and dated by the Nurse with an open date and expiration date. These will expire 28 days after opening unless otherwise specified by the manufacturer . 2. Observation on 8/8/2023 at 8:33 AM, in Resident #113's room revealed the LPN #3 left the medications to administer via Percutaneous Endoscopic Gastrostomy (PEG) unattended, and out of sight of LPN #3 when she went to wash her hands in the bathroom leaving the medications on the over bed table in the resident's room. During an interview on 8/8/2023 at 5:34 PM, LPN #3 was asked should the medications be left unattended and out of sight of the nurse. LPN #3 stated No . 3. Observation on 8/8/2023 at 9:12 AM, revealed Resident #3 was seated upright in bed. There was a white liquid medication in a cup and a tea colored liquid, and a pill in a cup on her over the bed table. Resident #3 confirmed the medications in the cups were for constipation as she picked up each and swallowed them. Resident was asked do the nurses always leave your medications for you to take yourself. Resident #3 stated, .some nurses stay and some leave. 4. Observation on 8/10/2023 at 8:08 AM, revealed LPN #4 went into the room across from Resident #32's room to wash her hands. She left the Station 2 Medication Cart unlocked, unattended, and out of sight of the nurse. During an interview on 8/10/2023 at 8:10 AM, LPN #4 was asked should the medication cart have been left unattended and unlocked. LPN #4 stated Oh, I left it unlocked. 5. Observation at the 100 Hall on 8/11/2023 from 2:26 PM to 2:31 PM, revealed an unlocked wound care cart. LPN #7 walked out of room [ROOM NUMBER], confirmed the wound care cart should have been locked, and then locked the wound care cart. 6. Observation on 8/15/2023 at 8:55 AM, of the Station 2 medication cart revealed the following: One bottle of Acetaminophen 325 mg (milligrams) 100 tablets opened with no open date. Expiration date 1/26. Anti-Diarrheal Loperamide Hydrochloride 2 mg, one box with 7 left from 12 count, had no open date. Lidocaine Pain Relief Patch one box with 4 left from a 5 count had no open date. Ipratropium Bromide and Albuterol Sulfate Inhalation Solution 7 vials left out of a 30 count. Expiration date Aug (August) 24 with open date 3/30/2023. Albuterol Sulfate Inhalation Aerosol 90 mcg (micrograms) with open date 1/8/2023. Albuterol Sulfate Inhalation Aerosol HFA (Hydrofluoroalkane) open date 7/10/2023. Albuterol Sulfate Inhalation Aerosol HFA 9 mcg inhaler prescription date 8/1/2023 and no open date. During an interview on 8/15/2023 at 9:05 AM, Registered Nurse (RN) #2 confirmed the bottle of Acetaminophen, the box of Anti -Diarrheal Loperamide Hydrochloride, the box of Lidocaine Patch, and the Albuterol Sulfate Inhalation Inhaler had no all had no open dates. Then RN #2 confirmed the Albuterol Inhalation inhaler opened on 1/8/2023 and the inhaler opened on 7/10/2023 were expired. 7. Observation on 8/15/2023 at 8:24 AM, in the Station 2 Medication Room revealed a box of 16 packets with a COVID-19 A 9 test Lot # 191765 label and an Expiration date 2023-06-07. 8. Observation on 8/15/2023 at 8:24 AM, in Station 2 Medication Room revealed the following medications were stored on the same self of the two door metal cabinet: 6 boxes of saline Laxative enemas 4.5 Fl (fluid) oz (ounces). 6 boxes containing 12 count of Bisacodyl 10 mg Suppositories. 1 box of Bisacodyl Suppositories 10 mg 50 count with 35 left to count. 3 boxes of Acetaminophen Suppositories 650 mg with 50 count in a box. 3 bottles of Milk of Magnesia 16 FL oz (473 ml (milliliters). 2 bottles of Miconazorb Antifungal Power 2.5 oz (71 grams). 3 bottles of Magnesium Citrate 10 FL oz. 5 bottles of Polyethylene Glycol 3350 Powder for Oral Solution, Osmotic Laxative 17.9 oz. 3 bottles of Chest Congestion Relief 16 Fl oz. 3 tubes of Zinc Oxide Ointment 16 oz. 1 bottle of Siltussin (cough medication) 473 ml with an expiration date 7/23. During an interview on 8/15/2023 at 9:24 AM, RN #2 was asked should the external and internal medications be stored together. RN #2 stated, No. Then RN #2 was asked if the Siltussin was expired. RN #2 stated, The expiration date is 7/2023 this is 8/2023, so yes. 8. During an interview on 8/16/2023 at 5:40 PM, the Director of Nursing (DON) was asked should the medication or treatment cart be left unlocked when the nurse is not present. No, ma'am. The DON was asked should the medications be left unattended and out of sight of the nurse. The DON stated, Never. The DON was asked should external and internal medications be stored together. The DON stated, No ma'am.

Based on facility policy review, Certified Nursing Assistant (CNA) Assignment Sheets, Nursing Home Licensing Checklist, facility time punches, the facility working schedule, and interview, the facility failed to ensure Daily Assignment Sheets were completed for 18 of 18 (1/2/2023, 1/9/2023, 1/13/2023, 2/10/2023, 2/14/2023, 2/15/2023, 3/4/2023, 3/5/2023, 3/14/2023, 3/21/2025, 3/25/2023, 3/31/2023, 4/2/2023, 4/8/2023, 4/14/2023, 5/11/2023, 7/1/2023, and 7/29/2023) days and sufficient staff were scheduled for 2 of 218 (3/23/2023 and 4/2/2023) days reviewed. The findings include: 1. Review of the facility policy titled, Nursing Services and Sufficient Staff, dated 10/24/2022, revealed .The facility shall supply services by sufficient numbers of each of the following personnel types on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans .licensed nurses .other nursing personnel, including but not limited to nurse aides .To meet the needs of patients or residents with dementia, at a minimum, the organization plans nurse staffing (RN [Registered Nurse], LPN [Licensed Practical Nurse], CNA [Certified Nursing Assistant]) based on the following .personal care needs .varying cognitive levels of the patient or resident population served .The level of supervision needed to maintain patient or resident safety .The facility is responsible for submitting timely and accurate staffing data through CME [Centers for Medicare and Medicaid] Payroll-Based Journal (PBJ) system . 2. Review of the CNA ASSIGNMENT SHEETS only contained a name and a date on 1/2/2023, 1/9/2023, 1/13/2023, 2/10/2023, 2/14/2023, 2/15/2023, 3/4/2023, 3/5/2023, 3/14/2023, 3/21/202, 3/25/2023, 3/31/2023, 4/2/2023, 4/8/2023, 4/14/2023, 5/11/2023, 7/1/2023, and 7/29/2023. 3. Review of the NURSING HOME LICENSING CHECKLIST dated 3/23/2023, revealed the facility had a census of 56. Review of the untitled facility working schedule dated 3/23/2023, revealed there were only 2 LPNs and 2 CNAs scheduled for the 6:00 PM to 6:00 AM shift. Review of the facility Work Summary Report, dated 3/23/2023, revealed only 2 LPNs and 2 CNAs worked the 6:00 PM to 6:00 AM shift. 1. Review of the NURSING HOME LICENSING CHECKLIST dated 4/2/2023, revealed the facility had a census of 55. Review of the untitled facility working schedule dated 4/2/2023, revealed only 2 LPNs and 2 CNAs scheduled for the 6:00 PM to 6:00 AM shift. Review of the facility Work Summary Report, dated 4/2/2023, revealed only 2 LPNs and 2 CNAs worked the 6:00 PM to 6:00 AM shift. 5. During an interview on 8/16/2023 at 3:27 PM, CNA #1 confirmed that she worked the 6:00 PM to 6:00 AM shift on 4/2/2023. CNA #1 was asked how many CNAs worked that night. CNA #1 stated, Two. CNA #1 was asked how many CNAs were scheduled for the night shift on 4/2/2023. CNA #1 stated, I don't know .we don't know. CNA #1 was asked was it typical for them to work with only 2 CNAs on the 6:00 PM to 6:00 AM shift. CNA #1 stated, Oh, no ma'am, normally 4 [CNAs] on nights . During an interview on 8/16/2023 at 3:34 PM, LPN #1 confirmed that he was the Staffing Coordinator, made the weekly schedules, and completed the daily staff postings. LPN #1 was asked how he determined how many CNAs to schedule. LPN #1 stated, .8 to 12 [residents per CNA] from 6 [6:00 AM] to 2 [2:00 PM], 12 to 15 [residents per CNA] from 2 [2:00 PM] to 10 [10:00 PM] or 15 to 20 [residents per CNA from 10:00 PM to 6:00 AM]. LPN #1 was asked were there nights when only 2 CNAs were scheduled to work. LPN #1 stated, Back when I was on night shift and our census was a lot lower .upper 30's, lower 40's [census] .don't know how long ago that was . LPN #1 confirmed that he worked nights until a couple of months ago. LPN #1 was asked if the facility had a census of 55 on night shift should there only be 2 CNAs staffed. LPN #1 stated, The bare minimum we would want for the first part [2:00 PM to 10:00 PM], 4 CNAs in the building for evening shift. After 10 o'clock [PM] we would want 3 [CNAs] and those are bare minimum numbers. LPN #1 was asked so what would you say if there was a census of 55 and only 2 CNAs schedule. LPN #1 stated, Management should come in. LPN #1 was asked if management did not come in would that be considered short staffed. LPN #1 stated, For 55 [census] it would be. During an interview on 8/17/2023 at 10:47 AM, revealed the ADON was asked the process for staffing assignment sheets. The ADON stated, Typically the charge nurse makes the assignments and tells them what room numbers they have and what their assignments for the day will be. The ADON was asked about the assignment sheet dated 3/21/2023 with a staff name present but the remainder of the sheet blank. The ADON stated, This is one sheet we had to go back and see who was scheduled. We didn't have an assignment sheet for that day, so we tried to give you a picture of who was assigned that day. The ADON was asked were the assignment sheets missing for all of the days which were blank except for a name and a date. The ADON stated, Yes ma'am. The ADON was asked what the CNAs did with the sheets after they received them from the charge nurse. The ADON stated, .put their I's [intake] and O's [output], what showers they have given .turns and dried .catheter .everything .to know that was pertinent to my shift. The ADON confirmed the CNAs were supposed to turn in the assignment sheets to their charge nurse, who turned them in to the Risk Manager, where they were filed and stored. The ADON confirmed they had missing assignment sheets back as far as January. The ADON was asked if the missing assignment sheet identified as an issue. The ADON stated, Yes ma'am .last night .weren't aware that this was happening to the extent it was .wasn't aware that we had to make sure we keep them, 100 percent .on the audits until last night .talking to our techs [CNAs] and charge nurses . The ADON was asked if the assignment sheets were not filled out how does the facility know which residents were assigned to which CNAs. The ADON stated, That's the reason we put room numbers on the papers .because we have no way to tell . The ADON was asked should the assignment sheets be filled out completely and kept on file. The ADON stated, Yes ma'am. During an interview on 8/17/2023 at 2:01 PM, the Administrator was asked about the staffing formula LPN #1 provided the surveyor. The Administrator stated, It's always been told to me that was best practice .he's a very new staffing coordinator. The Administrator was asked if LPN #1 was given the staffing formula as a best practice. The Administrator stated, It's just a guide for him to go by because census fluctuates. The Administrator was asked would it be safe to only have 2 CNAs and 2 nurses for a census of 55. The Administrator stated, I would have to look. The Administrator would not confirm or deny that 2 CNAs and 2 LPNs would be sufficient staff for a census of 55 residents.

Based on policy review, observation, and interview, the facility failed to ensure practices that prevent the potential spread of infection were maintained when 2 of 5 nurses (Licensed Practical Nurse (LPN #3, and #4) failed to clean reusable equipment before and after use, and when 1 of 3 staff Certified Nurse Assistant (CNA #7) failed to wear proper Personal Protective Equipment when entering the room of a resident positive for Covid-19. The findings include: 1. Review of the facility's policy titled Infection Prevention and Control Program, dated 10/24/2022, revealed .Equipment Protocol. All reusable items and requiring special cleaning or disinfection shall be cleaned in accordance with our current procedures governing the cleaning and disinfection of soiled or contaminated equipment .Reusable items potentially contaminated .The reusable equipment shall be decontaminated using a germicidal detergent prior to storing for reuse . Review of the facility's policy titled, Covid-19 Prevention, Response, and Reporting, dated 3/5/2020 and revised 5/12/2023, revealed .To provide guidance and prevent the spread of COVID-19 .The facility shall ensure that appropriate interventions are implemented .respond promptly .to identify, treat, and prevent the spread of the virus .who enters the room of a resident with suspected or confirmed SARS CoV-2 infection shall adhere to transmission based precautions and use a .with N95 filters or higher, gown, gloves, and eye protection . 2. Observation on 8/8/2023 at 8:27 AM, during medication administration for Resident #113, revealed LPN #3 did not clean the stethoscope before or after using the stethoscope to check placement while administering medications via the resident's Percutaneous Endoscopic Gastrostomy (PEG). During an interview on 8/8/2023 at 5:34 PM, LPN #3 was asked should the stethoscope have been cleaned before using it on Resident #113. LPN #3 stated, It should, I did not . 3. Observation on 8/10/2023 at 8:04 AM, in Resident #32's room, revealed LPN #4 did not clean the stethoscope or the blood pressure cuff before or after using the equipment on Resident #32. LPN #4 placed the stethoscope around her neck on entering and leaving the room. Then she placed the blood pressure cuff around the sharps box on the medication cart when done administering medications. LPN #4 failed to clean the stethoscope or the blood pressure cuff. During an interview on 8/16/2023 at 5:38 PM, the Director of Nursing (DON) was asked should the stethoscope and blood pressure cuff being cleaned and when should it be cleaned. The DON stated, Of course, before using on a resident and after, hopefully. 4. Review of the facilities Covid-19 SARS-Cov_2 Test results dated 8/14/2023 revealed Resident #57 tested positive. Review of Clinical Note dated 8/14/2023, revealed Resident #57 .presented with fever, body aches, chills .Covid test .Positive results noted . Observation at the 100 Hall on 8/15/2023 at 10:25 AM, revealed Certified Nurse Assistant (CNA#7) entered Resident #57's room without goggles, glasses, or a face shield on. During an interview on 8/14/2023 at 4:22 PM, the Administrator confirmed Resident #57 tested positive for Covid-19 on 8/14/2023. During an interview on 8/15/2023 at 10:35 AM, the Assistant Director of Nursing (ADON) was asked should staff who enter the room of a resident who is positive for Covid-19 wear a face shield or goggles. The ADON stated, Yes. The ADON confirmed the isolation cart, outside of Resident #57's room, was not stocked with any goggles or shields for staff to wear and should be stocked and readily available for use.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure a physician's order for a urinary catheter and failed to ensure appropriate diagnoses for the indwelling urinary catheter for 1 of 2 residents (Resident #214) sampled residents reviewed with urinary catheters. The findings include: Review of the facility's titled policy Promoting/Maintaining Resident Dignity Policy, dated 10/24/2022, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life .Maintain resident privacy . 2. Review of the medical record revealed Resident #214 was admitted to the facility on [DATE], with diagnoses of Femur Fracture, Atrial Fibrillation, Pulmonary Hypertension, Chronic Obstructive Pulmonary Disease, and Diabetes. Review of the Care Plan dated 8/2/2023, revealed At risk for infection R/T [related to] indwelling catheter .Catheter .Change catheter/bag per MD [Medical Doctor] order as needed . Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #214 had a Brief Interview for Mental Status (BIMS) of 8, which indicated moderate cognitive impairment. Further review revealed Resident #18 required extensive assistance to total dependence for activities of daily living (ADLs) and had an indwelling urinary catheter. Review of the Physician's Order Sheet dated August 2023 revealed there was not a physician's order for the use of an indwelling urinary catheter. Review of the medical record revealed Resident #214 did not have a diagnosis to justify the use of the indwelling urinary catheter. Observation on 8/7/2023 at 11:22 AM, revealed Resident #214 was sitting in the chair at bedside, the indwelling urinary catheter bag was on the left side of bed, visible from door with no privacy bag cover. Observation on 8/8/2023 at 10:55 AM, revealed the urinary catheter bag was hanging on the bed rail, was visible from the door, and was not covered with a privacy bag cover. Observation on 8/8/2023 at 10:52 AM, revealed Resident #214 was sitting in the chair at bedside, the urinary catheter bag was hanging on the bed rail, was visible from the door, was not covered with a privacy bag, and yellow urine was visible. During an interview on 8/14/2023 at 12:15 PM, the Director of Nursing (DON) was asked should a resident's catheter bag be visible from the door and not covered. The DON stated, No . you know that. During an interview on 8/16/2023 at 5:39 PM, the DON was asked if they had an appropriate diagnosis to justify the use of the urinary catheter for Resident #214. The DON stated, No ma'am, I do not. The DON was asked if there was a physician's order for the use of the urinary catheter. I don't see an order for that catheter either.

Based on policy review, medical record review, observation, and interview, the facility failed to assess 1 of 5 residents (Resident #32) reviewed for self-administration of medication. The findings include: Review of the facility's policy titled Self-Administration of Medication, dated 1/1/2023, revealed To provide guidance on self-administration of medication by the resident .A resident who desires to self-administer medication may be permitted to do so if the resident is assessed, using the Assessment for Self-Administration of Medication tool and deemed competent to self-administer medications safely as determined by the interdisciplinary team .If the resident is deemed competent to self-administer medications, per the Assessment of Self Administration, the physician must authorize self-administration by giving an order . Review of the medical record revealed Resident #32 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Encephalopathy, Osteoarthritis, Cerebral Brain Infarction, Congestive Heart Failure, and Sepsis. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #32 had a Brief Interview for Mental Status (BIMS) of 10, which indicated moderate cognitive impairment. Review of the quarterly MDS dated [DATE], revealed Resident #32 had a BIMS of 14, which indicated cognitively intact. Review of the Physician Order Sheet July 2023, revealed .fluticasone furoate 100 mcg [micrograms]-vilanterol 25 mcg/dose inhalation powder (1 puff) BLISTER, WITH INHALATION DEVICE Inhalation .1 puff daily in morning . Observation of medication administration on 8/10/2023 at 8:04 AM, revealed Licensed Practical Nurse (LPN #4) handed Resident #32 the inhaler and he administered 2 puffs. LPN #4 did not instruct Resident #32 to rinse out his mouth after the corticosteroid inhaler treatment. The physician order was for 1 puff daily, not 2 puffs that resident #32 administered to themselves. Review of Resident #32's comprehensive Care Plan dated 5/22/2023, did not include documentation of a plan for self-administration of medications. Review of the facility's undated form ASSESSMENT FOR SELF-ADMINISTRATION OF MEDICATIONS, revealed it was blank and had no medication listed that Resident #32 could self-administer. During an interview on 8/16/2023 at 5:39 PM, the Director of Nursing (DON) was asked should Resident #32 be allowed to self-administer his medications. The DON stated, No, this one [assessment for medication self-administration form] for [named Resident #32] is blank it would not be useful .

Based on policy review, observation, and interview, the facility failed to provide effective housekeeping to maintain a sanitary environment for 1 of 32 (Resident #213) resident bathrooms observed. The findings include: Review of the facility's policy, titled Housekeeping-Cleaning and Disinfecting, with a revision date of 5/15/2023 revealed, .Surfaces that are frequently touched . require more frequent cleaning. Specific areas include .bathrooms .Clean the entire toilet .rim . Observations in Resident #213's bathroom on 8/7/2023 at 11:13 AM and on 8/8/2023 at 7:45 AM, revealed the resident's bathroom had urine in toilet, a dark brown ring around the liquid inside the toilet, the toilet seat was raised and a dark brown round spot that was approximately dime-nickel size was on the left side of the bowl. Observations on 8/8/2023 at 10:50 AM, 12:14 PM, and 5:12 PM, revealed Resident #213's bathroom had a dark brown ring around the liquid inside the toilet, the toilet seat was raised, a dark brown round spot that was approximately dime-nickel size was on the left side of the bowl, and a brown smear that was approximately 2 inches long was on the inside down the front of the toilet bowl. Observation on 8/9/2023 at 8:07 AM, revealed Resident #213's bathroom had a dark brown ring around the liquid inside the toilet, the toilet seat was raised, a dark brown round spot that was approximately dime-nickel size was on the left side of the bowl, and a brown smear that was approximately 2 inches long was on the inside down the front of the toilet bowl. During an interview on 8/7/2023 at 2:14 PM, Resident #213 was asked if the bathroom had been cleaned resident stated, It [bathroom] needs cleaning. It hasn't been cleaned since I got here last Wednesday [8/2/2023]. During an interview on 8/8/2023 at 7:50 AM, the Administrator confirmed there should not be stains in the toilet. During an interview on 8/8/2023 at 5:12 PM, Resident #213 was asked if they had cleaned the toilet yet. Resident #213 stated, No. During an interview on 8/9/2023 at 8:27 AM, the Administrator was asked if they are having trouble with housekeeping. The Administrator stated, Had some turnover .hiring is just an issue . The Administrator was shown Resident #213's bathroom and confirmed the toilet still was not clean.

Based on review of facility policy, medical record review, facility investigations and interview, the facility failed to report the results of abuse allegation investigation outcomes within 5 working days of the alleged violation for 3 of 3 residents (Residents #11, #48, and #51) sampled for abuse allegation investigations. The findings include: 1. Review of the facility policy Abuse Prohibition Plan revision date of 10/24/22 showed .Notification of law enforcement and/or the State Agency .within the appropriate time frames .REPORTING IN ACCORDANCE WITH THE ELDER JUSTICE ACT .Each covered individual .shall report, or cause a report to be made, to the State Agency and one or more law enforcement entities .The local Police Department is the law enforcement entity for the political subdivision of this facility .The Administrator shall report results of all investigations to the State Agency, within (5 ) five working days of the allegation 2. Medical record review for Resident #11 documented an admitted [DATE], with diagnoses of Chronic ulcer of left ankle, Peripheral Vascular Disease, Alzheimer's Disease, Paranoid Schizophrenia, Hypothyroidism, Anxiety, Obsessive Compulsive Disorder, Insomnia, Abnormality of Gait and history of Repeated falls and Seizures. Review of quarterly MDS dated [DATE], revealed Resident #11 had a Brief Interview Mental Status Minimum (BIMS) score of 12 indicating cognitive impairment, required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #11 had a BIMS score of 14 indicating no cognitive impairment, required extensive assistance with bed mobility, transfer, dressing, toilet use and personal hygiene. 3. Medical record review for Resident #48 documented an admitted [DATE], with diagnoses of End Stage Renal Disease, Type 2 Diabetes Mellitus, Bipolar Disorder, Generalized Anxiety, Major Depression, Dependence on Renal Dialysis, Unsteadiness on Feet. Review of the MDS assessment dated [DATE] revealed Resident #49 had a BIMS score of 10, indicating moderate cognitive impairment. Further review revealed Resident #48 required extensive assistance with bed mobility, dressing, toilet use and personal hygiene and limited assistance with transfer walking and eating in room. 4. Medical record review for Resident # 51 revealed an admitted [DATE], with diagnoses of Chronic Kidney Disease, Hypertensive Crisis Heart Failure, Encephalopathy, Dysarthria and Anarthria cerebral Infarction, Depression, Anxiety, Anemia, History of cocaine use. Review of the reentry MDS dated [DATE], revealed a BIMS score of 11 indicating cognitive impairment with disorganized thinking, required supervision with ADL's bed mobility, transfer, eating, toilet use and personal hygiene with setup and 1 persona assist. Further review revealed Resident #51 used a wheelchair for mobility. 5. Review of the self-reported facility investigation dated 4/4/2023 6:00 AM, revealed a resident to resident abuse incident that was witnessed by staff. Resident #48 and Resident #51 were engaging in a verbal altercation in the hall by the dining room. Staff observed Resident #51 hit Resident #48 in the chest with a closed fist. Both were separated without further incident and assessed with no injuries noted. The residents reside on different hallways. Both residents were referred to psych for medication review. The incident was substantiated. The investigation did not contain documentation of the outcome findings and reported to the State Agency within 5 working days of the alleged violation. The incident was not reported to Police Department. 6. Review of the facility investigation dated 4/23/2023 at 3:45 PM, revealed an unwitnessed by staff, resident to resident abuse incident. Resident #11 was sitting at the dining table with another female resident. The female resident siting with Resident #11 was heard yelling that a man was hitting Resident #11. The female resident sitting with resident #11 was the only resident who was present for the incident. Resident #11 had a small red mark on her cheek. Both residents were interviewed and unable to identify the alleged perpetrator. The facility reviewed the endomorphic of it census in an attempt to identify an alleged perpetrator which may have been Resident #51 Resident #51 was not cooperative or able to participate in interview. The incident was unsubstantiated due to lack of evidence. The investigation did not contain documentation of the outcome findings and reported to the State Agency within 5 working days of the alleged violation. The incident was not reported to the Police Department. 7. Review of the self-reported an incident facility investigation dated 7/4/2023 9:45 AM, revealed a resident to resident allegation incident. Resident #48 was observed to be sitting on the floor in the dining room. The nurse asked the resident what happened and how did he fell . Resident #48 told the nurse that Resident #51 hit him on the head and pointed to top of his head, with redness noted to top of Resident #48's head. Resident #48 complained of discomfort to his right wrist and was sent to the emergency room for evaluation. The alleged perpetrator, Resident #51, was seen leaving the dining room in his wheelchair with a cup of coffee in his hand. Resident #51 was sent to emergency room for evaluation of hypertensive crisis due to not taking blood pressure medication and aggression. The Administrator interviewed both residents involved in the alleged incident, neither of which were able to tell what occurred. A kitchen staff member stated heard a noise in the dining room but did not actually see what happened. There were no witnesses to the incident. The incident was unsubstantiated due to lack of evidence and both residents were unable to provide creditable statements. The investigation did not contain documentation of the outcome findings and reported to the State Agency within 5 working days of the alleged violation. 8. During an interview on 8/17/2023 at 3:25 PM, the Administrator confirmed the outcome of the facility's investigations were not reported to the State Incident Reporting System within 5 working days of the alleged violation. The Administrator stated, .I'm responsible for reporting allegations of abuse .and completing the report in the reporting system. I was not aware that I did not report the outcome of the investigation . The Administrator confirmed the alleged violations involving resident abuse were not reported to law enforcement stating, I was not aware that I had to since there were no injuries .

Based on review of the Emergency Medical System Computer Aided Dispatch incident report, hospital records, policy review, medical record review, observation, and interview, the facility failed to ensure a safe environment and provide supervision to prevent an incident of elopement for 1 of 7 sampled residents (Resident #1) reviewed for elopement and wandering behaviors, which resulted in Immediate Jeopardy (IJ) when cognitive residents (Resident #1, #8, and #9) knew the door codes and when Resident #1, a vulnerable resident with decreased safety awareness, exited the building in his wheelchair through a facility door and was found at a local convenience store, 2.6 miles from the facility. The facility was unaware of Resident #1's location for 4 hours and 19 minutes. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Regional Director of Operations, Regional Nurse Manager/Regional Compliance Director, Administrator, and Interim Director of Nursing (DON) were notified of the Immediate Jeopardy on 10/15/2020 at 11:47 AM, in the Day Room. The facility was cited Immediate Jeopardy at F-689. The facility was cited F-689 at a scope and severity of J, which is Substandard Quality of Care. The IJ was effective 9/28/2020 through 10/18/2020. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 10/17/2020 at 10:30 AM, and was validated onsite by the surveyors on 10/17/2020 through 10/19/2020 by policy review, medical record review, observation, review of education records, auditing tools, and staff and resident interviews. The findings include: Review of the facility's policy titled, Elopements and Wandering Patients, revised 11/2017, showed, .This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents .'Elopement' occurs when a resident leaves the premises or a safe area without authorization ( .an order for [REDACTED].including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks .Adequate supervision will be provided to help prevent accidents or elopements . Review of the facility's policy titled, Accidents and Supervision, revised 3/2020, showed, .each resident receives adequate supervision .to prevent accidents .Identifying hazard(s) and risk(s) .All staff .are to be involved in observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident . Review of the facility's policy titled, Emergency Preparedness, revised 11/2019, showed, .Elopement (Code Green) .Tips for Prevention of Elopements .React to statements such as 'I want to go home' . Review of the medical record, showed Resident #1 was admitted to the facility on [DATE], was readmitted on [DATE] from the Geri-Psychiatric Hospital, and was discharged to the hospital on [DATE] due to an Urinary Tract Infection [MEDICAL CONDITION]. Resident #1 had [DIAGNOSES REDACTED]. Review of a Physical Therapy .Evaluation and Plan of Treatment, dated 1/6/2020, showed, .Reason for Referral .increased ms (muscle strength) weakness .fall risk, impaired safety awareness . Review of a Physical Therapy Treatment Encounter Note, dated 1/10/2020, showed, .Precautions/Contraindications .Fall risk, safety awareness, cognition . Review of a Clinical Note Report dated 1/27/2020, showed, .Social Worker was approached by the resident .stating that he was tired of being here and he was leaving .explained to resident that we are working on goals .stated that he did not care .explained to the resident that there is not a safe place for him to discharge .stated that he did not care . Review of a Clinical Note Report dated 3/13/2020, showed, .CNA (Certified Nursing Assistant) reported to this nurse that he had to escort resident (Resident #1) inside from smoke shack r/t (related/to) it thundering and lightening outside .Resident stated that he is 'tired of this whore house' and this is 'bullshit I have to come inside' .staff has noticed resident to be spending more time outside . Review of a Psychotherapy Progress Note dated 3/19/2020, showed, .due to finding out that he would not be able to return to independent living and will be here long term .he did have a short episode where he really wanted to leave this week . Review of a Progress Note dated 4/15/2020, showed, .(Named Resident #1) is more anxious today than in previous visits. He is upset because he wants to go home . There was no documentation after this date of Resident #1 stating he wanted to leave. Review of the quarterly Minimum Data Set ((MDS) dated [DATE], showed, Resident #1 was cognitively intact, was not coded for wandering behaviors, was assessed with [REDACTED]. The resident required supervision for all activities of daily living (ADLs), and used a wheelchair for mobility. Review of a Physical Therapy .Recert (recertification), Progress Report & (and) Updated Therapy Plan, dated 9/15/2020, showed Resident #1's barriers to impact a discharge to the next level of care was an exacerbation of cognitive impairment. Review of an Elopement Risk assessment dated [DATE], showed Resident #1 was not identified as being at a high risk for elopement. Review of a Psychiatric Evaluation dated 9/28/2020, showed, .He (Resident #1) admits to being anxious about being in the nursing home .says he wants to find a different facility or house but his family has been unable to help him .Judgement .Fair . Review of Resident #1's Care Plan dated 12/11/2019 and revised 9/28/2020, showed, .(Named Resident #1) has Highly Impaired Ability to Hear .Self care deficit R/T (related/to) .mobility .locomotion .Assist (Named Resident #1) as needed to desired location in/out of facility with wheelchair .as needed . Review of a Clinical Note Report dated 9/29/2020, showed, .this nurse (Licensed Practical Nurse (LPN) #7) was notified by other nurse (LPN #4) and CNA (Certified Nursing Assistant #1) that res (Resident #1) was not able to be found at 11 pm (11:00 PM) .building was searched inside and out, across. the street and down the road. DON was notified at that time and in rout (route) to facility .res (resident) was last seen by this nurse at 9 pm (9:00 PM) when administering his meds (medications) .did not have any complaints to voice at that time .was his normal self .social services arrived and police dept (department) was notified .was called at 0120 (1:20 AM) by police dept (department) and told res (Resident #1) was found and was being taken to ER (emergency room ) to be evaluated .returned to facility at 0238 (2:38 AM) via (by way of ) ambulance . Review of the Emergency Medical System Computer Aided Dispatch incident report, showed dispatch received a missing person call from the facility on 9/29/2020 at 12:13 AM, Police Officers were dispatched to the facility at 12:14 AM and a description of Resident #1 was provided to the Police Officers. The officers were advised the last contact with the resident was at 9:00 PM. The Police Officers began their search for the resident at 12:19 AM and they found the resident at 1:19 AM, at a local convenience store. Emergency Medical Services took him to the local emergency room at 1:25 AM. Review of a (Named Hospital) Emergency Physician Record dated 9/29/2020, showed, .'eloped' from NH (Nursing Home) .Pt (patient) missing from (Named Nursing Home) since 2100 (9:00 PM) tonight .found in wheelchair (symbol for approximately) 2 miles down the road .states he just had to get away .was tired of being at facility .needed to get out .rolled in wheelchair all the way to (Named convenience store where Resident #1 was found) .missing for < (less than) 5 hrs (hours) .Regrets the decision .States he memorized the code to get out door . Resident #1's temperature was recorded as 97.7 degrees Fahrenheit. Review of Resident #1's Care Plan last revised 9/29/2020 showed, .(Named Resident #1) exited from facility .Sent to inpatient Psych (Psychiatric Hospital) .Redirect if wandering develops .Prompt activity attendance to keep resident occupied .placed in a room close to nurses station upon re-admission due to impulsiveness and exiting behavior . Review of a Clinical Note Report dated 9/29/2020, showed, .(Named Hospital) has accepted resident for IP (inpatient) Psych (Psychiatric) admit (admission) . Review of a Geri-Psychiatric Hospitalist Admission History and Physical dated 9/29/2020, showed, .Patient has underlying dementia and depression with poor insight .was admitted to senior care for further behavioral management and medication adjustment . Resident #1 was readmitted to the facility on [DATE] from the Geri-Psychiatric Hospital. Review of a Clinical Note Report dated 10/7/2020, showed, .upon return from (Named Hospital) resident refused to all the staff to take him to his room on the quarantine hall .Resident stated that if he did not get to smoke right then he would take off (leave the facility) . Observation in the resident's room on 10/8/2020 at 2:34 PM, 10/9/2020 at 1:33 PM, 10/10/2020 at 11:59 AM, 10/11/2020 at 7:00 PM, 10/12/2020 at 10:19 AM, 10/13/2020 at 11:05 AM, and 10/14/2020 at 10:12 AM, showed Resident #1 remained in his room on the quarantine hall. Resident #1 was transferred to the hospital on [DATE] due to a UTI. During an interview on 10/8/2020 at 12:00 PM, CNA #3 stated, .I have seen him (Resident #1) open the door before .he knew the code .most likely he had overheard it .I was on the other side of the door trying to get in .opened it for me . CNA #3 stated, .I feel like I reported it to my charge nurse . CNA #3 stated, .do not remember the nurse I reported the incident to because it was several months back . CNA #3 confirmed that she had been employed in the facility since January 2020 and the door codes had not been changed during her employment, until 9/28/2020. CNA #3 also confirmed that all the door codes had been changed after 9/28/2020 with the exception of the exit door on the 200/300 Long Hall which was the door Resident #1 exited. During an observation and interview on 10/8/2020 at 12:14 PM, LPN #2 entered the code to the exit door on the 200/300 Long Hall. LPN #2 confirmed that there was approximately a 10 to 15 second interval before the alarm audibly sounded after the code was entered. The door that Resident #1 exited had approximately a 15 second delay before the alarm sounded after the code was entered into the door. During an interview on 10/8/2020 at 12:29 PM, Resident #1 confirmed that he left the faciity on [DATE]. Resident #1 stated, .Been in here a year and 10 months and I just had to get out for a little bit . Resident #1 stated, I know every code in this place with the exception of the front door .it ain't (isn't) hard to learn, you watch them people (staff) when they punch in the numbers and there you are .it's easy as pie to learn them . Resident #1 confirmed that he was in his wheelchair and the alarm sounded when he left the facility. The resident stated, .You wouldn't believe where I went there's a hill I went off of that's like that (held his arm out straight and pointed his hand straight down) .at night with no flashlight, no street light .but I had a moon lit night .When I got to the bottom of that hill .went off to the left and there was a minute mart kind of store .I went over and got me a pack of cigarettes and a (Named [MEDICATION NAME] beverage) then I went .through (Named town) .went to (Named Convenience Store) .it was about 1:30 (AM on 9/29/2020) and they didn't open up until about 4:00 (AM) .but to be honest with you I was really cold .didn't think about taking a jacket with me . Resident #1 stated, I told (Named Social Services Director)'s boss (the former Administrator) that's not here anymore (was employed at the facility from 9/2019-5/2020) .I was wanting out of here so bad and if I found an open door I was going to take it . During a telephone interview on 10/8/2020 at 3:26 PM, CNA #1 stated, .I've been telling people for the longest that they need to change the codes .I'm pretty positive every resident in this building knows the password (door code) .Everybody who brings them outside uses it (the door code) .no one is really careful .I don't know how they are surprised (Resident #1 eloped) . CNA #1 confirmed he was not surprised Resident #1 got out of the facility. CNA #1 confirmed that he had worked in the facility for several years and stated, I can't remember the last time it (door code) was changed . During an interview on 10/8/2020 at 4:54 PM, the Social Services Director confirmed she called local law enforcement when Resident #1 was unable to be located on the night of 9/28/2020 and provided them with a picture and demographics, searched his room, and found his wallet was missing. The Social Services Director stated, .(Named Resident #1) punched in the code and wheeled himself out the door .about a 15 second delay (on the alarm) .he's a smart man . The Social Services Director stated, .He (Resident #1) told me he knew the code and that he went down (Named road near the facility) .wheeled himself all the way .went to (Named gas station/convenience store #1) .he bought cigarettes and a (Named [MEDICATION NAME] beverage) .took a roll downtown and ended up at (Named local shopping center) .then to (Named gas station/convenience store #2) . During an interview on 10/8/2020 at 6:48 PM, LPN #1 confirmed she was aware that residents knew the door codes. LPN #1 further stated, .I did know there was one (resident that knew the code) .she spoke up and said what the code was .it's been a little while ago and I really don't remember which resident it was .was during a smoke break time .that could be how she knew the code . LPN #1 confirmed he did not notify Administration that a resident knew the code. Observation on 10/9/2020 at 11:06 AM, of the route Resident #1 took when he exited the facility on 9/28/2020, showed, Resident #1 exited the 200/300 Long Hall exit door in his non-motorized wheelchair, propelled himself along the sidewalk beside the facility to the parking lot, exited the facility parking lot and entered a heavily traveled State Highway. The resident turned onto a curvy back road which ended with a very steep descent into an intersection with a drop off and railroad tracks immediately past the road. The resident turned left at this intersection, traveled to the next intersection with a traffic light, turned right, and crossed the railroad tracks. He traveled through the next intersection with a traffic light and crossed a heavily traveled 4 lane State Highway to a local convenience store, where he bought cigarettes and a [MEDICATION NAME] beverage. The resident turned left out of the convenience store parking lot and traveled through the downtown area to a local shopping center. He then traveled through 2 intersections with traffic lights, crossed the heavily traveled 4 lane State Highway at another location and was located in the parking lot of a different convenience store, which was closed at the time. The distance Resident #1 traveled in his wheelchair was 2.6 miles. During an interview on 10/9/2020 at 11:13 AM, the owner of a local convenience store #1, confirmed that he worked the evening of 9/28/2020, and around 9:30 PM, a man (Resident #1) was sitting in his wheelchair in front of his store. The owner's brother-in-law confirmed that Resident #1 purchased cigarettes from him. The Owner stated, .he rolled to the left toward downtown .was a little bit chilly and his hands were doing this (indicated shaking with his hand) . The owner of the store stated Resident #1 was dressed in a t-shirt, pants, and shoes, and was not wearing a jacket. During an interview on 10/9/2020 at 4:17 PM, a local Police Officer #1 stated, We received the call at approximately midnight .facility had last seen him (Resident #1) at approximately 9 (PM) .gave us a Face Sheet with a picture, clothing description .looked around outside the facility .across the road .was about 40 degrees outside .my partner finally crossed (Named State Highway) and went to (Named local convenience store #2) .didn't think he would be there because we didn't think he would cross that road .he (Resident #1) stated he wanted a sausage and biscuit .waiting for them to open because he knew he couldn't make it back up that hill .he was cold to the touch .called EMS (Emergency Medical Services) and they took him to the hospital . During an interview on 10/10/2020 at 10:50 AM, LPN #5 stated, .I've watched the smokers sit up there and watch them put in the codes .I watched (Named LPN #6) go to the door today and one of the residents hollered the code down the hall to her .(Named Resident #8) . During an interview on 10/10/2020 at 11:14 AM, LPN #6 confirmed that Resident #8 yelled the door code down the hall to her earlier that day. Medical record review of Resident #8's annual MDS dated [DATE], showed a Brief Interview for Mental Status (BIMS) of 13, indicating he was cognitively intact. During an interview on 10/10/2020 at 2:15 PM, Resident #8 stated that he knew the exit door code. The resident stated, .Memorized it .known it for years . The resident confirmed the exit door code had not been changed in a long time. During an interview on 10/12/2020 at 11:42 AM, the Regional Director of Operations stated, We follow our policy .search .contact law enforcement .expand from there .We don't consider (Named Resident #1) an elopement because of his situation and mental capacity .he is not at risk for wandering and exit-seeking .his ability to take care of himself . The Regional Director of Operations confirmed staff did not know the location of Resident #1 for the 4 hours and 19 minutes he was missing and it was the facility's responsibility to make sure residents are safe. The Regional Director of Operations confirmed that Administration should be notified by staff if residents were aware of the door codes. The Regional Director of Operations stated, .someone with exit-seeking (behaviors) .they don't need to know the codes .but the codes are not completely off-limits to the residents if they are able to go out and have supervision . The Regional Director of Operations was asked about why the door code had not been changed on the door that Resident #1 exited. He stated, We've got a call in with (Named Security Supplier) but because of the system age they (Named Security Supplier) can't get it changed .we just placed a physical magnetic alarm on there (door) . During a telephone interview on 10/12/2020 at 2:21 PM, the former Administrator confirmed that Resident #1 told her that he would go out of the building if he could find an open door. The Former Administrator stated, .he (Resident #1) said he would wheel himself down the square and live homeless .that was an ongoing theme with him, back and forth .really depended on his mood of the day . During a telephone interview on 10/13/2020 at 1:50 PM, the Medical Director confirmed he was aware Resident #1 left the facility and was found downtown and 2.6 miles away from the facility. The Medical Director confirmed that he was not aware that residents knew the exit door codes. The Medical Director stated, .that shouldn't happen . The Medical Director confirmed that it was primarily the facility staff's responsibility to abide by rules and regulations to make sure the residents were safe. During a telephone interview on 10/13/2020 4:33 PM, Resident #1's Physician stated, .I was told the story .apparently he (Resident #1) learned the number on the codes .very sly .something I would expect of him . When told that the facility considered the resident to be cognitively intact, Resident #1's Physician stated, .not surprised that he would do something sneaky because he's like a kid .kids do sneaky things .He's probably the only resident who knows the code . When informed that other residents knew the door code, Resident #1's Physician stated, You know .would have been a great idea to change the door code frequently . During a telephone interview on 10/13/2020 at 6:37 PM, the Family Nurse Practitioner-Certified (FNPC) confirmed that he saw Resident #1 on 9/28/2020, the day he exited the facility. The FNPC stated, .(on 9/28/2020) he (Resident #1) said that he was anxious about being in the Nursing Home and missing his family .he said he wants to find a different facility or house .I did not see any indication that he would do that .we talked about increasing his medications but he didn't want to . During an interview on 10/13/2020 at 7:03 PM, LPN #7 confirmed she was Resident #1's nurse the night he exited the facility. LPN #7 stated, I gave him his medicine around 9 o'clock (9:00 PM) .was his normal self .he does on occasion say that he wants to get out of here but he's never tried to get out of here .at 11:00 PM they came to me and said he was missing .started checking the building, the closets, under the beds .when we couldn't find him inside, we went outside and started looking .I was sick at my stomach .searched across the street .in the ditches .in the woods .all around the building .that's when I called (Named Administrator) . LPN #7 confirmed that it was not safe for Resident #1 be outside of the facility. Medical record review of Resident #9's quarterly MDS dated [DATE], showed a BIMS of 12, indicating moderate cognitive impairment. During an interview conducted on 10/14/2020 at 10:19 AM, Resident #9 stated that she knew the code to the 200/300 Hall door. Resident #9 confirmed that she watched staff members put in the code. During an interview on 10/15/2020 at 11:22 AM, the Administrator, Interim DON, Regional Nurse Manager/Regional Compliance Officer, and the Regional Director of Operations confirmed that staff should be aware when residents leave the building. The Regional Director of Operations confirmed that there was not an assessment for Resident #1 to safely leave the facility without staff being aware. The Administrator confirmed that staff should make Administration aware if they know that residents know the exit door codes. During an interview on 10/15/2020 at 4:00 PM, the Vice President of Operations and Vice President of Clinical Services confirmed that they had determined Resident #1's exit from the facility was not an elopement. The Vice President of Operations stated, I think he has the right to make that trip .his decision .an independent human being . The Vice President of Operations stated, .that may not be the best decision .but that is a safe town . The Vice President of Clinical Services stated, He is allowed to go outside, and he's allowed to use the code. During an interview on 10/16/2020 at 2:34 PM, the Rehabilitation (Rehab) Manager confirmed that a wheelchair safety assessment was performed on 1/6/2020. The Rehab Manager stated, .assessed on evaluation .noted him independent .felt like he was safe within the confines of the facility .on a tile floor with no uneven surfaces . The Rehab Manager confirmed she would be concerned about the safety of Resident #1 on the roads, up and down hills, and crossing railroad tracks independently. The Rehab Manager confirmed Resident #1 was not assessed to safely leave the facility without staff being aware. The Rehab Manager confirmed that Resident #1's safety awareness and cognition were areas of concern. The Rehab Manager stated, .we had educated him repeatedly not to do certain things and he would do them anyway .he doesn't always make the best choices . The surveyors verified the Removal Plan by: 1. On 9/29/2020, the MDS Coordinator completed an Elopement Risk Assessment on Resident #1. Resident #1's Care Plan was revised with new interventions implemented for unplanned leave of absence (LOA) without notifying staff (elopement). Resident #1 was assessed by the Social Worker and found to have no psychosocial harm resulting from this event (elopement on 9/28/2020). Resident #1 was educated by the Social Worker on safety precautions taken to prevent unplanned LOA/personal outing without notifying staff (elopement). The surveyors reviewed Resident #1's Elopement Risk Assessment, Care Plan, and interviewed cognitive residents and staff members about the LOA procedure. 2. On 10/9/2020, cognitive/alert residents were educated on proper LOA/outing procedure. The surveyors interviewed cognitive residents and staff members about the LOA procedure. 3. On 9/30/2020 and 10/2/2020, 5 of 6 door codes were changed by the Regional Maintenance Supervisor and (Named Security Supplier). An additional magnetic alarm was placed on the door in which the resident exited the facility on 9/28/2020 until the code was able to be changed on 10/9/2020. The surveyors interviewed the Maintenance Supervisor and made observations of the all the doors. 4. On 10/13/2020, stop signs, alerting residents to notify the nurse prior to leaving facility, were placed on all facility exit doors. Signs were placed at all exit door keypads as a reminder to residents and an indication that keypads are for staff use only. The surveyors made observations of all the doors and the stop signs. 5. On 9/30/2020 and 10/15/2020, all doors were checked for the proper functioning of the alarms by the Regional Maintenance Supervisor. The surveyors made observations of all the doors, reviewed the in-services, the logbook, and interviewed staff on all shifts. 6. On 10/9/2020, Elopement Risk Assessments were reviewed on 100% of the residents by the Nurse Managers. Residents identified as high risk for elopement had interventions in place. All residents have been reassessed and Care Plans reviewed and revised as needed. The Interdisciplinary Team (IDT) will review all new admissions for Elopement Risk Assessment and Care Plans in morning Quality Assurance (QA) meeting. The surveyors reviewed the Care Plans and Elopement Risk Assessments and interviewed IDT members. 7. On 10/14/2020 and 10/15/2020, the Regional Director of Operations educated facility Administration and Nurse Managers on ensuring patient safety through monitoring elopement risks/concerns daily in QA meeting. Administration and Nurse Managers were in-serviced on the Accidents and Supervision Policy and Elopements and Wandering Patients Policy. The surveyors reviewed the in-services and sign in sheets conducted with Administration. 8. On 10/14/2020, on duty personnel were educated by the Administrator and Nurse Managers. The education included Occurrence (Incident) Reporting which included the Elopement and Wandering Patients Policy and Procedures. On duty personnel were educated on protecting door codes from being obtained by unauthorized personnel on 10/3/2020, 10/6/2020, and 10/15/2020. Off duty personnel will be educated prior to their return to work. The surveyors interviewed staff members on all shifts and reviewed the in-service and sign-in sheets. 9. All newly hired personnel will be educated during orientation on Occurrence (Incident) Reporting to include the Elopement and Wandering Patient Policy and Procedures. Newly hired personnel will be educated on protecting door codes from being obtained by unauthorized personnel. The surveyors interviewed staff members on all shifts and reviewed the in-service and sign in sheets. 10. On 10/15/2020, the Medical Director was notified by the Administrator of the Immediate Jeopardy. The Regional Director of Operations and Administrator spoke with the Medical Director via telephone on 10/16/2020 to discuss the Removal Plan of the Immediate Jeopardy and the interventions for Resident #1. The surveyors reviewed the minutes of the interview conducted with the Medical Director. 11. On 10/16/2020, Quality Assurance Performance Improvement (QAPI) Committee which included the Administrator, Interim DON, and Assistant Director of Nursing (ADON) met to review and discuss specifics of the Removal Plan of Immediate Jeopardy to prevent elopement and ensure resident safety. The surveyors reviewed the QAPI minutes. 12. Nursing staff will perform every shift checks daily to ensure the proper functioning of the magnetic alarm placed on the 200/300 Hall exit door until the keypad/alarm system has been updated. The surveyors interviewed the staff on all shifts regarding the process for checking the doors and the documentation of the process. Noncompliance at F-689 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, Emergency Medical System Computer Aided Dispatch incident report review, hospital records, medical record review, and interview, the facility failed to report an allegation of elopement to the State Survey Agency, within 24 hours of the event for 1 of 7 sampled residents (Resident #1) reviewed for wandering behaviors and elopement. The facility's failure to report an allegation of elopement to the State Survey Agency resulted in Immediate Jeopardy when Resident #1, a vulnerable resident with decreased safety awareness, exited the facility through a side door in his non-motorized wheelchair, and was found unsupervised in the parking lot of a local convenience store 2.6 miles from the facility. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Regional Director of Operations, Regional Nurse Manager/Regional Compliance Director, Administrator, and Interim Director of Nursing were notified of the Immediate Jeopardy on 10/15/2020 at 11:47 AM, in the Day Room. The facility was cited Immediate Jeopardy at F-609. The facility was cited F-609 at a scope and severity of J, which is Substandard Quality of Care. The IJ was effective from 9/28/2020 through 10/18/2020. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 10/17/2020 at 10:30 AM, and was validated onsite by the surveyors 10/17/2020 - 10/19/2020 through review of assessments, policies related to incident reporting, elopement, and behavior monitoring, in-service training records, auditing tools, observations, and interviews. The findings include: Review of the facility's policy titled, Elopements and Wandering Patients, revised 11/2017, showed, .'Elopement' .occurs when a resident leaves the premises or a safe area without authorization ( .an order for [REDACTED]. Review of the facility's policy titled, Abuse Prohibition Plan, revised 5/2019, showed, .EXTERNAL REPORTING .REPORTING IN ACCORDANCE WITH FEDERAL REGULATIONS FOR LONG TERM CARE FACILITIES .Reports to the State Agency will be made electronically by use of the state electronic reporting system .24 HOUR TIME LIMIT All alleged violations that do not involve abuse and did not result in serious bodily injury will be reported no later than 24 hours after the allegation is made . Review of the medical record, showed Resident #1 was admitted to the facility on [DATE], was readmitted on [DATE] from the Geri-Psychiatric hospital, and was discharged to the hospital on [DATE] due to a Urinary Tract Infection. Resident #1 had [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE], showed, Resident #1 was cognitively intact, was not coded for wandering behaviors, was assessed with [REDACTED]. Review of the Clinical Notes Report dated 9/29/2020 at 4:47 AM, showed that Resident #1 was last seen by a nurse on 9/28/2020 at 9:00 PM. At 11:00 PM, Certified Nursing Assistant (CNA) # 1 was unable to locate Resident #1. The building was searched, the street and road in front of the facility was searched. The DON and the Social Worker arrived. The police were notified and the facility was notified at 1:20 AM that Resident #1 was found by the police. Resident #1 was then taken to the emergency room , and returned to the facility on [DATE] at 2:38 AM with no injuries. Review of the Emergency Medical System Computer Aided Dispatch incident report, showed dispatch received a missing person call from the facility on 9/29/2020 at 12:13 AM, Police Officers were dispatched to the facility at 12:14 AM and a description of Resident #1 was provided to the Police Officers. The officers were advised the last contact with the resident was at 9:00 PM. The Police Officers began their search for Resident #1 at 12:19 AM and they found the resident at 1:19 AM, at a local convenience store. Emergency Medical Services took him to the local emergency room at 1:25 AM. Review of a (Named Hospital) Emergency Physician Record dated 9/29/2020, showed, .'eloped' from NH (Nursing Home) .Pt (patient) missing from (Named Nursing Home) since 2100 (9:00 PM) tonight .found in wheelchair (symbol for approximately) 2 miles down the road .states he just had to get away .was tired of being at facility .needed to get out .rolled in wheelchair all the way to (Named convenience store where Resident #1 was found) .missing for < (less than) 5 hrs (hours) .Regrets the decision .States he memorized the code to get out door . During an interview on 10/8/2020 at 10:30 AM, the Administrator confirmed that she had not reported any incidents to the State Survey Agency, including the elopement of Resident #1 on 9/28/2020. During an interview on 10/12/2020 at 11:42 AM, the Regional Director of Operations confirmed that the State Agency was not notified of Resident #1's elopement on 9/28/2020. During a telephone interview on 10/13/2020 at 1:50 PM, the Medical Director stated he did know the regulations but if reporting elopement incidents was a requirement, then the facility should have reported the elopement of Resident #1. The surveyors verified the Removal Plan by: 1. On 9/29/2020, Resident #1's Care Plan was revised with new interventions implemented for unplanned Leave of Absence (LOA) without notifying staff (elopement). Resident #1 was assessed by the Social Worker on 9/29/2020 and found to have no psychosocial harm resulting from the elopement. Resident #1 was educated by the Social Worker on safety precautions taken to prevent unplanned LOA/personal outings without notifying staff (elopement). The surveyors reviewed Resident #1's Care Plan, assessment by the Social Worker, and education by the Social Worker. 2. On 10/9/2020, cognitive/alert residents were educated on proper LOA/outing procedure. The surveyors interviewed cognitive residents and staff members about the LOA procedure. 3. On 10/16/2020, the Regional Director of Operations and Regional Nurse Manager/Regional Compliance Director educated the facility Administration and Nurse Managers on Post Occurrence (Incident) Management and the Occurrence (Incident) Reporting Policy including reporting requirements to the appropriate agency(s). The surveyors reviewed the in-service conducted with Administration and interviewed Administration. 4. On 10/14/2020, on duty personnel were educated by the Administrator and Nurse Managers on Occurrence (Incident) Reporting to include the Elopement and Wandering Patient policy and procedures. All off duty personnel will be educated upon return to work. The surveyors interviewed staff members on all shifts and reviewed the in-service handouts and sign-in sheets. 5. All newly hired personnel will be educated during orientation on Occurrence (Incident) Reporting to include the Elopement and Wandering Patient policy and procedures starting on 10/14/2020. The surveyors interviewed staff members on all shifts and reviewed the in-service and sign-in sheets. 6. On 10/15/2020, the Medical Director was notified by the Administrator of the Immediate Jeopardy. The Regional Director of Operations and Administrator spoke with the Medical Director via telephone on 10/16/2020 to discuss the Removal Plan of the Immediate Jeopardy and the interventions for Resident #1. The surveyors reviewed the minutes of the interview with the Medical Director. 7. On 10/16/2020, Quality Assurance Performance Improvement (QAPI) Committee (including Administrator, Interim Director of Nursing, and Assistant Director of Nursing) met to review and discuss specifics of Removal Plan. The surveyors reviewed the QAPI minutes. 8. Nurse Managers (to include Interim Director of Nursing, Assistant Director of Nursing, Medical Records Nurse, and MDS Coordinator) will audit completion of staff education on Occurrence (Incident) Reporting to include Elopement and Wandering Patient policy and procedures, Elopement Risk Assessments completed with Care Plans on new admissions reviewed by IDT team, and monitoring of nurse event notes for reportable events to ensure appropriate reporting procedures are followed. Audits will be completed daily for 7 days, weekly for 3 weeks, monthly for 2 months, and quarterly ongoing. The findings of the audits will be reported to the QAPI Committee which consists of the Administrator, Medical Director, Interim Director of Nursing, Assistant Director of Nursing, Medical Records Nurse, MDS Coordinator, Social Services, Activities, Dietary Supervisor, Maintenance Supervisor, Business Office Coordinator, and Infection Preventionist, and the audits will continue until substantial compliance is met. The surveyors confirmed the audits reviewed the audit sheets interviewed Nurse Managers. Noncompliance at F-609 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on the Board of Examiners of Nursing Home Administrators (BENHA) form review, job description review, medical record review, observation, and interview, the facility Administration failed to manage and provide oversight to ensure a safe environment, and failed to report an incident of resident elopement to the State Survey Agency. Administration failed to provide a safe environment for 1 of 7 sampled residents (Resident #1) reviewed for elopement and wandering behaviors. Resident #1, a vulnerable resident with decreased safety awareness, exited the facility and was found unsupervised in the parking lot of a local convenience store, 2.6 miles from the facility. This elopement resulted in Immediate Jeopardy for Resident #1. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Nursing Home Regional Director of Operations, Regional Nurse Manager/Regional Compliance Director, Administrator, and Interim Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 10/15/2020 at 11:47 AM, in the Day Room. The facility was cited Immediate Jeopardy at F-609, F-689 and F-835. The facility was cited F-609 and F-689 at a scope and severity of J, which is Substandard Quality of Care. The IJ was effective from 9/28/2020 through 10/18/2020. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 10/17/2020 at 10:30 AM, and was validated onsite by the surveyors on 10/17/2020 through 10/19/2020 through review of assessments, policies related to incident reporting, elopement, behavior monitoring, in-service training records, auditing tools, observations, and interviews. The findings include: Review of the facility's BENHA form revealed the facility had employed 2 Administrators and 2 interim Administrators since the last annual survey conducted on 9/12/2019. Review of the facility's Administrator Job Description revised 9/21/2020, showed, .The Administrator is responsible for establishing and directing the facility's overall day-to-day operations, both internal and external, and coordinate and maintain compliance to maximize high standards of care to patients .Meet with personnel as required and scheduled to assist in identifying and correcting issues, and/or the improvement of services .Assist in compliance efforts regarding state and/or federal requirements .monitor procedures to ensure compliance with state and federal guidelines .Attend and participate in orientation programs, on-going training .educational classes . Review of the facility's undated Director of Nursing job description showed, .The purpose of this position is to manage the nursing department and administer the nursing programs in compliance with state and federal regulations .ESSENTIAL FUNCTIONS: Plan .develop, organize, implement, evaluate and direct the Nursing Services Department .in compliance with rules and regulations governing long term care facilities .Recognize and respond to changes in residents' conditions and document observations, interventions and outcomes .Participate in various committees of the facility; care plans .quality assessment and assurance .QAPI (quality assurance performance improvement) . Review of the medical record, showed Resident #1 was admitted to the facility on [DATE], was readmitted on [DATE] from the Geri-Psychiatric Hospital, and was discharged to the hospital on [DATE] due to an Urinary Tract Infection [MEDICAL CONDITION]. Resident #1 had [DIAGNOSES REDACTED]. Review of a Clinical Note Report dated 1/27/2020, showed, .Social Worker was approached by the resident .stating that he was tired of being here and he was leaving .explained to resident that we are working on goals .stated that he did not care .explained to the resident that there is not a safe place for him to discharge .stated he did not care . Review of a Psychotherapy Progress Note dated 3/19/2020, showed, .due to finding out that he would not be able to return to independent living and will be here long term .he did have a short episode where he really wanted to leave this week . Review of the quarterly Minimum Data Set ((MDS) dated [DATE], showed, Resident #1 was cognitively intact, was not coded for wandering behaviors, was assessed with [REDACTED]. The resident required supervision for all activities of daily living (ADLs), and used a wheelchair for mobility. Review of a Clinical Note Report dated 9/29/2020, showed, .this nurse (Licensed Practical Nurse (LPN) #7) was notified by other nurse (LPN #4) and CNA (Certified Nursing Assistant #1) that res (Resident #1) was not able to be found at 11 pm (11:00 PM) .building was searched inside and out, across. the street and down the road. DON was notified at that time and in rout (route) to facility .res (resident) was last seen by this nurse at 9 pm (9:00 PM) when administering his meds (medications) .did not have any complaints to voice at that time .was his normal self .social services arrived and police dept (department) was notified .was called at 0120 (1:20 AM) by police dept (department) and told res (Resident #1) was found and was being taken to ER (emergency room ) to be evaluated .returned to facility at 0238 (2:38 AM) via (by way of ) ambulance . Review of the ER records dated 9/29/2020, showed Resident #1 did not have injuries and his vital signs were normal. During a telephone interview on 10/8/2020 at 3:26 PM, CNA #1 stated, I've been telling people for the longest .ever since we've been using that side door (the door Resident #1 exited) .these codes need to be changed .it's just been brushed off .I've told the Administrator .we've had so many Administrators . CNA #1 confirmed that he told a previous Administrator this also. During an interview on 10/8/2020 at 4:54 PM, the Social Services Director was asked when the door code was last changed. The Social Services Director stated, I couldn't give you a definitive answer on that .the challenge we have with our smokers .they're very attune, so when you're putting in the code they are able to watch . During an interview on 10/10/2020 at 11:14 AM, LPN #6 confirmed that Resident #8 yelled the door code down the hall to her earlier that day. Medical record review of Resident #8's annual MDS dated [DATE], showed a Brief Interview for Mental Status (BIMS) of 13, indicating he was cognitively intact. During an interview on 10/10/2020 at 2:15 PM, Resident #8 stated that he knew the exit door code. The resident stated, .Memorized it .known it for years . The resident confirmed the exit door code had not been changed in a long time. During an interview on 10/12/2020 at 11:16 AM, Licensed Practical Nurse (LPN) # 9 stated, I was the ADON (Assistant Director of Nursing) but stepped down October 1st (2020) . LPN #9 was asked if she was aware that any residents knew the exit door codes. LPN #9 stated, I can remember one .our little patient (Named Resident #9) .she's always really good about learning the code . LPN #9 stated, I made (Named the Maintenance Man) aware and he called Regional Maintenance to find out how to change the codes .was probably sometime last year .he and I stayed late trying to change that code and could never get it changed . LPN #9 confirmed that the former Administrator was made aware that a resident knew the exit door code. During an interview on 10/12/2020 at 11:42 AM, the Regional Director of Operations confirmed that Resident #1's exit from the facility was not reported to the State Survey Agency because the facility did not consider the incident an elopement. The Regional Director of Operations confirmed that the Vice President of Operations, Vice President of Clinical Services, Regional Nurse Manager/Regional Compliance Officer, Administrator, Interim DON, and himself made that determination. The Regional Director of Operations was asked about the 200/300 Long Hall exit door code that could not be changed. The Regional Director of Operations stated, We've got a call in with (Named Security Supplier) but because of the system age they (Named Security Supplier) can't get it changed .we just placed a physical magnetic alarm on there (door) . During an interview on 10/13/2020 at 5:24 PM, the Social Services Director stated, .He (Resident #1) has said if I could walk out of here I would . During an interview on 10/15/2020 at 11:22 AM, the Administrator was asked who is ultimately responsible for monitoring and supervising residents. The Administrator stated, .we use a team approach . Administration failed to immediately report an allegation of elopement to the State Survey Agency. Refer to F-609. Administration failed to provide oversight to ensure a safe environment and adequate supervision to prevent a vulnerable resident with decreased safety awareness from exiting the facility. Refer to F-689. The surveyors verified the Removal Plan by: 1. On 9/29/2020, Resident #1 was assessed in the local hospital ER with no injuries noted. The surveyors reviewed the ER records. 2. On 9/29/2020, the MDS Coordinator completed Resident #1's Elopement Risk Assessment. The surveyors reviewed the Elopement Risk Assessment. 3. On 9/29/2020, Resident #1's Care Plan was revised with new interventions implemented for unplanned Leave of Absence (LOA) without notifying staff (elopement). Resident #1 was assessed by the Social Worker on 9/29/2020 and found to have no psychosocial harm resulting from the event (elopement). Resident #1 was educated by the Social Worker on safety precautions taken to prevent unplanned LOA/personal outings without notifying staff (elopement). The surveyors reviewed Resident #1's Care Plan, assessment by the Social Worker, and education by the Social Worker. 4. On 9/30/2020 and 10/2/2020, 5 of 6 door codes were changed by the Regional Maintenance Supervisor and (Named Security Supplier). On 10/9/2020, an additional magnetic alarm was placed on the door in which the code was unable to be changed. On 10/13/2020, stop signs, alerting residents to notify the nurse prior to leaving the facility, were placed on all facility exit doors. On 10/13/2020 signs were placed at all exit door keypads, as a reminder to residents that keypads are for staff use only. All doors were checked for proper functioning of alarms by the Regional Maintenance Supervisor on 9/30/2020 and 10/15/2020. The surveyors made observations of all the doors, the Maintenance logbook, and interviewed staff on all shifts. 5. On 10/9/2020, cognitive/alert and oriented residents were educated on proper LOA/personal outing procedure. Elopement Risk Assessments were reviewed on 100% of the residents by the Nurse Managers. Residents identified as high risk for elopement had interventions implemented. All residents have been reassessed, Care Plans were reviewed and revised as needed. The Interdisciplinary Team (IDT) will review all new admissions for Elopement Risk Assessment and Care Plans in the morning Quality Assurance (QA) meeting. The surveyors interviewed cognitive residents and staff about the leave of absence procedure, reviewed the facility's Elopement Risk Assessments and Care Plans, and interviewed IDT members. 6. On 10/16/2020, the Regional Director of Operations and Regional Nurse Manager educated facility Administration and Nurse Managers on the Post Occurrence (Incident) Investigations and Occurrence (Incident) Reporting Policy which included the reporting requirements to the appropriate agency(s). The surveyors reviewed the in-service conducted with Administration and Nurse Managers, interviewed the Nurse Managers. 7. Administration will provide oversight and training of staff on Occurrence (Incident) Reporting, Accidents and Supervision, Elopement and Wandering Patients policies and procedures. The Regional Director of Operations and Regional Nurse Manager will monitor Administration by reviewing the reports and results of the audits, any concerns identified, and the corrective actions taken. The surveyors interviewed Administration. 8. On 10/14/2020, on duty personnel were educated by the Administrator and Nurse Managers on Occurrence (Incident) Reporting which will include the Elopement and Wandering Patients Policy and Procedures. All off duty personnel will be educated upon return to work. The surveyors interviewed staff members on all shifts and reviewed the in-service sign-in sheets. 9. All newly hired personnel will be educated during orientation on Occurrence (Incident) Reporting which will include the Elopement and Wandering Patients Policy and procedures. The surveyors interviewed staff members on all shifts and reviewed the in-service sign-in sheets. 10. On 10/15/2020, the Medical Director was notified by the Administrator of the Immediate Jeopardy. The Regional Director of Operations and Administrator spoke with the Medical Director via telephone on 10/16/2020 to discuss the Removal Plan. The surveyors reviewed minutes of the interview conducted with the Medical Director. 11. On 10/16/2020, the Quality Assurance Performance Improvement (QAPI) Committee which included the Administrator, Interim DON, and ADON met to review and discuss the specifics of the Removal Plan of the Immediate Jeopardy to prevent elopement and ensure resident safety. The surveyors reviewed the QAPI minutes. 12. Administration which includes the Administrator, Interim DON, and ADON will provide supervision and oversight for staff and vulnerable residents by monitoring the audits of the every shift alarm checks to ensure proper functioning of the magnetic alarm placed on the 200/300 Hall exit door until the keypad/alarm system has been updated, completion of staff education on Occurrence (Incident) Reporting to include Elopement and Wandering Patient Policy and Procedures, Elopement Risk Assessments completed with Care Plans on new admissions reviewed by the Interdisciplinary Team (IDT) and monitoring of nurse event notes for reportable events to ensure appropriate reporting procedures are followed. Audits will be completed daily for 7 days, weekly for 3 weeks, monthly for 2 months, and quarterly ongoing. The Regional Director of Operations and Regional Nurse Manager/Regional Compliance Officer will monitor Administration by reviewing reports of audit findings, concerns identified, and corrective actions taken weekly x 3 months. The findings of the audits will be reported to the QAPI Committee which consists of the Administrator, Medical Director, Interim DON, ADON, Medical Records Nurse, MDS Coordinator, Social Services, Activities, Dietary Supervisor, Maintenance Supervisor, Business Office Coordinator, and the Infection Preventionist. If compliance is not met, staff will be re-educated, and the audits will continue until substantial compliance is met. The surveyors reviewed the audit tool and interviewed management staff for compliance. Noncompliance at F-835 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on review of the "National Pressure Advisory Panel (NPUAP) Pressure Ulcer Prevention QUICK REFERENCE GUIDE," policy review, medical record review, observation and interview, it was determined the facility failed to properly assess a resident for a pressure ulcer or failed to ensure preventative measures were in place prior to the development of a pressure ulcer for 2 of 3 (Residents #16 and 120) sampled residents reviewed of the 41 residents included in the Stage 2 review. The facility's failure to properly assess and identify skin breakdown and ensure preventative measures were in place prior to the development of an unstageable pressure ulcer resulted in actual harm to Residents #16 and #120. The findings included: 1. Review of the "National Pressure Advisory Panel Pressure Ulcer Prevention QUICK REFERENCE GUIDE" documented, "...9 ... Unstageable/Unclassified: Full thickness skin or tissue loss-depth unknown Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown, or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV... 12... 3. Inspect skin regularly for signs of redness... Ongoing assessment of the skin is necessary to detect early signs of pressure damage. 4. Skin inspection should include assessment for localized heat, [MEDICAL CONDITION], or induration (hardness), especially in individuals with darkly pigmented skin..." Review of the facility's "Skin Care Guidelines" policy documented, "...SKIN/NUTRITION FOCUS TEAM... The Skin/Nutrition Focus Team is responsible for monitoring skin problems and interventions weekly during the Skin/Nutrition Focus Team meeting. This team is comprised of the DON (Director of Nursing) or ADON (Assistant Director of Nursing), the MDS (Minimum Data Set) coordinator and the Food Service Supervisor and reports to the Patient Care and Services Team monthly. The Weekly Progress Note (Form 4334) should be reviewed during the meeting... PRESSURE ULCER DOCUMENTATION... Once a pressure ulcer is identified, an assessment must be documented in the Nurses Notes... The Weekly Wound Progress Note (Form 4334) must then be initiated by the charge nurse. The Date of Onset and the Location must be documented. Completion of this form replaces the need for a weekly narrative nursing note, unless complications arise and a more detailed note is indicated... Pressure ulcers must be assessed and measured at least once a week on the same day of the week. Deterioration either in the pressure ulcer or the patient's overall condition will mandate additional assessments as well as reevaluation of the treatment plan..." 2. Medical record review for Resident #16 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]." Review of a physician's orders [REDACTED]. D/C (discontinue) current tx (treatment) to L hip 2. Cleanse wound c wound cleanser, pat periwound dry. Apply skin prep to periwound. Apply hydrogel gauze & cover c border foam. (Symbol for change) q (every) day & PRN." Review of a physician's orders [REDACTED]...2. Cleanse Lt. (left) trocanter (trochanter) c NS, Apply hydrogel gauze, secure c border foam QD (every day) & PRN 3. D/C current TX to Lt. hip (hydrogel gauze)..." Review of the weekly wound progress note dated 6/2/11 documented, "Location: Lt. Trocanter... Date of Onset: 4/4/11... Type of Ulcer... Pressure (circled)... For Pressure Ulcer: Stage Unstageable... Size: (in cm (centimeters)) L (length) 2.0 W (width) 1.5 D (depth) UTD (unable to determine)... Tissue Type: (check mark) Granulation (check mark) Slough (never on St. (stage) I or II)..." The facility was unable to provide any weekly wound progress note for the wound on the left hip prior to the assessment on 6/2/11. Review of the March 2011 and April 2011 treatment records had no weekly skin assessments documented from 3/16/11 through 4/6/11. Review of the nurses' progress notes dated 4/3/11 documented, "LE (late entry) for 4/2/11 6p (pm) - Per tx (treatment) nurse DC (discontinue) current tx to L/hip. Begin tx to cleanse, dry, apply hydrogel gauze, cover c border foam pending reassessment Monday 4-4-11..." There was no assessment of Resident #16's left hip wound or the progression of the wound documented in the nurses' progress notes. Review of the dietary notes dated 4/5/11 documented, "...Skin is intact..." Review of the dietary notes dated 4/21/11 documented, "...DTI (deep tissue injury) on L heel and R (right) buttock..." but failed to document the wound to the left hip. Review of the dietary notes dated 5/9/11 documented, "...Wound/Wt (weight) (symbol for decrease) Review: Tx noted to DTI on L heel, unst (unstageable) X (times) 1 R buttock..." but failed to document the wound to the left hip. Review of the MDS dated [DATE] documented, "...M0210. Unhealed Pressure Ulcers(s)... Does this resident have one or more unhealed pressure ulcers(s) at Stage 1 or higher? ...0...No..." Review of the MDS dated [DATE] documented, "...M0210. Unhealed Pressure Ulcers(s)... Does this resident have one or more unhealed pressure ulcers(s) at Stage 1 or higher? ...0...No..." Review of the physician progress notes [REDACTED].#16's left hip wound. Observations in Resident #16's room on 5/3/12 10:27 AM, revealed Resident #16 had a large wound (approximately dollar coin size) in her left hip. The wound bed was pink with pink skin around the edges. There was 100 percent (%) undermining to the wound edges. During an interview in the copying room on 5/2/12 at 2:30 PM, Nurse #2 was asked when Resident #16 acquired her pressure ulcers on her coccyx and left hip and what they looked like when first identified. Nurse #2 stated, "...the coccyx... on 3/15/11... the one on her hip (left)... 3/27/11... while a resident here... not sure what they (pressure ulcers) were (stage) when first identified..." During an interview in the lobby room on 5/3/12 at 3:30 PM, the Nurse Consultant was asked about the assessment and documentation of Resident #16's left hip wound. The Nurse Consultant stated, "...the left hip wound first started out as a scab on 3/27/11..." The Nurse Consultant was asked if there was any documentation prior to the weekly wound progress note dated 6/2/11. The Nurse Consultant stated, "...no assessment that I can put my hand on... when it is first assessed, it is an unstageable... tissue type is granulation... slough..." The Nurse Consultant was asked what documentation should be present when a resident has a pressure ulcer. The Nurse Consultant stated, "...skin assessments are scheduled weekly and done as needed... by the treatment nurse or charge nurse... documented on the TAR (treatment administration record)... if any issues, you would see a telephone order reflecting any new orders... any changes are documented on the weekly wound progress note..." The Nurse Consultant was asked about documentation for Resident #16's left hip wound. The Nurse Consultant stated, "...I don't see any documentation..." During an interview in the lobby room on 5/4/12 at 7:48 AM, the MDS Coordinator was asked if the MDS dated ,[DATE] or 5/3/11 accurately reflected Resident #16's pressure ulcers on her left hip or coccyx. The MDS Coordinator stated, "No sir." 3. Medical record review for Resident #120 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the "Braden Scale - for Predicting Pressure Sore Risk" dated 12/5/11 for the Resident #120 documented, "...12...a total score of 12 or less represents HIGH RISK..." Review of the "Prevention Strategies" documented, "...Preventative measures must be implemented as soon as the patient is identified at risk for pressure ulcer development... FRICTION AND SHEAR... score 1, noted as a problem... interventions to be implemented... Protect Heels... Protect elbows and heels if being exposed to friction..." Review of the December 2011 treatment record documented, "Weekly skin assessments q (every) Tuesday," on 12/6/11, 12/13/11 and 12/27/11. These dates were initialed on treatment record, but the facility was unable to provide the "Weekly Skin Assessment Sheets" for review. Review of a weekly wound progress note form dated 12/15/11 documented a "DTI (deep tissue injury)" to Resident #120's left heel. In the description / comments area of the form the wound was described as "purple / blackish, soft mushy blister noted to inside of Lt (left) heel. Blister deflated, flattened, 0 (no) s/sx (signs and symptoms) of infection. New Tx." The date of onset on this wound progress note was 12/15/11. Review of a weekly wound progress note dated 12/19/11 documented the area to left heel to be "unstageable DTI, necrotic / eschar." Review of the daily skilled nurses' note dated 12/15/11 documented under "other concerns" "Heels" (check mark). No other documentation was present regarding the resident's integumentary status. The daily skilled nurses' notes dated 12/16/11 and 12/17/11, both documented skin integrity within normal limits (WNL). The daily skilled nurses' note dated 12/18/11 documented, "Pressure Ulcer LLE (left lower extremity)", with no other description of the wound on the progress note. Review of the nurses' progress notes dated 12/15/11, documented, "...cleanse area to inner L (left) heel with NS. Apply [MEDICATION NAME], cover c (with) foam, wrap c gauze, change daily and prn..." There was no documentation of the wound description in the nurses' progress notes until 1/16/12, "...area noted to L heel- 3.7X (by) 2.7X UTI (UTD)- area with black, necrotic noted..." The nurses' progress notes dated 1/23/12, "...area to Lt heel- black necrotic..." Review of the admission MDS dated [DATE] in section M, M0210 documented no (0) pressure ulcer at a stage 1 or higher. Review of the 12/15/11 treatment record documented, "...CNA's (certified nursing assistants) inserviced to keep heel elevated c pillows between legs." Review of the admission care plan documented, "...16. SKIN INTEGRITY... Preventive care (checked)..." Review of the care plan dated 12/16/11 documented, "...pressure ulcer on the left heel which was unstageable due to eschar..." Observations in Resident #120's room on 5/2/12 at 4:10 PM, revealed Resident #120 lying in bed with heels flat on the sheet. Observations in Resident #120's room on 5/3/12 at 9:10 AM, during wound care to left heel by the wound care nurse revealed Resident #120's heels were flat on the sheet. Observations in Resident #120's room on 5/4/12 at 9:00 AM, revealed Resident #120 in bed with both heels on the sheet. During an interview at the nurses' station #1 on 5/3/12 at 9:40 AM, Nurse #2 stated, "...patient did not come into nursing home with the ulcer, developed in-house because of heel on the sheets..." During an interview in the lobby room on 5/3/12 at 5:05 PM, the corporate consultant nurse was asked about the pressure ulcer being an in - house acquired pressure ulcer. The corporate consultant nurse stated, "...it should not have happened... they (the facility) are taking proactive measures to prevent pressure ulcers... preventive measures to prevent heel breakdown..." During an interview in the lobby room on 5/4/12 at 9:30 AM, the Director of Nursing (DON) stated, "...did not see any documentation where the broda boots were taken on and off or the condition of the heels at this time... patient is to wear broda boots while up in w/c (wheelchair)... weekly skin assessments are "thrown away" after they are done... they are only documented on the TAR (treatment administration record) by the date that it is done... does not state what was found on the assessment... stated that she would expect residents skin to be assessed after the boot is taken off..." The facility's failure to properly assess and identify skin breakdown and ensure preventative measures were in place prior to the development of an unstageable pressure ulcer resulted in actual harm to Residents #16 and #120.

Based on review of the "National Pressure Advisory Panel (NPUAP) Pressure Ulcer Prevention QUICK REFERENCE GUIDE," policy review, medical record review, observation and interview, it was determined the facility failed to properly assess a resident for a pressure ulcer for 1 of 16 (Resident #16) sampled residents reviewed of the 41 residents included in the Stage 2 review. The facility's failure to properly assess and identify skin breakdown prior to the development of an unstageable pressure ulcer resulted in actual harm to Resident #16. The findings included: Review of the "National Pressure Advisory Panel Pressure Ulcer Prevention QUICK REFERENCE GUIDE" documented, "...9 ... Unstageable / Unclassified: Full thickness skin or tissue loss-depth unknown Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown, or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category / Stage III or IV... 12... 3. Inspect skin regularly for signs of redness... Ongoing assessment of the skin is necessary to detect early signs of pressure damage. 4. Skin inspection should include assessment for localized heat, [MEDICAL CONDITION], or induration (hardness), especially in individuals with darkly pigmented skin..." Review of the facility's "Skin Care Guidelines" policy documented, "...SKIN/NUTRITION FOCUS TEAM... The Skin/Nutrition Focus Team is responsible for monitoring skin problems and interventions weekly during the Skin/Nutrition Focus Team meeting. This team is comprised of the DON (Director of Nursing) or ADON (Assistant Director of Nursing), the MDS (Minimum Data Set) coordinator and the Food Service Supervisor and reports to the Patient Care and Services Team monthly. The Weekly Progress Note (Form 4334) should be reviewed during the meeting... PRESSURE ULCER DOCUMENTATION... Once a pressure ulcer is identified, an assessment must be documented in the Nurses Notes... The Weekly Wound Progress Note (Form 4334) must then be initiated by the charge nurse. The Date of Onset and the Location must be documented. Completion of this form replaces the need for a weekly narrative nursing note, unless complications arise and a more detailed note is indicated... Pressure ulcers must be assessed and measured at least once a week on the same day of the week. Deterioration either in the pressure ulcer or the patient's overall condition will mandate additional assessments as well as reevaluation of the treatment plan..." Medical record review for Resident #16 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]." Review of a physician's orders [REDACTED]. D/C (discontinue) current tx (treatment) to L hip 2. Cleanse wound c wound cleanser, pat periwound dry. Apply skin prep to periwound. Apply hydrogel gauze & cover c border foam. (Symbol for change) q (every) day & PRN." Review of a physician's orders [REDACTED]...2. Cleanse Lt. (left) trocanter (trochanter) c NS, Apply hydrogel gauze, secure c border foam QD (every day) & PRN 3. D/C current TX (treatment) to Lt. hip (hydrogel gauze)..." There was no change in treatment or new orders for the left hip pressure ulcer from 4/2/11 until 6/15/11. Review of the weekly wound progress note dated 6/2/11 documented, "Location: Lt. Trocanter... Date of Onset: 4/4/11... Type of Ulcer... Pressure (circled)... For Pressure Ulcer: Stage Unstageable... Size: (in cm (centimeters)) L (length) 2.0 W (width) 1.5 D (depth) UTD (unable to determine)... Tissue Type: (check mark) Granulation (check mark) Slough (never on St. (stage) I or II)..." The facility was unable to provide any weekly wound progress note for the wound on the left hip prior to the assessment on 6/2/11. Review of the March 2011 and April 2011 treatment records had no weekly skin assessments documented from 3/16/11 through 4/6/11. Review of the nurses' progress notes dated 4/3/11 documented, "LE (late entry) for 4/2/11 6p (pm) - Per tx nurse DC current tx to L/hip. Begin tx to cleanse, dry, apply hydrogel gauze, cover c border foam pending reassessment Monday 4-4-11..." There was no assessment of Resident #16's left hip wound or the progression of the wound documented in the nurses' progress notes. Review of the dietary notes dated 4/5/11 documented, "...Skin is intact..." Review of the dietary notes dated 4/21/11 documented, "...DTI (deep tissue injury) on L heel and R (right) buttock..." but failed to document the wound to the left hip. Review of the dietary notes dated 5/9/11 documented, "...Wound/Wt (weight) (symbol for decrease) Review: Tx noted to DTI on L heel, unst (unstageable) X (times) 1 R buttock..." but failed to document the wound to the left hip. Review of the MDS dated [DATE] documented, "...M0210. Unhealed Pressure Ulcers(s)... Does this resident have one or more unhealed pressure ulcers(s) at Stage 1 or higher? ...0... No..." Review of the MDS dated [DATE] documented, "...M0210. Unhealed Pressure Ulcers(s)... Does this resident have one or more unhealed pressure ulcers(s) at Stage 1 or higher? ...0... No..." Review of the physician's progress notes dated 4/5/11, 5/29/11 and 7/9/11 failed to document Resident #16's left hip wound. Observations in Resident #16's room on 5/3/12 10:27 AM, revealed Resident #16 had a large wound (approximately dollar coin size) on her left hip. The wound bed was pink with pink skin around the edges. There was 100 percent (%) undermining to the wound edges. During an interview in the copying room on 5/2/12 at 2:30 PM, the wound care nurse was asked when Resident #16 acquired her pressure ulcers on her coccyx and left hip and what they looked like when first identified. The wound care nurse stated, "...the coccyx... on 3/15/11... the one on her hip (left)... 3/27/11... while a resident here... not sure what they (pressure ulcers) were when first identified..." During an interview in the lobby room on 5/3/12 at 3:30 PM, the Nurse Consultant was asked about the assessment and documentation of Resident #16's left hip wound. The Nurse Consultant stated, "...the left hip wound first started out as a scab on 3/27/11..." The Nurse Consultant was asked if there was any documentation prior to the weekly wound progress note dated 6/2/11. The Nurse Consultant stated, "...no assessment that I can put my hand on... when it is first assessed, it is an unstageable... tissue type is granulation... slough..." The Nurse Consultant was asked what documentation should be present when a resident has a pressure ulcer. The Nurse Consultant stated, "...skin assessments are scheduled weekly and done as needed... by the treatment nurse or charge nurse... documented on the TAR (treatment administration record)... if any issues, you would see a telephone order reflecting any new orders... any changes are documented on the weekly wound progress note..." The Nurse Consultant was asked about documentation for Resident #16's left hip wound. The Nurse Consultant stated, "...I don't see any documentation..." During an interview in the lobby room on 5/4/12 at 7:48 AM, the MDS Coordinator was asked if the MDS dated [DATE] and 5/3/11 accurately reflected Resident #16's pressure ulcers on her left hip or coccyx. The MDS Coordinator stated, "No sir." The facility's failure to properly assess and identify skin breakdown prior to the development of an unstageable pressure ulcer resulted in actual harm to Resident #16.