Every finding on record at Winnie L Nursing & Rehabilitation

Based on observations, interviews, and record reviews, the facility failed to ensure the residents received services with reasonable accommodation of resident's needs and preferences, except when to do so would endanger the health and safety of the resident or other residents, for 4 of 20 residents on the 400 hall (Residents #01, #05, #13, and #38) reviewed for call light accessibility. The facility failed to ensure the call light system was accessible to Residents #01, #05, #13, and #38. This failure could place residents at risk of not being able to call for staff assistance to meet care needs. This could put the residents at risk of injury or pain.The findings include: Review of Resident #01's face sheet revealed she was admitted to the facility on [DATE]. Her primary diagnoses were unspecified dementia (cognitive decline and memory loss), failure to thrive (gradual physical and cognitive decline), major depressive disorder (intense sadness, hopelessness, and a loss of interest), anxiety (uncontrollable worry), and schizoaffective disorder (hallucinations or delusions). Review of resident #01's Quarterly MDS, dated [DATE], revealed the BIMS score of 7, reflecting that she had severe cognitive impairment. Resident #01's Quarterly MDS showed that he feels depressed and down. MDS showed Resident #01 did use a walker. Review of resident #01's Care plan dated 6/23/2025 revealed that resident #01 should have the call light within reach, and staff should respond promptly to all requests for assistance. Review of resident #05's face sheet revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. She had diagnoses of the following: Unspecified fracture of the left femur (broken thigh bone), depression (sadness and loss of interest), vascular dementia with severe agitation (impaired blood flow causing confusion and extreme restlessness), anxiety (uncontrollable worry), and bilateral primary osteoarthritis of the knee (Natural wear-and-tear of the cartilage in both knee joints). Review of resident #05's Quarterly MDS, dated [DATE], revealed a BIMS score of 2, reflecting that he had severe cognitive impairment. Resident #02's Quarterly MDS showed that he feels depressed and down. MDS showed Resident #05 had impairment on both lower extremities. Review of resident #05's Care plan dated 03/04/2025 revealed that resident #05 should have the call light within reach, and staff should respond promptly to all requests for assistance. Review of resident #13's face sheet revealed she was admitted to the facility on [DATE] with a readmission date of 2/28/2025. She had diagnoses of the following: Parkinson's disease with dyskinesia (progressive nervous system disorder), unspecified dementia without behavioral disturbances or psychotic disturbances (affecting memory, thinking, and reasoning), disorder of muscle (disease or condition that affects muscle tissue), and unspecified pain. Review of resident #13's Quarterly MDS, dated [DATE], revealed a BIMS score of 4, reflecting that he had severe cognitive impairment. Resident #13 showed a history of wandering, Hallucinations, and delusions. Review of resident #13's Care plan dated 11/24/2016 and revised on 12/06/2016 revealed that resident #13 should have the call light within reach, and staff should respond promptly to all requests for assistance. She needs a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light. Review of resident #38's face sheet revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. She had diagnoses of the following: Parkinson's disease with dyskinesia (progressive nervous system disorder), unspecified dementia (cognitive decline and memory loss), depression (sadness and loss of interest), anxiety (uncontrollable worry), and cerebral infarction (death of brain tissue caused by a blocked or disrupted blood supply). Review of resident #38's Quarterly MDS, dated [DATE], revealed a BIMS score of 3, reflecting that he had severe cognitive impairment. Resident #38's Quarterly MDS showed that he has a history of rejecting care. Review of resident #38's Care plan dated 9/23/2025 revealed Ensure/provide a safe environment: Call light in reach, adequate low-glare light,Bed in lowest position and wheels locked, Avoid isolation. An interview/Observation on 07/21/2026 at 9:50 AM with Resident #13 in her room. She was in the room at the time, standing in the room. She had a hard time answering questions. Her call light was curled up on the floor, not accessible if she was lying in bed. She stated that she did not know how the call light got on the floor or how long it had been there. She had a difficult time answering the questions. An interview/Observation on 07/21/2026 at 10:01 AM with Resident #05 in her room. He had a difficult time answering questions. Upon looking around the room, his call light was seen on the bedside table under some item. He stated that he did not know where his call light was. He stated that he had no concerns at the time. An Observation on 07/21/2026 at 10:05 AM revealed Resident #01 in his room sleeping at the time. His call light was on the side table not close to him while he was in bed. An Observation on 07/21/2026 at 10:23 AM with Resident #38. He was sleeping at the time. His call light was on the floor next to the bed where he could not reach it. An interview on 07/23/2026 at 2:15 PM, CNA E revealed the following. She stated that call lights should be on every bed and within reach. She stated that she is always checking for call lights. She stated that she goes up and down the hall more frequently. Tell residents they often use the call lights. She stated that residents could fall, and if they can't get to the call light, the resident could get hurt; call lights should be on the floor or on the nightstand. She stated that she has had Inservice on call lights; last time was a month ago. An interview on 07/24/2026 at 2:20 PM CNA C revealed the following. She stated that the call light should be on the bed next to the residents if they are lying in bed and not on the floor. She stated that the call light should not be on the side table. She stated that residents should be checked every two hours to make sure that the call light is close to them when they are in their rooms. She stated that if the call light is not next to the resident, then they can get up and try to do things themselves and get hurt. She stated that she has had in-service training on call lights and the last time was two months ago. An interview on 7/24/2026 at 2:27 PM with LVN A revealed the following. She stated that the call lights should be within each resident's reach. She stated that rounds are done frequently to check that call lights are close to residents when they are in the room. She stated that the call light should not be on the floor or on the bedside table. She stated that if call lights are not close to the residents, they can get seriously hurt if they try to get up and do something themselves. She said that she has had in-service training on call lights. She said that she could not remember the last time she had that in-service training. An interview on 7/24/2026 at 2:45 PM with DON revealed the following. She stated that staff are expected to check on the residents frequently. She stated that staff are expected to make sure the call lights are close to the residents. She stated that call lights should not be on the floor or on the bedside table. She stated that they have signs in the room to remind residents to use their call lights. She stated that staff are talked to regularly about call light placement. She stated that if call lights are not close to the residents, they could try to do something themselves, fall, and get injured. An interview on 7/24/2026 at 3:15 PM with ADM revealed the following. He stated that call lights should be close to the residents when they are in their rooms. He stated that staff are expected to check regularly and make sure all call lights are close to the residents when they are in their rooms. He said if call lights are not close to the residents, they could get injured by falling when they try to do something. He said that staff are talked to on a regular basis about call lights being close to residents. Review of the resident rights policy that was not dated revealed the following. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the residents.

Based on observations, interviews, and record review, the facility failed to ensure results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to survey were readily available to examine for 1 of 1 facility in that:The facility failed to ensure the results of the most recent survey were posted in the facility on 07/21/2026.This failure placed residents of the facility at risk of not knowing past and present citations of the facility and potentially being negatively affected by an area of citation. Findings included: An observation conducted throughout the facility on 07/21/2026 at 9:00 am revealed a sign on the wall beside the conference room that reflected, Survey results for [facility name] are available for inspection in the conference room in front lobby. The survey results binder was not in the conference room , lobby or common areas of the facility. Interview on 07/21/2026 at 11:30 am the Administrator stated he had only been the administrator at the facility for a few days. He stated there should be a survey binder with the results of investigations and the last annual survey in a common area where it would be accessible to residents, families, and visitors. He stated he checked the conference room, lobby, nurses station and the television area in the facility, and he did not find a survey binder. The Administrator stated he expected a survey binder be located in an area where the residents, families, and visitors had access to it and a sign stating where the binder is located. The Administrator stated he was going to take the responsibility to maintain the survey results binder. He stated that the binder should include the previous year's annual survey results and the plan of correction. The Administrator acknowledged that survey results were required to be accessible to everyone for review. The Administrator stated he was going to place a survey binder in the lobby He stated that the survey results binder was important because it allowed residents and their families to know what was occurring in their home and he was going to place a sign indicating where to locate the survey binder.During a confidential group interview conducted on 07/22/2026 at 10:00 am 7 of 7 residents revealed they did not know where or how to access the survey results in the facility. The Residents in the group stated they would have liked access to that information. They had not understood or been aware that the survey book existed or that they were able to review the results. Record review of the facility's Resident Rights, not dated, revealed The facility must post in a place readily accessible to residents, and family members, and legal representatives of residents, the results of the most recent survey of the facility.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for three of six residents (Resident #14, Resident #30 and Resident # 39) reviewed for care plans. The facility failed to revise a comprehensive care plan to reflect Resident #14's feeding preference.The facility failed to revise the comprehensive care plan to reflect Resident #30 and Resident #39 received in room activity programs.These failures could place residents at risk of not receiving appropriate interventions to meet their psychosocial and medical needs.Findings include:1. Record review of Resident #14's face sheet, dated 07/22/2026, reflected a [AGE] year-old-male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included quadriplegia, C1-C4 incomplete (paralysis of all four limbs and the torso. C1-C4 refers to the four uppermost vertebrae in the neck. The spinal cord was not completely severed, allowing the brain to still send some signals), polyneuropathy, unspecified ( damage to multiple peripheral nerves [part of the nervous system outside the brain and spinal cord that connects to your limbs and organs] the exact cause or specific nerve damage has not been identified by healthcare provider , and dysphagia unspecified ( when a person has difficulty swallowing, but the exact physical cause or specific phase of the swallow problem has not yet been identified).Record review of Resident #14's Quarterly MDS Assessment, dated 06/10/2026 reflected Resident #14 had a BIMS score of 15 indicating his cognition was intact. Resident #14 was dependent on staff for eating. He was assessed to have diagnosis of quadriplegia (medical condition involving the partial or total loss of use in all four limbs and the torso usually caused by a neck injury or brain damage), polyneuropathy(a medical condition where many peripheral nerves throughout the body are damaged at the same time, commonly causing numbness, tingling, and weakness starting in the hands and feet, and dysphagia( trouble or difficulty with swallowing)Observation on 07/21/2026 at 12:15 p.m. revealed Resident #14 was in the dining room sitting in his specialty motorized wheelchair. The MDS Coordinator LVN was standing beside Resident #14 and feeding him.Interview on 07/21/2026 at 1:30 p.m. Resident #14 stated It is easier for me to eat with staff standing when they are feeding me. This is my preference and I explained to the staff (MDS Coordinator LVN) who was feeding me today I preferred staff to stand when they was going to feed me my meals and my snacks. He stated it was a few months ago when he spoke with the staff (MDS Coordinator LVN) about his preference. Resident #14 did not recall the exact date or time. Record review of Resident #14's Care Plan, dated 06/16/2026, reflected there was not a focus area on the care plan for Resident #14's preference of staff standing while he was being assisted with feeding. Interview on 07/21/2026 at 2:45 p.m. the MDS Coordinator LVN stated Resident #14 preferred for the staff to stand when feeding him. She stated he did express his preference to her approximately 1 or 2 months prior to today (07/21/2026). The MDS Coordinator LVN stated she did not revise Resident #14's care plan to reflect his feeding preferences when he expressed his preference to her. She stated she was expected to revise Resident#14's care plan as soon as she learned he preferred for staff to stand instead of sitting. The MDS Coordinator LVN stated it was the facility's protocol for staff to sit when feeding a resident and other staff may not know Resident #14's preferences if it was not documented on his care plan. She stated, I forgot to put it on his care plan. 2. Record review of Resident # 30's face sheet, dated 07/22/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #30 had diagnoses which included generalized anxiety disorder (a group of mental health conditions defined by excessive, ongoing fear, dread, and worry that are hard to control and interferes with daily life), and schizophrenia, unspecified (a person experiences severe psychotic symptoms such as hallucinations or delusions [ a false sensory perception experienced without any real external stimulus such as seeing, hearing, smelling, tasting, or feelings things that do not exist outside the mind] that impair their daily functioning, but do not perfectly fit the diagnostic criteria for a specific psychotic disorder).Record review of Resident #30's Annual MDS Assessment, dated 06/10/2026, reflected Resident #30 had a BIMS score of 15, which indicated his cognition was intact. Resident #30's activity preferences that were very important to him were the following:Listening to music.Keep up with the news.Go outside to get fresh air when the weather was good.Participating in religious services and practices.Participating in group activities was not very important to Resident #30. Record review of Resident #30's Comprehensive Care Plan, revised on 07/01/2026, reflected Resident #30's activity care plan was not revised to meet his current activity preferences (receive in room activities).During an observation and interview on 07/22/2026 at 9:00 a.m., revealed Resident #30 was sitting on his bed. He was looking toward the news on his television. He stated he did not enjoy doing activities in a group. Resident #30 stated he enjoyed playing games and wanted someone to play games with him in his room and not in a group. He stated he did discuss his activity preferences with the activity person a few months ago. Resident #30 did not recall the date. Resident #30 stated he became nervous if he was in a group for a long period of time and he thought all staff needed to know his activity preference.During an interview on 07/23/2026 at 10:50 a.m. the Activity Director stated Resident #30 was on the in-room activity program. She stated she did not recall if she had documented his activity preference on his care plan. She stated she would need to review the care plan to determine if she needed to update Resident #30's care plan to reflect his activity preference of receiving in room activities. The Activity Director did not respond to any further questions related to revising residents' care plans such as if Resident #30's care plan was not updated would staff know his activity preferences.Record review of Resident # 39's face sheet, dated 07/22/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #39 had diagnoses which included Alzheimer's disease with late onset (a progressive brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple daily tasks- symptoms began at or after age of 65), and dementia in other diseases classified elsewhere , severe, with other behavioral disturbance (a person has advanced cognitive decline, it is severe enough to significantly interfere with a person's daily life, independence, and basic functioning and is accompanied by disruptive actions such as social disinhibition [ difficulty in regulating one's affect, urges, and impulses], sleep disturbances, wandering, and aggressive or uncooperative outbursts).Record review of Resident #39's Annual MDS Assessment, dated 02/11/2026, reflected Resident #39 had a BIMS score of 3, which indicated her cognition was severely impaired. Resident #39's activity preferences that were very important to her were the following:Listening to music.Keep up with the news.Go outside to get fresh air when the weather was good.Be around animals such as pets.Do things in groups of people.Do favorite activities.Record review of Resident #39's Quarterly MDS Assessment, dated 05/29/2026, reflected Resident #39 had a BIMS score of 3, which indicated her cognition was severely impaired. Record review of Resident #39's Comprehensive Care Plan, revised on 06/01/2026, reflected Resident #39's activity care plan was not revised to meet her current activity needs (receive in room activities).During an observation on 07/21/2026 at 2:30 p.m., revealed Resident #39 was lying in her bed. The television was on (talk show) and Resident #39 was looking toward the ceiling (watching a talk show). She was not interview able.Interview on 07/23/2026 at 10:50 a.m. the Activity Director stated Resident #39 needed in room activities. She stated Resident #39 had difficulty focusing when in group activities. She stated, I will need to review [Resident #39's] care plan to determine if I documented she needed in room activities. The Activity Director stated she did participate in care plan meetings every week. She did not respond to any further questions about the importance of care plans and the need of ensuring the residents activity care plan was accurate. Interview on 07/21/2026 at 2:45 p.m. the MDS Coordinator LVN stated the purpose of having a Comprehensive Care Plan was to inform staff how to give the care each resident needed such as physical, behaviors, emotional, activities, type of diet and any other interventions to prevent falls or any injuries. She stated she was responsible to monitor the care plans to ensure they were correct and completed on time. The MDS Coordinator LVN stated the information the CNAs followed on the Kardex (electronic system for CNAs use to know what type of care to give the residents) came from the care plan. She stated if a resident needed a certain type of care or had behaviors and it was not care planned, the CNAs or nurses would not have that information to know what type of care to give the residents. The MDS Coordinator stated it was the Activity Director's responsibility to ensure the activity care plans of the residents' activity preferences were documented on the care plan. She stated the IDT met once a week and discussed residents' care plans due that week. She stated the Activity Director attended weekly care plan meetings.In an interview on 07/23/2026 at 11:30 a.m., the DON stated her expectation was the care plan to be reviewed during care plan meetings to ensure it was correct. She stated all residents' preferences including Resident #30 were expected to be care planned. She stated the care plan for each resident was a communication tool for all staff to know exactly what type of care and needs each resident needed. She stated all residents were expected to have their activity preferences documented on the comprehensive care plan. The DON stated if a resident was sad or had behaviors, the staff would refer to the care plan to know what their activity preferences were to re-direct the resident.In an interview on 07/23/2026 at 12:30 p.m., the Administrator stated his expectations of care plans was the IDT discussed care of each resident and if there was a change with anything which included resident preferences the care plan was expected to be revised. He stated the IDT was expected to ensure the resident's information to give appropriate care to each resident was documented on the care plan whether it was physical, emotional, resident preference, activities, etc.Record review of the facility's Activity Documentation- General Guidelines, dated 05/06/2025, reflected A qualified Activity professional will complete all required medical record documentation per state and federal regulations. The Activity Director shall coordinate and supervise all documentation and be responsible for all areas of documentation, according to required time limits and practice guidelines. Practice guidelines: The following areas are considered documentation responsibilities of the Activity Director and staff and should be completed in a comprehensive and timely manner : Interdisciplinary team will assess the need for activities and reflect on the resident care : Problems or needsGoalsAppropriate approaches to related problems.

Based on observation, interview and record review the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for two of six residents (Resident # 30 and Resident #39) reviewed for activities.The facility failed to provide Resident #30 and Resident #39 with in-room activities on a regular basis from June 1, 2026, to July 17, 2026. This failure could place residents at risk for boredom, depression, and a diminished quality of life. Findings include:Record review of Resident #30's face sheet, dated 07/22/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #30 had diagnoses which included generalized anxiety disorder (a group of mental health conditions defined by excessive, ongoing fear, dread, and worry that are hard to control and interferes with daily life), and schizophrenia, unspecified (a person experiences severe psychotic symptoms such as hallucinations or delusions [ a false sensory perception experienced without any real external stimulus such as seeing, hearing, smelling, tasting, or feelings things that do not exist outside the mind] that impair their daily functioning, but do not perfectly fit the diagnostic criteria for a specific psychotic disorder).Record review of Resident #30's Annual MDS Assessment, dated 06/10/2026, reflected Resident #30 had a BIMS score of 15, which indicated his cognition was intact. Resident #30's activity preferences that were very important to him were the following:Listening to music.Keep up with the news.Go outside to get fresh air when the weather was good.Participating in religious services and practices.Participating in group activities was not very important to Resident #30. Record review of Resident #30's Comprehensive Care Plan, revised on 07/01/2026, reflected Resident #30's activity care plan was not revised to meet his current activity preferences (receive in room activities). During an observation and interview on 07/22/2026 at 9:00 a.m., revealed Resident #30 was sitting on his bed. He was looking toward the news on his television. He stated he did not enjoy doing activities in a group. Resident #30 stated he enjoyed playing games and wanted someone to play games with him in his room and not in a group. He stated he did discuss his activity preferences with the activity person few months ago. Resident #30 did not recall the date. Resident #30 stated he became nervous if he was in a group for a long period of time and he thought all staff needed to know his activity preference.Record review of Resident # 39's face sheet, dated 07/22/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #39 had diagnoses which included Alzheimer's disease with late onset (a progressive brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple daily tasks- symptoms began at or after age of 65), and dementia in other diseases classified elsewhere , severe, with other behavioral disturbance (a person has advanced cognitive decline, it is severe enough to significantly interfere with a person's daily life, independence, and basic functioning and is accompanied by disruptive actions such as social disinhibition [ difficulty in regulating one's affect, urges, and impulses], sleep disturbances, wandering, and aggressive or uncooperative outbursts).Record review of Resident #39's Annual MDS Assessment, dated 02/11/2026, reflected Resident #39 had a BIMS score of 3, which indicated her cognition was severely impaired. Resident #39's activity preferences that were very important to her were the following:Listening to music.Keep up with the news.Go outside to get fresh air when the weather was good.Be around animals such as pets.Do things in groups of people.Do favorite activities.Record review of Resident #39's Quarterly MDS Assessment, dated 05/29/2026, reflected Resident #39 had a BIMS score of 3, which indicated her cognition was severely impaired. Record review of Resident #39's Comprehensive Care Plan, revised on 06/01/2026, reflected Resident #39's activity care plan was not revised to meet her current activity needs (receive in room activities).Record review of activity participation records revealed Resident #30 and Resident #39 with in-room activities on a regular basis from June 1, 2026, to July 17, 2026. During an observation on 07/21/2026 at 2:30 p.m., revealed Resident #39 was lying in her bed. The television was on (talk show) and Resident #39 was looking toward the ceiling (watching a talk show). She was not interview able. During an interview on 07/23/2026 at 10:50 a.m. the Activity Director stated Resident #30 and Resident #39 were on the in-room activity program. She stated Resident #30 did not enjoy participating in group activities very often and he enjoyed playing cards in his room. The Activity Director stated she did not have any documentation of Resident #30 or Resident #39 receiving in-room activities. She stated she did not recall when she did in-room activities with Resident #30 or Resident #39. The Activity Director stated if a resident was not receiving activities there was a possibility a resident may become bored. The Activity Director did not respond to any further questions about Resident #30 or Resident #39's activity plan and who was responsible to ensure the residents were receiving in-room activities. Interview on 07/23/2026 at 12:30p.m., the Administrator stated it was very important for the residents unable to come out of their room or unable to participate in group activities to receive activities in their room. He stated the Activity Director was over the activity department and he was her supervisor. He stated there was a possibility that a resident may become lonely if they were not receiving activities in their room. The Administrator stated he expected all activities to be documented on every resident on a daily basis to capture who was attending group activities and what the residents were doing during in-room activities.Record review of the Activity Director's personnel file reflected how she began working at the facility on 03/04/2024 as an Activity Director. She had an activity director certificate and did not have an expiration date.Record review of the facility's Activity Programming Policy, dated 2019, reflected The Activity Director and staff will provide ongoing activity programs. Resident's or family's expressed needs and interests are included in the development of programs. Programming includes large groups, small groups, individual and independent opportunities. Activity programs are to be designed based on resident's leisure interests and implemented to [NAME] the needs ( physical, cognitive, social, spiritual, community, independent, and sensory) of the residents. Record review of the facility's Activity Documentation- General Guidelines, dated 05/06/2025, reflected A qualified Activity professional will complete all required medical record documentation per state and federal regulations. The Activity Director shall coordinate and supervise all documentation and be responsible for all areas of documentation, according to required time limits and practice guidelines. Practice guidelines: The following areas are considered documentation responsibilities of the Activity Director and staff and should be completed in a comprehensive and timely manner : Resident Participation Records.

Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 39.47% based on 15 out of 38 opportunities, which involved 3 of 5 residents (Resident #46, #14, #28) and 1 of 1 MAs (MA B) observed during medication administration reviewed for medication error. 1) The facility failed to ensure on 07/22/2026 at 8:22 AM that MA B administered Resident #46's medication per physician orders when he failed to administer Resident #46's physician ordered famotidine 20 mg (reduces stomach acid and treats ulcers), and her losartan potassium 100 mg (lowers high blood pressure). 2) The facility failed to ensure on 07/22/2026 at 8:24 AM that MA B administered Resident #14's medication per physician orders when he failed to administer Resident #14's physician ordered Magnesium oxide 400 mg (supplement and antacid to treat magnesium deficiency and constipation), omeprazole 20 mg (reduces stomach acid), Cholecalciferol 50 mg (vitamin d3 is supplement to improve calcium absorption, bone health and metabolic function), Methenamine Hippurate 1gm (used to prevent recurrent urinary tract infections by increasing the acidity of the urine), Aspirin 81 mg (over the counter blood thinner), Tizanidine HCL 4mg (muscle relaxant), and his docusate sodium 100 mg (stool softener). 3) The facility failed to ensure on 07/22/2026 at 8:35 AM that MA B administered Resident #28's medication per physician orders when he failed to administer Resident #28's physician ordered Calcitonin 200 units (nasal spray that helps strengthen bones and reduce the risk of fractures), Farxiga 5mg (reduces glucose in DM type 2), Ferrous sulfate 325mg (iron supplement), Keppra 500 mg (give as a mood stabilizer), Lactulose 10mg/15ml (laxative), and her liquid protein (supplement for wound healing). These deficient practices could place residents at risk of not receiving therapeutic dosage of medications and symptomatic changes in vital signs. Findings included: 1) Review of Resident #46's face sheet dated 07/22/2026 reflected an [AGE] year old female admitted to the facility on [DATE] with the following diagnoses Hypertensive urgency (severe elevation in blood pressure without evidence of organ damage), essential hypertension (high blood pressure), and GERD (chronic heartburn). Review of Resident #46's admission MDS dated [DATE] reflected it was still in progress and not yet completed. Review of Resident #46's base line care plan reflected the resident had a focus area dated 07/20/2026 The resident has hypertension. interventions included give antihypertensive medications as ordered. Observation on 07/22/2026 at 8:22 AM revealed MA B outside of Resident #46's room preparing her morning medication. MA B took her vital signs. Resident #46's blood pressure was 162/81 with a pulse of 56. MA B dispensed 6 medications into the medication cup:1) Allopurinol 100 mg one tab (for gout)2) Aspirin 81 mg one tab (for hypertension)3) Isosorbide dinitrate 30 mg one tab (for hypertension)4) Nifedipine ER 30 mg one tab (for hypertension)5) spironolactone 25 mg one tab (for hypertension)6) Torsemide 20 mg two tabs. (for hypertension) Observation further revealed MA B administered the medications to Resident #46 and went to the next resident. Review of Resident #46's consolidated physician orders and MAR for July 2026 reflected Resident #46 was also supposed to get the following medications at her AM medication pass which were not administered by MA B. 7) famotidine 20 mg one tab (for GERD)8) carvedilol 12.5mg one tab (hold if SBP <110, DBP <60 or pulse less than 60) (for hypertension)9) losartan potassium 100 mg one tab (no parameters were outlined to hold the medication) (for hypertension). Review of the documentation MA B documented on Resident #46's MAR reflected he documented with a check mark and his initial (review of the MAR chart code list reflected a check mark indicates the medication was administered) which indicated that Resident #46's famotidine, losartan potassium and carvedilol were given. In an interview on 07/22/2026 at 9:00 AM MA B stated he did not give Resident #46's famotidine because it was not with her medication. When he was told that the medication was over the counter MA B looked in the drawer and pulled it out and stated oh then stated he did not give it and stated he did not give her the carvedilol and losartan potassium because of her blood pressure and he did not think she should get it. He stated he did not know why he held the losartan when it did not have parameters to hold. He further stated that he did not report to the nurse about holding the medication. He stated he did not know why he did not report it. He stated he did not know why he documented the medications as if he gave them to Resident #46. He stated he guessed he should have documented the medication carvedilol and losartan as being held due to vital signs being outside of parameter and unavailable for the famotidine. In an interview on 07/22/2026 at 10:00 AM with the DON and MA B. The DON stated MA B should not have held Resident #46's medication losartan because it did not have physician ordered parameters to hold the medication and he should have reported holding the medication to Resident #46's nurse. The DON stated Resident #46's famotidine was over the counter and was on the medication cart and was available for administration and should have been given. The DON stated she was in-servicing the medication aide regarding medication administration. In an interview on 07/22/2026 at 10:34 AM the DON stated she notified Resident #46's physician regarding the missed medication and that MA B went back and administered Resident #46's medications that were missed during the morning medication pass. In an interview on 07/22/2026 at 11:10 am Resident #46 stated she had no idea what medications she was on or whether she was getting her medication. Review of Resident #46's Med Error report dated 07/22/2026 at 10:00 am completed by the DON and reported to Resident #46's physician reflected type of error not administered for any reason and failure to document medication appropriately. Description of error Medication aide did not give multiple medications charting unavailable even though medications available on medication cart. Instead, medication aide omitted to administer the medications including omitting an antihypertensive medication even though no parameters in place for that particular medication. Medication aide did this without informing charge nurse, ADON or DON. ASA 81mg chew tab 1 tab Famotidine 20mg 1 tab Losartan Potassium 100mg 1 tab. Under section for remarks by staff committing violation I guess I was nervous. 2) Review of Resident #14's face sheet dated 07/22/2026 reflected a [AGE] year old male admitted to the facility on [DATE] with the following diagnoses quadriplegia (paralysis of all four limbs), anxiety (a feeling of worry or nervousness), and thrombocytopenia (low blood platelet count). Review of Resident #14's quarterly MDS dated [DATE] reflected he was assessed to have a BIMS score of 15 indicating he was cognitively intact. Resident #14 was assessed to be dependent on staff for all ADLs. Resident #14 was assessed to be taking the following medication types: antidepressant; antibiotic, opioid, antiplatelet and an anticonvulsant medication. Review of Resident #14's comprehensive care plan reflected he had a focus area dated 03/23/2026 for orthostatic hypotension (low blood pressure) with an intervention to give medications as ordered. Further review of his care plan reflected a focus area dated 03/23/2026 Resident has an alteration in neurological status related to quadriplegia with an intervention to give medications as ordered. Observation on 07/22/2026 at 8:24 AM revealed MA B outside of Resident #14's room preparing his morning medication. MA B took his vital signs. Resident #14's blood pressure was 91/62 with a pulse of 77. MA B dispensed 6 medications into the medication cup:1) pregabalin 300 mg two tabs (for pain)2) oxycodone 5mg two tabs (for pain)3) Tylenol 325 mg two tabs (for pain4) Divalproex sodium ER on e tab (for anxiety)5) Midodrine HCL 5mg one tab (for orthostatic hypotension)6) Sertraline HCL 50 mg one tab (for depression) Observation further revealed MA B administered the medications to Resident #14 and went to the next resident. Review of Resident #14's consolidated physician orders and MAR for July 2026 reflected Resident #14 was also supposed to get the following medications at his AM medication pass which were not administered by MA B. 7) magnesium oxide 400 mg two tabs (for magnesium supplementation)8) omeprazole 20 mg one tab (for GERD)9) Cholecalciferol 50 mg one tab (for vitamin D3 supplementation)10) Methenamine Hippurate 1gm (for prophylactic UTI treatment)11) Aspirin 81 mg one tab (for prophylactic treatment)12) Tizanidine HCL 4 mg one tab (for cramps and spasms due to quadriplegia)13) Docusate Sodium 100 mg one tab (for constipation) Review of the documentation MA B documented on Resident #14's MAR reflected MA B documented that Resident #14's Magnesium oxide, omeprazole, Methenamine Hippurate, Tizanidine HCL were UN (unavailable). Review of the chart code for UN reflected it = unavailable (contact DON/ADON). MA B documented that Resident #14's cholecalciferol, aspirin, and docusate sodium were given. In an interview on 07/22/2026 at 9:00 AM MA B after looking at the list of medications he gave to Resident #14 stated that was all he gave. He stated he did not know about the seven medications he was due to get but did not get. He stated some were not available. When asked about the OTC medications he just shrugged his shoulders and stated that he guessed he was nervous that he usually gives all the medications that are due. In an interview on 07/22/2026 at 9:54 AM the DON stated she went over all of Resident #14's medications with MA B and all his medications were on the cart and available for administration expect for his Methenamine which she is having the pharmacy to bring out right away. She stated that MA B did not report that Resident #14's medications were unavailable which he should have. The DON stated all the medications except for the Methenamine were actually on his medication cart and it seems like he just did not look for them. She stated MA B should never have documented that a medication was given when it was not. In an interview on 07/22/2026 at 10:34 AM the DON stated she notified Resident #14's physician regarding the missed medications and that MA B went back and administered Resident #14's medications that were missed during the morning medication pass. In an interview on 07/22/2026 at 11:00 am Resident #14 stated he was not sure if he was getting all his medications. He stated he relies on the staff to give him his meds. Resident #14 stated he felt fine like he normally does and has not noticed a change. Review of Resident #14's Med Error report dated 07/22/2026 at 9:00 AM completed by the DON and reported to Resident #14's physician reflected type of error not administered for any reason and failure to document medication appropriately. Description of error Medication aide did not give multiple medications, nor did medication aide look for overstock medication instead medication aide omitted to administer the medications or informing charge nurse, ADON or DON. tizanidine 4mg 1 tab cholecalciferol 50mcg 2 tablets docusate sodium 50mg 1 cap Omeprazole 20mg 1 cap, magnesium Oxide 400mg 2 tabs, and Methenamine Hippurate 1gm. Under section for remarks by staff committing violation I guess I was nervous. 3) Review of Resident #28's face sheet dated 07/22/2026 reflected a [AGE] year old female admitted to the facility on [DATE] with the following diagnoses Type 2 Diabetes (high blood sugar and insulin resistance), Vitamin D deficiency (low calcium and phosphate levels), cirrhosis of the liver (advanced scarring of the liver), dementia (cognitive decline affecting memory, thinking and behavior) and legal blindness. Review of Resident #28's quarterly MDS dated [DATE] reflected that she was assessed to have a BIMS score of 15 indicating she was cognitively intact. Resident #28 was assessed to be taking the following classes of medication: antidepressant, diuretic, opioid, hypoglycemic and anticonvulsant. Review of Resident #28's comprehensive care plan reflected a focus area dated 12/01/2025 Resident has type 2 diabetes mellitus with diabetic polyneuropathy (diabetic kidney disease), diabetic retinopathy with macular degeneration (conditions of the eyes related to DM).interventions included to give diabetes medication as ordered. Further review reflected a focus area dated 04/02/2026 Resident has an anticonvulsant medication for dementia with mood disturbance . interventions include to give resident medication as ordered. Another focus area dated 12/01/2025 Resident has protein-calorie malnutrition and vitamin D deficiency. Interventions included to administer medications as ordered. Observation on 07/22/2026 at 8:35 AM revealed MA B outside of Resident #28's room preparing her morning medication. MA B took her vital signs. Resident #28's blood pressure was 119/57 with a pulse of 57. MA B dispensed 9 medications into the medication cup:1) furosemide 20 mg one tab (for fluid overload)2) spironolactone 25 mg one tab (for cirrhosis of the liver)3) Tylenol 325 mg two tabs (for pain)4) ciprofloxacin HCL 500 mg one tab (for UTI)5) duloxetine HCL 30 mg one tab (for major depressive disorder)6) omeprazole 20 mg one tab (for GERD)7) Vitamin B12 1000mg one tab (for supplement)8) Tramadol 50 mg one tab (for pain)9) pregabalin 25 mg one tab (for diabetic polyneuropathy) Observation further revealed MA B administered the medications to Resident #28 and went to the next resident. Review of Resident #28's consolidated physician orders and MAR for July 2026 reflected Resident #28 was also supposed to get the following medications at her AM medication pass which were not administered by MA B.10) Farxiga 5mg one tab (for Type 2 Diabetes)11) ferrous sulfate 325 mg one tab (for supplement)12) Keppra 500 mg one tab (for dementia)13) lactulose 10mg/15ml give 15mls (for cirrhosis of liver)14) liquid protein 30 ml (for wound healing) Review of the documentation MA B documented on Resident #28's MAR reflected MA B documented that Resident #28's Farxiga, ferrous sulfate, and Lactulose were UN (unavailable). Review of the chart code for UN reflected it = unavailable (contact DON/ADON). MA B documented that Resident #28's Keppra and liquid protein were given. In an interview on 07/22/2026 at 9:00 AM MA B after looking at the list of medications he gave to Resident #28 he stated that was all he gave. He stated he did not know about the five medications she was due to get but did not get. He stated some were not available. When asked about the OTC medications he just shrugged his shoulders and stated that he guessed he was nervous that he usually gives all the medications that are due. In an interview on 07/22/2026 at 9:54 AM the DON stated she went over all of Resident #28's medications with MA B and all her medications were on the cart and available for administration. She stated that MA B did not report that Resident #28's medications were unavailable which he should have. The DON stated all the medications were actually on his medication cart and it seems like he just did not look for them. She stated MA B should never have documented that a medication was given when it was not. In an interview on 07/22/2026 at 10:34 AM the DON stated she notified Resident #28's physician regarding the missed medications and that MA B went back and administered Resident #28's medications that were missed during the morning medication pass. In an interview on 07/22/2026 at 11:30 AM Resident #28 stated she cannot see well and is not sure when she gets her medication if she is getting all her meds. Review of Resident #28's Med Error report dated 07/22/2026 at 9:00 AM completed by the DON and reported to Resident #28's physician reflected type of error not administered for any reason and failure to document medication appropriately. Description of error Medication aide did not give multiple medications, nor did medication aide look for overstock medication instead medication aide omitted to administer the medications documenting unavailable despite medications stocked on the med cart. Medication aide did all without informing charge nurse, ADON or DON. Lactulose 10mg/15ml 15 ml Liquid protein 30ml Keppra (levetiracetam) 500mg 1 tab Farxiga (Dapagliflozin) 5mg 2 tabs Omeprazole 20mg 1cap, Ferrous Sulfate 325mg 1 tab Vitamin B12 1000mcg 1 tab Under section for remarks by staff committing violation I guess I was nervous. In an interview on 07/23/2026 at 10:00 am the DON stated she expected the residents to get the right medication at all times. She stated there was no reason for MA B to not give the medications to the residents since they were on the cart. She stated he never really gave an explanation as to why he did not give all the pills or report to the nurse when he held medication. She stated he was a PRN staff and would not be using him anymore. She stated he also had a disciplinary action done. The DON stated by the resident not getting their medication it could affect their health. Review of the facility's Medication Administration and General Guidelines policy dated (with only the year) 2025 reflected Medications are administered as prescribed, in accordance with State Regulations using good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication, monograph of all medications is available.Medications are administered in accordance with written orders of the attending physician. If a dose seems excessive considering the resident's age and condition, or a medication order is unrelated to the resident's current diagnosis or condition, the physician is contacted for clarification prior to the administration of the medication. The interaction with the physician is documented in the nursing notes and elsewhere in the medical record as appropriate. Adheres to the 6 Rights of Medication Administration: 1) Right Dose, 2) Right Route, 3) Right Resident, 4) Right Medication, 5) Right Time, 6) Right Documentation.

Based on observation, interview, and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to 1 of 3 medication carts (Medication Cart #1) reviewed for pharmacy services. The facility failed to ensure Medication Cart #1, was locked, medications secured, and not accessible to other staff, residents, or visitors on 07/22/2026. This failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications. Findings included: During an observation in the dining room on 07/22/2026 at 8:09 a.m., revealed Medication Cart #1 was facing toward the entrance area of the dining room. The lock was protruding outward on Medication Cart #1. Observation revealed Med Aide B had his back turned toward the medication cart and he was at the back of the dining room. There were not any other nurses around Medication Cart #1. Med- Aide B walked toward the medication cart located near the entrance of the dining room. During an interview with Med- Aide B on 07/22/2026 at 8:12 a.m., he stated he was trained on medication storage. He stated the nurse or medication aide who was working on the cart was responsible for locking the medication cart. He stated if the staff left the medication cart unlocked and unattended, a resident could get into the medication cart and take medication that did not belong to them. Med Aide B stated everyone monitored to ensure the medication carts were locked. Med Aide B stated he was unable to view Medication Cart #1 from where he was standing toward the back of the dining room. He stated he had been in-serviced on locking the medication cart; however, he did not recall the date or time. Med- Aide B did not respond to why he left the Medication Cart #1 unlocked. During an interview on 07/23/2026 at 11:30 a.m., the DON stated all medication carts were expected to be locked when the med-aide or nurse was not standing in front of the medication cart. She stated the nurse or the medication aide, who was on the medication cart, was responsible for ensuring the medication cart was locked. She stated if the medication cart was left unlocked and unattended a resident could get into the medication cart and take medications. The DON stated leadership monitored to ensure staff locked the medication cart. She stated nurse leadership was to monitor by doing observations and in-service training. She stated she did not know why Med- Aide B left the medication carts unlocked. Record review of the facility's policy titled, Medication Storage in the Facility, dated 2025 reflected, Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medication. Medication rooms, carts, medication supplies are locked or attended to by persons with authorized access.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the 1 of 1 kitchen reviewed. The facility failed to ensure food safety by not discarding expired food in the kitchen, not labeling and dating food, not maintaining a sanitary kitchen, and not keeping hair covered while in the kitchen. These failures can place residents at risk for foodborne illness. Findings included: An observation on 7/23/2026 at 9:05 AM of the walk-in cooler revealed the following. Single cup servings of milk and juice on a tray had no label or dates. Opened Package of butter that was not sealed. 1-gallon jug of orange juice dated 4/9/2026 with no use-by date Sealed bag of sliced cheese with an open date of 4/25/2026 with no use-by date. Plastic container of unknown liquid, with no label of what is in the container, or any dates. Sliced lunchmeat in a sealed bag with a date of 7/19/2026 with no use-by date. Clear container of jelly covered with plastic wrap with no label of what was in the container and no open or used by dates. Open bag of lettuce that was not sealed. Sliced yellow cheese in a sealed bag with a date of 7/6/2026 with no use-by date. An observation on 7/28/2026 at 9:09 AM of the walk-in freezer revealed the following. Pancakes in an open original package with an open date of 7/15/2026 and no use-by date. Croissants in its original bag with no open or use-by dates on the package. An observation on 7/28/2026 at 9:12 AM of the pantry revealed the following. Clear container of single-serve crackers with no label of what was in the container and no open or used by dates. A sealed bag of corn tortilla chips that was dated 6/26/2026, with no use-by date. Observation on 7/2028/2026 at 9:15 AM revealed the following. DTM was not wearing her hair net in the kitchen. She ended up putting on her hair net a couple minutes later. An observation on 7/28/2026 at 9:33 AM of the kitchen revealed the following. One of three kitchen drawers that had debris in the drawer with the kitchen utensils that are used in the kitchen. An observation on 7/28/2026 at 12:29 PM revealed the following. DA H grabbed the food tongs with his hands and gave them to the DTM to get food off of the serving station. DTM was stopped before she could use the tongs. An observation on 7/30/2026 at 2:02 PM revealed the following. DA H was not wearing a beard guard to cover the hair on his face while in the kitchen. DA was reminded that he needed to be always wearing a beard guard in the kitchen. An interview on 7/30/2026 at 2:15 PM with DA G revealed the following. She stated that it is everybody's responsibility for labeling and dating food items in the kitchen. She stated that everybody in the kitchen should always wear a hairnet or something covering their hair when in the kitchen. She stated that if she sees somebody not wearing a hair cover, she will remind them to put it on. She stated that it is everybody's responsibility to clean the drawers where the utensils are kept. She stated that those drawers should be cleaned out once a week. She stated that there is a checklist for things that are completed to clean, but no one uses it. She stated that if these things are not done, then residents could get sick. She stated that she has had in-service training on labeling and dating, kitchen cleanliness, and hairnets. She stated that they do training once a year. An interview on 7/30/2026 at 2:22 PM with DA H revealed the following. He stated that it is everybody's responsibility to be labeling and dating food items in the kitchen. He stated that if he finds out-of-date food items, then he throws them away. He stated that everyone in the kitchen should be wearing hair restraints anytime they were in the kitchen. He stated that he had forgotten to wear his hairnet because he was about to go home and was asked to stay longer. He stated that the drawers where the utensils are kept are cleaned by the cooks. He stated that those drawers are cleaned every two weeks. He stated that there is a check-off list when things are cleaned, but nobody really uses it. He stated that he has had in-service training on labeling and dating, cleaning, and hairnets. He stated the last time he had inservice training was a month ago. An interview on 7/30/2026 at 2:30 PM with CK revealed the following. She stated that it is everybody's responsibility to label and date food items in the kitchen. She stated that all open items should be used by the date on the package. She stated that they check the walk-in cooler daily. She stated that all food items in the cooler should be sealed. She stated that everyone in the kitchen should have all their hair covered. She stated that if she sees somebody not wearing a hair guard, then she will remind them to put one on. She stated that the kitchen drawers where the utensils are kept should be cleaned weekly. She stated that they had been shorthanded, so it was missed. She stated that if these things are not done, then residents could get sick. She stated that she has had in-service training on hairnets, cleanliness, and labeling and dating. She said that she could not remember the last time she had those trainings. An interview on 7/30/2026 at 2:35 PM with DTM revealed the following. She stated that all food items in the kitchen should have an open and used by date on them. She stated that all staff are responsible for labeling and dating food items in the kitchen. She stated that all food items should be sealed and not exposed to air. She stated that everybody in the kitchen is responsible for cleaning, and the drawers with the utensils in them should be cleaned weekly. She stated that all staff should be wearing hair nets in the kitchen. When asked why she was not wearing a hairnet on Tuesday, she stated that she was wearing one. She stated that if these things are not followed, then residents could get sick. She stated that there was a check-off list for when a certain area is cleaned off, but it has not been used. She stated she is going to start making staff use that check-off list when they clean. She stated that she has given in-service to staff monthly about cleaning, hairnets, and labeling and dating. An interview on 7/30/2026 at 2:45 PM with DON revealed the following. He stated that all staff are required to wear hair nets covering any hair that is exposed. He stated that all food items in the kitchen should be labeled with an open and used by date. He stated that staff should clean the kitchen regularly and there should be no debris in the drawers where the utensils are kept. He stated this could cause the residents to get sick if these are not followed. Record review of the dietary services policy & Procedure manual dated 2012 revealed the following. Open packages of food are stored in closed containers with covers or in sealed bags and dated as to when opened. It is the responsibility of the Dietary Service Manager to prepare the daily, weekly, and monthly cleaning schedules. Cleaning schedules are posted at the beginning of each month in the kitchen. Cleaning schedules are to be individualized to the facility, and it is the responsibility of the DM to ensure that the assigned tasks are completed when assigned, and in a thorough manner. The cleaning schedules should be updated routinely to include areas that are noted as needing additional cleaning by the white glove inspection checklist, the sanitation check, DM or administrator walk-through inspections, as well as the kitchen observation audit form that is performed monthly by the dietary manager. Hair nets should always be worn in the kitchen.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three of five residents (Residents #46, #14, #28) reviewed for medication pass. 1) The facility failed to ensure on 07/22/2026 at 8:22 AM that MA B administered Resident #46's medication in a sanitary manner. MA B failed to sanitize his hands and used his bare hands to place all of Resident #46's medications into the medication cup prior to administering the medication. 2) The facility failed to ensure on 07/22/2026 at 8:24 AM that MA B administered Resident #14's medication in a sanitary manner. MA B failed to sanitize his hands and used his bare hands to place all of Resident #14's medications into the medication cup prior to administering the medication. 3) The facility failed to ensure on 07/22/2026 at 8:35 AM that MA B administered Resident #28's medication in a sanitary manner. MA B failed to sanitize his hands and used his bare hands to place all of Resident #28's medications into the medication cup prior to administering the medication. These failures could place residents at risk for developing infections and risk for healthcare associated cross-contamination and infections. Finding included: 1) Review of Resident #46's face sheet dated 07/22/2026 reflected an [AGE] year old female admitted to the facility on [DATE] with the following diagnoses Hypertensive urgency (severe elevation in blood pressure without evidence of organ damage), essential hypertension (high blood pressure), and GERD (chronic heartburn). Review of Resident #46's admission MDS dated [DATE] reflected it was still in progress and not yet completed. Review of Resident #46's base line care plan reflected the resident had a focus area dated 07/20/2026 The resident has hypertension. interventions included give antihypertensive medications as ordered. Observation on 07/22/2026 at 8:22 AM revealed MA B outside of Resident #46's room preparing her morning medication. MA B without washing or sanitizing his hands dispensed Resident #46's medication from the blister packet or bottle into his hand and placed the medication into the medication cup. 2) Review of Resident #14's face sheet dated 07/22/2026 reflected a [AGE] year old male admitted to the facility on [DATE] with the following diagnoses quadriplegia (paralysis of all four limbs), anxiety (a feeling of worry or nervousness), and thrombocytopenia (low blood platelet count). Review of Resident #14's quarterly MDS dated [DATE] reflected he was assessed to have a BIMS score of 15 indicating he was cognitively intact. Resident #14 was assessed to be dependent on staff for all ADLs. Resident #14 was assessed to be taking the following medication types: antidepressant; antibiotic, opioid, antiplatelet and an anticonvulsant medication. Review of Resident #14's comprehensive care plan reflected he had a focus area dated 03/23/2026 for orthostatic hypotension with an intervention to give medications as ordered. Further review of his care plan reflected a focus area dated 03/23/2026 Resident has an alteration in neurological status related to quadriplegia with an intervention to give medications as ordered. Observation on 07/22/2026 at 8:24 AM revealed MA B outside of Resident #14's room preparing his morning medication. MA B without washing or sanitizing his hands dispensed Resident #14's medication from the blister packet or bottle into his hand and placed the medication into the medication cup. 3) Review of Resident #28's face sheet dated 07/22/2026 reflected a [AGE] year old female admitted to the facility on [DATE] with the following diagnoses Type 2 Diabetes (high blood sugar and insulin resistance), Vitamin D deficiency (low calcium and phosphate levels), cirrhosis of the liver (advanced scarring of the liver), dementia (cognitive decline affecting memory, thinking and behavior) and legal blindness. Review of Resident #28's quarterly MDS dated [DATE] reflected that she was assessed to have a BIMS score of 15 indicating she was cognitively intact. Resident #28 was assessed to be taking the following classes of medication: antidepressant, diuretic, opioid, hypoglycemic and anticonvulsant. Review of Resident #28's comprehensive care plan reflected a focus area dated 12/01/2025 Resident has type 2 diabetes mellitus with diabetic polyneuropathy, diabetic retinopathy with macular degeneration.interventions included to give diabetes medication as ordered. Further review reflected a focus area dated 04/02/2026 Resident has an anticonvulsant medication for dementia with mood disturbance . interventions include to give resident medication as ordered. Another focus area dated 12/01/2025 Resident has protein-calorie malnutrition and vitamin D deficiency. Interventions included to administer medications as ordered. Observation on 07/22/2026 at 8:35 AM revealed MA B outside of Resident #28's room preparing her morning medication. MA B without washing or sanitizing his hands dispensed Resident #28's medication from the blister packet or bottle into his hand and placed the medication into the medication cup. In an interview on 07/22/2026 at 10:00 AM MA B stated he did not use hand sanitizer or wash his hands between residents during med pass. He stated he did pop the pills into his hand before placing them in the cup. MA B stated he did not know you were not supposed to touch the pills and that they should go directly into the cup. He stated, that makes sense. In an interview on 07/23/2026 at 10:00 AM the DON stated she expected staff to sanitize their hands before and after medication administration. The DON further stated nurses and medication aides should never touch pills to prevent cross contamination. Review of the facility's policy medication administration and general guidelines dated 2025 reflected The person administering medications adheres to Universal Precautions, using proper hand hygiene, gloves when appropriate, before beginning a medication pass, prior to handling any medication, and after coming into direct contact with a resident. Checklist for completing proper steps in the administration of medications: Washes hands using proper technique; Does not handle pills with bare hands.

Based on observation, interview and record review, the facility failed to ensure the resident had a right to a comfortable and homelike environment for 1-19 residents reviewed for environment.The facility failed to have a TV in Resident #25's room which meant if she wanted to watch TV, she would have to watch what everyone else was watching in the day room.This deficient practice could place residents at risk of a decreased quality of life.The findings include: Review of Resident #25's face sheet revealed the following. She was admitted to the facility on [DATE]. Her primary diagnosis was unspecified dementia, unspecified severity, (general loss of global cognitive abilities-such as memory, problem-solving, and language). She was also diagnosed with the following: type two diabetes (body cannot properly process blood sugar), hyperlipidemia (high concentration of lipids or fats), major depressive disorder (A persistent mood disorder characterized by a sustained low mood, a loss of interest in activities, fatigue, and impaired emotional functioning). panic disorder (overwhelming physical terror and physical responses like a racing heart or shortness of breath), and anxiety disorder (continuous, and intrusive worry or fear regarding everyday situations). Review of Resident #25's Quarterly MDS, dated [DATE], revealed a BIMS score of 4, reflecting that she had severe cognitive impairment. Resident #25's Quarterly MDS showed that she had memory loss, urinary incontinence, behavioral symptoms, and falls. Review of Resident #25's Care plan dated 6/29/2026 revealed that Resident #25 had nothing in her care plan that said that she should not have a TV in her room. An interview/observation on 7/21/2026 at 10:07 AM with Resident #25. Resident #25 was in her room at the time. She was standing in the room looking around at the time. She had difficulty answering some of the questions at the time. She stated she could not remember how long she had been at the facility. During an observation it was revealed that there was no TV in her room. She stated that she likes to watch TV in her room and wishes she had one. She was unable to answer any other questions at the time. An interview on 07/23/2026 at 2:15 PM, CNA E revealed the following. She stated that she did not know why there was no TV in Resident #25's room. She stated that Resident #25 has not been in the facility for long, but she did not know the exact time she has been at the facility. She stated that if she sees something wrong with a resident's room, there is a QR code for maintenance to fix it. She stated that every resident should have a TV in their room so the residents can watch what they want. An interview on 07/24/2026 at 2:20 PM with CNA C. She stated that she did not know that Resident #25 did not have a TV in her room. She stated that she thought all residents were supposed to have a TV in their room. She stated that if residents do not have a TV in their room, then they will not be able to watch what they want and must watch TV in the common area with other residents. An interview on 7/24/2026 at 2:27 PM with LVN A revealed the following. She stated that the resident had not been in the facility for very long. She stated that every resident should have a TV in their room. She stated that if a resident does not have a TV in their room, then they would have to watch what other residents were watching in the common area. An interview on 7/24/2026 at 2:30 PM with the Activity Director. She stated that the resident has been in the facility for about a month. She stated that all residents are supposed to have a TV in their room. She stated that the room that the resident is currently staying in was previously a maintenance storage room. She stated that if a resident does not have a TV in their room, they could become bored and must watch TV in the common area with other residents. She stated that if this happens, she will not get to watch what she wants on TV and must watch what other residents want to watch. She stated that not having a TV in the room is not a home-like environment for the residents. An interview on 7/24/2026 at 3:15 PM with ADM. He stated that he did not know the resident did not have a TV in her room. He stated that all residents should have a TV in their room. He stated that if the resident does not have a TV in the room the resident would have to watch what other residents were watching, He stated that this is not a home environment. He said that they were going to work on getting Resident #25 a TV in her room. Record review of the Resident Rights policy that was not dated revealed the following. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the residents.

Based on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two of eight residents (Resident # 15 and Resident # 28) reviewed for ADL care. The facility failed to ensure Resident #15 and Resident #28's nails were clean on 07/21/2026. This failure could place residents at risk for poor hygiene, dignity issues, and decreased quality of life. Findings include: 1. Record review of Resident #15's face sheet, dated 07/22/2026, reflected a [AGE] year-old-male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #15 had diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (hemiplegia- resident is completely paralyzed related to a stroke in the right side of the brain. Hemiparesis- partial weakness on the left side of the body from a stroke. The right side of the brain controls the left side of the body. Since the damage is on the right side, the left side of the body is impaired), and type 2 diabetes mellitus with diabetic neuropathy, unspecified (a lifelong medical condition where your body cannot use insulin the right way or make enough of it, causing too much sugar to stay in your blood. Diabetic neuropathy- is nerve damage and the type of nerve damage was not defined by medical professional).Record review of Resident #15's Quarterly MDS Assessment, dated 05/24/2026, reflected Resident #15 had a BIMS score of 10, which indicated his cognition was moderately impaired. Resident #15 required assistance with one staff for hygiene (helper does more than half the effort). Record review of Resident #15's Comprehensive Care Plan, completed on 06/12/2026 reflected Resident #15 had ADL Self Care Performance Deficit. Intervention: Personal hygiene- Resident #15 required 1 staff assistance. Bathing: check nail length- trim and clean on bath day and as needed. Observation and interview on 07/21/2026 at 10:42 a.m. revealed Resident #15 was in his room lying in bed watching television. Underneath Resident #15's fingernails on his right hand of his forefinger, middle and ring finger was a blackish/ brownish substance. He stated, I don't know. when asked about if staff cleaned his fingernails. Resident #15 stated he was unable to clean or trim his own fingernails. He stated he did not remember if he reported to anyone that his nails needed to be cleaned. He did not respond to any further questions about his ADL care of his fingernails. 2. Record review of Resident #28's face sheet, dated 07/22/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #28 had diagnoses which included type 2 diabetes mellitus with unspecified complications (a chronic condition where the body cannot use insulin properly or make enough insulin but the specific problems were not detailed in the medical record), and legal blindness as defined in USA (not total darkness or a complete lack of sight- a person must stand 20 feet away to see what a person with normal vision sees from 200 feet away).Record review of Resident #28's Quarterly MDS Assessment, dated 06/05/2026, reflected Resident #28 had a BIMS score of 15, which indicated her cognition was intact. Resident #28 required partial/ moderate assistance with hygiene (helper does less than half the effort).Record review of Resident #28's Comprehensive Care Plan, dated 06/01/2026, reflected Resident #28 had an ADL self-care performance deficit. Interventions: Personal Hygiene: Resident #28 required supervision with personal hygiene. Bathing: check nail length, trim, and clean on bath day and as needed.Observation and interview on 07/21/2026 at 11:10 a.m., revealed Resident #28 was lying in bed watching television. Underneath Resident #28's fingernails on her right hand of her middle and ring fingers was a blackish/brownish substance. Resident #28 did not want to answer any questions.In an interview on 07/23/2026 at 9:15 a.m., CNA E stated if a CNA observed any problems with a resident's nails, the CNA was to report it to the nurse supervisor with any resident. CNA E stated the CNAs completed all nail care for residents without a diabetes diagnosis. She stated if there was a blackish substance on the residents' fingertips or underneath their nails, and the resident swallowed the blackish substance, there was a possibility a resident may become ill, such as nausea and diarrhea. CNA E stated she was in-serviced on cleaning, filing, and trimming residents' nails but she did not recall the date. CNA E stated anytime a resident refused any type of care she reported it to the charge nurse and the charge nurse would document it in the resident's medical record. CNA E stated she had given some care to Resident #28 and Resident #15, however, she stated they did not refuse nail care. She stated she was not aware of Resident #15 and Resident #28's shower schedules. CNA E stated she was not assigned to Resident #15 or Resident #28 on 07/21/2026. In an interview on 07/23/2026 at 9:30 a.m., LVN A stated nail care was usually completed during showers, and as needed. LVN A stated if a resident had brownish/blackish substance underneath their nails, and if a resident swallowed the substance, there was a possibility a resident may become ill, such as an infection in the stomach. She stated there was a possibility a resident may have nausea and vomiting. She stated if a resident refused showers, nail care, or any type of care, the nurses documented it in the nurse's progress notes. LVN A stated she was in-serviced on ADL care, and all staff were to report any nail issues with the resident to the nurse. She stated she was not aware of Resident #28 or Resident #15 refusing nail care. LVN A stated the nurses completed all diabetic fingernail care and the CNAs completed the nail care on all residents without a diagnosis of diabetes.In an interview on 07/23/2026 at 11:30 a.m., the Director of Nurses stated the CNAs were responsible for cleaning and trimming all residents' nails, except for the residents with diabetes. She stated the nurses were responsible for nail care of all residents with a diagnosis of diabetes. The Director of Nurses stated the residents' nails were usually cleaned during showers and as needed. She stated if a resident ingested the blackish/brownish substance underneath their nails, there was a potential the resident may experience vomiting or diarrhea. The Director of Nurses stated it depended on the type of bacteria if a resident needed to be assessed at the Emergency Room. She stated anytime there was an issue with nails the CNAs was to report it to the nurse supervisor. The Director of Nurses stated any refusal of care would be documented on the resident's care plan.In an interview on 07/23/2026 at 10:45 a.m., CNA F stated if a CNA observed any problems with a resident's nails the CNAs was to report it to the nurse supervisor with any resident. CNA F stated the CNAs completed all nail care for residents without a diabetes diagnosis. She stated if there was a blackish substance on the residents' fingertips or underneath their nails and the resident swallowed the blackish substance there was a possibility a resident may become ill, such as nausea and diarrhea. CNA F stated she was in-serviced on cleaning, filing, and trimming residents' nails but she did not recall the date. CNA F stated anytime a resident refused any type of care she reported it to the charge nurse and the charge nurse would document it in the resident's care plan. CNA F stated she had given some care to Resident #28 and Resident #15, however, she was not aware of these residents refusing nail care. She stated she was not aware of Resident #28 or Resident #15's shower schedules. CAN F stated she was not assigned to Resident #28 or Resident #15 on 07/21/2026.Record review of the facility's Nail Care Policy, not dated, reflected Nail management is the regular care of the toenails and fingernails to promote cleanliness, and skin integrity of tissues, to prevent infection, and injury from scratching by fingernails or pressure of shoes on toenails. It includes cleansing, trimming, smoothing, and cuticle area and is usually done during the bath. Nail care will be performed regularly and safely. The resident will be free from infection.

Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one of three residents reviewed for catheter care (Resident #2) The facility failed to ensure Resident #2's suprapubic catheter was secured to his body with a catheter secure device which was observed to be missing 07/22/2026. This failure could place residents with urinary catheters at risk for traumatic removal and catheter acquired infections. Findings included: Review of Resident #2's face sheet dated 07/23/2026 reflected he was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses urinary tract infection, and disorder of the penis. Review of Resident #2's quarterly MDS assessment dated [DATE] reflected he was assessed to have a BIMS score of 15 indicating he was cognitively intact. Resident #2 was assessed to have an indwelling catheter. Review of Resident #2's comprehensive care plan reflected a focus area dated 08/22/2024 [Resident #2] has an indwelling Supra pubic Catheter related to Urinary Retention. This catheter will possibly result in long term use due to bladder wall thickening with multiple diverticula and bilat Hydroureter causing chronic bladder outlet obstruction or neurogenic bladder. Interventions included Assess urine every shift and document. Notify MD/NP as needed. has 16F 10cc bulb. Position catheter bag and tubing below the level of the bladder and away from entrance room door. Monitor/document for pain/discomfort due to catheter. Provide foley catheter care q shift the plan of care did not address placement of a catheter secure device. Observation on 07/22/2026 at 2:28 PM revealed Resident #2 in room to have catheter care performed. LVN A removed Resident #2's cover and brief to reveal he had a supra pubic catheter. No catheter secure device was in place, and tension was observed in the tube as it hung over onto the bed from his stoma (site of catheter entry in the stomach). In an interview with LVN A on 07/22/2026 at 2:29 PM she stated Resident #2 should have a catheter secure device in place to prevent the tube from pulling. She stated she was responsible for ensuring the device was in place. She stated she did not know he did not have one and she would make sure he got one. In an interview on 07/23/2026 at 10:06 am the DON stated she expected all residents with urinary catheters to have catheter secure devices in place to prevent dislodgement or infection. Review of the facility's policy Catheter Care (not dated) reflected General Guidelines:. Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks. Keep tubing off floor and minimize friction or movement at insertion site. The facility policy did not directly address catheter secure devices or other methods to secure the catheter.

Based on observations, interviews, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 3 medication carts (Medication Cart #1) reviewed for medication storage.The facility failed to ensure Medication Cart #1 were locked and medications were secured and not accessible to other staff, residents, or visitors.This failure could place residents at risk of having unauthorized access to prescriptions, biologicals, and over-the counter medications. Findings included:Observation on 05/12/2026 at 4:40 p.m. revealed the locking mechanism protruding outward (indicated the medication cart was unlocked) on Medication cart #1 at the end of 400 hall. There was no nurses on the hall. In an interview on 05/12/2026 at 5:30 p.m. LVN B stated he forgot to lock medication cart when he exited 400 hall and entered another hall. He stated all medication carts were to be locked except when a nurse was obtaining medications from the cart. LVN B stated if a resident did ingest medications such as inhalers or any type of medications there was a possibility resident was allergic to the medications and may need to be transferred to the hospital for further evaluation. He stated there were needles on the medication cart and a resident could obtain a needle and hurt themselves or another resident. He stated he had been in-serviced on locking medication carts; however, he did not recall the date of this in-service. LVN B stated there were all types of inhalers, insulin and some medications on the cart.In an interview on 05/12/2026 at 4:50 p.m. the Director of Nurses stated her expectation was for all medication carts to be locked when the nurse was not administering medications. She stated the staff had been in-serviced on securing the medication carts when not in use. The Director of Nurses stated she did not know the exact date of the in-service. She stated residents, other staff, and visitors would have access to the medications in the unlocked medication cart. She stated if a resident ingested medications not prescribed to them; there was a potential the resident may have an allergic reaction or may need to be admitted to the hospital. She stated it was the nurse or Medication Aide's responsibility to ensure the medication cart was locked when not dispensing a resident's medication. The Director of Nurses stated she was responsible for monitoring the nurse supervisors.Record review of the facility's Policy on Medication Cart Security and Locking Procedures, not dated, reflected Medication carts must remain locked at all times when not actively in use. This includes during resident care, charting breaks, and any time the nurse or medication aide steps away.

Based on observation, interviews and record review, the facility failed to ensure residents had the right to be free from exploitation and misappropriation of property for one of four residents (Resident #1) reviewed for misappropriation of resident property.The facility failed to prevent a diversion (misappropriation) of Resident #1's Hydrocodone Oral Tablet 10-300 mg, 38 pills reported missing on 05/07/2026. Hydrocodone was used to treat pain.This failure could place residents at risk for decreased quality of life, unrelieved pain, and dignity.Findings included:Review of Resident #1's face sheet printed 05/12/2026 reflected a [AGE] year-old male admitted to the facility 02/02/2026. His diagnoses included unspecified subluxation of right patella subsequent encounter partial kneecap dislocation- considered serious, debilitating injury that requires medical evaluation-causes severe pain) and anxiety disorder (a group of treatable mental health conditions characterized by excessive, persistent, and uncontrollable fear, dread, worry that interferes with daily life.Review of Resident #1's first assessment since the most recent admission /entry MDS, dated [DATE], reflected Resident #1 Section C was not required to be filled out on this type of MDS assessment. Resident #1 had short term memory recall. He had some difficulty making decisions in new situations. He received PRN pain medications.Review of Resident #1's comprehensive care plan, dated 03/26/2026, Resident #1 was on pain medication therapy related to unspecified subluxation of right patella subsequent encounter. Interventions: Administer medication as ordered. Observe for adverse reactions with ever interaction with the resident. Monitor for increased for falls.Review of Resident #1's physician order reflected a supply last order date was on 4/24/2026 and was revised on 05/07/2026 of Hydrocodone- Acetaminophen oral tablet 5-325 mg give 2 tablets by mouth every 6 hours as needed for pain. This was discontinued.Review of Resident #1's physician order reflected supply last order date was on 05/07/2026 and revision date was 05/07/2026 of Hydrocodone- Acetaminophen 10-325 MG give 1 tablet by mouth every 4 hours as needed for pain.Review of Resident #1's physician order reflected supply last order was on 04/25/206 and revision date 5/7/2026 Hydrocodone- Acetaminophen Tablet 10-300 MG. Give one tablet by mouth every 6 hours as needed for pain. This was discontinued ( does not indicate the discontinue date)Review of the Provider Investigation Report dated 05/11/2026 reflected, it was discovered on 05/08/2026 that 38 hydrocodone's were unaccounted for, along with the count sheet that goes with the narcotics. The Facility immediately followed drug diversion protocol:Self-report completed 05/08/2026Staff that could have potentially been involved have been interviewed and all have been drug tested.Residents were interviewed regarding if they have received doses as documented on the narcotic medication log.Card count sheet has been initiatedCounts have been verified for every controlled drug in the facility.Narcotic shift change sheets have been auditedMedical Director, pharmacy consultant, and policy have all be notified. Police report #2605-02809.Nursing staff have been in-service related to controlled medication counting procedures; counting with oncoming nurse, logging individual controlled dose at the time of medication administration, abuse and neglect.Narcotics were delivered on 04/24/2026, resident ( Resident #1) was administered two doses before going to the hospital on [DATE]. Resident ( Resident #1) returned from the hospital on [DATE].Interviews with staff reveal that the count sheet was verified and accounted for prior to the time it went missing.Residents interviewed verified that they have been receiving doses as documented on the narcotic medication log.Drug test results reveal that no nurse had tested positive for the narcotic that was missing.Other parties notified: physician, pharmacy and police.The facility was unable to locate the missing narcotics.Staff interviews did not identify an eyewitness to the medications being taken. The facility could not identify anyone with access to the carts besides those designated to be on their designated shifts. The pharmacy confirmed delivery of 40 tablets on 04/26/2026. Record review in conjunction with the questioning of [Resident #1] reflected on 05/07/2026 LVN C noticed Resident #1 did not have Hydrocodone in the medication cart. She contacted the physician and received an order for Acetaminophen with codeine 300-60 mg ordered 5/6/2026 d/c 5/7/2026 related to Resident #1 was in pain. Review of Resident #1's medication administration record for May 2026, reflected Resident #1 did not miss a dose of Hydrocodone- Acetaminophen 10-300 mg except for 5/6/2026 and he received another medication for pain.Review of Resident #1's clinical records reflected pain assessment for 05/06/2026 through 05/12/2025 was conducted on Resident #1 and his pain level was from 6-8 on the scale , 10 being the worst pain.Observation on 05/12/2026 of the 500-hall nurse's narcotics book and cart, 100, 200 and 400-halls medication aide narcotics book and cart revealed all medications and blister packets were correct per the narcotic count by the staff. During an interview on 05/12/2026 10:00 am, Resident #1 stated he did not have concerns of not getting his pain medications. Resident #1 stated all was well with his medications. Resident #1 stated the pain medications the nurses give him helps him with his pain. Resident #1 stated when he returned from hospital he did receive a different pain medication the doctor ordered for one or two times, and he stated it did help with his pain. He stated the staff ensured whenever he asks for pain medication and it was time for him to have a pill they always give it to him and he appreciated them being fast in getting his pain under control with the pills.Review of facility's Pharmacy record on 05/12/2026, reflected the facility did receive 40 tablets of Hydrocodone tablets 10- 300 mg on 04/24/2026 Interview on 05/12/2026 about 11:25 am, the DON stated Resident #1's had pills of hydrocodone that was delivered on 04/24/2026 and 38 of those pills were missing night of 05/07/2026. The DON stated there was no evidence of the count sheet. The DON stated she called the pharmacy for refill of Resident #1's hydrocodone and the medication was refilled and delivered to the facility on [DATE]. She stated Resident #1 was in the hospital from [DATE] and returned on 5/6/2026. She stated when he returned from hospital was when LVN C noticed the hydrocodone was missing in the medication cart and she called the physician to obtain pain medication from the emergency kit. The DON stated this order was only for 1 or 2 days. She stated on 5/7/2026 during change of shift was when LVN D and LVN E was notified from LVN C of Resident #1's hydrocodone was missing from the medication cart. She stated LVN D and LVN E began searching the medication carts and looked at everyone's medication to determine if the medication was misplaced with another residents medication. The medication was not found. She stated LVN D did text her on 05/07/2026 and stated he needed to talk to her as soon as she came to the facility. DON stated when she entered the facility on 05/07/2026 she went to a meeting and during the meeting LVN D came to the door and asked her to leave the meeting. She stated this was when the facility investigation began on the missing hydrocodone. DON stated all medication carts was searched again and they began drug testing on all the nurses who had access to the medication cart. She stated the results of the drug testing was negative of any staff having hydrocodone. She stated they immediately began services and interviews with staff. The DON stated with the investigation LVN C and LVN D stated last time they saw the hydrocodone in medication cart was on Sunday 05/05/2026. She stated when the nurses counted narcotics they reviewed the count on the form but did not actually look at the medication blister card. She stated they have changed the system of counting narcotics. DON stated all nurses was to actually look at the blister card with the medication in the card and count the pills in the card and sign that the medication was in the medication cart. She stated LVN F stated last time she saw Resident #1's hydrocodone was the last time she worked on 05/06/2026 and the count was correct on 05/06/2026. The DON and surveyor reviewed the facility policy on Medication Administration. The policy reflected Medication errors and adverse drug reactions are immediately reported to the resident's Physician. In addition, the Director of Nurses and or designee should be notified of any medication errors. Any medication error will require a medication error report that includes the errors and actions to prevent the occurrence. The DON stated LVN C did not follow the facility policy. She stated LVN C was expected to contact DON, Administrator and Physician immediately when she found the hydrocodone was missing. The DON stated the former way of counting the controlled drugs form was not following the facility policy. She stated the nurses was not capturing everything we do on the form. She stated on the old form it is not documented of the actual narcotics being counted. The nurses was not looking at the blister card to count the narcotics. She stated without looking at the actual medication it is difficult to determine how long the hydrocodone was missing due to Resident #1 was in the hospital and his medications was not being administered. Attempted to call the Physician on 05/12/2026 at 12:46 pm and the physician stated she was not in the position to talk. She did not return surveyors phone call.Interview on 05/12/2026 approximately 12:45 pm LVN D stated when he entered the facility on 05/07/2026 and he received report from LVN C, and he did count medications with her. He stated every medication was accounted for according to the sheets that was in the narcotic book . He stated LVN E was with him when the medications was counted with LVN C. He stated LVN C mentioned when she began to give Resident #1 his hydrocodone she noticed the medications was not in the medication cart. LVN D stated she had called the Physician to get a order for a pain medication from the emergency kit. He stated he had worked on the weekend, and he did see Resident #1's hydrocodone on the medication cart on Sunday 05/05/2026. He stated Resident #1 was in the hospital. He stated he text the DON ad stated he needed to talk to her and it was urgent. (he did not have his phone with him to show the text). LVN D stated I suspected the hydrocodone was missing and the narcotic sheet for the hydrocodone was also missing. He stated when the DON entered the facility on 05/07/2026 she went to a meeting, and he asked her to leave the meeting he needed to speak to her as soon as possible. He stated the DON and the former Administrator began the investigation of the missing Hydrocodone. LVN D stated Resident #1 did not complain about being in pain and he was satisfied with the pain medication ordered on 05/06/2026. He stated the pharmacy system was not working and it did take until early Friday 05/08/2026, before Resident #1 did receive his hydrocodone. LVN D stated he was administered another pain medication until the hydrocodone arrived on 05/08/2026 to the facility. He stated he did take a drug test and was inserviced on drug diversion. LVN D stated a new system was put in place immediately when counting narcotics during change of shift. He stated the new system was more effective than the old system. He stated the nurses was required to actually look at the medications and do the count and the old system of counting narcotics was not required to actually look at the medication.Interview on 05/12/2026 at 1:30 pm LVN C stated she counted medications with LVN G on Monday (05/04/2026) and Resident #1's hydrocodone was in the medication cart. She stated Resident #1 was in the hospital and he did return from the hospital on [DATE]. She stated when Resident #1 returned from the hospital and the night of 05/06/2026 approximately 9:00 pm Resident #1 began to complain about being in pain. She stated at this time is when I noticed his ( Resident #1) hydrocodone was missing. She stated she did not believe any one had stole the hydrocodone and believed the DON had taken the hydrocodone out of the medication cart related to Resident #1 being in the hospital. She stated she did not think about calling the DON or anyone about the missing hydrocodone. LVN C stated she did contact the Physician and ordered pain medication in the emergency kit. She stated Resident #1 pain subsided after he was administered pain medication. LVN C stated he did not complain about being in pain the rest of the night. She stated she looked at another Resident in the hospital to determine if her narcotic medication was taken off the cart and her narcotic medication was still on the medication cart. She stated she did not know what to think about Resident #1's missing hydrocodone. She stated she continued working and did not think anything about the missing medications. She stated now she realized she was expected to call the DON Administrator immediately, but she did not want to wake anyone up about the situation. LVN C stated she did take a drug test, and she was in-service on reporting missing medications and medication errors. LVN C stated she was suspended from the facility until the facility completed investigation. She stated she continued to be suspended.Interview on 05/12/2026 approximately 1:50 pm LVN E stated the last time he saw Resident #1's hydrocodone was on Sunday (05/03/2026). He stated when he entered the facility for duty on 05/07/2026 is when LVN C stated Resident #1's hydrocodone was missing. LVN E stated they ( LVN D ) began looking in every medication cart attempting to locate the hydrocodone. He stated the narcotic sheet was also missing. LVN E stated LVN D sent a text to the DON he needed to talk to her as soon as possible. LVN E stated the hydrocodone was not in any of the medication carts. He stated when the DON came to the facility an investigation began and all nursing staff was interviewed , in serviced on drug diversion and received a drug test. LVN E stated a new system was in place when counting narcotics and it was a better system. He stated the staff was required to actually look at the medication. He stated he did not have anything else to add to the situation of the missing narcotic. Interview on 05/12/2026 at 5:00 PM LVN G stated she was off on 05/05/2026 and returned to work on 05/07/2026. She stated when she returned to work on 05/08/2026 was when she was notified of the missing hydrocodone. She stated she did work on 05/04/2026 and received report from LVN C. LVN G stated I did a narcotic count with LVN C, however, I do not recall if the hydrocodone was missing on 05/04/2026. She stated she did not remember. LVN G stated she was given a drug test and in-service on the new form to use when counting narcotics and drug diversion. She stated she needed to take care of her children and did not have anything to add about the situation of the missing hydrocodone. Review of the facility's AD Hoc QAPI meeting was held on 05/08/2026 related to the diversion of medications. The former Administrator, DON, Adon, Medical Director , Social Worker and Activity Director was in attendance.Review of the facilities in-service dated 05/08/2026 given by the Director of Nurses reflected an in-service titled :Controlled medication counting proceduresCounting with oncoming nurseLogging individual controlled dose at the time of medication administration. Review of interviews with interview able ( not dated when the interviews was conducted with the residents) Residents reflected all residents stated they did receive the correct medications. Signed by the DON. Reviewed LVN C personnel record on 05/12/2026 reflected LVN C was suspended until facility completed investigation.Record review of the facility's policy of Controlled Medications, revised on 04/06/2026 reflected Medications included in the Drug Enforcement Administration classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility, in accordance with federal and state laws and regulations. Procedure:At each shift change, a physical inventory of all controlled medications is conducted by two licensed nurses and or one nurse and a CMS, QMAP, Med Tech or equivalent as allowed by your State regulatory agency and is documented on the audit record. Alternatively, the shift change audit may be recorded on the accountability record if there is a designated column for the audit.Current controlled medication accountability records and audits records are kept on the medication cart, either in the MAR or in a separate folder. When completed, audit and accountability records are submitted to the Director of Nursing and kept on file for three years at the facility.Any discrepancy in controlled substance medication counts is reported to the Director of Nursing immediately. The Director of Nursing or designee investigates and makes every reasonable effort to reconcile all reported discrepancies. The Director of Nursing documents irreconcilable discrepancies in a report to the Administrator. If a major discrepancy of a pattern of discrepancies occurs or if there is apparent criminal activity , The Director of Nursing notified the Administrator and the Consultant Pharmacy immediately. A determination will be made by the Administrator, the Consultant Pharmacist, and the Director of Nursing concerning possible notification of police or other enforcement agencies and any other actions to be taken.Controlled medications are not surrendered to anyone, including the resident's physician; other than releasing controlled medications for a resident on pass or therapeutic leave. However, controlled medications may be surrendered to DEA or other law enforcement officials functioning in a professional capacity in exchange for a receipt documenting the transaction.Controlled medications remaining in the facility after the order has been discontinued are retained in the facility, in a securely locked area with restricted access, until destroyed by the facility Director of Nursing, Administrator, and Consultant Pharmacist; or as otherwise directed by state and federal law.Safety of the facility personnel and residents is to be assured in the event of an intruder entering into the facility for the purpose of stealing controlled medications. This may necessitate surrendering medications if bodily harmed is threatened. The local public safety agency, the Administrator, and the Director of Nursing ore notified immediately in that order once the intruder has gone.

Based on observation, interviews, and record reviews the facility failed to ensure the facility remained free of accidents and hazards a for one of two housekeepers carts (Housekeeping Cart #1) reviewed for hazards.The facility failed to ensure Housekeeping Cart #1, with chemicals inside the compartments, was locked when unsupervised. The housekeeping cart was located on 400 hall in front of room [ROOM NUMBER]. This failure could place residents at risk for injuries, illness, and hospitalization.Observation on 05/12/2026 at 9:03 am Housekeeping Cart #1 was located in front of 405 room. The compartment where chemicals were stored was not locked. The compartment had micro-kill bleach, disinfectant cleaner, Clorox, and two bottles filled with chemicals without a label on the bottles. Housekeeper G was not standing near the housekeeping cart. She exited room [ROOM NUMBER] at 9:00 a.m. and walked to the housekeeping cart and was standing beside surveyor. There were not any residents or staff in hallway when observation was made of the housekeeping cart #1 was unlocked.During an interview on 05/12/2026 at 9:10 a.m., Housekeeper A stated the housekeeping cart was expected to be locked anytime housekeeper walked away from the cart. Housekeeper A stated she could not see Housekeeping Cart #1 from inside the 405 room and the door was partially closed. She stated there was a possibility that if a resident drank some of the chemicals the resident may become sick with stomach issues or have an allergic reaction. She stated it was possible a resident may need to be evaluated at the hospital. Housekeeper A stated all chemicals were required to have labels on the bottles. She stated she did have a key to the housekeeping cart. Interview on 5/12/2026 at 9:25 am, the Housekeeping Supervisor stated all housekeeping carts were expected to be locked anytime the housekeeper was not standing in front of the cart. The Housekeeping Supervisor stated if a resident ingested some chemicals there was a potential for an allergic reaction, such as burning their throat, stomach and may need to be assessed at the hospital. She stated all housekeeping staff was in-service on locking housekeeping carts. She stated there was a possibility if a resident spilled chemical on their skin it may cause irritation to the skin. Review of the administrative staff on 5/12/2026 schedules reflected the Administrator was no longer an employee at the facility. Her last day was on 5/11/2026. Review of the Facilities Daily Common Area Cleaning, not dated, reflected Housekeeping carts/chemicals must be locked when not within the eyesight of a staff member.

Based on observation, interview and record reviews the facility failed to ensure that licensed nurses have the specific competencies, and skill sets necessary to care for residents' needs for 1 (LVN A) of 3 staff reviewed for nursing competency assessments after a fall for Resident # 1.The facility failed to ensure LVN A assessed Resident #1 for injuries after a fall. This failure could potentially affect the residents by placing them at risk for injuries. Findings include: Record review of Resident #1's face sheet, dated 09/19/2025, revealed Resident #1 was an [AGE] year-old-female who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: Alzheimer's disease (a progressive brain disorder that destroys memory and thinking skills, leading to the inability to perform the simplest daily tasks), other specified bone density and structure, unspecified site (a bone disorder that changes the bone's density or structure but without a specific location or site being identified) and, secondary hypertension (high blood pressure that is caused by another medical condition). Record review of Resident #1's Quarterly MDS Assessment, dated 09/04/2025, reflected Resident #1 was rarely/never understood. She had poor short- and long-term memory recall. She had disorganized thinking (rambling and irrelevant conversation). Resident #1 required partial/moderate assistance with transfers (helper does more than half the effort). Resident #1 had a history of falls. Record review of Resident #1's Comprehensive Care Plan reflected (problem initiated on 11/16/2022) Resident #1 was at risk for falls related to unaware of safety, lack of coordination (difficulty controlling one's movements to be smooth, balanced, and purposeful). Record review of the facility's in-service on fall protocol on 06/23/2025 given by the Administrator reflected LVN A attended the in-service meeting, and the fall policy was reviewed during the in-service. Observation and interview on 09/19/2025 at 10:15 AM Resident #1 was propelling herself in the common area of the facility leading into the dining room. She did not respond to any questions about her recent fall. Resident #1 made eye contact and continued to propel herself in the common area. Interview on 09/19/2025 at 9:40 AM LVN A stated she was informed on 08/27/2025 by CNA B Resident #1 was on the floor in Resident #1's room. LVN A stated she entered Resident #1's room and observed Resident #1 on the floor beside her wheelchair. She stated Resident #1 had some blood from a cut on Resident #1's head. LVN A stated she instructed CNA B to transfer Resident #1 from the floor to the bed. She stated she assessed Resident #1 from head to toe and completed vital signs after Resident #1 was in bed. LVN A stated she was expected to complete head to toe assessment and vital signs prior to transferring Resident#1 from the floor to the bed. She stated she forgot to assess Resident #1 prior to moving her from the floor. LVN A stated it was the protocol for residents not to be moved from the floor or anywhere after a fall until the resident is assessed head to toe and staff obtain vital signs. She stated a resident may have a broken bone or some other type of injury and nurses were expected to do complete assessments before moving a resident. LVN A stated she did not follow the proper protocol. She stated she had watched videos and received in person training on what the nurses were expected to do when assessing a resident after the fall. LVN A stated she had been instructed not to move a resident until after gathering information such as vital signs and complete head to toe assessment. LVN A stated the last time she was in-service was in June or July of 2025. She stated she was unsure what may happen to a resident after a fall if they were transferred prior to completing assessments. She stated she was having a stressful day the day Resident #1 fell. Interview on 09/19/2025 at 10:20 AM CNA B stated LVN A did not complete vital signs or head to toe assessment on Resident #1 until after Resident #1 was transferred from the floor to the bed. CNA B stated she had been in-serviced on fall protocol, and she learned to follow the nurses' directions. Interview on 09/19/2025 at 1:30 PM the Director of Nurses stated anytime a resident is found on the floor after a fall the nurse's best practice was not to move the resident until a head-to-toe assessment is completed and vital signs are obtained by the nurse. She stated the head-to-toe assessment includes but not limited to check for injuries of the skin, any pain near bone areas, movement of extremities, any abnormal position of extremity and any change of condition. She stated the following vital signs were expected to be obtained prior to moving resident after a fall: blood pressure (a number representing the pressure when the heart beats and when the heart rests between beats), respiratory rate (the number of breaths a person takes per minute), heart rate (the speed at which the heart beats, and O2 stats (percentage of oxygen in the blood). She stated LVN A was expected not to give directions to CNA B to move Resident #1 from the floor to the bed. She stated LVN A did not follow proper fall protocol. She stated she did not recall the last in-service given on fall protocol. The Director of Nurses stated anytime fall protocol in-service was given the facility policy was given to each employee and they review the policies. She stated the expectations of assessing residents and obtaining vital signs prior to moving the resident was discussed in the in-services. Interview on 09/19/2025 at 3:20 PM, The Hospice Physician stated assisting a resident from the floor to the bed prior to completing head to toe assessment or vital signs was very unlikely for the resident to obtain any type of injury or fracture. She stated she was familiar with Resident #1, and she does have a history of falls. Interview on 09/19/2025 at 3:32 PM, The Medical Director Doctor stated in her opinion if a resident was transferred from the floor to the bed prior to the nurse completing head to toe assessment or receiving vital signs, this would not result in a fracture or injury. She did not have an issue of the assessments being completed after transfer from the floor to the bed. Record Review of the Facility's Policy on Competency Nursing Job Description, dated 2014, reflected knowledge base:Ability to organize workflow, respond to emergencies.Give directions to Nurses' Aides for appropriate care of residents.Implement established nursing policy and procedures, educating support staff regarding care needs of residents. The ability to effectively multi-task and work in a stressful environment are also essential functions to this job. Record Review of the Facility's Policy of Falls, not dated, reflected in instances where fall risks do not prevent a fall, the resident will be assessed immediately for injury. Vital signs and first aid measures will be completed immediately.

Based on observations, interviews, and record reviews, the facility failed to provide adequate supervision for 1 of 5 residents reviewed for accidents and supervision. (Resident #1)The facility failed to ensure Resident #1 received adequate supervision to prevent elopement. On 08/07/2025 at an unknown time Resident #1 eloped from the facility by reading the door code that was placed by the door and let herself out the front door. Resident # 1 was found by CNA A standing on the front porch when she left work between 6:30PM and 7:00PM. The non-compliance was identified as past non-compliance. The immediate jeopardy began on 08/07/2025 at 6:50 PM and ended on 08/08/2025 2:20 PM .The facility had corrected the noncompliance prior to the start of the survey. The facility had implemented corrective actions and returned to compliance before the investigation began. This failure had the potential to affect other residents and could result in residents not receiving appropriate supervision, placing them at risk for serious injury, harm, or death.During an observation on 08/13/2025 at 11:00 AM all exit doors were checked and locked and equipped with functioning alarms. Additionally, the outside of the entrance door had a sign stating , Please do not let Resident or person not in your party out of front door. The front door code was only posted from outside the door and written in words instead of numbers. Record review of Resident # 1's face sheet (unknown date) reflected an [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of dementia with severe other behavior disturbance (memory decline with acting out). Record Review of Resident #1's MDS quarterly assessment, dated 05/17/2025, reflected Resident #1 BIMS score of 10 which indicates a moderate cognitive impairment. Section C Cognitive - pattern reflected short -term memory loss.Record review of Resident #1's care plan dated 05/07/2025, reflected The resident is at risk for wandering; INTERVENTION: Provide structured activities: toileting, walking inside and outside, reorientation, strategies including signs, pictures and memory boxes. The resident is risk for falls r/t hx of falling and INTERVENTIONS: The resident needs activities that minimize the potential for falls while providing diversion and distraction, Resident resides in the Secure Care Unit, related to diagnosis of dementia (or related diagnosis) and risk for elopement. INTERVENTIONS: Admit to Secure Care unit per MD orders, allow resident to perform ADLs to their highest ability, offer assistance as needed, Assist and monitor resident for off unit activities if able and Engage resident in group activities and provide them with individualized meaningful activities.Review of Resident #1's incident report dated 08/07/2025 at 6:30PM reflected Resident walked out front door was seen by a CNA when they were leaving the building after their shift, CNA attempted to redirect resident back to the building, redirection unsuccessful, CNA came to get this nurse, and we assisted resident back inside. Immediate action: Resident to reside on secure unit due to history of elopement with active exit seeking behaviors. Vital sign as follows: BP 158/80 Temp 97.7 HR 68 RR 17 O2 98%. Physician, DON, Administrator and RP notified. Record review of a written interview given by ADM on 08/07/2025 to Resident # 1 and signed by Resident #1 and witnesses by CNA A , in a question-and-answer format reflected, [ADM question]: were you trying to go somewhere earlier when you went out the front door. [Resident #1 answer] I went outside. [ADM question] yes, you went outside and was found right outside the front door. Were you needing anything that causes you to go outside? [Resident #1 answer] Well, no, not that I can think of. [ADM question] Are you doing ok right now do you need anything? [Resident #1 answer] I'm fine, thank you for asking. During an observation and interview with Resident #1 on 08/13/2025 at 12:15 PM revealed her walking around in the secure unit with an ink pen in her hand and asked for some paper to write on. Resident #1 was asked her name by Surveyor, and she stated her name and began to repeat yes are you here for me. Therefore, an interview with Resident # 1 was not completed. During an interview with CNA A on 08/13/25 at 1:00 pm, she stated she was leaving for work approximately at 6:30 PM and she observed Resident # 1 standing on the front porch of the facility. She stated Resident #1 was not walking and standing in one spot. She stated she asked Resident # 1 to come back in and she refused. Therefore, she opened the front entrance door to ask for help to MA B, but he could not hear her, so she ran back into the building and told the charge nurse (LVN A) Resident # 1 was outside and she would not come in. She stated LVN A came outside with her to assist, and Resident #1 had walked to unit 200 covered patio area . She stated she could not remember if Resident # 1 was sitting or standing on the patio; however, LVN A was able to get her to come back into the building. She stated Resident # 1 was assessed by LVN A. She stated Resident #1 knew how to read numbers, and it was possible she let herself out or she went out the door when a visitor left. She stated Resident #1 use to leave on the secure unit, but she was moved out because she was not showing exit seeking behaviors. An interview on 08/13/2025 at 1:30 PM with LVN A was attempted by phone; however, she did not answer, and a voicemail was left for her to return my call. During an interview with RP on 08/13/2025 at 2:00PM, she said she was okay with Resident #1 moving to the unsecure unit, but she knew the elopement was going to happen eventually. She stated she wanted to give Resident #1 a chance to prove her wrong ; however, she believed Resident #1 read the pin code instructions and let herself out the front door. She said the facility did call her the day of the incident (08/07/2025) and made her aware that Resident # 1 eloped . During an interview with ADON on 08/13/25 at 3:00pm she stated the day of Resident #1's elopement she was present and was meeting with a visiting family. She stated she last saw Resident # 1 standing by the nursing station between 5:30PM- 6:00 PM. She stated their facility team and family members had discussed moving Resident #1 to a non- secure area for some time , so they decided to move her on 07/17/2025. She stated she was moved to hall 500 and was able to recognize her name on her door and there was no exit seeking behaviors. She stated her RP wanted Resident # 1 to have free access to the vending machine at her leisure, which gave the team another reason to move her to a non-secure area. She said she completed an elopement assessment and secure care unit assessment before and after the incident on 08/07/2025 and Resident #1 moved from the secure unit on 07/21/2025. She stated on 08/07/2025, Resident #1 was assessed for injuries and was moved back to the secure unit, and her RP gave consent to move her back. An interview on 08/13/2025 at 3:15 PM with MA A was attempted by phone; however, he did not answer after two attempts. MA A voicemail was not set-up; therefore, a voice mail was not left. During an interview on 08/13/2025 at 6:20 PM with Social Worker, she stated she had observed Resident # 1 never exit seeking and she remembered they talked about her moving out of the secure unit because since her admission she has never showed any exit seeking behavior. The Social Worker looked at Resident EHR to find documents of an official IDT meeting, and stated she could not find any documents, but she knew her RP agreed with the move. She stated she could not explain why any pre-move meetings was not documented and was not sure if Resident #1's Physician agreed with her move for the secure unit. During an interview on 08/14/2025 with LVN A at 6:34 PM she stated on 08/07/2025 , CNA A was leaving work and saw Resident # 1 standing outside on the front porch . She stated Resident # 1 would not come in for CNA A; therefore, she went outside to assist. She stated Resident # 1 was not overheated and was found walking on the sidewalk to hall 200's outside covered patio sitting . She stated she was dressed in clothes appropriate for the warm weather. She stated once Resident # 1 came into the facility she completed her vitals and there were no concerns. She stated she called the ADM and informed her Resident #1 was found outside and she contacted her RP and Physician. She stated earlier on 08/07/2025 she observed Resident #1 demonstrating exit seeking behaviors by walking around the facility with some bags and a box. She stated she observed her with her belongings while walking around the nurse's station and Resident # 1 was redirected to put her things up, and she did. She stated prior to 08/07/2025, Resident # 1 did not demonstrate any exit seeking behaviors once she was moved from the secure unit. She stated the alarm to the front doors work and was never broken, and if Resident #1 had pushed the door the alarm would have sounded . She stated it was very likely for Resident # 1 read the code and let herself out the front door because she could read. She stated she did not know if the IDT had met prior to Resident # 1's move but the facility did provide in-services on self- report / missing resident or elopement protocol elopement drills and ANE. Record Review of Elopement nurse's note-12hr dated 08/07/2025 at 6:54 PM by LVN A reflected, 3. Follow-Up: Resident walked out front door was seen by a CNA when they were leaving the building after their shift, CNA attempted to redirect resident back to the building, redirection unsuccessful, this nurse followed CNA to resident and assisted back inside. New order from Physician: Resident to reside on secure unit due to history of elopement with active exit seeking behaviors. Review of Secure care Environment Screening Tool dated 05/8/2025 for Resident # 1 reflected, diagnosis of Alzheimer's disease or related dementia disorders, resident continue to exhibit exit seeking behavior. Record review of elopement risk assessment dated [DATE] reflected Resident #1 had no history of attempts to leave facility. Her current behaviors: restlessness. [Resident #] 1 can state her name and recognizes stop lights and signs; however, she did not know her current residence, or recognize her physical needs. Record Review of Elopement Assessments dated 08/8/2025, reflected all current residents who were located in the secure unit and non-secure unit were re-assessed for elopement risk. No new residents were identified to be at high risk who resided in non- secure unit. During an interview on 08/14/2025 at 2:00 PM with ADM she stated she, the DON and ADON were in-serviced by their [NAME] President of clinical services on Pre and Post tools because they did not follow the facility protocol to ensure Resident #1's move was documented, and she was monitored after her move. She stated all staff was in-serviced on ANE, missing resident / elopement monitoring which included checking locking mechanism or alarm function properly on all exit doors, and elopement drills which would be conducted monthly on different shifts at random time. She stated other in-services was a Post elopement drill all staff and QAPI evaluation checklist for administrative staff . She stated without proper pre and post move transfer meeting and monitoring from a secure unit to non-secure being done a negative outcome could be Resident elopement , injury or even death of they are lost and have health issues. Record review of facility's policy on elopement/wandering unknown date, reflected , Every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement.1. The Elopement Risk Assessment will be completed upon admission. The assessment should becompleted by reviewing the resident's medical history and social history. Informationmay be obtained by reviewing current medical records, if available, interview withresident/family, or conference with the interdisciplinary team member. The assessmenttool should be completed, and interventions implemented as indicated. The ElopementRisk Assessment is to be completed at least quarterly and upon change of condition.2. All residents who are at risk for harm because of wandering (elopement) will be assessed by theinterdisciplinary care planning team.Interventions into elopement episodes will be entered onto the resident's care plan and medical.6. Should an elopement episode occur, the contributing factors, as well as the interventions tried,will be documented on the nurses' notes. Director of Risk Management and\or Director ofNursing Services should be notified of elopement.7. If a resident is discovered to be missing, a search shall begin immediately. On 08/13/2025 at 6:50 PM, the ADM was informed of an IJ. The non-compliance was identified as past non-compliance. The IJ began on 08/07/2025 and ended on 08/08/2025 at 2:20PM The facility had corrected the noncompliance before the investigation began. The interventions and plan of correction included: Review of Resident #1 EMR revealed Resident #1 was moved to the secure unit for her safety immediately.Review of Resident # 1 EMR revealed she was seen by her MD on 08/08/2025. It was recommended by MD for Resident #1 to remain in secure unit. No other concerns noted.Review of facility in-services dated 08/07/2025-08/8/2025 revealed all staff were educated regarding elopements, securing doors and activating alarms, abuse and neglect and supervision of residents. Staff were instructed to notify DON, Admin regarding any attempts of elopement or resident who may have increased confusion and attempt to exit. Review of Elopement drills dated 08/08/2025 revealed a drill was completed on all shifts. Review of Elopement Assessments dated 08/07/2025 revealed current residents were assessed for elopement/wandering risk. No new residents were identified to be at high risk.Review of Ad Hoc QAPI meeting held on 08/08/2025 revealed an QAPI meeting was held to discuss the elopement of Resident #1. Record review of elopement follow- up interviews conducted by DON to all staff on 08/08/2025.Observations at facility on 08/13/2025 - 08/14/2025 and did not reveal observations of exit seeking or wandering residents. Interviews with facility staff on 8/13/2025-8/14/205 revealed they were educated on elopements, securing doors and alarms, supervision of residents, abuse and neglect, monitoring and documenting procedures during pre and post move from secure unit to a non- secure unit.

Based on observation, interview, and record review the facility failed to ensure residents the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 3 (Resident #24, Resident #11 and Resident #18) of 9 residents reviewed for accommodation of needs. 1. The facility failed to ensure that Residents #24's call light was within reach. 2. The facility failed to ensure that Resident #11's call light was within reach. 3. The facility failed to ensure that Resident #18's call light was within reach. These failures placed residents at risk of not being able to call for assistance and have their needs met. Findings included: 1. Record review of Resident #24's undated Face Sheet reflected she was a an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions) late onset, difficulty in walking and cognitive communication deficit (communication is impaired due to problems with attention, memory and reasoning rather than with language or speech itself). Record review of Resident #24's Comprehensive MDS dated [DATE] reflected she was unable to complete a BIMS assessment. Record review of Resident #24's Care Plan dated 05/29/2024 and revised on 12/11/2024 reflected Focus: has a communication problem related to Dementia, sometimes understands, sometimes understood. Goal: Anticipate and meet needs. Ensure/provide a safe environment. Call light in reach. Observation on 05/20/2025 at 10:08 AM revealed Resident #24 was in her bed and her call light was not in reach. Resident #24 was not interviewable. 2. Record review of Resident #11's undated Face Sheet reflected she was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions) late onset, and a history of falling. Record review of Resident #11's Quarterly MDS dated [DATE] reflected she was unable to complete a BIMS assessment. Record review of Resident #11's Care Plan dated 09/30 /2024 reflected Focus: The resident has a communication problem with Alzheimer's. She is mostly non-verbal. Interventions/Tasks: Ensure/provide a safe environment: Call light in reach. Observation on 05/20/2025 at 10:29 AM revealed Resident #11 was sitting in a reclining wheelchair in her room. There was no call light in reach. The resident was not interviewable. 3. Record review of Resident #18's undated Face Sheet reflected she was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Unspecified Dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) without behavioral disturbance, Cognitive Communication Deficit (communication is impaired due to problems with attention, memory and reasoning rather than with language or speech itself) and history of falling. Record review of Resident #18's Quarterly MDS dated [DATE] reflected she was unable to complete a BIMS assessment. Record review of Resident #18's Care Plan dated 08/22/2024 and revised on 03/10/2025 reflected Focus: The resident has a communication problem r/t advanced Alzheimer's disease, Cognitive Communication Deficit, age-related cognitive decline r/t Alzheimer's progression. Goal: the resident will be able to make basic needs known on a daily basis through the next review date. Interventions/Tasks: Anticipate and meet needs. Ensure/provide a safe environment: Call light in reach. Observation on 05/20/2025 at 2:32 PM revealed Resident #18 was sitting in her wheelchair in her room. Resident #18's call light was on her bed and not in reach. Resident #18 stated I need help. The surveyor asked the resident if they could push her call light and she stated yes. During observation and interview on 05/20/2025 at 2:35 PM the Social Worker came into Resident #18's room to see what she needed. She stated she helped the nursing staff to answer call lights. She stated the resident needed to have her call light in reach. She further stated by not having her call light in reach, the resident could have fallen and could have gotten hurt. In an interview on 05/22/2025 at 7:35 AM CNA D stated call lights should have been kept in reach of all residents and all staff were responsible. She stated if the call lights were not kept in reach for the residents Something bad could happen to the resident. She stated she had not received any in-services regarding call light placement. In an interview on 05/22/2025 at 7:26 AM LVN B stated she had worked at the facility since April 7th, 2025. She stated she made rounds on 500 Hall about three times a day and she did check for call light placement. She stated the potential risk if a resident could not reach their call light would be a delay in the resident receiving care. She stated they could fall. In an interview on 05/22/2025 at 11:35 AM the DON stated her expectations would be for every resident to have their call lights always in reach whether they were in the bed or a wheelchair. She stated they could need anything such as the bathroom, food, drink or even just want to get out of the room. She further stated if the call light was not in reach, they could potentially fall trying to reach the call light. She stated they could hurt themselves, get a skin tear or even a fracture. In an interview on 05/22/2025 at 12:24 PM the ADM stated any staff that entered a resident room should make sure their call light was in reach. She stated if they took a resident back to their room or did rounds, they should ensure the call light was in reach. She further stated the potential risk to the resident was that their needs would not be met. She stated the resident could fall and be injured if their call light was not in reach. In an interview on 05/22/2025 at 12:24 PM the ADM stated there was no specific policy regarding call light placement.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for one of one medication storage rooms in the facility and one of three medication carts reviewed for medication safety. A. The facility failed to ensure expired supplies and/or medications were removed from the nurse's medication cart for the secure unit. B. The facility failed to ensure expired/discontinued supplies and/or medications were removed from the medication storage room. This failure could place residents at risk of not receiving the intended therapeutic benefits of their medications. Findings included: A. During an observation on 05/21/2025 at 10:25 AM of the medication cart for the secure unit with LVN B there were two insulin pens that were beyond the use dates of 28 days after opening for Resident #14. A Lantus Solostar Subcutaneous Solution Pen injector had an open date of 4/17/25, expired on 05/15/2025. An Insulin Lispro Subcutaneous Pen Injector had an open date of 4/4/25, expired on 05/02/2025. Pens were removed from the medication cart and discarded by LVN B. B. During an observation on 05/21/2025 at 10:53AM of the medication storage room with DON there were eight bottles of Jevity 1.2K tube feeding formula with an expiration date of 04/01/2025. Eight bottles of expired product were removed from medication storage by DON to be discarded. In an interview with LVN B on 5/21/25 at 10:25 AM, LVN B stated that the insulin pens expire after 28 days from opening. She stated that she should have checked the expiration date and discarded the pens. She stated it was the responsibility of the nurse administering the medication to check the expiration date prior to administering the medication. She stated that the impact to the resident for receiving expired insulin was that the medication might not work to lower blood sugar as intended. In an interview on 05/21/25 at 02:20PM, the DON stated that it was the nurse's responsibility to check expiration dates on medications and products for residents prior to administration. She stated that a pharmacy consultant comes to review the medication storage and carts, but she has not been here in a few weeks to catch the expired products found during review. She stated that her expectation was that the staff discard any expired medications or products and reorder them, if needed. She stated that the risk to the resident with receiving expired tube feeding formula was the possibility of gastrointestinal upset, diarrhea, and vomiting. She stated there were no residents in the facility at this time requiring the tube feeding formula that was expired. She stated that the risk to the resident regarding the expired insulin was that the product may not work to lower the blood sugar of the resident and put them at risk for DKA (an emergency situation due to increased blood sugar levels in the body). In an interview with ADM on 05/21/25 at 02:35 PM, ADM stated that removing expired products should be a shared responsibility between nurses, medication aides, DON, and pharmacy consultant. She stated the products should have been removed from stock on the day of expiration and disposed of properly. She stated that she would prefer to defer to the clinical judgement of her DON regarding the risks for the resident with the expired products. Review of Facility policy on Recommended Medication Storage, revised 07/2012 reflected, Medications that require an open date as directed by the manufacturer should be dated when opened in a manner that it is clear when the medication was opened. Below is a list of medications that require a date when opening and the recommended time frame the medication should be used. This is not an all-inclusive list and the manufacturer recommendations will supersede this list. INSULINS (Vials, Cartridge, Pens) Insulin Glargine (Lantus) Review of [Medication Brand] Prescribing information for Lantus Solostar subcutaneous pen reflected that the Pen should be discarded after 28 days from opening. Review of [Medication Brand] Complete instructions for non-branded Insulin Lispro pen reflected, Do not use your Pen past the expiration date printed on the Label or for more than 28 days after you first start using the Pen.

Based on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 1 of 6 residents (Resident #6) reviewed for ADLs. The facility failed to ensure that assistance was provided to Resident #6 to remove all BM from hands and face before the lunch meal on 05/20/2025. This failure could place residents at risk of cross contamination and not being provided care and assistance when needed. Findings include: Review of Face Sheet for Resident #6 reflected an [AGE] year-old female admitted on [DATE]. Diagnoses included Alzheimer's Disease (dementia disorder related to protein formation in the brain), Acquired Absence of Left Upper Limb Above Elbow, and Need for Assistance with Personal care. Review of MDS for Resident #6 dated 02/12/2025 reflected a BIMS score of 2 (severe cognitive impairment). Section G0110 for Activities of Daily Living Assistance indicated that Resident #6 required Supervision of one assistance person with eating and Extensive Assistance from one to two staff for Bed Mobility, Transfers, and Toilet Use. Review of Care Plan for Resident #6 reflected a Focus Area stating the resident, has bladder and bowel incontinence r/t ALZHEIMER'S DISEASE. Date Initiated: 08/11/2023 with an intervention to, PERFORM INCONTINENT CARE AFTER EACH INCONTINENT EPISODE. Date Initiated: 01/21/2025. There was a Focus Area stating the Resident, has an ADL Self Care Performance Deficit r/t ALZHEIMER'S DISEASE and Left Arm Above Elbow Amputation. Date Initiated: 08/30/2023 with an intervention of, TOILET USE: [Resident #6] requires ASSIST with 1 staff participation to use toilet and has occasional bowel and bladder incontinence which requires staff assist with incontinent care. Date Initiated: 08/30/2023. Observation and interview on 05/20/25 at 10:23 AM with Resident #6 revealed resident lying in bed on her right side. There was a smear of brown substance across her right cheek approximately 1.5 inches long. She stated she has no concerns regarding her care at the facility. Observation on 05/20/25 at 12:10PM of Resident #6 revealed resident sitting at a dining table, waiting for lunch. Her right hand had a brown substance under all the nails with a smear across her thumb and her right cheek. Resident had an amputation to her left arm above the elbow. Resident smelled of BM. The resident stated that she likes her nails longer. Resident stated that there was nothing under her nails. Observation on 05/20/2025 at 12:45PM revealed Resident #6 sitting at the table, eating her meal with her right hand using a spoon and her fingers to eat. The brown substance remained under her nails and the brown smear was still on her right cheek. Resident took a bite of her chicken and licked the fingers of her right hand. In an interview on 05/20/2025 at 01:03PM CNA E stated that she cleaned Resident #6's hands with a wipe before the meal. She stated she did not see the brown residue under her nails and on her face before it was brought to her attention by surveyor. She stated that she did not know what the brown substance was. She stated she would take the resident back to the room to clean her up. She stated that the resident could get an infection if her hands were soiled with BM while she was eating a meal. In an interview on 05/20/2025 at 01:20PM CNA E stated that it was BM under Resident #6's nails when she took the resident back to clean her up. She stated that she cleaned the Resident's face and nails. Observation on 05/22/2025 at 08:52AM revealed CNA F assisting Resident #6 with her meal tray and positioning her for comfort in her bed. Resident #6 nails were clipped short. Her hands, face, and all visible person and clothing were clean. In an interview on 05/22/2025 at 08:52AM Resident #6 stated she was doing fine. Resident denied any upset stomach. In an interview on 05/22/2025 at 11:08AM, LVN B stated that the CNAs and charge nurses work together to ensure good hygiene for Resident #6 and all other residents. She stated that she did not see the soiled hands, nails, and face for Resident #6 before someone brought it up. She stated that if the staff did not assist the resident with hand hygiene when residents are soiled and prior to meals she could get sick. In an interview on 05/22/2025 at 11:17AM, CNA F stated that Resident #6 has a behavior of scratching her skin and handling her brief sometimes. She stated that she assists the Resident to wipe her hands after providing incontinent care, before meals, and as needed, including removing any debris from under her nails. She stated that if staff do not assist residents with hand hygiene and ADL care when it is needed, the residents could get an infection. In an interview on 05/22/2025 at 01:50 PM, the Regional Compliance Nurse stated the facility had no specific policy and procedure for ADL care. She stated the only related policy they had was for Infection Control. In an interview on 05/22/2025 at 02:40 PM, the Administrator stated that if a CNA or a nurse saw that a resident was not clean, then it was her expectation that staff assist them with cleaning themselves if they are not able. She stated that her expectation was that staff assist all residents with hand hygiene prior to meals. She stated that the potential impact to the resident if staff do not assist with hand hygiene prior to meals, is that they could get sick. In an interview on 05/22/2025 at 02:53PM DON stated that it was the responsibility of all staff to monitor the residents and ensure cleanliness of their clothing and their person. She stated that all staff assisting with dining, especially CNAs and nurses were to assist residents with hand hygiene especially before meals and as needed. She stated that a resident could get sick from having nails and hands soiled with BM while they are eating. She stated it could also be embarrassing for the resident. She stated that she has in-serviced staff on hand hygiene and ADL care and educated staff to ensure that they are aware of the expectations. Review of facility policy for Infection Control (No Date) reflected: The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection.

Based on observation, interviews, and record reviews, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (Residents #15) reviewed for accidents hazards and supervision: The facility failed to ensure Resident #15 had a fall mat in place and the bed was in the low position on 05/20/2025 while in bed. This failure could place the residents at risk for falls with the possibility of injury, including fractures. Findings include: Review of Face Sheet for Resident #15 reflected a [AGE] year-old man admitted on [DATE]. Diagnoses included: Dementia, Bipolar Disorder (a mental illness that causes extreme mood swings), Aphasia (difficulty using or comprehending language), and Deaf. Review of MDS for Resident #15 dated 05/02/2025 reflected a BIMS score of 1 (severe cognitive impairment). Section G0110 for Activities of Daily Living Assistance reflected the resident requires Extensive Assistance of Two or more persons with bed mobility and transfers. Review of Care plan for Resident #15 reflected a Focus area stating the resident, has a communication problem r/t aphasia and he is also deaf. Date initiated 04/28/2025 with an intervention to keep the bed in the lowest position. Further review reflected a Focus area stating the resident, is risk for falls r/t Gait/balance problems, Unaware of safety needs, hearing problems, Date Initiated: 04/28/2025, with interventions to Anticipate and meet the resident's needs. Date initiated 04/28/2025 and Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes. Date Initiated: 05/01/2025 Review of Event Nurse's Note for Resident #15 with date of 04/26/2025 reflected resident was found on the floor by the bedside. Review of Progress Notes for Resident #15 reflected a note on 05/09/2025 stating, Resident had a fall. Location: Resident Room .Fall information: Unwitnessed, Discovered on floor, . Next to bed. Cognition / Behavior at Time of Event: Oriented / no problem, Agitated, Restless, Refuses to call for assistance Nurse walking down & noticed resident on floor in his room. Charge nurse immediately started head to toe assessment. resident able to [NAME] upper & lower without difficulty, no rotation noted to lower extremities, able to straighten both legs without hesitation v/s 148/70, 72, 20, 97.5, 98% neuros initiated resident non verbal, communicates with writing- example dry erase board, also able to nod head yes or no if you write down questions, hard of hearing No Pain. Initial Treatment/New Orders: floor mat beside bed Review of Physician Orders for Resident #15 reflected no orders for fall mat prior to 05/22/2025. Observation on 05/20/2025 at 02:45PM reflected Resident #15 was lying in bed. The bed was not in the low position and there was no fall mat on the floor beside the bed. No fall mat was observed in the room. Observation on 05/22/2025 at 09:09AM revealed Resident #15 was sitting in his WC. No fall mat was in the room. In an interview on 05/22/2025 at 10:00AM CNA F stated that Resident #15 did not have a fall mat in his room. She stated she was not sure of the circumstances for Resident #15's falls but was aware Resident #15 had fallen in the past. In an interview on 05/22/2025 at 10:15AM, the DOR stated that he was familiar with Resident #15. He stated that he screens the residents after falls. He stated they review residents after falls to screen for their ability and for the source of the falls. He stated that Resident #15 did have a fall out of bed. He stated that a fall mat would be a good temporary intervention to attempt to prevent major injury with falls for Resident #15. He stated that he recommended a defined perimeter mattress, which is similar to a scoop mattress, but less restrictive for the resident. He stated that it would be a better approach than a fall mat. He stated that he did not have any defined perimeter mattresses to his knowledge at the time. He stated that he was not aware that the Resident did not have a fall mat. He stated that if the Resident had a fall out of bed without a fall mat it could contribute to fractures. In an interview on 05/22/2025 at 11:15 AM, LVN B stated that she was aware that Resident had a history of falls. She stated that her fall interventions for Resident #15 included watching him closely, especially during smoke breaks. She stated that he should have a fall mat, a low bed, and staff should ensure the call light is in reach. She confirmed that Resident#15 does not currently have a fall mat in his room. She stated that it is everyone's responsibility to help with fall prevention. She stated all the care staff are responsible to ensure the fall interventions are in place. She stated that everyone should be monitoring for appropriate fall interventions. She stated that if the resident did not have the appropriate interventions in place for falls, like a fall mat, that the resident could hit is head and possibly have a brain bleed. In an interview on 05/22/2025 at 1100 AM, DOR stated he found a defined perimeter mattress cover and applied it to the bed. Observation on 05/22/2025 at 1100 AM revealed that a new mattress topper was applied to Resident #15's mattress. It has raised edges on the top and bottom and a more gradual raised edge in the middle of the mattress. The bed was in the low position. In an interview on 05/22/2025 at 02:53 PM, the DON stated that she agreed with the DOR and was comfortable with the mattress topper as an adequate intervention for falls for Resident #15. She stated that she would update the care plan and the records to reflect the change and remove the fall mat. Review of facility policy of Fall Prevention, revised 10/02/2016, reflected: Procedure: 1. The facility will complete a fall risk assessment on each resident at the time of admission to the facility. The Fall Assessment Tool will be used to assess the resident's risk of falls until completion of the comprehensive MDS assessment. 2. The comprehensive MDS assessment will assist in identifying those residents as risk for falls. 3. Residents at risk will be care planned for fall prevention. 4. After risk is assessed, individualized nursing care plans will be implemented to prevent falls. The resident and family members will be educated on methods to prevent falls. Interventions will focus on manipulating the environment, educating the resident/family, implementing rehabilitation programs to improve functional ability, and care monitoring of medication side effects. Incident Reporting: Reported falls will be thoroughly investigated to assess fall risk factors and contributing factors in order to provide a safe environment for the resident(s). Environment: Keep bed in low position. Keep the bed wheels locked. Use mobility handles or ¼ rails in bed, low bed, scoop mattress, bolsters, or any combination of the previous. Place the call light and other objects within easy reach. Use bed/chair alarm systems to monitor unsafe activity as needed. Maintain adequate illumination in bedrooms and bathrooms. Maintain non-slip floor surface. Keep hallway clear. Provide grab bars and toilet risers in the bathroom.

Based on interview and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 4 residents (Resident #1) reviewed for significant medication errors. The facility failed to ensure Resident #1 received the medication Xarelto, an anticoagulant/blood thinner, which could have resulted in the resident developing or the worsening of a blood clot diagnosed soon after Resident #1 missed 24 doses of the medication from 05/15/24 to 06/08/24. This failure could place residents at risk of increased pain and health deterioration. Findings include: Record review of Resident #1's face sheet revealed she was an [AGE] year-old admitted to the facility on [DATE] with diagnoses including chronic embolism (obstruction of an artery usually by a blood clot or air bubble) and thrombosis (blood clot) of unspecified deep veins of right lower extremity, peripheral vascular disease (a circulatory disease-causing blood vessels to narrow) and chronic pain. Record review of Resident #1's Admission MDS Assessment, dated 05/23/24, reflected Section C BIMS score was a 7, which indicated a severe cognitive impairment. Record review of Resident #1's Care Plan, undated, revealed a focus added on 6/13/24, for PVD with a history of chronic DVT. The goal is for Resident #1 to remain free from complications related to PVD. The interventions include give Xarelto for improved blood flow. Record review of Resident #1's Admission Packet from Resident #1's hospice agency dated 5/14/24, revealed medication orders included Xarelto 10mg tablet daily. Record review of Resident #1's, May 2024 MAR revealed Xarelto was not included in the medications scheduled to be given. Continued review of the June 2024 MAR indicated on June 9th the medication Xarelto was given for the first time by the facility. Record review of Resident #1's Physician telephone orders revealed an order dated 06/06/2024 for a doppler ultrasound of RLE to rule out DVT. Record review of Resident #1's progress notes dated 06/09/24 at 10:42 am, completed by LVN A reflected, : Resident continues with swelling to Rt leg thigh area Resident with routine care did require nurse and CNA to assist with turning in bed. Swelling to her Rt thigh is pitting edema +2 (a slight indention requiring 15 seconds or less to rebound when pressure is applied to skin), and tender to touch. (Hospice provider name) hospice to send tech out to facility for doppler to r/o (rule out) DVT/clot. Imaging test not performed at this time. Staff did encourage resident to limit getting out of bed. This nurse did speak with hospice on call (hospice nurse name) to inquire about imaging and to report change in the functional status, as resident has confusion and seems weaker with ADL's. This nurse asked about imaging as well. (Hospice nurse name) told this nurse that testing would be done on Monday 6/10/24 as they were waiting on machine to become available. She did instruct nurse to have facility to call back on tomorrow. (Hospice nurse name) also stated that a (hospice nurse name) hospice nurse would be out to see resident. Resident also reported that she did not receive a shower and request aide be sent out as well. (Hospice nurse name) assured this nurse that both would be out to facility today. Will continue to monitor. Continued review revealed a second note dated 06/09/24 at 4:20 pm, completed by LVN A reflected, Resident family in house at this time inquiring about resident condition as well as medication. This nurse did contact hospice and spoke again with (Hospice nurse's name) regarding medication list and was informed that Resident is to take Xarelto 10 mg at bedtime. This nurse did update facility med list adding to the MAR, medication is in house and to be given at bedtime. Resident did also complain to family that she had tingling in her fingertips. This nurse did inform family and resident that if she would like she could be sent to the ER department for evaluation and treatment d/t numbness and tingling in the hands as well as the swelling in the Rt leg. This nurse had informed hospice of this as well and was told, if she does go to hospital for work up and come back that is fine but if admitted to hospital, hospice services would bed [sic] discontinued until discharged from hospital. Resident and family both declined ER visit stating, resident could wait for doppler and numbness and tingling in her hands was not new. Resident not sent to ER. v/s 123/74(blood pressure-62(pulse)-18 (respirations)-93%(oxygen saturation) on RA. Record review of Medication Error Report, dated 6/13/24, revealed the report documented the error as having occurred on 5/15/24. The report notes the DON missed the medication Xarelto on the orders during Resident #1's admission to the facility. The outcome to resident notes No harm to resident/DVT found after ultrasound. Interview on 7/1/24 at 12:27 pm with Resident#1's FM revealed they were visiting on 6/9/24 and asked LVN A about her medications. They were concerned she had the swelling to her leg indicating a blood clot like she had before. LVN A discovered Resident #1 had not been given her Xarelto. FM stated they were also concerned a doppler ordered by hospice on 6/06/24 not been completed. FM stated they met with the facility and hospice and the DON admitted there had been a medication error that she had misread the orders. The hospice agency reported they were having problems with their sonogram provider; it was not done until 6/11/24. LVN A had offered to send Resident #1 to the hospital on 6/9/24 but we had refused. Interview on 7/1/24 at 2:18pm with LVN A revealed she was Resident #1's admitting nurse. She stated they were surprised to see her arrive as they had not known she was coming to be admitted . LVN A stated there was not a nurse with Resident #1 as there usually is with new admissions, and she was told one would be coming in later that day. LVN A stated the DON had gotten the orders from the hospice referral documents. LVN A stated a couple of weeks ago Resident #1's family was visiting and asked if she was still taking the Xarelto, when she went to check, she realized the medication had not been added at time of admission although it was on the orders. LVN A stated they also had some in her medication supply. She added it that day. LVN A stated the family was asking because a doppler had been ordered by hospice due to swelling to her leg. The doppler had not occurred yet so she called hospice and there was a delay with the doppler provider. LVN A stated she offered to send Resident #1 to the hospital to have it done but the family declined. The hospice nurse was informed of the error having occurred and the hospice physician was notified. When the doppler was done it confirmed that Resident #1 had a blood clot. Resident #1's Xarelto was increased temporarily by the hospice doctor. When asked, LVN A stated she knew it had been a significant error and had caused the resident to be unable to toilet herself as she had been, due to the pain in her leg. Interview on 7/1/24 at 2:48pm with Hospice CM RN B revealed she was not involved in Resident #1's initial admission. She stated she put the order in on 6/6/24 for the doppler sonogram after redness and swelling was noted to the resident's RLE. Once it was discovered Resident #1 was not receiving her Xarelto the Hospice Physician was notified of that error. Interview on 7/1/24 at 3:01pm with facility DON revealed that the facility was not expecting Resident #1 when she was admitted . Usually, a hospice nurse will accompany the resident but Resident #1 had an aide with her. DON stated she took off the orders from the documentation that arrived with Resident #1 because the Charge Nurse was busy. Usually, they will write the orders and the hospice nurse will check the orders to ensure they are correct, but that did not happen with Resident #1's admission. At the time she learned of the error she wrote out an error report including no harm to the residents because she did not yet know about the DVT. After becoming aware of the DVT she added the information. The DON stated they had a meeting with the hospice agency to let them know that a hospice nurse needs to come with a resident admitting to the facility to provide a second set of eyes checking the orders to catch mistakes at time of admission. Interview on 7/1/24 at 3:41pm with Adm revealed he was aware of the medication error involving Resident #1's Xarelto. He stated they usually do better than that. Administrator stated there was confusion in the process because the hospice nurse was a traveling nurse. They have since had an in-service regarding nursing ensuring that two nurses verify orders. He stated they also met with the hospice provider and let them know we wanted them to check that we have the orders right for their patient. Interview on 7/2/24 at 9:09 am with Hospice Phy revealed he was the primary doctor for Resident #1 while she has been with hospice. He works with her hospice provider. He stated the intent was for Resident #1 to routinely take a scheduled blood thinner as she has a history of developing blood clots. He stated missing the Xarelto probably did not cause her to develop the blood clot. He said she probably already had it and it worsened. Review of policy titled Adverse Consequences and Medication Errors, dated 2001 revealed it included the following: 1. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. 2. Examples of medication errors include: a. omission- a drug is ordered but not administered And 3. A significant medication-related error is defined as: a. Requiring medication discontinuation or dose modification. (Consult the current list of medications that should not be abruptly discontinued.) b. Requiring hospitalization , or extending a hospitalization . c. Resulting in a disability. d. Requiring treatment with a prescription medication. e. Resulting in cognitive deterioration or impairment. f. Life threatening. g. Resulting in death.

Based on interview and record review, the facility failed to immediately notify the resident's physician when there was an unwitnessed fall in the resident's physical status for one (Resident #1) of four residents reviewed for resident rights. The facility failed to ensure Resident #1's Physician was notified on 05/03/2024 when resident was found on the floor by CMA A. An Immediate Jeopardy (IJ) situation was identified on 05/30/2024 at 6:05 PM. While the IJ was removed on 05/31/2024 at 7:05 PM, the facility remained out of compliance at a scope of isolated with potential for more than minimal harm that is not immediate jeopardy because all staff had not be trained on falls. This failure placed residents at risk of injury, uncontrolled pain, and a decreased quality of life. Findings included: Record review of Resident #1's face sheet dated 05/30/2024 reflected an [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses of fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing (breaks or rupture in bone situated between the hip and the knee), difficulty with walking ( problems with bones or pain can make it difficult to walk properly), abnormalities in gait and mobility ( an injury or underlying medical condition can cause an abnormal gait), Alzheimer's disease ( a brain disease that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), unspecified lack of coordination ( muscle control problem that causes an inability to coordinate movements. It leads to jerky, unsteady, to and from motion of the middle of the body and an unsteady walking style), and unspecified fall (finding of sudden movement downward, usually resulting in injury). Record review of Resident #1's Annual MDS Assessment, dated 04/11/2024, reflected Resident #1 had a BIMS score of 0 indicated severe cognitive impairment. She was assessed to have poor short- and long-term memory recall. Her decision-making ability was severely impaired. Resident #1 was assessed to require assistance with ADLs including the following: transfers, eating, personal hygiene, showers, and dressing. Record review of Resident #1's Comprehensive Care Plan revised on 05/31/2024 reflected Resident #1 had impaired cognitive function or impaired thought process related to Alzheimer's Disease. Intervention: Keep resident's, routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Resident #1 was prone to skin tears and bruising related to fragile skin. Intervention: all injuries will be monitored until they are resolved. Notify charge nurse of any new bruising or skin tears. She was high risk for falls related to unsteady balance, incontinence, poor safety awareness and being forgetful. Interventions: educate the resident/ family and care givers about safety reminders and what to do if a fall occurs. Anticipate and meet the resident's needs. Follow facility protocol. Record review of Resident #1's electronic medical records reflected Resident #1 did not have any nursing note entries on 05/03/2024. Record review of Resident #1's electronic medical records reflected Resident #1 did not have a pain assessment or incident/accident report on 05/03/2024. There was one entry at 10:38 AM B/P was 129/79 mmHg. Record review of Resident #1's Nurses notes, at 1:13 PM on 05/04/2024, reflected Resident #1 continued to decline with a B/P of 96/55 and pulse of 55 within an hour of having elevated blood pressure earlier in AM. Resident #1 had a glazed (expression is dull, usually because a person is tired or had difficulty concentrating on something) look to her eyes and small pinpoint pupils. Her 02 sats dropped from 94 % R/A to 86 % R/A. O2 per nasal cannula put on Resident #1 to aid in oxygen saturation. O2/3L/NC 93%. NP was notified and new order to send Resident #1 to the emergency room for evaluation and treatment. Resident #1 was transported by EMS to the emergency room at 11:44 AM. Family and ADON was notified of Resident #1 being transported to the emergency room . Written by RN C. Record review of Resident #1's Nurses Notes, at 1:49 PM on 05/04/2024, reflected Resident #1 was hospitalized . Record review of Resident #1's Hospital Records dated 05/04/2024 reflected minimally displaced left sub capital femoral neck fracture (these fractures occur in the neck of the thighbone). There were no other injuries according to the x-ray report. Observation and interview on 05/30/2024 at 9:00 AM, Resident #1 were sitting in the common area beside another resident. She smiled and she did not respond to questions. Resident #1 did not show any signs or symptoms of any distress. She was relaxed and watching people. In an interview on 05/30/2024 at 9:12 AM, CNA B stated on 05/03/2024 CMA A came to her after lunch when she was giving Resident #2 a shower and requested if she had time to assist her in transferring Resident #1 from the floor to the wheelchair. She stated CMA A explained she found Resident #1 lying on the floor. CNA B stated she asked CMA A to find CNA D she was unable to leave the shower. CNA B stated she was assigned to Resident #1 on 05/03/2024. She stated she went to the nurse's desk after giving Resident #2 a shower and assisted Resident #2 to her room. CNA B also stated she observed Resident #1 sitting in her wheelchair and she was her normal self. She stated she would stand and walked from chair to chair. She stated this was her usual routine when sitting in the common area near nurses' desk. She stated she received a verbal report from LVN E and she stated she believed Resident #1 slid out of her wheelchair. She also stated she had been in-serviced on what to do if a resident fell or was found on the floor. CNA B stated only nurses was allowed to touch the resident and complete a skin assessment, pain assessment and if there was an injury to call the physician and the non-nursing staff including CMAs was expected to wait and follow the nurses' directions on what to do with the resident and when to move the resident. Interview on 05/30/2024 at 10:03 AM, LVN F stated he was coming on duty for the night shift on 05/03/2024 and LVN E was giving him verbal report of what occurred on the day shift on 05/03/2024. He stated during the verbal report LVN E informed him Resident #1 had a fall and she did not report anything else about Resident #1. He stated he monitored her on the night shift for any changes in her mental or physical condition. LVN F stated Resident # 1 never complained of pain and was at her baseline physically and mentally on his shift (from 6:00 PM on 05/03/2024 to 6:00 AM on 05/04/2024). He stated he had been in-serviced on fall protocol. He stated only nurses are allowed to complete range of motion, neuro checks, pain assessment and completed incident/ accident report. LVN F stated the physician, DON, and family was expected to be notified. He also stated he would follow the physician directions of what treatment he believed the resident needed. Interview on 05/30/2024 at 10:15 AM, CMA A stated she was walking by the activity area near the nurse's desk and observed Resident #1 on the floor in front of the television. She stated Resident #1's wheelchair was a few feet away from her by a table. She stated Resident #1 was not a good historian and unable to give any information of the incident of her lying on the floor. CMA A stated Resident #1 was lying on her back. She also stated she went to get assistance from CNA B. She stated CNA B was giving another resident a shower and was unable to assist her with transferring Resident #1 from the floor to her wheelchair. She stated she found LVN E. She stated LVN E was busy with a new admission and was unable to assist her with Resident #1. CMA A stated there were other nurses in the facility and did not think about going to find another nurse. CMA A stated she did not want Resident #1 laying on the floor any longer and she had observed nurses perform range of motion on residents after they had fall and she decided she would perform range of motion and she asked a CNA to assist her in transferring Resident #1 to the wheelchair. She stated she put the vital signs on a piece of paper and laid it on the desk and she does not know if the Nurse completed an assessment on Resident #1. She stated she did not follow up on the incident. CMA A stated she had been in-service on fall protocol. She stated she was instructed during the in-service the nurses was the only staff was allowed to assess a resident found on the floor and complete range of motion. She stated she was not to assess Resident #1 or complete range of motion. She stated she was wrong, and she knows she did everything wrong in the situation of finding Resident #1 on the floor. She stated it was a busy day and she did not think to go and report it to DON or Administrator. She stated she could have asked another nurse but she was wanting to assist resident off the floor as soon as possible. In an interview via phone on 05/30/2024 at 10:38 AM, LVN E stated 05/03/2024 was her last day to work at this facility. She stated it was a very busy day. LVN E stated she did not recall anyone come to her and report anyone on the floor. She stated she was busy with a new admit all day and if anyone fell it would have been when LVN G worked on 05/02/2024. LVN E stated to contact LVN G and ask her about anyone falling. She stated I think Resident #1 fell on LVN G's shift on 05/02/2024. She stated she was at work and needed to go back to work. LVN E stated she did not have anything else to say about Resident #1. In an interview on 05/30/2024 at 10:50 AM, LVN G stated she did work on 05/02/2024. She stated no one fell on her shift. LVN G stated Resident #1 did not fall or was found on the floor the date of 05/02/2024. LVN G stated when she came back to work on 05/06/2024 it was reported to her Resident #1 was in the hospital with a hip fracture during the morning meeting. LVN G stated it was not mentioned she was found on the floor or had a on 05/03/2024. She stated it was unknown how she fractured her hip. She stated she had been in-serviced on falls assessments and what to do if a resident fell . LVN G stated if a resident was found on the floor or witnessed a fall only the nurses was allowed to assess the residents and do range of motion. She stated the nurse would complete head to toe skin assessment, neuro checks, vitals and call the physician immediately if there was an injury. LVN G also stated she would follow the physician directions and would also contact the DON and the responsible party of the resident. She stated a nurse's note was required to be completed after any incident of a resident. In an interview on 05/30/2024 at 11:20 AM, CNA D stated No when asked if he was aware of anything happening to Resident #1 on 5/3/2024. CNA D would only answer yes/no type questions. He would not respond to any questions that required detailed information. In an interview on 05/30/2024 at 11:55 AM, CMA H stated he did work with LVN G on 05/02/2024. He stated if there were any changes with a resident including finding a resident on the floor or witnessing a fall, they reported to each other. He stated he was not aware of Resident #1 falling on 05/02/2024. CMA H stated he would definitely know if anyone fell when he is working in the facility. He stated he had been in-serviced on fall protocol. CMA H also stated only nurses was allowed to assess a resident if a resident was found on the floor or if it was a witnessed fall. He stated no one but the nurse was complete entire assessment such as neuro checks, pain assessment, incident/ accident report or do range of motion on a resident. CMA H stated other staff was allowed to assist resident with transfer only after the nurse completed assessments and gave instructions to other staff it was safe to transfer the resident. He stated if he found someone on the floor and the nurse supervisor for that particular resident was not available, he would find another nurse and would not touch the resident until the nurse did their assessment. In an interview on 05/30/2024 at 1:30 PM, the DON stated she was working on 05/03/2024 and no one reported to her of Resident #1 being found on the floor or any incident with Resident #1. She stated there were two nurse supervisors, MDS Nurse and she was in the facility on 05/03/2024. She stated only a LVN or RN was allowed to complete pain assessments, head to toe skin assessments, neuro checks, incident/ accident reports. She stated if a resident was injured the nurse would contact the physician and follow the physician orders. She also stated if a resident was not injured, she expected the physician to be contacted. The DON also stated the responsible party of the resident was also expected to be contacted. She stated the nurse would direct other staff what to do after she had assessed the resident and contacted the physician. She also stated CMA was not qualified to do range of motion on a resident or to do any type of pain assessments or neuro checks. She stated if the nurse responsible for Resident #1 was not available CMA A was expected to find another nurse to assess Resident #1. The DON also stated the nurse was expected to complete incident/ accident report, pain assessment, and a nurses note. She also stated the CMA or LVN E was expected to notify DON or ADON when there is a fall or a resident found on the floor. She stated she was not aware of Resident #1 was found on the floor. The DON stated there was not incident report, pain assessment, nurses note or any documentation in the electronic medical record about Resident #1 found on the floor. In an interview on 05/30/2024 at 2:15 PM, the ADON stated she reviewed Resident #1's electronic medical record and there was not any documentation of any type of incident on 05/03/2024 of Resident #1 being found on the floor. She stated CMA A or any CMA was not qualified to do range of motion, skin assessments, neuro checks or determine if a resident was injured. She stated if CMA A reported to a nurse and the nurse was busy it was expected for any staff including CMA A to find another nurse in the facility to assess Resident #1. She also stated Resident #1 was required to be assessed by a nurse before anyone transferred her from the floor to the wheelchair. She stated CMA A was not qualified to determine if it was safe to transfer Resident #1. The ADON stated she was not working on 05/03/2024, however, there were 2 nurse supervisors, DON, and MDS nurse in the facility. She stated CMA A did not follow the facilities fall protocol. In an interview on 05/30/2024 at 3:10 PM, the Administrator stated he was not notified of Resident #1 being found on the floor. He stated his expectations was for a nurse to assess a resident anytime a resident is found on the floor or any type of incident. The Administrator stated CMA A was not qualified to do range of motion, complete pain assessments or incident /accident reports. He stated if a nurse was busy, he expected the staff to find another nurse in the facility and have them to assess a resident or give care to a resident in an emergency. He stated this was not the correct protocol for this facility for a non- licensed nurse to do any type of nursing treatment on a resident. CMA A was given written disciplinary action. In an interview on 05/30/2024 at 3:40 PM, the Physician stated he was not notified of any incident in May of Resident #1 except when the Administrator did contact him about her fracture and being in the hospital. He stated he was not notified of Resident #1 being found on the floor. The Physician stated the Administrator, DON, ADON or a nurse always contacted him if there was a fall or any change of condition with a resident. He stated the Administrator would always contact him about any incident with a resident when he was notified. He also stated the nurses always notified him but the Administrator would contact him also. The Physician stated Resident #1 could have broken any bone without falling. He stated she does have brittle bones and it would be difficult for him to determine if Resident #1 may have broken a bone without knowing if she actually fell or laid on the floor. Record review of Inservice on Falls, dated 04/14/2024 reflected the following was discussed during the in-service: 1. When a resident falls all non- licensed nursing staff will notify the nurse. Once the Nurse assess the resident such as: vitals, does a resident have an injury, change of condition then the nurse will make decision of whether to transfer resident back to bed or wheelchair or does the resident require to be transferred to the hospital. All unwitnessed falls must have neuros. 2. Nurse will notify the Administrator, Director of Nurses, Responsible Party, and the Physician. Incident report completed by the nurse and sign/ date the report. (the in-service was signed by CMA A). Record review of Facility Policy on Falls- Clinical Protocol, revised March 2018, reflected the nurse shall assess and document the following: a. Vital signs. b. Recent injury, especially fracture or head injury. c. Musculoskeletal function, observing for change in normal range of motion, weight bearing, etc. d. Change in condition or level of consciousness. e. Neurological status. f. Pain g. Frequency and number of falls since last physician visit. h. Precipitating factors, details on how falls occurred. i. All current medications, especially those associated with dizziness or lethargy. j. All active diagnoses. The Administrator was notified on 05/30/2024 at 6:19 PM,that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 05/31/2024 at 1:44 PM: Date 05/31/2024 On 05/30/2024 a facility self-reportable investigation was initiated at the facility. 05/30/2024 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an Immediate Jeopardy to resident health and safety. The notification of Immediate Jeopardy states as follows: The facility failed to ensure care was provided by qualified persons in accordance with professional standards of practice. Interventions: 1. On 5/30/24 safe surveys with all oriented residents were completed by administrative staff to ensure no other falls/incidents have not been reported or addressed. 2. On 5/30/24 pain assessments on all residents were started by nursing administration to ensure all pain needs were addressed with interventions in place. 3. On 5/30/24 disciplinary action was begun for CMA A and CNA B by the DON/ Administrator for practicing outside their practice by moving and assessing resident #1, and not reporting incident to the Administrator or DON. 4. Nurse in question no longer works at facility. 5. Administrator/DON initiated an in-service for all staff on 5/30/24 on incident/accident policy, incident communication between staff and administration, abuse neglect exploitation, assessments post fall/incident to be completed by licensed nurse only, and scope of practice by position. A post-test will be performed with staff over information in-serviced on by administration, and a score of 100% must be achieved. If less than 100%, staff will be reeducated and retest until 100% is achieved. 6. Administrator/DON initiated an in-service for nursing staff on 5/30/24 on physician and family notification of incidents or change in status, neuro protocol for unwitnessed falls or falls with head injury, completing a new fall risk assessment after fall, and assessing residents after a fall/incident by licensed nurse only. A post-test will be performed with staff over information in-serviced on by administration, and a score of 100% must be achieved. If less than 100%, staff will be reeducated and retest until 100% is achieved. 7. Administrator/DON initiated an in-service for CMA A and CNA B a one-on-one in-service about notification of administrator/DON of a fall/incident, and to stay within scope of practice for their position. A post-test will be performed with staff over information in-serviced on by administration, and a score of 100% must be achieved. If less than 100%, staff will be reeducated and retest until 100% is achieved. 8. Administrator and DON were in-serviced on 5/31/24 by Regional Director of Operations on all the policies mentioned above, and to notify regional/corporate staff of ALL falls/incidents and are to notify regional/corporate staff of any discrepancies. Regional/corporate staff will follow-up on each fall/incident in question and direct with appropriate interventions. If staff are unable to attend any of the in-services, they will be required to complete the in-service before starting their assigned shift. Any agency will be in-serviced prior to the beginning of their shift. Any new hires will be in-serviced on hire, prior to working a shift. The Medical Director was made aware of the Immediate Jeopardy 5/30/24 at 9:00 PM and has been involved in developing the Plan of Removal. These conversations are considered part of the QA process. A QAPI meeting was held on 5/30/24 with attendance of Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Regional Director of Clinical Services, and Regional Director of Operations. This plan was initially implemented 5/30/24 and will be monitored through completion by corporate and regional staff. Plan of Removal completion date is 5/31/24 by 5:00 PM with continuation of oncoming staff and follow-up. The Surveyor monitored the POR on 05/31/2024 as followed: 1. Review of the facility's safe surveys with all the oriented residents reflected it was completed and conducted by the Director of Nurses on 05/31/2024. The safe surveys revealed any additional falls/ incidents had not been reported. 2. Review of the facility's pain assessments on all residents were completed on 05/31/2024 by the Director of Nurses, LVN I and LVN J. 3. Review of the facility's disciplinary action for CMA A and CNA B for performance and safety. Violated policy performance expectations, inefficient, intentional, careless or any poor / substandard performance of duties, conducting endangering life, safety or health of others and failure to comply with business rules, regulations, and policies/ procedures. 4. Verified LVN E no longer is an employee at the facility. Reviewed LVN E personnel record. LVN E resigned from the facility. LVN E resigned on 05/05/2024. 5. Review of the following in-service conducted on 05/30/2024 for nursing staff and other disciplines: a. Accidents and Incidents- Accidents and incidents should be reported immediately to the nurse on duty. The nurse to intervene immediately. All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator. The nurse supervisor/ charge nurse/or the department or supervisor shall complete a Report of Incident/ Accident form and submit the original to the Director of Nurses within 24 hours of the incident or accident. b. Disciplinary action for all staff involved with communication failure. It is expected for all staff to communicate as a team. Failure to communicate or report a change of condition, a fall, etc. could result in discipline up to termination. If a staff member does not take appropriate action after staff has communicated an issue, please contact the Administrator or Director of Nurses immediately. c. Abuse and Neglect- All residents have the right to be free from any abuse, neglect or exploitation. Staff is expected to report any abuse or neglect to the nurse on duty then immediately to the administrator for immediate intervention. d. Falls - If a resident falls, the nurse must be notified immediately. If your nurse is unavailable, someone will need to send an aide to the other hall so that the nurse from the other unit can come and assess the resident. The Director of Nurses, Assistant Director of Nurses, and MDS nurse are also available to do assessments for falls as well. No one other that the nurse should assess or move the resident. When a resident falls, no matter your title, please let the Administrator, Director of Nurses and Assistance Director of Nurses know so that the fall will be followed up as soon as possible. e. Scope of Practice and Duties- All staff have job duties and are expected to complete them. Any job no completed or doing a job or duties that is beyond your training or scope of practice is not allowed. Discipline will follow. Only nurses can assess a resident and do range of motion. (job duties for all disciplines were reviewed). f. Post Test- reviewed the post tests given to staff after the in-services. There were 32 staff had taken the post test and made 100 on the test. g. Physician and responsible party notification- NP/ Physician must be notified and documented for all incidents including falls and behaviors and document/complete all incidents neuros, and pertinent information. Family, responsible party and/ or resident needs to be notified in the event of a fall or change of condition. h. Neuro checks protocol for unwitnessed falls or falls with head injury. Fall assessment to be completed after each fall and quarterly. Neuro checks must follow any unwitnessed fall or evidence of head trauma. Incident reports are completed fore each fall. Documentation of incidents must be charted in the progress note, and must contain investigation of cause of fall, interventions to prevent further falls, assessment summary including injuries, vital signs, and initiation neuros indicated. i. Filling out Risk Assessment after fall - Everything must be addressed and completed. Must have vital signs included in the report. Must have an intervention. Include all notified example: Director of Nurses, Administrator, Doctor, and Responsible Party. Do progress note from this report. Be sure to sign report under signature. j. Incident communications- Charge nurses will communicate all incidents on shift change with oncoming nurses and on the hall and specify any adverse findings and document appropriately in resident's record and notify all parties such as: responsible party, Physician, Administrator and the Director of Nurses. Inservice one-on-one on 05/31/2024 with CMA A: if a resident falls the nurse must be notified immediately. If your nurse is unavailable, someone will need to send an aide to the other hall so that the nurse from the other unit can come assess the resident. The Director of Nurses, Assistant Director of Nurses and the MDS Nurse are also available to do assessments for falls. No one other than the nurse should assess or move the resident. When a resident falls, no matter your title, please let the Administrator, Director of Nurses and the Assistant Director of Nurses know about the fall. Inservice one-on-one on 05/31/2024with CNA B: If a resident is found on the floor, a nurse must immediately assess the resident before moving the resident. If one (nurse) is not available one from another hall must be summons. Resident is not to be moved or assessed by a non-nurse. After every fall, please notify the Administrator. The Director of Nurses or the Assistant Director of Nurses will go follow up with nursing to ensure documentation has been completed and the family and physician has been notified. The Administrator and Director of Nurses was in-serviced by the Regional Director of Operations on 05/31/2024 on the following topics: a. Incident/ Accident policy b. Incident communication between staff and Administrator c. Abuse, neglect, and exploitation d. Assessment post fall e. Incident report to be completed by licensed nurse only. f. Scope of practice by position g. Physician and family notification of residents or change in status. h. Neuro protocol for unwitnessed falls or falls with head injuries. i. Completing a new fall risk assessment after a fall. j. All staff will be required to complete all required in-services prior to the beginning of their first shift. Review of the QAPI Meeting Report dated 05/30/2024 reflected the following were in attendance: Administrator, Director of Nurses, Assistant Director of Nurses, MDS Coordinator, Regional Director of Clinical Services, and Regional Director of Operations. The Medical Director was made aware of the Immediate Jeopardy on 05/30/2024 at 9:00 PM and was involved with the Plan of Removal. Observation on 05/30/2024 at 5:45 PM- 6:05 PM the ADON and the DON was conducting in-services and the post test before the 6:00 PM - 6:00 AM staff could give care to the residents. This was ongoing on 05/30/2024. In an interview on 05/31/2024 at 2:10 PM, Laundry Aide K stated she had been in-service on Incident/ Accidents- if she saw a resident fall, she was to find a nurse immediately. She stated she was not to touch the resident and report what happened to the nurse. She stated she was in-service on abuse and neglect. She stated abuse was if a staff yelled at a resident or hit a resident. She stated neglect was when a staff refused to give resident a drink of water or food. She stated she did take a test and made 100 on it. She also stated only the nurse was allowed to touch the resident until she assessed the resident. In an interview on 05/31/2024 at 2:15 PM, LVN F stated he had been in-service on incident and accidents policy/protocol. He stated only nurses was allowed to assess a resident after a fall, or if found on floor and/or any type of incident/accident. LVN F stated the nurse completed neuro checks, completed head to toe skin assessment, vital signs and if there was an injury the physician was called immediately and follow the orders from the Physician. He stated he was also not to move the resident if there was an injury until EMR transported the resident to hospital. LVN F stated the family, DON and Administrator was also to be notified immediately if there were any change of condition with a resident. He stated if the nurse assigned to the resident who was found on the floor and that nurse was busy it was expected any nurse can assess the resident. He stated he was inserviced on abuse and neglect. LVN F stated abuse was when a staff or another resident slapped a resident, cussed a resident and neglect was when staff refused to give resident their scheduled medication or refused to assist resident to the bathroom. He stated job duties was discussed and to follow your job duties. He stated only nurses are allowed to complete the nursing documentation of incident/ accident reports, nurses notes, skin assessments, etc. He stated if it is a new fall it is required to complete a new fall risk assessment. LVN F also stated after any incident / accident the physician, family and the DON/ Administrator was to be contacted immediately. He stated he did take a posttest and made 100 on the test. In an interview on 05/31/2024 at 2:26 PM, Dietary Aide/CNA L stated she worked as a CNA and some days in the kitchen. She stated she was in-service on 5/31/2024 on the following: 1. Abuse and neglect 2. Not to move a resident or touch a resident until nurse assess the resident if they had fallen. The nurse was to give directions of what to do after she completed all her assessments. 3. Report any falls or accidents immediately to the nurse. If nurse supervisor was not available, find another nurse such as Director of Nurses or MDS nurse. Always report Abuse to the Administrator, your supervisor and if the Administrator not available can call him or report to Director of Nurses. If you are not certain, supervisor has reported to the Administrator always check and make sure he is notified of any changes of condi [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure services provided or arranged by the facility, as outlined by the comprehensive care plan were provided by qualified persons in accordance with each residents written plan of care for one (Resident #1) of four residents reviewed for qualified persons. The facility failed to ensure Resident #1 received assessment after an unwitnessed fall by a qualified staff member on 05/03/2024 when CMA A stated she conducted range of motion assessment, transferred the resident from the floor to the wheelchair and did not inform administrative staff. An Immediate Jeopardy (IJ) situation was identified on 05/30/2024 at 6:05 PM. While the IJ was removed on 05/31/2024 at 7:05 PM, the facility remained out of compliance at a scope of isolated with potential for more than minimal harm that is not immediate jeopardy because all staff had not be trained on falls. These failures placed residents at risk for not receiving appropriate care and treatment by qualified staff. Findings included: Record review of Resident #1's face sheet dated 05/30/2024 reflected an [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses of fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing (breaks or rupture in bone situated between the hip and the knee), difficulty with walking ( problems with bones or pain can make it difficult to walk properly), abnormalities in gait and mobility ( an injury or underlying medical condition can cause an abnormal gait), Alzheimer's disease ( a brain disease that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), unspecified lack of coordination ( muscle control problem that causes an inability to coordinate movements. It leads to jerky, unsteady, to and from motion of the middle of the body and an unsteady walking style), and unspecified fall (finding of sudden movement downward, usually resulting in injury). Record review of Resident #1's Annual MDS Assessment, dated 04/11/2024, reflected Resident #1 had a BIMS score of 0 indicated severe cognitive impairment. She was assessed to have poor short- and long-term memory recall. Her decision-making ability was severely impaired. Resident #1 was assessed to require assistance with ADLs including the following: transfers, eating, personal hygiene, showers, and dressing. Record review of Resident #1's Comprehensive Care Plan revised on 05/31/2024 reflected Resident #1 had impaired cognitive function or impaired thought process related to Alzheimer's Disease. Intervention: Keep resident's, routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Resident #1 was prone to skin tears and bruising related to fragile skin. Intervention: all injuries will be monitored until they are resolved. Notify charge nurse of any new bruising or skin tears. She was high risk for falls related to unsteady balance, incontinence, poor safety awareness and being forgetful. Interventions: educate the resident/ family and care givers about safety reminders and what to do if a fall occurs. Anticipate and meet the resident's needs. Follow facility protocol. Record review of Resident #1's electronic medical records reflected Resident #1 did not have any nursing note entries on 05/03/2024. Record review of Resident #1's electronic medical records reflected Resident #1 did not have a pain assessment or incident/accident report on 05/03/2024. There was one entry at 10:38 AM B/P was 129/79 mmHg. Record review of Resident #1's Nurses notes, at 1:13 PM on 05/04/2024, reflected Resident #1 continued to decline with a B/P of 96/55 and pulse of 55 within an hour of having elevated blood pressure earlier in AM. Resident #1 had a glazed (expression is dull, usually because a person is tired or had difficulty concentrating on something) look to her eyes and small pinpoint pupils. Her 02 sats dropped from 94 % R/A to 86 % R/A. O2 per nasal cannula put on Resident #1 to aid in oxygen saturation. O2/3L/NC 93%. NP was notified and new order to send Resident #1 to the emergency room for evaluation and treatment. Resident #1 was transported by EMS to the emergency room at 11:44 AM. Family and ADON was notified of Resident #1 being transported to the emergency room . Written by RN C. Record review of Resident #1's Nurses Notes, at 1:49 PM on 05/04/2024, reflected Resident #1 was hospitalized . Record review of Resident #1's Hospital Records dated 05/04/2024 reflected minimally displaced left sub capital femoral neck fracture (these fractures occur in the neck of the thighbone). There were no other injuries according to the x-ray report. Observation and interview on 05/30/2024 at 9:00 AM, Resident #1 were sitting in the common area beside another resident. She smiled and she did not respond to questions. Resident #1 did not show any signs or symptoms of any distress. She was relaxed and watching people. In an interview on 05/30/2024 at 9:12 AM, CNA B stated on 05/03/2024 CMA A came to her after lunch when she was giving Resident #2 a shower and requested if she had time to assist her in transferring Resident #1 from the floor to the wheelchair. She stated CMA A explained she found Resident #1 lying on the floor. CNA B stated she asked CMA A to find CNA D she was unable to leave the shower. CNA B stated she was assigned to Resident #1 on 05/03/2024. She stated she went to the nurse's desk after giving Resident #2 a shower and assisted Resident #2 to her room. CNA B also stated she observed Resident #1 sitting in her wheelchair and she was her normal self. She stated she would stand and walked from chair to chair. She stated this was her usual routine when sitting in the common area near nurses' desk. She stated she received a verbal report from LVN E and she stated she believed Resident #1 slid out of her wheelchair. She also stated she had been in-serviced on what to do if a resident fell or was found on the floor. CNA B stated only nurses was allowed to touch the resident and complete a skin assessment, pain assessment and if there was an injury to call the physician and the non-nursing staff including CMAs was expected to wait and follow the nurses' directions on what to do with the resident and when to move the resident. Interview on 05/30/2024 at 10:03 AM, LVN F stated he was coming on duty for the night shift on 05/03/2024 and LVN E was giving him verbal report of what occurred on the day shift on 05/03/2024. He stated during the verbal report LVN E informed him Resident #1 had a fall and she did not report anything else about Resident #1. He stated he monitored her on the night shift for any changes in her mental or physical condition. LVN F stated Resident # 1 never complained of pain and was at her baseline physically and mentally on his shift (from 6:00 PM on 05/03/2024 to 6:00 AM on 05/04/2024). He stated he had been in-serviced on fall protocol. He stated only nurses are allowed to complete range of motion, neuro checks, pain assessment and completed incident/ accident report. LVN F stated the physician, DON, and family was expected to be notified. He also stated he would follow the physician directions of what treatment he believed the resident needed. Interview on 05/30/2024 at 10:15 AM, CMA A stated she was walking by the activity area near the nurse's desk and observed Resident #1 on the floor in front of the television. She stated Resident #1's wheelchair was a few feet away from her by a table. She stated Resident #1 was not a good historian and unable to give any information of the incident of her lying on the floor. CMA A stated Resident #1 was lying on her back. She also stated she went to get assistance from CNA B. She stated CNA B was giving another resident a shower and was unable to assist her with transferring Resident #1 from the floor to her wheelchair. She stated she found LVN E. She stated LVN E was busy with a new admission and was unable to assist her with Resident #1. CMA A stated there were other nurses in the facility and did not think about going to find another nurse. CMA A stated she did not want Resident #1 laying on the floor any longer and she had observed nurses perform range of motion on residents after they had fall and she decided she would perform range of motion and she asked a CNA to assist her in transferring Resident #1 to the wheelchair. She stated she put the vital signs on a piece of paper and laid it on the desk and she does not know if the Nurse completed an assessment on Resident #1. She stated she did not follow up on the incident. CMA A stated she had been in-service on fall protocol. She stated she was instructed during the in-service the nurses was the only staff was allowed to assess a resident found on the floor and complete range of motion. She stated she was not to assess Resident #1 or complete range of motion. She stated she was wrong, and she knows she did everything wrong in the situation of finding Resident #1 on the floor. She stated it was a busy day and she did not think to go and report it to DON or Administrator. She stated she could have asked another nurse but she was wanting to assist resident off the floor as soon as possible. In an interview via phone on 05/30/2024 at 10:38 AM, LVN E stated 05/03/2024 was her last day to work at this facility. She stated it was a very busy day. LVN E stated she did not recall anyone come to her and report anyone on the floor. She stated she was busy with a new admit all day and if anyone fell it would have been when LVN G worked on 05/02/2024. LVN E stated to contact LVN G and ask her about anyone falling. She stated I think Resident #1 fell on LVN G's shift on 05/02/2024. She stated she was at work and needed to go back to work. LVN E stated she did not have anything else to say about Resident #1. In an interview on 05/30/2024 at 10:50 AM, LVN G stated she did work on 05/02/2024. She stated no one fell on her shift. LVN G stated Resident #1 did not fall or was found on the floor the date of 05/02/2024. LVN G stated when she came back to work on 05/06/2024 it was reported to her Resident #1 was in the hospital with a hip fracture during the morning meeting. LVN G stated it was not mentioned she was found on the floor or had a on 05/03/2024. She stated it was unknown how she fractured her hip. She stated she had been in-serviced on falls assessments and what to do if a resident fell . LVN G stated if a resident was found on the floor or witnessed a fall only the nurses was allowed to assess the residents and do range of motion. She stated the nurse would complete head to toe skin assessment, neuro checks, vitals and call the physician immediately if there was an injury. LVN G also stated she would follow the physician directions and would also contact the DON and the responsible party of the resident. She stated a nurse's note was required to be completed after any incident of a resident. In an interview on 05/30/2024 at 11:20 AM, CNA D stated No when asked if he was aware of anything happening to Resident #1 on 5/3/2024. CNA D would only answer yes/no type questions. He would not respond to any questions that required detailed information. In an interview on 05/30/2024 at 11:55 AM, CMA H stated he did work with LVN G on 05/02/2024. He stated if there were any changes with a resident including finding a resident on the floor or witnessing a fall, they reported to each other. He stated he was not aware of Resident #1 falling on 05/02/2024. CMA H stated he would definitely know if anyone fell when he is working in the facility. He stated he had been in-serviced on fall protocol. CMA H also stated only nurses was allowed to assess a resident if a resident was found on the floor or if it was a witnessed fall. He stated no one but the nurse was complete entire assessment such as neuro checks, pain assessment, incident/ accident report or do range of motion on a resident. CMA H stated other staff was allowed to assist resident with transfer only after the nurse completed assessments and gave instructions to other staff it was safe to transfer the resident. He stated if he found someone on the floor and the nurse supervisor for that particular resident was not available, he would find another nurse and would not touch the resident until the nurse did their assessment. In an interview on 05/30/2024 at 1:30 PM, the DON stated she was working on 05/03/2024 and no one reported to her of Resident #1 being found on the floor or any incident with Resident #1. She stated there were two nurse supervisors, MDS Nurse and she was in the facility on 05/03/2024. She stated only a LVN or RN was allowed to complete pain assessments, head to toe skin assessments, neuro checks, incident/ accident reports. She stated if a resident was injured the nurse would contact the physician and follow the physician orders. She also stated if a resident was not injured, she expected the physician to be contacted. The DON also stated the responsible party of the resident was also expected to be contacted. She stated the nurse would direct other staff what to do after she had assessed the resident and contacted the physician. She also stated CMA was not qualified to do range of motion on a resident or to do any type of pain assessments or neuro checks. She stated if the nurse responsible for Resident #1 was not available CMA A was expected to find another nurse to assess Resident #1. The DON also stated the nurse was expected to complete incident/ accident report, pain assessment, and a nurses note. She also stated the CMA or LVN E was expected to notify DON or ADON when there is a fall or a resident found on the floor. She stated she was not aware of Resident #1 was found on the floor. The DON stated there was not incident report, pain assessment, nurses note or any documentation in the electronic medical record about Resident #1 found on the floor. In an interview on 05/30/2024 at 2:15 PM, the ADON stated she reviewed Resident #1's electronic medical record and there was not any documentation of any type of incident on 05/03/2024 of Resident #1 being found on the floor. She stated CMA A or any CMA was not qualified to do range of motion, skin assessments, neuro checks or determine if a resident was injured. She stated if CMA A reported to a nurse and the nurse was busy it was expected for any staff including CMA A to find another nurse in the facility to assess Resident #1. She also stated Resident #1 was required to be assessed by a nurse before anyone transferred her from the floor to the wheelchair. She stated CMA A was not qualified to determine if it was safe to transfer Resident #1. The ADON stated she was not working on 05/03/2024, however, there were 2 nurse supervisors, DON, and MDS nurse in the facility. She stated CMA A did not follow the facilities fall protocol. In an interview on 05/30/2024 at 3:10 PM, the Administrator stated he was not notified of Resident #1 being found on the floor. He stated his expectations was for a nurse to assess a resident anytime a resident is found on the floor or any type of incident. The Administrator stated CMA A was not qualified to do range of motion, complete pain assessments or incident /accident reports. He stated if a nurse was busy, he expected the staff to find another nurse in the facility and have them to assess a resident or give care to a resident in an emergency. He stated this was not the correct protocol for this facility for a non- licensed nurse to do any type of nursing treatment on a resident. CMA A was given written disciplinary action. In an interview on 05/30/2024 at 3:40 PM, the Physician stated he was not notified of any incident in May of Resident #1 except when the Administrator did contact him about her fracture and being in the hospital. He stated he was not notified of Resident #1 being found on the floor. The Physician stated the Administrator, DON, ADON or a nurse always contacted him if there was a fall or any change of condition with a resident. He stated the Administrator would always contact him about any incident with a resident when he was notified. He also stated the nurses always notified him but the Administrator would contact him also. The Physician stated Resident #1 could have broken any bone without falling. He stated she does have brittle bones and it would be difficult for him to determine if Resident #1 may have broken a bone without knowing if she actually fell or laid on the floor. Record review of Inservice on Falls, dated 04/14/2024 reflected the following was discussed during the in-service: 1. When a resident falls all non- licensed nursing staff will notify the nurse. Once the Nurse assess the resident such as: vitals, does a resident have an injury, change of condition then the nurse will make decision of whether to transfer resident back to bed or wheelchair or does the resident require to be transferred to the hospital. All unwitnessed falls must have neuros. 2. Nurse will notify the Administrator, Director of Nurses, Responsible Party, and the Physician. Incident report completed by the nurse and sign/ date the report. (the in-service was signed by CMA A). Record review of Facility Policy on Falls- Clinical Protocol, revised March 2018, reflected the nurse shall assess and document the following: a. Vital signs. b. Recent injury, especially fracture or head injury. c. Musculoskeletal function, observing for change in normal range of motion, weight bearing, etc. d. Change in condition or level of consciousness. e. Neurological status. f. Pain g. Frequency and number of falls since last physician visit. h. Precipitating factors, details on how falls occurred. i. All current medications, especially those associated with dizziness or lethargy. j. All active diagnoses. The Administrator was notified on 05/30/2024 at 6:19 PM,that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 05/31/2024 at 1:44 PM: Date 05/31/2024 On 05/30/2024 a facility self-reportable investigation was initiated at the facility. 05/30/2024 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an Immediate Jeopardy to resident health and safety. The notification of Immediate Jeopardy states as follows: The facility failed to ensure care was provided by qualified persons in accordance with professional standards of practice. Interventions: 1. On 5/30/24 safe surveys with all oriented residents were completed by administrative staff to ensure no other falls/incidents have not been reported or addressed. 2. On 5/30/24 pain assessments on all residents were started by nursing administration to ensure all pain needs were addressed with interventions in place. 3. On 5/30/24 disciplinary action was begun for CMA A and CNA B by the DON/ Administrator for practicing outside their practice by moving and assessing resident #1, and not reporting incident to the Administrator or DON. 4. Nurse in question no longer works at facility. 5. Administrator/DON initiated an in-service for all staff on 5/30/24 on incident/accident policy, incident communication between staff and administration, abuse neglect exploitation, assessments post fall/incident to be completed by licensed nurse only, and scope of practice by position. A post-test will be performed with staff over information in-serviced on by administration, and a score of 100% must be achieved. If less than 100%, staff will be reeducated and retest until 100% is achieved. 6. Administrator/DON initiated an in-service for nursing staff on 5/30/24 on physician and family notification of incidents or change in status, neuro protocol for unwitnessed falls or falls with head injury, completing a new fall risk assessment after fall, and assessing residents after a fall/incident by licensed nurse only. A post-test will be performed with staff over information in-serviced on by administration, and a score of 100% must be achieved. If less than 100%, staff will be reeducated and retest until 100% is achieved. 7. Administrator/DON initiated an in-service for CMA A and CNA B a one-on-one in-service about notification of administrator/DON of a fall/incident, and to stay within scope of practice for their position. A post-test will be performed with staff over information in-serviced on by administration, and a score of 100% must be achieved. If less than 100%, staff will be reeducated and retest until 100% is achieved. 8. Administrator and DON were in-serviced on 5/31/24 by Regional Director of Operations on all the policies mentioned above, and to notify regional/corporate staff of ALL falls/incidents and are to notify regional/corporate staff of any discrepancies. Regional/corporate staff will follow-up on each fall/incident in question and direct with appropriate interventions. If staff are unable to attend any of the in-services, they will be required to complete the in-service before starting their assigned shift. Any agency will be in-serviced prior to the beginning of their shift. Any new hires will be in-serviced on hire, prior to working a shift. The Medical Director was made aware of the Immediate Jeopardy 5/30/24 at 9:00 PM and has been involved in developing the Plan of Removal. These conversations are considered part of the QA process. A QAPI meeting was held on 5/30/24 with attendance of Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Regional Director of Clinical Services, and Regional Director of Operations. This plan was initially implemented 5/30/24 and will be monitored through completion by corporate and regional staff. Plan of Removal completion date is 5/31/24 by 5:00 PM with continuation of oncoming staff and follow-up. The Surveyor monitored the POR on 05/31/2024 as followed: 1. Review of the facility's safe surveys with all the oriented residents reflected it was completed and conducted by the Director of Nurses on 05/31/2024. The safe surveys revealed any additional falls/ incidents had not been reported. 2. Review of the facility's pain assessments on all residents were completed on 05/31/2024 by the Director of Nurses, LVN I and LVN J. 3. Review of the facility's disciplinary action for CMA A and CNA B for performance and safety. Violated policy performance expectations, inefficient, intentional, careless or any poor / substandard performance of duties, conducting endangering life, safety or health of others and failure to comply with business rules, regulations, and policies/ procedures. 4. Verified LVN E no longer is an employee at the facility. Reviewed LVN E personnel record. LVN E resigned from the facility. LVN E resigned on 05/05/2024. 5. Review of the following in-service conducted on 05/30/2024 for nursing staff and other disciplines: a. Accidents and Incidents- Accidents and incidents should be reported immediately to the nurse on duty. The nurse to intervene immediately. All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator. The nurse supervisor/ charge nurse/or the department or supervisor shall complete a Report of Incident/ Accident form and submit the original to the Director of Nurses within 24 hours of the incident or accident. b. Disciplinary action for all staff involved with communication failure. It is expected for all staff to communicate as a team. Failure to communicate or report a change of condition, a fall, etc. could result in discipline up to termination. If a staff member does not take appropriate action after staff has communicated an issue, please contact the Administrator or Director of Nurses immediately. c. Abuse and Neglect- All residents have the right to be free from any abuse, neglect or exploitation. Staff is expected to report any abuse or neglect to the nurse on duty then immediately to the administrator for immediate intervention. d. Falls - If a resident falls, the nurse must be notified immediately. If your nurse is unavailable, someone will need to send an aide to the other hall so that the nurse from the other unit can come and assess the resident. The Director of Nurses, Assistant Director of Nurses, and MDS nurse are also available to do assessments for falls as well. No one other that the nurse should assess or move the resident. When a resident falls, no matter your title, please let the Administrator, Director of Nurses and Assistance Director of Nurses know so that the fall will be followed up as soon as possible. e. Scope of Practice and Duties- All staff have job duties and are expected to complete them. Any job no completed or doing a job or duties that is beyond your training or scope of practice is not allowed. Discipline will follow. Only nurses can assess a resident and do range of motion. (job duties for all disciplines were reviewed). f. Post Test- reviewed the post tests given to staff after the in-services. There were 32 staff had taken the post test and made 100 on the test. g. Physician and responsible party notification- NP/ Physician must be notified and documented for all incidents including falls and behaviors and document/complete all incidents neuros, and pertinent information. Family, responsible party and/ or resident needs to be notified in the event of a fall or change of condition. h. Neuro checks protocol for unwitnessed falls or falls with head injury. Fall assessment to be completed after each fall and quarterly. Neuro checks must follow any unwitnessed fall or evidence of head trauma. Incident reports are completed fore each fall. Documentation of incidents must be charted in the progress note, and must contain investigation of cause of fall, interventions to prevent further falls, assessment summary including injuries, vital signs, and initiation neuros indicated. i. Filling out Risk Assessment after fall - Everything must be addressed and completed. Must have vital signs included in the report. Must have an intervention. Include all notified example: Director of Nurses, Administrator, Doctor, and Responsible Party. Do progress note from this report. Be sure to sign report under signature. j. Incident communications- Charge nurses will communicate all incidents on shift change with oncoming nurses and on the hall and specify any adverse findings and document appropriately in resident's record and notify all parties such as: responsible party, Physician, Administrator and the Director of Nurses. Inservice one-on-one on 05/31/2024 with CMA A: if a resident falls the nurse must be notified immediately. If your nurse is unavailable, someone will need to send an aide to the other hall so that the nurse from the other unit can come assess the resident. The Director of Nurses, Assistant Director of Nurses and the MDS Nurse are also available to do assessments for falls. No one other than the nurse should assess or move the resident. When a resident falls, no matter your title, please let the Administrator, Director of Nurses and the Assistant Director of Nurses know about the fall. Inservice one-on-one on 05/31/2024 with CNA B: If a resident is found on the floor, a nurse must immediately assess the resident before moving the resident. If one (nurse) is not available one from another hall must be summons. Resident is not to be moved or assessed by a non-nurse. After every fall, please notify the Administrator. The Director of Nurses or the Assistant Director of Nurses will go follow up with nursing to ensure documentation has been completed and the family and physician has been notified. The Administrator and Director of Nurses was in-serviced by the Regional Director of Operations on 05/31/2024 on the following topics: a. Incident/ Accident policy b. Incident communication between staff and Administrator c. Abuse, neglect, and exploitation d. Assessment post fall e. Incident report to be completed by licensed nurse only. f. Scope of practice by position g. Physician and family notification of residents or change in status. h. Neuro protocol for unwitnessed falls or falls with head injuries. i. Completing a new fall risk assessment after a fall. j. All staff will be required to complete all required in-services prior to the beginning of their first shift. Review of the QAPI Meeting Report dated 05/30/2024 reflected the following were in attendance: Administrator, Director of Nurses, Assistant Director of Nurses, MDS Coordinator, Regional Director of Clinical Services, and Regional Director of Operations. The Medical Director was made aware of the Immediate Jeopardy on 05/30/2024 at 9:00 PM and was involved with the Plan of Removal. Observation on 05/30/2024 at 5:45 PM- 6:05 PM the ADON and the DON was conducting in-services and the post test before the 6:00 PM - 6:00 AM staff could give care to the residents. This was ongoing on 05/30/2024. In an interview on 05/31/2024 at 2:10 PM, Laundry Aide K stated she had been in-service on Incident/ Accidents- if she saw a resident fall, she was to find a nurse immediately. She stated she was not to touch the resident and report what happened to the nurse. She stated she was in-service on abuse and neglect. She stated abuse was if a staff yelled at a resident or hit a resident. She stated neglect was when a staff refused to give resident a drink of water or food. She stated she did take a test and made 100 on it. She also stated only the nurse was allowed to touch the resident until she assessed the resident. In an interview on 05/31/2024 at 2:15 PM, LVN F stated he had been in-service on incident and accidents policy/protocol. He stated only nurses was allowed to assess a resident after a fall, or if found on floor and/or any type of incident/accident. LVN F stated the nurse completed neuro checks, completed head to toe skin assessment, vital signs and if there was an injury the physician was called immediately and follow the orders from the Physician. He stated he was also not to move the resident if there was an injury until EMR transported the resident to hospital. LVN F stated the family, DON and Administrator was also to be notified immediately if there were any change of condition with a resident. He stated if the nurse assigned to the resident who was found on the floor and that nurse was busy it was expected any nurse can assess the resident. He stated he was inserviced on abuse and neglect. LVN F stated abuse was when a staff or another resident slapped a resident, cussed a resident and neglect was when staff refused to give resident their scheduled medication or refused to assist resident to the bathroom. He stated job duties was discussed and to follow your job duties. He stated only nurses are allowed to complete the nursing documentation of incident/ accident reports, nurses notes, skin assessments, etc. He stated if it is a new fall it is required to complete a new fall risk assessment. LVN F also stated after any incident / accident the physician, family and the DON/ Administrator was to be contacted immediately. He stated he did take a posttest and made 100 on the test. In an interview on 05/31/2024 at 2:26 PM, Dietary Aide/CNA L stated she worked as a CNA and some days in the kitchen. She stated she was in-service on 5/31/2024 on the following: 1. Abuse and neglect 2. Not to move a resident or touch a resident until nurse assess the resident if they had fallen. The nurse was to give directions of what to do after she completed all her assessments. 3. Report any falls or accidents immediately to the nurse. If nurse supervisor was not available, find another nurse such as Director of Nurses or MDS nurse. Always report

Based on observation, interviews and record review , the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #1) of 5 residents reviewed for quality of care. The facility failed to ensure Resident #1, who was found on the floor by CMA A was properly assessed or monitored on 05/3/2024 until Resident #1 was transferred to the hospital on 05/04/2024 at approximately 10:30 AM. An Immediate Jeopardy (IJ) situation was identified on 05/30/2024 at 6:05 PM. While the IJ was removed on 05/31/2024 at 7:05 PM, the facility remained out of compliance at a scope of isolated with potential for more than minimal harm that is not immediate jeopardy because all staff had not be trained on falls. These failures could place residents at risk of not receiving necessary medical care, harm, and death. Findings included: Record review of Resident #1's face sheet dated 05/30/2024 reflected an [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses of fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing (breaks or rupture in bone situated between the hip and the knee), difficulty with walking ( problems with bones or pain can make it difficult to walk properly), abnormalities in gait and mobility ( an injury or underlying medical condition can cause an abnormal gait), Alzheimer's disease ( a brain disease that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), unspecified lack of coordination ( muscle control problem that causes an inability to coordinate movements. It leads to jerky, unsteady, to and from motion of the middle of the body and an unsteady walking style), and unspecified fall (finding of sudden movement downward, usually resulting in injury). Record review of Resident #1's Annual MDS Assessment, dated 04/11/2024, reflected Resident #1 had a BIMS score of 0 indicated severe cognitive impairment. She was assessed to have poor short- and long-term memory recall. Her decision-making ability was severely impaired. Resident #1 was assessed to require assistance with ADLs including the following: transfers, eating, personal hygiene, showers, and dressing. Record review of Resident #1's Comprehensive Care Plan revised on 05/31/2024 reflected Resident #1 had impaired cognitive function or impaired thought process related to Alzheimer's Disease. Intervention: Keep resident's, routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Resident #1 was prone to skin tears and bruising related to fragile skin. Intervention: all injuries will be monitored until they are resolved. Notify charge nurse of any new bruising or skin tears. She was high risk for falls related to unsteady balance, incontinence, poor safety awareness and being forgetful. Interventions: educate the resident/ family and care givers about safety reminders and what to do if a fall occurs. Anticipate and meet the resident's needs. Follow facility protocol. Record review of Resident #1's electronic medical records reflected Resident #1 did not have any nursing note entries on 05/03/2024. Record review of Resident #1's electronic medical records reflected Resident #1 did not have a pain assessment or incident/accident report on 05/03/2024. There was one entry at 10:38 AM B/P was 129/79 mmHg. Record review of Resident #1's Nurses notes, at 1:13 PM on 05/04/2024, reflected Resident #1 continued to decline with a B/P of 96/55 and pulse of 55 within an hour of having elevated blood pressure earlier in AM. Resident #1 had a glazed (expression is dull, usually because a person is tired or had difficulty concentrating on something) look to her eyes and small pinpoint pupils. Her 02 sats dropped from 94 % R/A to 86 % R/A. O2 per nasal cannula put on Resident #1 to aid in oxygen saturation. O2/3L/NC 93%. NP was notified and new order to send Resident #1 to the emergency room for evaluation and treatment. Resident #1 was transported by EMS to the emergency room at 11:44 AM. Family and ADON was notified of Resident #1 being transported to the emergency room . Written by RN C. Record review of Resident #1's Nurses Notes, at 1:49 PM on 05/04/2024, reflected Resident #1 was hospitalized . Record review of Resident #1's Hospital Records dated 05/04/2024 reflected minimally displaced left sub capital femoral neck fracture (these fractures occur in the neck of the thighbone). There were no other injuries according to the x-ray report. Observation and interview on 05/30/2024 at 9:00 AM, Resident #1 were sitting in the common area beside another resident. She smiled and she did not respond to questions. Resident #1 did not show any signs or symptoms of any distress. She was relaxed and watching people. In an interview on 05/30/2024 at 9:12 AM, CNA B stated on 05/03/2024 CMA A came to her after lunch when she was giving Resident #2 a shower and requested if she had time to assist her in transferring Resident #1 from the floor to the wheelchair. She stated CMA A explained she found Resident #1 lying on the floor. CNA B stated she asked CMA A to find CNA D she was unable to leave the shower. CNA B stated she was assigned to Resident #1 on 05/03/2024. She stated she went to the nurse's desk after giving Resident #2 a shower and assisted Resident #2 to her room. CNA B also stated she observed Resident #1 sitting in her wheelchair and she was her normal self. She stated she would stand and walked from chair to chair. She stated this was her usual routine when sitting in the common area near nurses' desk. She stated she received a verbal report from LVN E and she stated she believed Resident #1 slid out of her wheelchair. She also stated she had been in-serviced on what to do if a resident fell or was found on the floor. CNA B stated only nurses was allowed to touch the resident and complete a skin assessment, pain assessment and if there was an injury to call the physician and the non-nursing staff including CMAs was expected to wait and follow the nurses' directions on what to do with the resident and when to move the resident. Interview on 05/30/2024 at 10:03 AM, LVN F stated he was coming on duty for the night shift on 05/03/2024 and LVN E was giving him verbal report of what occurred on the day shift on 05/03/2024. He stated during the verbal report LVN E informed him Resident #1 had a fall and she did not report anything else about Resident #1. He stated he monitored her on the night shift for any changes in her mental or physical condition. LVN F stated Resident # 1 never complained of pain and was at her baseline physically and mentally on his shift (from 6:00 PM on 05/03/2024 to 6:00 AM on 05/04/2024). He stated he had been in-serviced on fall protocol. He stated only nurses are allowed to complete range of motion, neuro checks, pain assessment and completed incident/ accident report. LVN F stated the physician, DON, and family was expected to be notified. He also stated he would follow the physician directions of what treatment he believed the resident needed. Interview on 05/30/2024 at 10:15 AM, CMA A stated she was walking by the activity area near the nurse's desk and observed Resident #1 on the floor in front of the television. She stated Resident #1's wheelchair was a few feet away from her by a table. She stated Resident #1 was not a good historian and unable to give any information of the incident of her lying on the floor. CMA A stated Resident #1 was lying on her back. She also stated she went to get assistance from CNA B. She stated CNA B was giving another resident a shower and was unable to assist her with transferring Resident #1 from the floor to her wheelchair. She stated she found LVN E. She stated LVN E was busy with a new admission and was unable to assist her with Resident #1. CMA A stated there were other nurses in the facility and did not think about going to find another nurse. CMA A stated she did not want Resident #1 laying on the floor any longer and she had observed nurses perform range of motion on residents after they had fall and she decided she would perform range of motion and she asked a CNA to assist her in transferring Resident #1 to the wheelchair. She stated she put the vital signs on a piece of paper and laid it on the desk and she does not know if the Nurse completed an assessment on Resident #1. She stated she did not follow up on the incident. CMA A stated she had been in-service on fall protocol. She stated she was instructed during the in-service the nurses was the only staff was allowed to assess a resident found on the floor and complete range of motion. She stated she was not to assess Resident #1 or complete range of motion. She stated she was wrong, and she knows she did everything wrong in the situation of finding Resident #1 on the floor. She stated it was a busy day and she did not think to go and report it to DON or Administrator. She stated she could have asked another nurse but she was wanting to assist resident off the floor as soon as possible. In an interview via phone on 05/30/2024 at 10:38 AM, LVN E stated 05/03/2024 was her last day to work at this facility. She stated it was a very busy day. LVN E stated she did not recall anyone come to her and report anyone on the floor. She stated she was busy with a new admit all day and if anyone fell it would have been when LVN G worked on 05/02/2024. LVN E stated to contact LVN G and ask her about anyone falling. She stated I think Resident #1 fell on LVN G's shift on 05/02/2024. She stated she was at work and needed to go back to work. LVN E stated she did not have anything else to say about Resident #1. In an interview on 05/30/2024 at 10:50 AM, LVN G stated she did work on 05/02/2024. She stated no one fell on her shift. LVN G stated Resident #1 did not fall or was found on the floor the date of 05/02/2024. LVN G stated when she came back to work on 05/06/2024 it was reported to her Resident #1 was in the hospital with a hip fracture during the morning meeting. LVN G stated it was not mentioned she was found on the floor or had a on 05/03/2024. She stated it was unknown how she fractured her hip. She stated she had been in-serviced on falls assessments and what to do if a resident fell . LVN G stated if a resident was found on the floor or witnessed a fall only the nurses was allowed to assess the residents and do range of motion. She stated the nurse would complete head to toe skin assessment, neuro checks, vitals and call the physician immediately if there was an injury. LVN G also stated she would follow the physician directions and would also contact the DON and the responsible party of the resident. She stated a nurse's note was required to be completed after any incident of a resident. In an interview on 05/30/2024 at 11:20 AM, CNA D stated No when asked if he was aware of anything happening to Resident #1 on 5/3/2024. CNA D would only answer yes/no type questions. He would not respond to any questions that required detailed information. In an interview on 05/30/2024 at 11:55 AM, CMA H stated he did work with LVN G on 05/02/2024. He stated if there were any changes with a resident including finding a resident on the floor or witnessing a fall, they reported to each other. He stated he was not aware of Resident #1 falling on 05/02/2024. CMA H stated he would definitely know if anyone fell when he is working in the facility. He stated he had been in-serviced on fall protocol. CMA H also stated only nurses was allowed to assess a resident if a resident was found on the floor or if it was a witnessed fall. He stated no one but the nurse was complete entire assessment such as neuro checks, pain assessment, incident/ accident report or do range of motion on a resident. CMA H stated other staff was allowed to assist resident with transfer only after the nurse completed assessments and gave instructions to other staff it was safe to transfer the resident. He stated if he found someone on the floor and the nurse supervisor for that particular resident was not available, he would find another nurse and would not touch the resident until the nurse did their assessment. In an interview on 05/30/2024 at 1:30 PM, the DON stated she was working on 05/03/2024 and no one reported to her of Resident #1 being found on the floor or any incident with Resident #1. She stated there were two nurse supervisors, MDS Nurse and she was in the facility on 05/03/2024. She stated only a LVN or RN was allowed to complete pain assessments, head to toe skin assessments, neuro checks, incident/ accident reports. She stated if a resident was injured the nurse would contact the physician and follow the physician orders. She also stated if a resident was not injured, she expected the physician to be contacted. The DON also stated the responsible party of the resident was also expected to be contacted. She stated the nurse would direct other staff what to do after she had assessed the resident and contacted the physician. She also stated CMA was not qualified to do range of motion on a resident or to do any type of pain assessments or neuro checks. She stated if the nurse responsible for Resident #1 was not available CMA A was expected to find another nurse to assess Resident #1. The DON also stated the nurse was expected to complete incident/ accident report, pain assessment, and a nurses note. She also stated the CMA or LVN E was expected to notify DON or ADON when there is a fall or a resident found on the floor. She stated she was not aware of Resident #1 was found on the floor. The DON stated there was not incident report, pain assessment, nurses note or any documentation in the electronic medical record about Resident #1 found on the floor. In an interview on 05/30/2024 at 2:15 PM, the ADON stated she reviewed Resident #1's electronic medical record and there was not any documentation of any type of incident on 05/03/2024 of Resident #1 being found on the floor. She stated CMA A or any CMA was not qualified to do range of motion, skin assessments, neuro checks or determine if a resident was injured. She stated if CMA A reported to a nurse and the nurse was busy it was expected for any staff including CMA A to find another nurse in the facility to assess Resident #1. She also stated Resident #1 was required to be assessed by a nurse before anyone transferred her from the floor to the wheelchair. She stated CMA A was not qualified to determine if it was safe to transfer Resident #1. The ADON stated she was not working on 05/03/2024, however, there were 2 nurse supervisors, DON, and MDS nurse in the facility. She stated CMA A did not follow the facilities fall protocol. In an interview on 05/30/2024 at 3:10 PM, the Administrator stated he was not notified of Resident #1 being found on the floor. He stated his expectations was for a nurse to assess a resident anytime a resident is found on the floor or any type of incident. The Administrator stated CMA A was not qualified to do range of motion, complete pain assessments or incident /accident reports. He stated if a nurse was busy, he expected the staff to find another nurse in the facility and have them to assess a resident or give care to a resident in an emergency. He stated this was not the correct protocol for this facility for a non- licensed nurse to do any type of nursing treatment on a resident. CMA A was given written disciplinary action. In an interview on 05/30/2024 at 3:40 PM, the Physician stated he was not notified of any incident in May of Resident #1 except when the Administrator did contact him about her fracture and being in the hospital. He stated he was not notified of Resident #1 being found on the floor. The Physician stated the Administrator, DON, ADON or a nurse always contacted him if there was a fall or any change of condition with a resident. He stated the Administrator would always contact him about any incident with a resident when he was notified. He also stated the nurses always notified him but the Administrator would contact him also. The Physician stated Resident #1 could have broken any bone without falling. He stated she does have brittle bones and it would be difficult for him to determine if Resident #1 may have broken a bone without knowing if she actually fell or laid on the floor. Record review of Inservice on Falls, dated 04/14/2024 reflected the following was discussed during the in-service: 1. When a resident falls all non- licensed nursing staff will notify the nurse. Once the Nurse assess the resident such as: vitals, does a resident have an injury, change of condition then the nurse will make decision of whether to transfer resident back to bed or wheelchair or does the resident require to be transferred to the hospital. All unwitnessed falls must have neuros. 2. Nurse will notify the Administrator, Director of Nurses, Responsible Party, and the Physician. Incident report completed by the nurse and sign/ date the report. (the in-service was signed by CMA A). Record review of Facility Policy on Falls- Clinical Protocol, revised March 2018, reflected the nurse shall assess and document the following: a. Vital signs. b. Recent injury, especially fracture or head injury. c. Musculoskeletal function, observing for change in normal range of motion, weight bearing, etc. d. Change in condition or level of consciousness. e. Neurological status. f. Pain g. Frequency and number of falls since last physician visit. h. Precipitating factors, details on how falls occurred. i. All current medications, especially those associated with dizziness or lethargy. j. All active diagnoses. The Administrator was notified on 05/30/2024 at 6:19 PM,that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 05/31/2024 at 1:44 PM: Date 05/31/2024 On 05/30/2024 a facility self-reportable investigation was initiated at the facility. 05/30/2024 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an Immediate Jeopardy to resident health and safety. The notification of Immediate Jeopardy states as follows: The facility failed to ensure care was provided by qualified persons in accordance with professional standards of practice. Interventions: 1. On 5/30/24 safe surveys with all oriented residents were completed by administrative staff to ensure no other falls/incidents have not been reported or addressed. 2. On 5/30/24 pain assessments on all residents were started by nursing administration to ensure all pain needs were addressed with interventions in place. 3. On 5/30/24 disciplinary action was begun for CMA A and CNA B by the DON/ Administrator for practicing outside their practice by moving and assessing resident #1, and not reporting incident to the Administrator or DON. 4. Nurse in question no longer works at facility. 5. Administrator/DON initiated an in-service for all staff on 5/30/24 on incident/accident policy, incident communication between staff and administration, abuse neglect exploitation, assessments post fall/incident to be completed by licensed nurse only, and scope of practice by position. A post-test will be performed with staff over information in-serviced on by administration, and a score of 100% must be achieved. If less than 100%, staff will be reeducated and retest until 100% is achieved. 6. Administrator/DON initiated an in-service for nursing staff on 5/30/24 on physician and family notification of incidents or change in status, neuro protocol for unwitnessed falls or falls with head injury, completing a new fall risk assessment after fall, and assessing residents after a fall/incident by licensed nurse only. A post-test will be performed with staff over information in-serviced on by administration, and a score of 100% must be achieved. If less than 100%, staff will be reeducated and retest until 100% is achieved. 7. Administrator/DON initiated an in-service for CMA A and CNA B a one-on-one in-service about notification of administrator/DON of a fall/incident, and to stay within scope of practice for their position. A post-test will be performed with staff over information in-serviced on by administration, and a score of 100% must be achieved. If less than 100%, staff will be reeducated and retest until 100% is achieved. 8. Administrator and DON were in-serviced on 5/31/24 by Regional Director of Operations on all the policies mentioned above, and to notify regional/corporate staff of ALL falls/incidents and are to notify regional/corporate staff of any discrepancies. Regional/corporate staff will follow-up on each fall/incident in question and direct with appropriate interventions. If staff are unable to attend any of the in-services, they will be required to complete the in-service before starting their assigned shift. Any agency will be in-serviced prior to the beginning of their shift. Any new hires will be in-serviced on hire, prior to working a shift. The Medical Director was made aware of the Immediate Jeopardy 5/30/24 at 9:00 PM and has been involved in developing the Plan of Removal. These conversations are considered part of the QA process. A QAPI meeting was held on 5/30/24 with attendance of Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Regional Director of Clinical Services, and Regional Director of Operations. This plan was initially implemented 5/30/24 and will be monitored through completion by corporate and regional staff. Plan of Removal completion date is 5/31/24 by 5:00 PM with continuation of oncoming staff and follow-up. The Surveyor monitored the POR on 05/31/2024 as followed: 1. Review of the facility's safe surveys with all the oriented residents reflected it was completed and conducted by the Director of Nurses on 05/31/2024. The safe surveys revealed any additional falls/ incidents had not been reported. 2. Review of the facility's pain assessments on all residents were completed on 05/31/2024 by the Director of Nurses, LVN I and LVN J. 3. Review of the facility's disciplinary action for CMA A and CNA B for performance and safety. Violated policy performance expectations, inefficient, intentional, careless or any poor / substandard performance of duties, conducting endangering life, safety or health of others and failure to comply with business rules, regulations, and policies/ procedures. 4. Verified LVN E no longer is an employee at the facility. Reviewed LVN E personnel record. LVN E resigned from the facility. LVN E resigned on 05/05/2024. 5. Review of the following in-service conducted on 05/30/2024 for nursing staff and other disciplines: a. Accidents and Incidents- Accidents and incidents should be reported immediately to the nurse on duty. The nurse to intervene immediately. All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator. The nurse supervisor/ charge nurse/or the department or supervisor shall complete a Report of Incident/ Accident form and submit the original to the Director of Nurses within 24 hours of the incident or accident. b. Disciplinary action for all staff involved with communication failure. It is expected for all staff to communicate as a team. Failure to communicate or report a change of condition, a fall, etc. could result in discipline up to termination. If a staff member does not take appropriate action after staff has communicated an issue, please contact the Administrator or Director of Nurses immediately. c. Abuse and Neglect- All residents have the right to be free from any abuse, neglect or exploitation. Staff is expected to report any abuse or neglect to the nurse on duty then immediately to the administrator for immediate intervention. d. Falls - If a resident falls, the nurse must be notified immediately. If your nurse is unavailable, someone will need to send an aide to the other hall so that the nurse from the other unit can come and assess the resident. The Director of Nurses, Assistant Director of Nurses, and MDS nurse are also available to do assessments for falls as well. No one other that the nurse should assess or move the resident. When a resident falls, no matter your title, please let the Administrator, Director of Nurses and Assistance Director of Nurses know so that the fall will be followed up as soon as possible. e. Scope of Practice and Duties- All staff have job duties and are expected to complete them. Any job no completed or doing a job or duties that is beyond your training or scope of practice is not allowed. Discipline will follow. Only nurses can assess a resident and do range of motion. (job duties for all disciplines were reviewed). f. Post Test- reviewed the post tests given to staff after the in-services. There were 32 staff had taken the post test and made 100 on the test. g. Physician and responsible party notification- NP/ Physician must be notified and documented for all incidents including falls and behaviors and document/complete all incidents neuros, and pertinent information. Family, responsible party and/ or resident needs to be notified in the event of a fall or change of condition. h. Neuro checks protocol for unwitnessed falls or falls with head injury. Fall assessment to be completed after each fall and quarterly. Neuro checks must follow any unwitnessed fall or evidence of head trauma. Incident reports are completed fore each fall. Documentation of incidents must be charted in the progress note, and must contain investigation of cause of fall, interventions to prevent further falls, assessment summary including injuries, vital signs, and initiation neuros indicated. i. Filling out Risk Assessment after fall - Everything must be addressed and completed. Must have vital signs included in the report. Must have an intervention. Include all notified example: Director of Nurses, Administrator, Doctor, and Responsible Party. Do progress note from this report. Be sure to sign report under signature. j. Incident communications- Charge nurses will communicate all incidents on shift change with oncoming nurses and on the hall and specify any adverse findings and document appropriately in resident's record and notify all parties such as: responsible party, Physician, Administrator and the Director of Nurses. Inservice one-on-one on 05/31/2024 with CMA A: if a resident falls the nurse must be notified immediately. If your nurse is unavailable, someone will need to send an aide to the other hall so that the nurse from the other unit can come assess the resident. The Director of Nurses, Assistant Director of Nurses and the MDS Nurse are also available to do assessments for falls. No one other than the nurse should assess or move the resident. When a resident falls, no matter your title, please let the Administrator, Director of Nurses and the Assistant Director of Nurses know about the fall. Inservice one-on-one on 05/31/2024 with CNA B: If a resident is found on the floor, a nurse must immediately assess the resident before moving the resident. If one (nurse) is not available one from another hall must be summons. Resident is not to be moved or assessed by a non-nurse. After every fall, please notify the Administrator. The Director of Nurses or the Assistant Director of Nurses will go follow up with nursing to ensure documentation has been completed and the family and physician has been notified. The Administrator and Director of Nurses was in-serviced by the Regional Director of Operations on 05/31/2024 on the following topics: a. Incident/ Accident policy b. Incident communication between staff and Administrator c. Abuse, neglect, and exploitation d. Assessment post fall e. Incident report to be completed by licensed nurse only. f. Scope of practice by position g. Physician and family notification of residents or change in status. h. Neuro protocol for unwitnessed falls or falls with head injuries. i. Completing a new fall risk assessment after a fall. j. All staff will be required to complete all required in-services prior to the beginning of their first shift. Review of the QAPI Meeting Report dated 05/30/2024 reflected the following were in attendance: Administrator, Director of Nurses, Assistant Director of Nurses, MDS Coordinator, Regional Director of Clinical Services, and Regional Director of Operations. The Medical Director was made aware of the Immediate Jeopardy on 05/30/2024 at 9:00 PM and was involved with the Plan of Removal. Observation on 05/30/2024 at 5:45 PM- 6:05 PM the ADON and the DON was conducting in-services and the post test before the 6:00 PM - 6:00 AM staff could give care to the residents. This was ongoing on 05/30/2024. In an interview on 05/31/2024 at 2:10 PM, Laundry Aide K stated she had been in-service on Incident/ Accidents- if she saw a resident fall, she was to find a nurse immediately. She stated she was not to touch the resident and report what happened to the nurse. She stated she was in-service on abuse and neglect. She stated abuse was if a staff yelled at a resident or hit a resident. She stated neglect was when a staff refused to give resident a drink of water or food. She stated she did take a test and made 100 on it. She also stated only the nurse was allowed to touch the resident until she assessed the resident. In an interview on 05/31/2024 at 2:15 PM, LVN F stated he had been in-service on incident and accidents policy/protocol. He stated only nurses was allowed to assess a resident after a fall, or if found on floor and/or any type of incident/accident. LVN F stated the nurse completed neuro checks, completed head to toe skin assessment, vital signs and if there was an injury the physician was called immediately and follow the orders from the Physician. He stated he was also not to move the resident if there was an injury until EMR transported the resident to hospital. LVN F stated the family, DON and Administrator was also to be notified immediately if there were any change of condition with a resident. He stated if the nurse assigned to the resident who was found on the floor and that nurse was busy it was expected any nurse can assess the resident. He stated he was inserviced on abuse and neglect. LVN F stated abuse was when a staff or another resident slapped a resident, cussed a resident and neglect was when staff refused to give resident their scheduled medication or refused to assist resident to the bathroom. He stated job duties was discussed and to follow your job duties. He stated only nurses are allowed to complete the nursing documentation of incident/ accident reports, nurses notes, skin assessments, etc. He stated if it is a new fall it is required to complete a new fall risk assessment. LVN F also stated after any incident / accident the physician, family and the DON/ Administrator was to be contacted immediately. He stated he did take a posttest and made 100 on the test. In an interview on 05/31/2024 at 2:26 PM, Dietary Aide/CNA L stated she worked as a CNA and some days in the kitchen. She stated she was in-service on 5/31/2024 on the following: 1. Abuse and neglect 2. Not to move a resident or touch a resident until nurse assess the resident if they had fallen. The nurse was to give directions of what to do after she completed all her assessments. 3. Report any falls or accidents immediately to the nurse. If nurse supervisor was not available, find another nurse such as Director of Nurses or MDS nurse. Always report Abuse to the Administrator, your supervisor and if the Administrator not available can call him or repor [TRUNCATED]

Based on observation, interview and record review the facility failed to provide treatment and care in accordance with the comprehensive person-centered care plan and in accordance with professional standards of practice for four of four residents (#1, #2, #3 and #4) reviewed for quality of care, in that: The facility failed to monitor and provide care and services for Resident #1's foley catheter and abdominal pain resulting in Resident #1 being admitted to the hospital for [CONDITION(S)], UTI and [MEDICATION(S)]. The facility failed to have a system in place for the care and monitoring of Resident #1, #2, #3 and #4 indwelling catheters. This failure resulted in an Immediate Jeopardy on 07/08/2021 at 4:48 p.m. While the IJ was removed on 07/09/2021 at 5:26 p.m., the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope identified as isolated. This failure placed facility residents with catheters at risk of contracting urinary tract infection and becoming septic. Findings include: Record review of Resident #1's face sheet revealed a 72- year- old male DOB 11/26/1948 with admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's MDS assessment dated [DATE] revealed a BIMS score of 13 out 15, indicating he was cognitively intact. Record review of Resident #1's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] May replace indwelling foley PRN as needed related to retention of urine, unspecified, dated 05/27/2021. May change BSD bag as needed related to retention of urine, unspecified, dated 05/22/2021 There were no orders to monitor or document urine output. Record review of Resident #1's Care Plan dated 06/22/2021 revealed Resident #1 had an indwelling catheter due to retention of urine. Monitor/record/report to MD for UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior change in eating patterns, may replace indwelling foley PRN. Record review of Resident #1's Medication Administration Records and Treatment Administration Records from 06/22/2021 through 07/04/2021 reflected no documentation of urine output. Record review of Resident #1's clinical nursing progress notes dated 07/01/2021, written by LVN A, reflected Resident #1 complained of leakage from his catheter and discomfort to the penile area on 07/01/2021. It was also reflected the resident had decrease PO intake due to abdominal discomfort from the catheter. Review of Resident #1's nursing progress notes dated 07/01/2021 to 07/04/2021 reflected no documentation of urine output, no follow up on Resident #1's urinary status after he complained on 07/01/2021 until 07/04/2021 when he was sent to the local hospital ER. There was nothing in the progress notes indicating the doctor or nurse practitioner were notified of the changed of condition. Record review of hospital medical records revealed that, Resident #1 was admitted to the local hospital on 07/04/2021 due to [CONDITION(S)], secondary to UTI from foley catheter. Record re view of Resident #1's hospital records dated 07/04/2021 revealed the following: Resident #1's urine was collected, and it was amber and cloudy. Urinalysis was done. WBC ==14.8 (H)-normal range 4.8 - 10.8 Resident #1 was diagnosed with [CONDITION(S)] ([CONDITION(S)] is a serious condition resulting from the presence of harmful microorganisms in the blood or other body tissues and the body's response to their presence, potentially leading to the malfunction of various organs, shock and death. [CONDITION(S)] usually produces an elevated WBC) due to UTI, bacteria and pneumonia. ED work up showed UTI on urine analysis and CT of the abdomen showed [MEDICATION(S)] ([MEDICATION(S)] is an infection in any part of the urinary system, the kidney, the bladder the urethra) as well. Resident #1 was started on IV antibiotics [MEDICATION(S)] 1 gram in [MEDICATION(S)] 0.9% 50 ml IVPB. In an interview on 07/06/2021 at 3:30 p.m. Resident #1 stated the nursing staff were not emptying his catheter or checking the drainage system, so he was doing it on his own. He also stated the discomfort to his ABD, and penile area started on Thursdays, 07/01/2021 and the nurses were notified. He also stated he asked the LVN A to remove the catheter on 07/01/2021 because of the severe discomfort but she refused stating, there is no doctor's order for that. He stated, the nurse adjusted the catheter and the pain was relieved a little, but no one checked on it until Sunday, 07/04/2021. He stated, he could not eat due to the discomfort. In an interview on 07/06/2021 at about 3:35 p.m., Resident #1's family stated, she was visiting with Resident #1 on Sunday, 07/04/2021 when he got sent out to the local hospital ER. She also stated, Resident #1 had been complaining of his foley catheter for few days before. She stated, Resident #1's room had a foul odor, his catheter was leaking, and the urine was on his pillow. She stated, Resident #1 did not eat his lunch due to complaints of pain. In an interview on 07/07/2021 at 10:53 a.m. CNA A stated she worked with Resident #1 on the 6 a.m. to 2 p.m. shift from July 1-4, 2021. She stated Resident #1 would notify the nursing staff of how much urine was in his bag. She stated, Resident #1 told her his catheter was leaking on 07/01/2021 and she notified LVN A. She stated on 07/04/2021 Resident #1 complained of severe pain and his catheter was leaking and she notified the ADON. She stated Resident #1's pillowcase was saturated with urine. She stated when the ADON removed Resident#1's catheter, blood came out, and white stuff came out and urine kept coming out for about 5 minutes. CNA A stated whenever she empties a resident's catheter, she gives the number of the amount of urine that was in the catheter bag to the nurse. She stated there was nowhere for CNAs to document urine output for residents with catheter. In an interview on 07/07/2021 at 11:29 a.m. LVN A stated she worked the 6 a.m. to 6 p.m. shift on 07/01/2021. She stated Resident #1 complained of catheter leakage and abdominal pain. She stated she intervened by inflating and deflating the balloon of the foley catheter and the foley was draining urine in the bag, but she could not remember the amount of urine output from the catheter. She stated usually urine outputs are written on a piece of paper which is discarded at the end of shift because there was nowhere to document. She stated Resident #1 asked her to remove the foley catheter because of discomfort and she refused because there were no doctor's orders. She stated when the nursing staff provide care, they were supposed to document what they did. In an interview on 07/07/2021 at 2:39 p.m. CNA B stated she worked the 2 p.m. to 10 p.m. on 07/01/2021 and 0703/2021. She stated on 07/01/2021 Resident #1 complained of abdominal pain and he did not eat his dinner due to the pain. She stated she was told in report Resident #1 did not eat his lunch, she was concerned and notified LVN A. She stated LVN A told her not to worry, it is ok, there is nothing wrong with Resident #1's foley catheter. She stated on 07/03/2021, Resident #1 did not complain of pain but there was no urine in the foley catheter bag to empty during her shift. She stated she notified the 6 p.m. to 6 a.m. nurse there was no urine in the foley catheter drainage bag. She stated usually she empties the resident's foley bag at the end of the shift and gives the output number to the nurses. She stated there is nowhere for the CNAs to document urine output. In an interview on 07/07/2021 at 3:08 p.m. CNA C stated she worked the 2 p.m. to 10 p.m. shift on 07/02/2021 and there was no urine output in Resident #1's foley catheter bag the entire shift. She stated she notified the nurse. She stated usually she empties the resident's foley bag at the end of the shift and gives the output number to the nurses. She stated there is nowhere for the CNAs to document urine output. In an interview on 07/07/2021 at 11:56 a.m. the ADON stated she worked with Resident #1 on 07/04/2021. She stated Resident #1 did not eat breakfast due to discomfort to his catheter, so she went to check on him before lunch and took him ice cream. She stated, Resident #1 was in his chair, and his family were visiting. She stated Resident #1 said his catheter was wet and she could see blood tinged on the pillowcase. She stated, there was foul odor and she thought Resident #1 had a bowel movement but later realized the odor was from his foley catheter. She stated she removed the catheter after notifying the NP and blood came out, followed by [MEDICATION(S)] and later a lot of urine. She stated, from what I saw, I thought he had some type of infection and the catheter was not draining properly it had some build up. She stated the facility will not be able to know if Resident #1's catheter was draining properly because there was no documentation. She stated the nursing staff were supposed to document urinary output to be able to know if the foley catheter is functioning well. She stated the CNAs were supposed to empty resident's catheter bags at the end of their shift and PRN. She stated a nurse does not need a doctor's order to change a resident's catheter, it is nursing judgement. She also stated the nurses should have followed up with Resident #1's catheter from the day he started to complain. She stated, it was neglect if the facility did not follow up with Resident #1's catheter care from July 1-4, 2021. She stated, Resident #1's family member requested he be sent to the ER. In an interview on 07/07/2021 at 3:19 p.m. the NP stated she was made aware Resident #1 had complained of pain at his penis on 07/04/2021, the foley catheter was removed and a mixture of urine, pus-like mucous and blood tinged with foul odor came out. She stated the large amount of urine, blood, puss-like mucous and odor indicated infection/UTI. She stated she was not made aware that Resident #1's foley catheter had no urine output from 07/01/2021 to 07/04/2021. She stated, I think they documented the urine output from the drainage bag, or they should be. I don't know if Resident #1 is emptying his own foley bag, no one told me. You should be able to see fluids in the drainage bag; we can track the amount as long as we are emptying the foley catheter drainage bag. The nursing staff were supposed to make sure the catheter was draining. She stated an order was not needed to replace a catheter if the resident is in distress, that would be nursing judgement. She stated It was her expectation that if a foley catheter needs to be changed, it should be changed. In an interview on 07/08/2021 at 11:27 a.m. the ER MD A stated Resident #1 was treated in the local hospitalER on [DATE]. He stated, based on EMS report, Resident #1 was sent from the SNF due to not being able to flush Resident #1's catheter, tenderness in the belly and pus from the penis after catheter was removed. He stated Resident #1's urine was dark and cloudy when he saw the resident, he did not observe pus from the resident's penis but knew something was off, from the look of the urine, it looked infected. He stated Resident #1 had a lot of abdominal pain and a lot of urine was drained in the catheter bag. He stated while Resident #1 was in the ER, he was diagnosed with [CONDITION(S)] due to UTI. He stated he was not able to say how long the urine had been in Resident #1's bladder to cause UTI/[CONDITION(S)]. ER MD B added by saying, when infection is occurring a lot of cells formed, it will settle to the back of the bladder, infected cells build up, cannot confirm if its 24-hour build-up period or not. Urine is sterile and any bodily fluid that sits there for a period of time will get infected. He stated the catheter was leaking because the urine was too much for the bladder to hold, not draining through the catheter and was trying to find a way out. In an interview on 07/08/2021 at 11:43 a. m. the ER Nurse stated Resident #1 was in the local hospitalER on [DATE] and she was his admitting nurse. She stated she got information from EMS stating Resident #1's foley catheter was removed at the SNF because it was not draining, once the catheter was pulled, pus and blood drainage was noted. She stated she reinserted a new foley catheter and got dark amber urine with little [MEDICATION(S)] and no clots noted. She stated she could not recall if there was any smell. Record review of Resident #2's MDS assessment dated [DATE] revealed no BIMS score. Resident #2 was interviewable on 07/07/2021 at 12:41 p.m. It was revealed Resident #2 had an indwelling catheter. Record review of Resident #2's face sheet revealed an 89- year- old female DOB 07/26/1931 with admitted [DATE] with original admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's Care Plan dated 04/28/2020 revealed the following: monitor/document for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Record review of Resident #2's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Change FC and bag monthly every day shift starting on the 1st and ending on the 1st every month related retention of urine, unspecified, dated 07/03/2021 FC care every shift related retention of urine, unspecified, dated 07/03/2021 Monitor FC proper placement every shift related retention of urine, unspecified, dated 07/03/2021 Record review of Resident #2's Medication Administration Records and Treatment Administration Records for the months of June and July 2021 reflected no documentation of urine output. There was no indication of how foley catheter output was being monitored. Record review of Resident #2's nursing progress notes for the months of June and July 2021 reflected no documentation of urine output. Observation on 07/07/2021 at 12:41 p.m. revealed Resident #2 had an indwelling foley catheter. Upon observation, catheter was draining clear yellow urine. Record review of Resident #3's face sheet revealed a 71- year- old male DOB 08/12/1949 with admitted [DATE] and original admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #'3's Care Plan dated 07/30/2018 revealed Resident #3 is incontinent of bowel and has suprapubic catheter, monitor/document for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Record review of Resident #3's MDS assessment dated [DATE] revealed a BIMS score of 99. Staff assessment was done and reflected memory problem. Record review of Resident #3's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Change foley catheter and bag monthly every day shift starting on the 24th and ending on the 24th every month for Wound Healing. Flush suprapubic catheter with 30ml sterile water every shift Change F/C and bag PRN as needed for Wound Healing As needed Record review of Resident #3's nursing progress notes, Medication Administration Records and Treatment Administration Records for the months of June and July 2021 reflected no documentation of urine output. There was no indication of how foley catheter output was being monitored. Observation on 07/07/2021 at 10:40 a.m. revealed Resident #3 had an indwelling foley catheter. Observation revealed clear yellow urine in the drainage bag. Review of Resident #4's face sheet revealed a 93- year- old female DOB 03/04/1928 with admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #4's MDS assessment dated [DATE] revealed a BIMS score of 10 out of 15, indicating moderate cognitive impairment. It was also revealed Resident #4 had indwelling catheter. Record review of Resident #4's Care Plan dated 06/22/2021 revealed Resident #4 has an Indwelling suprapubic catheter due to retention of urine, monitor/document for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Record review of Resident #4's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] May flush F/C with 30ml sterile water every shift PRN as needed related retention of urine, unspecified, date 03/10/2021 Monitor F/C for proper placement every shift related retention of urine, unspecified, 03/10/2021 Change Foley Bag two times a month on the 10th and 24th every day shift starting on the 24th and ending on the 24th every month related retention of urine, unspecified, 03/10/2021 Foley catheter care every shift related retention of urine, unspecified, 03/10/2021 Record review of Resident #4's nursing progress notes, Medication Administration Records and Treatment Administration Records for the months of June and July 2021 reflected no documentation of urine output. There was no indication of how foley catheter output was being monitored. In an interview on 07/07/2021 at 2:51 p.m. the Medical Director stated when a resident has a catheter, it becomes a part of them. When staff is evaluating the resident, they should make sure the catheter was functioning properly, if not normal it should be checked. He stated his expectation for nursing staff for residents with a catheter was for the nursing staff to make sure the catheter was functioning, check for urine output, document how urine is in the drainage bag. He stated if the resident was having problems with the catheter, the nursing staff should track urine output by documenting. He stated, if a resident is complaining of abdominal pain, catheter is leaking and the resident is not eating due to the discomfort, the nurse should assess the resident and notify the NP or MD. If leakage is around you should see urine flow pretty quickly, if no urine in the drainage bag it should be documented, and resident should be checked on again. If the catheter is leaking around, that means the urine in the bladder is trying to make its way out. He stated, anytime a resident has a complain of pain it should be communicated to monitor the resident. A doctor's order is not needed to change catheter, nurses should make their own judgement based on nursing standard of practice. In an interview on 07/14/2021 at 1:30 p.m. the Administrator stated it is his expectation the facility is free from any abuse and neglect. He also stated staff were not doing their job appropriately and not checking on Resident #1's catheter for four (4) days, that would be considered neglect. Record review of facility's policy titled Urinary Catheter Policy and Procedure undated reflected: Management of Obstruction-if obstruction occurs and it is likely that the catheter material is contributing to obstruction, change the catheter. An Immediate Jeopardy was identified on 07/08/2021 at 4:48 p.m. The Administrator was notified of the Immediate Jeopardy on 07/08/2021 at 5:20 p.m. and IJ template was provided. The Administrator expressed understanding of the Immediate Jeopardy and a Plan of Removal was requested. The Plan of Removal was accepted on 07/09/2021 at 5:26 p.m. Record review of the facility's Plan of Removal reflected the following: On 07/08/2021 the physicians of all residents residing in facility with indwelling catheters, and suprapubic catheters were notified of the immediate jeopardy, and need for orders of catheter care, monitoring catheters, monitoring urine (to include consistency and color), and monitoring output of urine of each resident. Orders were obtained for the removal of one resident's indwelling catheter recently readmitted from the hospital. Care plans of each resident with an indwelling catheter/ or suprapubic were updated by the MDS Coordinator 07/08/2021 to include catheter care, catheter and urine monitoring, and urine output documentation each shift. Additional orders were obtained and implemented on 07/08/2021 and 07/09/2021 by the MDS Coordinator from physicians of the 2 residents residing at the facility with indwelling catheters/or suprapubic catheters (orders will be received on one resident in hospital upon readmission) for the following: A) Monitoring of catheter, urine consistency, and urine color by resident's charge nurse every shift. This will be implemented on the treatment administration record of each resident for documentation by the charge nurse each shift. Complete. B) Catheter care to be provided by charge nurse every shift for each resident to be implemented on treatment administration record. Complete. C) Urine output for each resident with an indwelling catheter/ or suprapubic catheter to be implemented on the treatment administration record and documented by the charge nurse. The facility has updated the policy on Indwelling Catheters/ Catheter Care to include Catheter Care, Catheter Monitoring including urine consistency and color, and Urine Output to be done every shift and documentation to occur every shift to reflect changes above, and the in-services listed below. Completed on 07/09/2021. Education began on 07/08/2021 with all licensed nursing staff by the Director of Nursing/ or Designee on the following: A) All residents with an indwelling catheter/ or suprapubic MUST have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . It must also be placed on the treatment administration record for documentation every shift. B) Catheter care every shift and documentation on the treatment administration record of each resident with an indwelling catheter/ or suprapubic. C) Monitoring of catheter site, urine consistency, and urine color of each resident with an indwelling catheter/ or suprapubic, and documentation on resident's treatment administration record. D) Monitoring and documentation of urine output of each resident with an indwelling catheter/ or suprapubic to be completed each shift and documented on resident's treatment administration record. E) Signs and Symptoms of possible infections in residents with an indwelling catheter, and signs and symptoms of possible occlusion in residents with an indwelling catheter. Started on 07/09/2021 with all current licensed nursing staff scheduled. All remaining licensed nursing staff will be in serviced prior to their next scheduled shift. Education began on 07/08/2021 with all nursing staff, to include CNAs, CMAs, LVNs, and RNs, by the director of nursing/ or designee on the following: A) Documentation of intake in Point of Care for each resident with an indwelling catheter/ or suprapubic, reporting of abnormalities, and monitoring of intake by charge nurse. Education began on 07/08/2021 with the director of nursing/ or designee, assistant director of nursing, and MDS coordinator by the Regional Director of Clinical Services on the following: A) Ensuring any new admissions or readmissions to the facility with an indwelling catheter/ or suprapubic orders must be verified to ensure catheter care, catheter monitoring to include urine, and urine output are included in admitting or readmitting orders, and documentation available and present on the treatment administration record. Education also began on 07/09/2021 with all staff on Abuse and Neglect, reporting of abuse and neglect, who the abuse coordinator is, and the importance of following the facility policies. This was conducted by the Administrator/ or Designee with return verbalization of understanding. All policy and systemic changes have been implemented and completed on 07/09/2021. All education began on 07/08/2021 and 07/09/2021 and has been completed with all scheduled staff working on 07/08/2021 and 07/09/2021. All additional staff will be in serviced prior to their next shift; this includes any new hires. Monitoring The DON/ or designee will review all new admission or readmission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Any negative finding will be corrected and reviewed with the QA committee. The DON/ or designee will also review all resident's treatment administration record for existing residents with an indwelling catheter/ or suprapubic to ensure proper documentation daily in morning standup for a period of 8 weeks, then randomly thereafter. Any discrepancies will be corrected, reeducation with charge nurse, and reviewed with the QA committee. All residents residing in the facility with an indwelling/ or suprapubic catheter will be reviewed in Standards of Care meeting weekly with IDT (including DON/ or Designee, Administrator/ or Designee, ADON, treatment nurse, and MDS Coordinator) to ensure orders, records, and documentation are accurate and present for a period of 8 weeks, then randomly thereafter. Any negative findings will be corrected and reviewed with the QA committee. Reeducation with staff if needed will also take place. The DON/ or Designee, and Administrator/ or Designee, will be responsible for the monitoring of the effectiveness of the education provided by observation and verbalization on-going. Any discrepancies will be corrected, reeducated, and reviewed with the QA committee. This plan was initially implemented on 07/08/2021 and will be monitored by completion of items and personal observation by the Administrator/ or Designee, Director of Nurses/ or Designee, Regional Director of Operations, and Regional Clinical Director to ensure compliance. The Survey Team monitored the current plan of removal as follows: Monitoring done on 07/09/2021 through 07/11/2021 reflected the following. In an interview on 07/09/2021 at 6:43 p.m. CNA D was able to verbalize training done on catheter care and documentation. In an interview on 07/09/2021 at 6:53 p.m. LVN C was able to verbalize training done on catheter care and documentation. In an interview on 07/10/2021 at 1:38 p.m. MA A was able to verbalize training done on catheter care and documentation. In an interview on 07/10/2021 at 1:47 p.m. CNA E was able to verbalize training done on catheter care and documentation. In an interview on 07/10/2021 at 2:03 p.m. CNA B was able to verbalize training done on catheter care and documentation. In an interview on 07/10/2021 at 2:13 p.m. CNA was able to verbalize training done on catheter care and documentation. In an interview on 07/10/2021 at 2:40 p.m. CNA A was able to verbalize training done on catheter care and documentation. In an interview on 07/11/2021 at 9:43 p.m. CNA C was able to verbalize training done on catheter care and documentation. In an interview on 07/11/2021 at 12:09 p.m. CNA G was able to verbalize training done on catheter care and documentation. Record Reviews reflected an in-service titled Catheter Documentation Orders dated 07/08/2021 with two (2) participants, the ADON and LVN A. Record Reviews reflected an in-service titled Catheter Documentation and care dated 07/08/2021 with forty-seven (47) participants, nurses and CNAs. Record Reviews reflected an in-service titled Catheter Complications 07/09/2021 with five (5) participants, nurses. Record reviews on 07/09/2021 at 6:20 p.m. to ensure proper documentation in TARS for Residents # 3 & #4. Record reviews on 07/09/2021 at 6:22 p.m. of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record reviews on 07/09/2021 at 6:25 p.m. revealed Residents # 3 & #4's TARs and Care Plans were updated on 07/08/2021 to include catheter monitoring/care each shift, documenting output, positioning. Review of Resident #2's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Administrator was informed on 07/11/2021 at 10:20 p.m. the Immediate Jeopardy was removed, and the facility remained out of compliance at a severity of actual harm with the potential for more than minimal harm and a scope identified as isolated.

Based on interviews and record reviews, the facility failed to ensure that residents received care in accordance with professional standards of practice, and the comprehensive person-centered care plan for one (1) of seven (7) residents reviewed for quality of care. (Resident #1) CNA B failed to follow Resident #1's care plan. Resident #1 required 2 person transfer and CNA B transferred Resident #1 without assistance which resulted in fractures to Resident #1's toes. This failure could place residents at risk of not having their needs met, decreased quality of life or injury. Findings included: A review of Resident #1's facility face sheet dated 07/30/2020 reflected an [AGE] year old female, admitted [DATE] with [DIAGNOSES REDACTED]. A review of Resident #1's quarterly MDS dated [DATE] reflected her BIMS was 99 indicating she was unable to complete the interview. Section G indicated she was a two-person transfer. A review of Resident #1's Care Plan noted under the category of skin impairment to use caution with transfers to prevent striking arms, legs and hands against any sharp or hard surface. The Care Plan also reflected under the category of ADL care, she was a total assist, two-person transfer. A review of Social Worker Quarterly assessment for Resident #1 dated 07/29/2020, Resident #1 was non-verbal. In an interview on 9/30/2020 at 10:22 AM the ADM stated the facility found Resident #1's toes to be red on 7/24/2020 at 5:00 PM and called the physician for an x-ray. He stated the incident was thoroughly investigated and he concluded the resident must have bumped her toes during transfer in the shower. In an interview on 9/30/2020 at 11:38 AM LVN A stated she was aware Resident #1 was a two-person transfer. She stated she regretted not helping CNA B with the transfer back to bed. In an interview on 09/30/2020 at 12:03 PM CNA B stated she could not remember anything about that day. CNA B stated Resident #1 was a two-person transfer. As her statement was read aloud she said LVN A did help her with the transfer of Resident #1 on that day. Review of the provider investigation report dated 7/24/2020 reflected that after the investigation it appears that the resident may have inadvertently bumped her right toes during a transfer on 7/23/2020. The report contained a signed, handwritten statement by LVN A dated 7/28/2020 who wrote she observed CNA B transfer Resident #1 by herself. LVN A wrote that on 07/23/2020, she saw CNA B putting her arms underneath under Resident #1's arms to transfer her to a standing position from the shower chair. She wrote then CNA B then used one arm behind the resident's back and one arm underneath the resident's legs to transfer her to the bed placing her in a sitting position before lying her down on the bed for wound care. Review of CNA B's personnel file indicated she was trained on two-person transfers. Review of facility's in-service trainings revealed a training on 7/24/2020 specific to Resident #1's transfers and care. There were also 2 other trainings on transfers dated 7/21/2020 and 6/23/2020. Review of facility's CNA job description, job knowledge section, #3, Provides nursing care in accordance with Resident Care Policies and Procedures and ensures the safety and well-being of the residents is maintained. Review of the facility's resident transfer policy and procedure, undated, reflected step by step directions for two-person transfer.

Based on observations, interviews, and record reviews the facility failed to ensure each residents environment remained free of accident and hazards for one (1) of five (5) residents reviewed for accidents and hazards. (Resident #1) CNA B failed to follow Resident #1's care plan. Resident #1 required two-person transfer and CNA B transferred Resident #1 without assistance which resulted in fractures to Resident #1's toes. This failure could place residents at risk for injury. Findings included: Review of Resident #1's face sheet dated 7/30/2020 reflected an [AGE] year-old female, admitted [DATE] with diagnoses of [CONDITION(S)], pressure ulcers, dementia, major depressive disorder, anxiety, tremor, and polyneuropathy. Review of Resident #1's quarterly MDS dated [DATE] reflected her BIMS was 99 indicating she was unable to complete the interview. Section G indicated she was a two-person transfer. Review of Resident #1's Care Plan noted under the category of skin impairment to use caution with transfers to prevent striking arms, legs and hands against any sharp or hard surface. The Care Plan also reflected under the category of ADL care, she was a total assist, two-person transfer. Review of Social Worker Quarterly assessment for Resident #1 dated 07/29/2020, Resident #1 was non-verbal. Review of the provider investigation report dated 7/24/2020 reflected after the investigation it appears that the resident may have inadvertently bumped her right toes during a transfer on 7/23/2020. The report contained a signed, handwritten statement by LVN A dated 7/28/2020 who wrote she observed CNA B transfer Resident #1 by herself. LVN A wrote that on 07/23/2020, she saw CNA B putting her arms underneath Resident #1's arms to transfer her to a standing position from the shower chair. She wrote then CNA B then used one arm behind the resident's back and one arm underneath the resident's legs to transfer her to the bed placing her in a sitting position before lying her down on the bed for wound care. In an interview on 9/30/2020 at 10:22 AM the ADM stated the facility found Resident #1's toes to be red on 7/24/2020 at 5:00 PM and called the physician for an x-ray. He stated the incident was thoroughly investigated and he concluded the resident must have bumped her toes during transfer in the shower. In an interview on 9/30/2020 at 11:38 AM LVN A stated she was aware Resident #1 was a two-person transfer. She stated she regretted not helping CNA B with the transfer back to bed. In an interview on 9/30/2020 at 12:03 PM CNA B stated she could not remember anything about that day. CNA B stated Resident #1 was a two-person transfer. As her statement was read aloud she said Nurse A did help her with the transfer of Resident #1 on that day. In an interview on 9/30/2020 at 1:41 PM ADM stated he thought LVN A was telling the truth about her statement. He stated he asked the nurse aides, and both said they helped each other and he did not focus on LVN A's statement. nor interview her. He said that was a failure on his part, but still felt that Resident #1 bumped her toes during the shower. He said if he had read the statement he would have had LVN A in-serviced for not assisting CNA B. In an interview on 9/30/2020 at 3:28 PM Hospice RN stated when she saw Resident #1's toes for the first time on 7/23/2020, the resident flinched when toes were touched so she reported it to the nursing department immediately. She stated that was the day she got orders for an x-ray and the results were four fractures of right foot; metatarsals #2, #3, #4, and #5. She said the administrator told her the resident was dropped in the shower or maybe bumped her toes, he was not sure, and she confirmed he said that three times during the conversation. Review of CNA B's personnel file indicated she was trained on two-person transfers and abuse and neglect. Review of facility's in-service trainings reflected a training on 7/24/2020 specific to Resident #1's transfers and care. There were also 2 other trainings on transfers dated 7/21/2020 and 6/23/2020. Review of facility's CNA job description, job knowledge section, #3, Provides nursing care in accordance with Resident Care Policies and Procedures and ensures the safety and well-being of the residents is maintained. Review of the facility's resident transfer policy and procedure, undated, reflected step by step directions for two-person transfer.

Based on interviews and record reviews, the facility failed to ensure that residents received care in accordance with professional standards of practice, and the comprehensive person-centered care plan for one (1) of seven (7) residents reviewed for quality of care. (Resident #1) CNA B failed to follow Resident #1's care plan. Resident #1 required 2 person transfer and CNA B transferred Resident #1 without assistance which resulted in fractures to Resident #1's toes. This failure could place residents at risk of not having their needs met, decreased quality of life or injury. Findings included: A review of Resident #1's facility face sheet dated 07/30/2020 reflected an [AGE] year old female, admitted [DATE] with [DIAGNOSES REDACTED]. A review of Resident #1's quarterly MDS dated [DATE] reflected her BIMS was 99 indicating she was unable to complete the interview. Section G indicated she was a two-person transfer. A review of Resident #1's Care Plan noted under the category of skin impairment to use caution with transfers to prevent striking arms, legs and hands against any sharp or hard surface. The Care Plan also reflected under the category of ADL care, she was a total assist, two-person transfer. A review of Social Worker Quarterly assessment for Resident #1 dated 07/29/2020, Resident #1 was non-verbal. In an interview on 9/30/2020 at 10:22 AM the ADM stated the facility found Resident #1's toes to be red on 7/24/2020 at 5:00 PM and called the physician for an x-ray. He stated the incident was thoroughly investigated and he concluded the resident must have bumped her toes during transfer in the shower. In an interview on 9/30/2020 at 11:38 AM LVN A stated she was aware Resident #1 was a two-person transfer. She stated she regretted not helping CNA B with the transfer back to bed. In an interview on 09/30/2020 at 12:03 PM CNA B stated she could not remember anything about that day. CNA B stated Resident #1 was a two-person transfer. As her statement was read aloud she said LVN A did help her with the transfer of Resident #1 on that day. Review of the provider investigation report dated 7/24/2020 reflected that after the investigation it appears that the resident may have inadvertently bumped her right toes during a transfer on 7/23/2020. The report contained a signed, handwritten statement by LVN A dated 7/28/2020 who wrote she observed CNA B transfer Resident #1 by herself. LVN A wrote that on 07/23/2020, she saw CNA B putting her arms underneath under Resident #1's arms to transfer her to a standing position from the shower chair. She wrote then CNA B then used one arm behind the resident's back and one arm underneath the resident's legs to transfer her to the bed placing her in a sitting position before lying her down on the bed for wound care. Review of CNA B's personnel file indicated she was trained on two-person transfers. Review of facility's in-service trainings revealed a training on 7/24/2020 specific to Resident #1's transfers and care. There were also 2 other trainings on transfers dated 7/21/2020 and 6/23/2020. Review of facility's CNA job description, job knowledge section, #3, Provides nursing care in accordance with Resident Care Policies and Procedures and ensures the safety and well-being of the residents is maintained. Review of the facility's resident transfer policy and procedure, undated, reflected step by step directions for two-person transfer.

Based on observation, interview and record review the facility failed to ensure two (2) of eight (8) Residents (Resident # 3 and 12) reviewed for pressure ulcers entered the facility without pressure sores did not develop pressure sores and received necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. A) Resident # 3 was re-admitted to the facility on [DATE] without pressure ulcers and developed pressure ulcers on 05/07/2013. Treatment was not started until 05/13/2013 to promote healing. B) Resident # 12 developed a Stage III pressure ulcer on 05/20/2013 . Treatment was not initiated until 05/21/2013. This deficient practice placed four (4) residents with pressure sores at risk for development of new pressure sores, infection and worsening of current pressure sores. Findings Include: A) Review of Resident # 3's Face Sheet reflected a [AGE] year old female who first entered the facility on 10/06/2006 and readmitted on [DATE]. Resident # 3's [DIAGNOSES REDACTED]. Review of Resident # 3's Significant Change Minimum Data Set (MDS) assessment dated [DATE] reflected a Staff Mental Assessment of moderately impaired with poor decision making. Supervision and cues were required. The assessment reflected Resident # 3 was totally dependent upon two staff members for bed mobility, bathing and transfer. The assessment reflected Resident # 3 was required extensive assistance of one staff member for locomotion on and off the unit, dressing and toilet use. The assessment reflected Resident # 3 was always incontinent and had a Stage I pressure sore. Review of Resident # 3's Comprehensive Plan of Care dated 04/17/2013 reflected Resident # 3 had a potential for skin breakdown with a goal to maintain intact skin integrity by providing incontinent care next 90 days and reflected a target date of 07/17/2013. Review of Resident # 3's Pressure Sore Record reflected the Stage I to the Resident's left buttock was identified on 02/18/2013 and healed on 02/26/2013. Review of Resident # 3's Re-admittance assessment dated [DATE] reflected no areas on the diagram however the comment section for skin condition reflected "see skin assess sheet." There was no skin assessment sheet provided dated 03/25/2013. Review of Resident # 3's Treatment Record for March, 2013 reflected the Resident received a treatment of [REDACTED]." The March 2013 treatment record reflected the treatment was applied 03/26/2013, 03/27/2013, 03/28/2013, 03/30/2013 and 03/31/2013. The April, 2013 Treatment Record did not show any treatment performed to Resident # 3's buttocks. Review of Resident # 3's Weekly Skin Integrity Review dated 05/07/2013 reflected a new open area was identified on the Resident's right buttock that measured 4.0 x 2.2 centimeters. There was no Stage identified nor depth to the pressure area. The same Weekly Skin Integrity Review sheet reflected an entry dated 05/13/2013 of an old open area to Resident # 3's right buttock. There were no measurements. Review of Resident # 3's Interim Plan of Care dated 05/10/2013 reflected a Stage II pressure sore to coccyx. Approaches included provide treatment as ordered, monitor for signs and symptoms of infection, report adverse findings to physician and hospice and turn and reposition every two hours and as needed. Review of Resident # 3's Physician Orders reflected a telephone order dated 05/12/2013 to "cleanse wound to coccyx with w/c (wound cleaner), pat dry, apply [MEDICATION NAME] dressing, change q (every) 3 days and PRN (as needed)." Review of Resident # 3's Treatment Record for May, 2013 reflected the telephone order dated 05/12/2013 was not started until 05/13/2013. Review of Resident # 3's Assessment made by a Wound Care Specialist from a medical company dated 05/13/2013 reflected the Resident # 3 was assessed as follows: 1. A healing Stage III to left sacrum that measured 2.5 x 2.25 with 0.5 depth. There was moderate Exudate and no tunneling or undermining. Recommended treatment was Puracol 2 x 2 and Bordered Foam White Slick 4 x 4 every day. The assessment documented the wound with 100% granulation tissue with pale pink scar tissue and "Previous treatment with [MEDICATION NAME] not effective. Now in need of QD (every day) changes Collagen application encourages deposition of and organization of newly formed collagen fibers and granulation tissue. Collagen increased the re-[MEDICATION NAME] rate by establishing moist wound bed for new [MEDICATION NAME] migration to wound closure/foam dressing to allow protection of frail new tissues and promotes moist wound healing also to thermoregulate area by elevating wound temperature. Foam is non adherent to minimize pain with dressing changes." Treatment Intervention: "Cleanse with normal saline and pat dry apply Collagen dressing to the wound base and cover with bordered foam dressing Secure to the surrounding skin and change QD." 2. An unstageable Pressure Ulcer to Resident # 3's right sacrum that measured 3.5 x 2.0 cm with undertermined depth. Recommended treatment was Puracol 2 x 2 and Bordered Foam White Slick 4 x 4 every day. The assessment reflected "Wound Bed: 60% slough 40% granulation tissue. Periwound: pale scar tissue. Clinical Rationale Wound Comments: Daily dressing changes required secondary to daily enzymatic protocol required to remove necrotic tissue prolonging [MEDICAL CONDITION] phase and delaying healing; Collagen to provide protein matrix and support angiogenesis to promote granulation tissue proliferation QD. Foam to maintain thermal regulation to elevate wound temperature and increase oxygen saturation promoting healing and to provide barrier to pathogen invasion, minimizing risk of bacteria/contaminants. Treatment Intervention: Cleanse with normal saline and pat dry. Apply a pea sized portion of Santyl ointment to the wound bed and cover with a bordered foam dressing. Change QD." The assessment made by the Wound Care Specialist was signed and dated 05/13/2013 and reflected a verbal/telephone physician order was received. Review of Physician Orders for Resident # 3 dated 05/16/2013 reflected the following: 1. Treatment to left sacrum: cleanse with normal saline, pat dry, apply Puracol (2 x 2) and bordered foam white slick 4 x 4 dressing per day. 2. Treatment to right sacrum: cleanse with normal saline, apply Santyl ointment sparingly to necrotic area. Apply Puracol (2 x 2) and bordered foam pink 4 x 4 dressing per day. (start when available). Review of the Treatment Record for May, 2013 reflected the physician order dated 05/16/2013 began on 05/17/2013. Review of Physician Orders for Resident # 3 dated 05/21/2013 reflected a clarification order to cleanse left and right buttocks with normal saline or wound cleanser, pat dry, apply Santyl ointment sparingly to right buttock necrotic area. Apply Collagen to left and right buttock. cover with bordered foam dressing every day. (Start when available.) Review of the May, 2013 Treatment Record reflected the physician order dated 05/21/2013 began on 05/21/2013. Observation on 5/21/2013 at 2:30 PM revealed LVN E preformed wound care on Resident #3's right buttock Stage III pressure sore and Sacral Stage III pressure sore. No dressing was present on Resident #3's Right buttock pressure sore or sacral pressure sore at time of observation. LVN E, after hand hygiene and new gloves, took the wound cleaner and sprayed 4x4 gauze. LVN E took the gauze and wiped on the center of the area of the right buttock pressure sore and the sacral pressure sore then went to the top edge of the right buttock pressure sore and wiped across the area from top to bottom three times. She wiped across both pressure sores without changing the position of the gauze or using new gauze. LVN E then preformed hand hygiene and applied new gloves. LVN E then applied Santyl (an enzyme that works by breaking up and removing dead tissue.) over entire area of the right buttock pressure sore and sacral pressure sore and involved the healthy tissue around the ulcers. LVN E measured the pressure ulcer to Resident # 3's right buttock as a Stage III and measured 1.7 x 2.0 cm. LVN E did not measure depth however, depth was noted by the Surveyor. Resident # 3's sacral pressure ulcer had noted slough in the wound bed and measured at 0.5 x 0.3 cm. In an interview on 05/21/2013 at 3:32 PM, LVN B stated Resident # 3 had a Stage III to her right buttock and a Stage II to the middle of her buttocks. LVN B stated she was not in charge of the treatment for [REDACTED]. In an interview on 05/21/2013 at 4:00 PM Registered Nurse (RN) A stated Resident # 3's pressure sores for February and March had healed out since there was no treatment recorded in April. The pressure sores identified in May were new areas. In an interview on 05/21/2013 at 4:30 the Director of Nurses (DON) stated the Treatment Nurse had resigned and nursing staff were responsible for ensuring wound treatments are performed. The DON stated she had assessed the pressure sores for Resident # 3 on 05/10/2013 as Stage II and advised nursing staff to obtain an order for [REDACTED]. The DON stated she could not find where the physician had been faxed. B) Review of Resident #12 ' s Face Sheet reflected a [AGE] year old female admitted to the facility on [DATE] and Readmitted on [DATE]. Resident #12 ' s [DIAGNOSES REDACTED]. Review of Resident #12 Significant Change MDS dated [DATE] reflected the Resident to scored three (3) out of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The assessment reflected Resident #12 was totally dependent on staff for all Activities of Daily Living (ADL ' s). The assessment further reflected Resident #12 to be at risk of developing pressure ulcers and indicated Resident #12 had one (1) Stage two (2) pressure ulcer present. Review of Resident #12's Comprehensive Care Plan dated 4/5/2013 reflected no care plan for the Stage II on the Resident's right buttock. In an interview on 5/22/2013 at 5:45 PM LVN B stated the pressure ulcer on Resident #12 ' s right buttock was identified on 5/20/2013. LVN B further stated she contacted Resident #12 ' s physician and orders were obtained. LVN B stated she did not start treatment on Resident #12 ' s pressure ulcer but told LVN F who was assigned treatments, to start treatment. LVN B further stated that on 5/21/2013 when she went to do the treatment on Resident #12 ' s right buttock pressure ulcer there was no dressing on Resident #12 ' s right buttock pressure ulcer. LVN B stated she did not think it had been done. In an interview on 5/22/2013 at 6:00 PM LVN F stated she did not treat a pressure sore on Resident #12 ' s right buttock. LVN F further stated she was unaware that Resident #12 had a pressure ulcer. In an interview on 5/22/2013 at 7:00 PM the DON stated she expected the nurses to start treatment right away. Review of Resident #12 ' s Treatment Record dated May 2013 reflected an order to cleanse Right buttock decubitus with normal saline or wound cleanser, pat dry, apply [MEDICATION NAME] dressing Monday, Wednesday, Friday, and as needed. There was no initial for 5/20/2013 on the treatment record which indicated the treatment was not done. Review of Resident #12 ' s Nurse ' s Notes dated 5/20/2013 no time reflected an entry " New decub 0.6 x 0.5 x 0.1 cm. Right buttock red in color, no drainage, cleanse with normal saline or wound cleanser, pat dry, apply [MEDICATION NAME] dressing, every Monday, Wednesday, Friday , PRN, call light in reach " signed by LVN B. Further review of Resident #12 ' s Nurses Notes reflected no entry that treatment to Right buttock pressure ulcer was completed. Observation on 5/22/2013 at 4:55 PM revealed a Stage III pressure sore to Resident #3 right buttock. The pressure sore measured 0.6X0.5X0.1 per LVN B. The pressure sore was red in color, and had a raised rim around the parameter of the pressure sore, no slough was noted. LVN B did not stage the wound at time of observation. In an interview on 5/22/2013 at 7:00 PM the DON stated that a pressure sore with depth is a Stage III pressure sore. In an interview on 5/22/2013 at 6:29 PM the DON stated it was not proper technique to wipe a wound or decubitus across the wound area. The DON further stated it was her expectation that the nurses to use proper wound care procedures. The DON stated the nurses should only apply Santyl to the wound bed because it breaks down healthy skin " Makes your problem bigger. " Review of website http://www.webmd.com/drugs/drug-9489-Santyl+Top.aspx?drugid=9489&drugname=Santyl+Top reflected: Pain or a burning feeling at the affected area may occur. Temporary redness/irritation may also occur in the skin around the affected area. If any of these effects persist or worsen, tell your doctor or pharmacist promptly. To avoid redness/irritation in the surrounding skin, be careful to apply the ointment only within the affected area. Review of the facility policy regarding Pressure Ulcer Protocols dated 12/01/2011 reflected: Purpose: Nursing Home residents, due to commorbidities and underlying clinical conditions, may develop pressure ulcers during their stay at the facility. Process: I. Assessment of Risk - All residents are considered at risk for the development of pressure ulcers. During the admission nursing assessment process, the condition of the resident's skin should be noted. II. Pressure Ulcer Care [MEDICATION NAME] agents should be used when non-viable tisue is present. (Eschar,necrosis) Cleaning agents should be used to maintain a clean wound bed. Products should be selected based upon wound assessment and treatment goals. Evaluation of the rate of healing guides the interdisciplinary team toward alterations in care approaches. The facility provided a list of 4 residents who had pressure ulcers.

Based on observation, interview and record review the facility failed to ensure one (1) of eight (8) Residents (Resident # 2) reviewed for pressure sores who entered the facility without a pressure sore did not develop a pressure sore and received necessary treatment and services to promote healing, prevent new ulcers from developing and once developed, failed to ensure necessary treatment and services to promote healing. Resident #2 developed a Stage II pressure sore to right buttock on 6/20/2013. Resident #2's physician was not notified and treatment was not initiated until 6/26/2013. Resident #2's Stage II pressure sore to right buttock progressed from 0.2 centimeters (cm) x 0.1 cm x 0.1 cm to two (2)cm x 2 cm in six (6) days. This deficient practice placed 12 residents with pressure sores at risk for development of new pressure sores, infection and worsening of current pressure sores. Findings Include: Review of Resident #2's Face Sheet reflected a [AGE] year old male admitted to facility on 12/28/2011 and re-admitted on [DATE]. Resident #2 ' s [DIAGNOSES REDACTED]. Review of Resident #2's Significant Change Minimum Data Set ((MDS) dated [DATE] reflected Resident #2 to be severely cognitively impaired. The MDS further reflected Resident #2 to be totally dependent on staff for assist with bed mobility, transfer, dressing, personal hygiene and bathing. Resident #2 was coded to always be incontinent of bowel and bladder. Resident #2 was coded to be high risk for developing pressure ulcers. The MDS also reflected Resident #2 did not have a pressure sore. Review of Resident #2 ' s Comprehensive Care Plan dated 5/30/2013 reflected Resident #2 had potential for skin breakdown. Approaches included provide treatment as ordered to Stage one (1) ( Stage I pressure sore defined as intact skin with non-blanch able redness of a localized area usually over a bony prominence) to buttock area and notify hospice/ physician as needed. Provide diet as ordered, assist with repositioning every two (2) hours and as needed, pressure reducing mattress in place, and to monitor for skin redness or breakdown. The Comprehensive Care Plan further reflected that if skin redness or breakdown was found, assess, document and report to physician. Observation on 6/26/2013 at 10:25 AM revealed Resident #2 in bed sleeping on left side. Review of Resident #2's Weekly Skin Integrity Review dated 6/3/2013 reflected Resident #2's skin condition "ulcer coccyx healed" . Review of Resident #2's Weekly Skin Integrity Review dated 6/6/2013 reflected Resident #2's skin condition "skin intact " . Review of Resident #2's Weekly Skin Integrity Review dated 6/13/2013 reflected Resident #2's skin condition "skin intact " . Review of Resident #2's Weekly Skin Integrity Review dated 6/20/2013 reflected Resident #2's skin condition "Open area, new 0.2 cm x 0.1 cm x 0.1 cm right buttock" . Review of Resident #2's Physician Orders reflected an order dated 5/29/2013 "Calazine with zinc(a barrier product) to buttocks q(every) shift and after each incontinent episode change to q shift and PRN." No other orders for treatment to buttocks were noted. Observation on 6/26/2013 at 12:00 Noon revealed Resident #2 in bed on his right side. A Stage II pressure sore (Stage II pressure sore defined as partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough) was noted approximately two (2) cm by two (2) cm to right buttock (approximation made by surveyor). The Stage II pressure sore was red/pink in color and presented as a shallow crater. The skin surrounding the open area was pink, and macerated with the skin peeling one inch around the crater with two scabbed areas noted from the peeling skin. Resident #2's coccyx and buttock was covered with a white cream. Resident #2's Stage II pressure sore to right buttock was not measured by staff during observation. In an interview on 6/26/2013 at 12:05 PM Resident #2 was unable to communicate verbally but would answer yes and no questions by shaking his head. Resident #2 indicated he was not in pain. In an interview on 6/26/2013 at 12:07 PM the Director of Nurses (DON) stated the area to Resident # 2's right buttock was open and there should be a treatment order. In an interview on 6/26/2013 at 12:10 PM Licensed Vocational Nurse (LVN) A stated the area to the right buttock was open. LVN A further stated there was confusion as to who notifies the physician when a problem is found since the Treatment Nurse, LVN B, found the area, she was unsure if the Treatment Nurse or the Charge Nurse should have gotten an order for [REDACTED]. Review of Resident #2's Pressure Sore Record reflected and entry dated 6/26/2013 by LVN A, after the surveyor had identified the area, reflecting a Stage II pressure sore to right buttock one (1) cm x 0.5 cm no depth was noted, color was described as pink. In an interview on 6/26/2013 at 2:05 PM LVN B stated she had not seen the area on Resident #2's right buttock since 6/20/2013. LVN B stated the area on Resident #2's right buttock was as big as a pin point when she noted it on 6/20/2013. LVN B stated the area to Resident #2's right buttock was different than before "it is in the same spot it is just bigger now " . In an interview on 6/26/2013 at 3:00 PM LVN B stated she did not notify Resident #2's Physician of the new area on Resident #2's right buttock because there was already an order for [REDACTED]. In an interview on 6/26/2013 at 3:15 PM the DON stated the facility did not have standing orders for treatments, but that [MEDICATION NAME] was what they usually use so we did not fax or notify Resident # 2's Physician because the Resident was already on [MEDICATION NAME]. The DON stated that is what the Physician would have ordered anyway. In an interview on 6/26/2013 at 3:20 PM Resident #2's Physician stated that if the facility had notified him of the new open area he probably would have changed the order. Resident #2's Physician further stated he expected the facility to contact him within 24 hrs of any change in resident skin condition. In an interview on 6/26/2013 at 3:30 PM the DON stated the facility used the American Medical Technologies recommended guidelines for treatment of [REDACTED]. Review of the American Medical Technologies recommended guidelines dated 2013 reflected recommended guidelines for treatment of [REDACTED]. Further review of guidelines reflected guideline for treatment of [REDACTED]." Review of the facility policy for Pressure Ulcer Protocols dated 12/1/2011 reflected "The Physician should be informed of the presence of a pressure ulcer, or the failure of an ulcer to respond to treatment; Physicians orders for care should be recorded. " In an interview on 6/26/2013 at 3:23 PM the Administrator stated LVN B should have notified Resident #2's Physician for treatment of [REDACTED]. The facility provided a list of 12 residents who were at high risk for pressure sores. This deficient practice was cited on 5/22/2013 and the facility remained out of compliance.

Based on observation, interview and record review the facility failed to implement policies and procedures that prohibit neglect for 1 of 1 residents reviewed for wandering (Resident #8) The facility failed to monitor, adequately supervise, and follow facility policy and procedures for identifying unsafe wandering residents and develop interventions to prevent Resident #8 from exiting the facility through an unoccupied and unmonitored resident hallway on 3/20/12. This resulted in an Immediate Jeopardy (IJ) on 4/3/12. While the IJ was lowered on 4/6/12, the facility remained out of compliance at a pattern with the potential for more than minimal harm that is not an IJ as the facility had not had time to implement, monitor and evaluate the effectiveness of their Plan of Removal. This deficient practice could result in injury due to falls or exposure to environmental elements for Resident #8 and 2 (two) additional wandering residents identified by the facility. Findings include: Review of the Facesheet reflected Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the hospital History and Physical dated 7/7/11 reflected Resident #8 had a history of [REDACTED]. A neighbor found him lying in the street and called 911. He had wandered 8 (eight) blocks from home where he fell in the street. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] reflected Resident #8's ability to see in adeguate light was impaired. His skills for daily decision making were severely impaired. He had long term and short term memory impairment. He had trouble concentrating and was short-tempered and easily annoyed. He was totally dependant on staff for transfers. He required supervision for locomotion throughout the facility. He used a wheelchair for mobility. He had limited range of motion to his lower extremeties. He had falls since admission. He received antipsychotic and antianxiety medication. Review of the Care Plan dated 8/30/11 reflected Resident #8 is calmer, but still occasionally tries to leave the facility and has periods of agitated behavior. Review of the Care Plan dated 3/29/12 reflected Resident #8 had severe Alzheimer's Dementia. He was confused and disoriented; mentally wanders; unable to express his needs or thoughts. Resident #8 had a history of [REDACTED]. He required total assistance with transfers due to severe confusion. He had no safety awareness. There was no plan of care or interventions for Resident #8's wandering and exit seeking behavior. Review of a Fall Risk assessment dated [DATE] reflected Resident #8 scored a 25 where 10 or above represents High Risk; and 3/26/12 reflected Resident #8 scored a 24. Review of Resident 8 's Clinical Record reflected there were no Wandering/Elopement Risk assessments for the resident. Observation on 4/4/12 at 8:13 AM revealed Resident #8 holding the hand rail and pulling himself up the 300 Hall. He had a self-release safety belt in place and Hoyer (mechanical lift) lift sling underneath him in his wheelchair. Observation on 4/4/12 at 2:45 PM revealed Resident #8 scooting himself in his wheelchair with his feet, near the Nurses ' Station. He had a personal alarm, a self-release safety belt in place and a Hoyer lift sling underneath him in his wheelchair. Observation on 4/5/12 at 12:09 PM, revealed two unidentified Certified Nurse Aide (CNAs) pushing Resident #8, in his wheelchair, to the dining room. In an interview on 4/3/12 at 1:20 PM the Administrator stated that Resident #8 was the only wandering resident in the facility. Review of Nurses' Notes revealed the following: 8/3/11-Up in wheelchair wandering facility-kept going to door at end of hallway wanting to leave facility. 8/31/11-Confused and forgetful. Wandering aimlessly up and down halls. Personal alarm on at all times. Does not ask for help when wanting to stand or transfer. 9/1/11-Up in wheelchair propelling self freely in hallway. Remains confused. Looking for a way to leave. 9/2/11-Propelling self-up and down hallway in his wheelchair with his feet. 9/7/11-Up in wheelchair propelling self freely in hallway. Wanders aimlessly throughout the day, opening doors. 9/15/11-Up in wheelchair. Propels with his feet. Wanders about the facility. Will wander away from supper while eating. 9/17/11-Up in wheelchair propelling self-up and down hallways. Roams about facility. Wanders into other Resident 's rooms. Poor safety awareness. 2/22/12-Propels self in wheelchair up and down halls. 3/17/12-Found on floor in hall. 3/20/12-6:00 PM-Found outside of 200 Hall Stuck in the mud, by a CNA. Incident Report done. Family and Physician notified. Review of the Incident/Accident report dated 3/20/12 at 6:00 PM reflected an attempted elopement by Resident #8 who had memory and decision making impairment. The report, documented by LVN A, reflected that Resident #8 was located beside the porch of the 200 Hall. It was described that an unidentified CNA found Resident #8 outside the 200 Hall right next to the porch and was brought back in without incident. The recommended steps to prevent recurrence, documented on 3/21/12 by the Director of Nurses (DON), reflected only to "be sure doors are closed to 200 Hall especially in the PM (evening) when there is less staff activity." The Incident/Accident report was signed by the DON and the Administrator on 3/21/12. There was no documentation that the incident had been investigated or that any other interventions were put in place for Resident #8. Review of a Progress Note dated 3/20/12 reflected Resident #8 was pushing himself backwards in his wheelchair in the hallway. He was confused and had decreased cognition. Review of a Fax to the physician dated 3/20/12 reflected Resident #8 was "found outside of 200 Hall just off porch. No injuries." Review of the consolidated physician's order [REDACTED]. Alarm sounds when resident tries to remove seat belt. Personal alarm on at all times. Use Mechanical Lift with three-person assist for transfers. Mobility per wheelchair. May have Lap Buddy when up in wheelchair to enable resident to safely propel self in wheelchair and as a reminder to not get up out of wheelchair unassisted due to resident will stand up out of wheelchair and forget to lock breaks-has no safety awareness. " In an Interview 4/3/12 at 2:00 PM Administrator stated she did not know much about Resident #8 ' s attempted elopement. She stated Resident #8 will go up to door and "fiddle with knobs" and we have told the staff to watch him more closely. They take residents onto the 200 Hall to weigh them, he had never done that before, that's why we watch him more closely. No investigation report was done; she stated she just made "mental notes." She stated she did sign off on the Incident/Accident report, but didn't know much about it. She stated that the DON was to tell nurses to watch Resident #8 more closely, to make sure doors were closed, and that nurses unlock doors in the morning and lock them at night. The panic bar is supposed to stay locked during the day, and unlocked at night. She stated that if residents go outside, its ok, they won't get hurt, residents are allowed to go out to the "gazebo." In an interview on 4/3/12 at 3:27 PM the Administrator stated that they discussed Resident #8's attempted elopement in the morning "Stand Up" meeting. She stated, "I knew we had talked about it." Review of the Stand Up Agenda which was dated 4/3/12 reflected that Resident #8 was "out onto 200 Hall porch--to keep 200 Hall doors closed." In an Interview 4/3/12 at 4:02 PM Licensed Vocational Nurse (LVN) A stated that it was a normal day, Resident #8 was going up and down halls like he usually did. She stated that they were weighing residents on the scale inside the 200 Hall and that he got past everyone to go to the outside patio off of the 200 Hall. His wheelchair was stuck in mud outside of the patio. She stated that a CNA found him and brought him back in, but she couldn't remember who the CNA was. LVN A stated that residents don't go outside alone. They should only go outside with a responsible party. In an interview on 4/4/12 at 2:30 PM CNA B stated that Resident #8 had no sense of where he was. She stated that Resident #8 was always trying to leave the facility. He was always trying to open the kitchen doors and the doors to other resident rooms. She stated that Resident #8 tried to leave through the front door one evening but they were always able to catch him before he got out the door. She stated, " We always watched him very close because he was always trying to go home. " She stated that she was not aware that Resident #8 had gotten outside at all until " You guys came. " She stated that she then heard that Resident #8 had gotten out the 200 Hall. She stated that the 200 Hall Fire Doors were always closed since there were no residents down that hall, but Resident #8 could open those doors. "I've seen him do it." CNA B stated that on the evening shift (2:00 PM to 10:00 PM) they used to have a resident on the 500 Hall that kept trying to leave the facility. That resident had been recently discharged from the facility. She stated that the facility never had alarms on the doors. To protect the wandering resident and let them know if she tried to leave, they attached Personal Alarms to the exit doors on the 500 Hall by setting the alarming device in the handrail and the magnet on the Panic Bar. CNA B stated that when that resident would try to go out the door, the magnet would detach from the device and alarm. She stated that she thinks the DON and Administrator came up with the idea to protect the resident. CNA B stated that the alarms were only placed on the 500 Hall because the 300 and 400 Hall exits could be seen from the Nurses' Station but the 500 Hall exits could not. She stated that she never really checked any of the doors to see if they were locked from the outside or to see that they were completely closed. CNA B stated that if they went on break, they always came in the 300 Hall door or the front door that were just left unlocked. She stated that she was not aware of anyone locking or securing the exit doors to the outside, she just assumed the nurses locked the doors. CNA B further stated that if anyone came in or went out a door, they would know because the Personal Alarm that they placed on the Panic Bar in the evening would go alarm. She stated that she never paid attention to whether the exit doors actually closed or locked. In an interview on 4/5/12 at 9:50 AM, CNA D stated that she and another CNA stepped outside at the end of 300 Hall around 6:00 PM. She stated that the other CNA walked to the corner of the patio area outside the 300 Hall and called her over to see Resident #8 outside the middle door on the 200 Hall, in his wheelchair with the door closed behind him. The front right wheel of his wheelchair was off the sidewalk in the grass. CNA D stated that she brought Resident #8 back in the same door on the 200 Hall. She stated that the door was closed but not locked from the outside. She stated that Resident #8 had gone into the 200 Hall through the Fire Doors on his own before, so she knew he was capable of doing it. She stated that no one ever went down the 200 Hall because there were no residents there. She stated she was not sure if the exit doors on 200 Hall or any hall were ever locked to the outside but the door was not locked to the outside when she brought Resident #8 back in. She stated that she had worked at the facility for approximately a year and a half but had worked at the facility in the past and never remembered alarms being on the doors. She stated that if there had been alarms on the doors she would remember. She stated that she knew that the front door, the exit door on the 300 Hall where the ambulance came in and the exit on the 300 Hall to the laundry building were never locked to the outside. In an interview on 4/5/12 at 3:30 PM CNA C stated that she had worked at the facility for approximately six months. She stated that she worked the evening Resident #8 was found outside but she did not find him. She stated that CNA D found Resident #8 outside. She stated that Resident #8 wandered a lot. He wandered throughout the entire facility, especially into other resident's rooms, into the dining room and anywhere he could get into as long as he was out of bed. She stated that Resident #8 got around on his own pretty well in his wheelchair by pushing himself with his feet or pulling himself down the halls using the handrails. She stated that Resident #8 was sometimes seen pushing on doors. She stated that he tried to leave the facility at times but they were always able to catch him in the past. CNA C stated that on the evening shift the CNAs or the Charge Nurse would put Personal Alarms on the exit doors at the end of 500 Hall, 400 Hall and the dining room exit so if a resident attempted to leave, the alarm would go off. She stated that the facility had an alarm system for the doors but it was never used because no one knew how to work it. She stated that she was not aware of anyone ever locking or securing the exit doors to the outside. She stated she thought the nurses locked the doors but she was not sure because she had never seen anyone do it. Observation on 4/3/12 at 10:46 AM revealed that the 200 Hall was unoccupied by residents. The Fire Doors at the front of the hall were closed. The Southwest exit door located midway down the hall exited to a grassy, empty courtyard between the 200 and 300 Halls. There was a narrow sidewalk that ran between the 200 Hall central door and 300 Hall central door. At the end of the 200 Hall there was an exit door that lead to a covered patio area toward the front of the building (Southeast exit door). The door did not close automatically with the pneumatic door closer. There was a three foot high rod iron fence around the patio area that extended 3/4 of the way to the 300 Hall exit and patio area. Observation on 4/3/12 at 12:15 PM revealed that the 400 Hall Southwest, and Northeast exit doors were unlatched and open approximately 1 ? to 2 inches and did not close automatically with the pneumatic door closer. The doors were able to be pushed open without use of the Panic Bar. The Southwest door had to be manually forced close. The Northeast exit door would not close even by force. Observation on 4/3/12 at 1:30 PM on the 300 Hall revealed that the South door would not close properly with the pneumatic door closer. The Southeast and Northeast doors were locked into the open position making doors unlocked from the outside and did not close properly with the pneumatic door closer. There were no alarms on the doors. The facility was located in a rural area with a house on the North and a pasture on the South. There was a parking lot and a pasture to the West and a parking lot and street to the East. In an interview on 4/3/12 at 1:30 PM, the Maintenance Supervisor stated the building is shifting and they have had a lot of rain. He stated that he was not aware how long doors had not been shutting because he had only been there for one month. He was not sure who secured the doors. Observation on 4/3/12 at 2:30 PM Housekeeper E entered Hall 400 Southwest door. The door did not close behind her. In an Interview on 4/3/12 at 2:30 PM Housekeeper E stated she never pays attention to doors closing. Review of the Resident Council Minutes dated 3/7/12 documented that the Activity Director explained to residents of the need to keep the 500 hall patio door locked (from outside) and temporary alarm due to some confused residents and their safety. In an Interview 4/5/12 at 12:29 PM the Activity Director stated that a resident had attempted to get out, but that the resident was no longer here. The door had a personal alarm like the one you put on a wheelchair. Observation on 4/3/12 at 2:15 PM revealed a perimeter alarm box mounted on the wall at the nurses' station. Posted near the alarm box was a sign with instructions on how "to disarm the entire system" and "to alarm the system." The A/C light was lit up in red. The instructions reflected that when the system was disarmed the A/C light should be on. In an interview on 4/3/12 at 2:30 PM the Regional Director of Operations stated that it would not be alright for a confused resident with Alzheimer's and impaired decision making to go outside unsupervised. He stated that the facility should try to prevent that. He further stated that the facility's doors should be locked by the staff at night. He stated that the facility also had a perimeter alarm that was to be activated. He stated that he was not sure what the perimeter alarm monitored but he would find out. In an interview on 4/3/12 at 2:55 PM the Regional Director of Operations stated that they discovered that the perimeter alarm did not monitor all exit doors. He stated that the perimeter alarm was not activated and the instructions that were posted were not all correct. In an interview on 4/3/12 at 4:23 PM the Regional Director of Operations stated that they "abandoned the perimeter alarm because it gets to confusing." He stated that they planned to purchase an alarm for each door instead of using the perimeter alarm system. In an interview on 4/3/12 at 4:23 PM LVN H stated that she had never used the perimeter alarm. She stated, "I wasn't even aware it existed." Review of the facility 's Policy and Procedure titled Abuse Investigation, revised December 2009, reflected the following: Recognizing Signs and Symptoms of Abuse/Neglect 2. " Neglect " is defined as failure to provide goods and services as necessary to avoid physical harm. 3. b#9 Leaving someone unattended who needs supervision. Review of the facility's Policy and Procedure for Wandering, Unsafe Resident, revised December 2007, reflected the following: Wandering, Unsafe Resident Policy Interpretation and Implementation 1. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). 2. The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering. 3. The resident ' s care plan will indicate the resident is at risk for elopement or other safety issues. 4. Interventions to try to maintain safety will be included in the resident ' s care plan. 5. Nursing staff will document circumstances related to unsafe actions, including wandering, by the resident. 6. Staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behavior. According to Weather Underground the temperature on 3/20/12 at 5:55 PM was 62.6 degrees Fahrenheit. The facility's Administrator, Director of Nurses, Assistant Director of Nurses, Regional Nurse Consultant and Regional Director of Operations were notified that an IJ existed on 4/3/12 at 4:45 PM due to the facility's failure to adequately monitor, supervise and implement preventive interventions for Resident #8, a known cognitively impaired, wandering, exit seeking, high fall risk resident to prevent his wandering onto an unoccupied/unmonitored hallway separated from the general facility population by closed Fire Doors and exiting the facility unsupervised and failed to ensure that facility staff secured the building from outside intruders by securely closing and locking facility doors. The facility provided the following plan of removal on 4/4/12 at 7:30 AM: Plan of Removal Resident #8 was placed on one on one constantly while his plan of care was being evaluated. The IDT (Interdisciplinary Team) has determined that alarms on all doors will prevent any elopements from Resident #8 in the future. All residents have the potential to be affected by the alleged deficient practice. Every resident in the building had an elopement assessment completed by the nursing staff, led by regional staff, to determine their current safety. Any residents at risk for elopement will have their plan of care evaluated and adapted accordingly. This will be completed by the end of the day 4/3/2012 by qualified nursing staff. The Minimum Data Set (MDS)/Care Plan Coordinator will update the care plan of each resident identified to be an elopement risk. The Medical Director was initially made aware of the immediate jeopardy, and has been involved in the development of the plan to remove. These conversations are considered a part of the Quality Assurance (QA) process. Facility staff will be in-serviced on elopement and building security as well as appropriate follow up for any accident/incident report by regional clinical staff. All in-servicing began 4/3/2012 and will be completed by end of the day 4/4/2012 to ensure all staff are in-serviced, regardless of their work schedule. The system for building security is as follows: 1. The front door will be locked from 9:00 PM to 6:00 AM every night. The front door bell will be used for any permitted visitors. 2. The exit door to the laundry department will be alarmed from 9:00 PM to 6:00 AM every night. 3. All other exits from the building will be alarmed constantly. 4. The entrance to Zone 2 (200 Hall) will be alarmed constantly. 5. All staff have been in-serviced on the alarm procedure. 6. The Maintenance Supervisor and/or designee will check each alarm weekly to ensure they are in good working condition and the batteries are operable. 7. All Administrative Staff have in-serviced on proper follow up for accident/incidents. Following is a list of all in-servicing completing pertaining to the alleged deficient practice: 1. All staff have been in-serviced to lock the front door from the hours of 9:00 PM to 6:00 AM. Any permitted visitors can use the doorbell. 2. All staff has been in-serviced on securing the building at night. This includes instructions on how to alarm and reset each one. 3. The Maintenance Supervisor has added checking the door alarms weekly to the preventative maintenance system. 4. All nursing staff and administrative staff have been in-serviced on proper accident/incident follow up. To monitor for compliance, the Administrator and/or designee will run a weekly Standards of Care meeting to include monitoring of all incident and accidents. In this meeting all incident reports from the past week will be reviewed for completion, accuracy, appropriate interventions, reportability, and the final disposition. In addition, tracking and trending of incidents and accidents will be completed and analyzed. Members of this meeting are to include the Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Social Worker, and Therapy Representative. Any negative findings will be forwarded to the Administrator and the QA committee. The next QA meeting is scheduled for 4/25/2012. This plan was initially implemented 4/3/2012 and will be monitored, through personal observation, through completion by Regional Director of Operations, Regional Directors of Reimbursement, and President. All staff will be in-serviced before returning to work Addendum: 4/4/12 The facility will also complete the following: 1. Checking all exit alarms will be placed on the 24 hour report for the nurse on duty to document when completed. All nursing staff has been in-serviced on April 5, 2012 to check all exit alarms at the beginning of their shift. 2. All exit doors have been checked as of April 4, 2012 and are in good working condition. The Maintenance Supervisor will add checking those doors to the weekly Preventative Maintenance System. Securing Building: 1. The front door should be locked between the hours of 9:00 PM and 6:00 AM. The doorbell can be used for any permitted visitors. 2. The ALARM on both exit doors on the end of Zone 5 should be on constantly. 3. The ALARM for the two exits on the end of Zone 4 (400 Hall) should be on constantly. 4. The ALARM for end exit on Zone 3 (300 Hall) should be on constantly. (Exits are marked by EXIT signs). 5. The ALARM for the side door on Zone 5 (500 Hall) should be on constantly. 6. The ALARM for the side door on Zone 4 should be on constantly. 7. The ALARM for the door in the dining room (Zone 6) should be on constantly. 8. The ALARM for the left end door on Zone 3 should be on constantly. 9. The ALARM for the side door on Zone 3 should be on constantly. 10. The ALARM for the exit to laundry should be turned on from 9:00 PM to 6:00 PM. 11. The ALARM for entering Zone 2 should be on at all times. The facility's Plan of Removal was accepted on 4/5/12 at 7:30 AM. Observation on 4/3/12 at 2:55 PM revealed Resident #8 on 1:1 staff monitoring. Observation on 4/3/12 at 4:40 PM revealed staff in-servicing taking place. Observation on 4/4/12 at 8:00 AM revealed alarms on all exit doors and the Fire Doors entering the 200 Hall. Observations on 4/4/12 from 8:00 AM through 4/6/12 at 3:40 PM revealed staff monitoring alarms on doors and the security of exit doors. On 4/6/12 at 4:00 PM, the Administrator and Corporate staff were informed that the IJ was removed. However, the facility remained out of compliance at a pattern with the potential for more than minimal harm that is not Immediate Jeopardy. The facility had not had time to implement, monitor and evaluate the effectiveness of their Plan of Removal. Source of the Facility's 672 reflected a census of 44 residents. The facility provided Elopement Risk Assessments for all residents on 4/4/12 that reflected 3 wandering Residents and 12 Residents at risk for elopement.

Based on observation, interview and record review the facility failed to implement written policies and procedures for 1 of 1 residents review for wandering (Resident #8) when; The facility failed to follow policies and procedures to ensure staff monitored, adequately supervised, identified unsafe wandering residents and developed interventions to prevent Resident #8 from exiting the facility through an unoccupied and unmonitored resident hallway on 3/20/12. This resulted in an Immediate Jeopardy (IJ) on 4/3/12. While the IJ was lowered on 4/6/12, the facility remained out of compliance at a pattern with the potential for more than minimal harm that is not an IJ as the facility had not had time to implement, monitor and evaluate the effectiveness of their Plan of Removal. This deficient practice could result in injury due to falls or exposure to environmental elements for Resident #8 and 2 (two) additional wandering residents identified by the facility. Findings include: Review of the facility 's Policy and Procedure titled Abuse Investigation, revised December 2009, reflected the following: Recognizing Signs and Symptoms of Abuse/Neglect 2. " Neglect " is defined as failure to provide goods and services as necessary to avoid physical harm. 3. b#9 Leaving someone unattended who needs supervision. Review of the facility's Policy and Procedure for Wandering, Unsafe Resident, revised December 2007, reflected the following: Wandering, Unsafe Resident Policy Interpretation and Implementation 1. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). 2. The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering. 3. The resident ' s care plan will indicate the resident is at risk for elopement or other safety issues. 4. Interventions to try to maintain safety will be included in the resident ' s care plan. 5. Nursing staff will document circumstances related to unsafe actions, including wandering, by the resident. 6. Staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behavior. Review of the Facesheet reflected Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the hospital History and Physical dated 7/7/11 reflected Resident #8 had a history of [REDACTED]. A neighbor found him lying in the street and called 911. He had wandered 8 (eight) blocks from home where he fell in the street. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] reflected Resident #8's ability to see in adeguate light was impaired. His skills for daily decision making were severely impaired. He had long term and short term memory impairment. He had trouble concentrating and was short-tempered and easily annoyed. He was totally dependant on staff for transfers. He required supervision for locomotion throughout the facility. He used a wheelchair for mobility. He had limited range of motion to his lower extremeties. He had falls since admission. He received antipsychotic and antianxiety medication. Review of the Care Plan dated 8/30/11 reflected Resident #8 is calmer, but still occasionally tries to leave the facility and has periods of agitated behavior. Review of the Care Plan dated 3/29/12 reflected Resident #8 had severe Alzheimer's Dementia. He was confused and disoriented; mentally wanders; unable to express his needs or thoughts. Resident #8 had a history of [REDACTED]. He required total assistance with transfers due to severe confusion. He had no safety awareness. There was no plan of care or interventions for Resident #8's wandering and exit seeking behavior. Review of a Fall Risk assessment dated [DATE] reflected Resident #8 scored a 25 where 10 or above represents High Risk; and 3/26/12 reflected Resident #8 scored a 24. Review of Resident 8 's Clinical Record reflected there were no Wandering/Elopement Risk assessments for the resident. Observation on 4/4/12 at 8:13 AM revealed Resident #8 holding the hand rail and pulling himself up the 300 Hall. He had a self-release safety belt in place and Hoyer (mechanical lift) lift sling underneath him in his wheelchair. Observation on 4/4/12 at 2:45 PM revealed Resident #8 scooting himself in his wheelchair with his feet, near the Nurses ' Station. He had a personal alarm, a self-release safety belt in place and a Hoyer lift sling underneath him in his wheelchair. Observation on 4/5/12 at 12:09 PM, revealed two unidentified Certified Nurse Aide (CNAs) pushing Resident #8, in his wheelchair, to the dining room. In an interview on 4/3/12 at 1:20 PM the Administrator stated that Resident #8 was the only wandering resident in the facility. Review of Nurses' Notes revealed the following: 8/3/11-Up in wheelchair wandering facility-kept going to door at end of hallway wanting to leave facility. 8/31/11-Confused and forgetful. Wandering aimlessly up and down halls. Personal alarm on at all times. Does not ask for help when wanting to stand or transfer. 9/1/11-Up in wheelchair propelling self freely in hallway. Remains confused. Looking for a way to leave. 9/2/11-Propelling self-up and down hallway in his wheelchair with his feet. 9/7/11-Up in wheelchair propelling self freely in hallway. Wanders aimlessly throughout the day, opening doors. 9/15/11-Up in wheelchair. Propels with his feet. Wanders about the facility. Will wander away from supper while eating. 9/17/11-Up in wheelchair propelling self-up and down hallways. Roams about facility. Wanders into other Resident 's rooms. Poor safety awareness. 2/22/12-Propels self in wheelchair up and down halls. 3/17/12-Found on floor in hall. 3/20/12-6:00 PM-Found outside of 200 Hall Stuck in the mud, by a CNA. Incident Report done. Family and Physician notified. Review of the Incident/Accident report dated 3/20/12 at 6:00 PM reflected an attempted elopement by Resident #8 who had memory and decision making impairment. The report, documented by LVN A, reflected that Resident #8 was located beside the porch of the 200 Hall. It was described that an unidentified CNA found Resident #8 outside the 200 Hall right next to the porch and was brought back in without incident. The recommended steps to prevent recurrence, documented on 3/21/12 by the Director of Nurses (DON), reflected only to "be sure doors are closed to 200 Hall especially in the PM (evening) when there is less staff activity." The Incident/Accident report was signed by the DON and the Administrator on 3/21/12. There was no documentation that the incident had been investigated or that any other interventions were put in place for Resident #8. Review of a Progress Note dated 3/20/12 reflected Resident #8 was pushing himself backwards in his wheelchair in the hallway. He was confused and had decreased cognition. Review of a Fax to the physician dated 3/20/12 reflected Resident #8 was "found outside of 200 Hall just off porch. No injuries." Review of the consolidated physician's orders [REDACTED]. Alarm sounds when resident tries to remove seat belt. Personal alarm on at all times. Use Mechanical Lift with three-person assist for transfers. Mobility per wheelchair. May have Lap Buddy when up in wheelchair to enable resident to safely propel self in wheelchair and as a reminder to not get up out of wheelchair unassisted due to resident will stand up out of wheelchair and forget to lock breaks-has no safety awareness. " In an Interview 4/3/12 at 2:00 PM Administrator stated she did not know much about Resident #8 ' s attempted elopement. She stated Resident #8 will go up to door and "fiddle with knobs" and we have told the staff to watch him more closely. They take residents onto the 200 Hall to weigh them, he had never done that before, that's why we watch him more closely. No investigation report was done; she stated she just made "mental notes." She stated she did sign off on the Incident/Accident report, but didn't know much about it. She stated that the DON was to tell nurses to watch Resident #8 more closely, to make sure doors were closed, and that nurses unlock doors in the morning and lock them at night. The panic bar is supposed to stay locked during the day, and unlocked at night. She stated that if residents go outside, its ok, they won't get hurt, residents are allowed to go out to the "gazebo." In an interview on 4/3/12 at 3:27 PM the Administrator stated that they discussed Resident #8's attempted elopement in the morning "Stand Up" meeting. She stated, "I knew we had talked about it." Review of the Stand Up Agenda which was dated 4/3/12 reflected that Resident #8 was "out onto 200 Hall porch--to keep 200 Hall doors closed." In an Interview 4/3/12 at 4:02 PM Licensed Vocational Nurse (LVN) A stated that it was a normal day, Resident #8 was going up and down halls like he usually did. She stated that they were weighing residents on the scale inside the 200 Hall and that he got past everyone to go to the outside patio off of the 200 Hall. His wheelchair was stuck in mud outside of the patio. She stated that a CNA found him and brought him back in, but she couldn't remember who the CNA was. LVN A stated that residents don't go outside alone. They should only go outside with a responsible party. In an interview on 4/4/12 at 2:30 PM CNA B stated that Resident #8 had no sense of where he was. She stated that Resident #8 was always trying to leave the facility. He was always trying to open the kitchen doors and the doors to other resident rooms. She stated that Resident #8 tried to leave through the front door one evening but they were always able to catch him before he got out the door. She stated, " We always watched him very close because he was always trying to go home. " She stated that she was not aware that Resident #8 had gotten outside at all until " You guys came. " She stated that she then heard that Resident #8 had gotten out the 200 Hall. She stated that the 200 Hall Fire Doors were always closed since there were no residents down that hall, but Resident #8 could open those doors. "I've seen him do it." CNA B stated that on the evening shift (2:00 PM to 10:00 PM) they used to have a resident on the 500 Hall that kept trying to leave the facility. That resident had been recently discharged from the facility. She stated that the facility never had alarms on the doors. To protect the wandering resident and let them know if she tried to leave, they attached Personal Alarms to the exit doors on the 500 Hall by setting the alarming device in the handrail and the magnet on the Panic Bar. CNA B stated that when that resident would try to go out the door, the magnet would detach from the device and alarm. She stated that she thinks the DON and Administrator came up with the idea to protect the resident. CNA B stated that the alarms were only placed on the 500 Hall because the 300 and 400 Hall exits could be seen from the Nurses' Station but the 500 Hall exits could not. She stated that she never really checked any of the doors to see if they were locked from the outside or to see that they were completely closed. CNA B stated that if they went on break, they always came in the 300 Hall door or the front door that were just left unlocked. She stated that she was not aware of anyone locking or securing the exit doors to the outside, she just assumed the nurses locked the doors. CNA B further stated that if anyone came in or went out a door, they would know because the Personal Alarm that they placed on the Panic Bar in the evening would go alarm. She stated that she never payed attention to whether the exit doors actually closed or locked. In an interview on 4/5/12 at 9:50 AM, CNA D stated that she and another CNA stepped outside at the end of 300 Hall around 6:00 PM. She stated that the other CNA walked to the corner of the patio area outside the 300 Hall and called her over to see Resident #8 outside the middle door on the 200 Hall, in his wheelchair with the door closed behind him. The front right wheel of his wheelchair was off the sidewalk in the grass. CNA D stated that she brought Resident #8 back in the same door on the 200 Hall. She stated that the door was closed but not locked from the outside. She stated that Resident #8 had gone into the 200 Hall through the Fire Doors on his own before, so she knew he was capable of doing it. She stated that no one ever went down the 200 Hall because there were no residents there. She stated she was not sure if the exit doors on 200 Hall or any hall were ever locked to the outside but the door was not locked to the outside when she brought Resident #8 back in. She stated that she had worked at the facility for approximately a year and a half but had worked at the facility in the past and never remembered alarms being on the doors. She stated that if there had been alarms on the doors she would remember. She stated that she knew that the front door, the exit door on the 300 Hall where the ambulance came in and the exit on the 300 Hall to the laundry building were never locked to the outside. In an interview on 4/5/12 at 3:30 PM CNA C stated that she had worked at the facility for approximately six months. She stated that she worked the evening Resident #8 was found outside but she did not find him. She stated that CNA D found Resident #8 outside. She stated that Resident #8 wandered a lot. He wandered throughout the entire facility, especially into other resident's rooms, into the dining room and anywhere he could get into as long as he was out of bed. She stated that Resident #8 got around on his own pretty well in his wheelchair by pushing himself with his feet or pulling himself down the halls using the handrails. She stated that Resident #8 was sometimes seen pushing on doors. She stated that he tried to leave the facility at times but they were always able to catch him in the past. CNA C stated that on the evening shift the CNAs or the Charge Nurse would put Personal Alarms on the exit doors at the end of 500 Hall, 400 Hall and the dining room exit so if a resident attempted to leave, the alarm would go off. She stated that the facility had an alarm system for the doors but it was never used because no one knew how to work it. She stated that she was not aware of anyone ever locking or securing the exit doors to the outside. She stated she thought the nurses locked the doors but she was not sure because she had never seen anyone do it. Observation on 4/3/12 at 10:46 AM revealed that the 200 Hall was unoccupied by residents. The Fire Doors at the front of the hall were closed. The Southwest exit door located midway down the hall exited to a grassy, empty courtyard between the 200 and 300 Halls. There was a narrow sidewalk that ran between the 200 Hall central door and 300 Hall central door. At the end of the 200 Hall there was an exit door that lead to a covered patio area toward the front of the building (Southeast exit door). The door did not close automatically with the pneumatic door closer. There was a three foot high rod iron fence around the patio area that extended 3/4 of the way to the 300 Hall exit and patio area. Observation on 4/3/12 at 12:15 PM revealed that the 400 Hall Southwest, and Northeast exit doors were unlatched and open approximately 1 ? to 2 inches and did not close automatically with the pneumatic door closer. The doors were able to be pushed open without use of the Panic Bar. The Southwest door had to be manually forced close. The Northeast exit door would not close even by force. Observation on 4/3/12 at 1:30 PM on the 300 Hall revealed that the South door would not close properly with the pneumatic door closer. The Southeast and Northeast doors were locked into the open position making doors unlocked from the outside and did not close properly with the pneumatic door closer. There were no alarms on the exit doors. The facility was located in a rural area with a house on the North and a pasture on the South. There was a parking lot and a pasture to the West and a parking lot and street to the East. In an interview on 4/3/12 at 1:30 PM, the Maintenance Supervisor stated the building is shifting and they have had a lot of rain. He stated that he was not aware how long doors had not been shutting because he had only been there for one month. He was not sure who secured the doors. Observation on 4/3/12 at 2:30 PM Housekeeper E entered Hall 400 Southwest door. The door did not close behind her. In an Interview on 4/3/12 at 2:30 PM Housekeeper E stated she never pays attention to doors closing. Review of the Resident Council Minutes dated 3/7/12 documented that the Activity Director explained to residents of the need to keep the 500 hall patio door locked (from outside) and temporary alarm due to some confused residents and their safety. In an Interview 4/5/12 at 12:29 PM the Activity Director stated that a resident had attempted to get out, but that the resident was no longer here. The door had a personal alarm like the one you put on a wheelchair. Observation on 4/3/12 at 2:15 PM revealed a perimeter alarm box mounted on the wall at the nurses' station. Posted near the alarm box was a sign with instructions on how "to disarm the entire system" and "to alarm the system." The A/C light was lit up in red. The instructions reflected that when the system was disarmed the A/C light should be on. In an interview on 4/3/12 at 2:30 PM the Regional Director of Operations stated that it would not be alright for a confused resident with Alzheimer's and impaired decision making to go outside unsupervised. He stated that the facility should try to prevent that. He further stated that the facility's doors should be locked by the staff at night. He stated that the facility also had a perimeter alarm that was to be activated. He stated that he was not sure what the perimeter alarm monitored but he would find out. In an interview on 4/3/12 at 2:55 PM the Regional Director of Operations stated that they discovered that the perimeter alarm did not monitor all exit doors. He stated that the perimeter alarm was not activated and the instructions that were posted were not all correct. In an interview on 4/3/12 at 4:23 PM the Regional Director of Operations stated that they "abandoned the perimeter alarm because it gets to confusing." He stated that they planned to purchase an alarm for each door instead of using the perimeter alarm system. In an interview on 4/3/12 at 4:23 PM LVN H stated that she had never used the perimeter alarm. She stated, "I wasn't even aware it existed." According to Weather Underground the temperature on 3/20/12 at 5:55 PM was 62.6 degrees Fahrenheit. The facility's Administrator, Director of Nurses, Assistant Director of Nurses, Regional Nurse Consultant and Regional Director of Operations were notified that an IJ existed on 4/3/12 at 4:45 PM due to the facility's failure to adequately monitor, supervise and implement preventive interventions for Resident #8, a known cognitively impaired, wandering, exit seeking, high fall risk resident to prevent his wandering onto an unoccupied/unmonitored hallway separated from the general facility population by closed Fire Doors and exiting the facility unsupervised and failed to ensure that facility staff secured the building from outside intruders by securely closing and locking facility doors. The facility provided the following plan of removal on 4/4/12 at 7:30 AM: Plan of Removal Resident #8 was placed on one on one constantly while his plan of care was being evaluated. The IDT (Interdisciplinary Team) has determined that alarms on all doors will prevent any elopements from Resident #8 in the future. All residents have the potential to be affected by the alleged deficient practice. Every resident in the building had an elopement assessment completed by the nursing staff, led by regional staff, to determine their current safety. Any residents at risk for elopement will have their plan of care evaluated and adapted accordingly. This will be completed by the end of the day 4/3/2012 by qualified nursing staff. The Minimum Data Set (MDS)/Care Plan Coordinator will update the care plan of each resident identified to be an elopement risk. The Medical Director was initially made aware of the immediate jeopardy, and has been involved in the development of the plan to remove. These conversations are considered a part of the Quality Assurance (QA) process. Facility staff will be in-serviced on elopement and building security as well as appropriate follow up for any accident/incident report by regional clinical staff. All in-servicing began 4/3/2012 and will be completed by end of the day 4/4/2012 to ensure all staff are in-serviced, regardless of their work schedule. The system for building security is as follows: 1. The front door will be locked from 9:00 PM to 6:00 AM every night. The front door bell will be used for any permitted visitors. 2. The exit door to the laundry department will be alarmed from 9:00 PM to 6:00 AM every night. 3. All other exits from the building will be alarmed constantly. 4. The entrance to Zone 2 (200 Hall) will be alarmed constantly. 5. All staff have been in-serviced on the alarm procedure. 6. The Maintenance Supervisor and/or designee will check each alarm weekly to ensure they are in good working condition and the batteries are operable. 7. All Administrative Staff have in-serviced on proper follow up for accident/incidents. Following is a list of all in-servicing completing pertaining to the alleged deficient practice: 1. All staff have been in-serviced to lock the front door from the hours of 9:00 PM to 6:00 AM. Any permitted visitors can use the doorbell. 2. All staff has been in-serviced on securing the building at night. This includes instructions on how to alarm and reset each one. 3. The Maintenance Supervisor has added checking the door alarms weekly to the preventative maintenance system. 4. All nursing staff and administrative staff have been in-serviced on proper accident/incident follow up. To monitor for compliance, the Administrator and/or designee will run a weekly Standards of Care meeting to include monitoring of all incident and accidents. In this meeting all incident reports from the past week will be reviewed for completion, accuracy, appropriate interventions, reportability, and the final disposition. In addition, tracking and trending of incidents and accidents will be completed and analyzed. Members of this meeting are to include the Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Social Worker, and Therapy Representative. Any negative findings will be forwarded to the Administrator and the QA committee. The next QA meeting is scheduled for 4/25/2012. This plan was initially implemented 4/3/2012 and will be monitored, through personal observation, through completion by Regional Director of Operations, Regional Directors of Reimbursement, and President. All staff will be in-serviced before returning to work Addendum: 4/4/12 The facility will also complete the following: 1. Checking all exit alarms will be placed on the 24 hour report for the nurse on duty to document when completed. All nursing staff has been in-serviced on April 5, 2012 to check all exit alarms at the beginning of their shift. 2. All exit doors have been checked as of April 4, 2012 and are in good working condition. The Maintenance Supervisor will add checking those doors to the weekly Preventative Maintenance System. Securing Building: 1. The front door should be locked between the hours of 9:00 PM and 6:00 AM. The doorbell can be used for any permitted visitors. 2. The ALARM on both exit doors on the end of Zone 5 should be on constantly. 3. The ALARM for the two exits on the end of Zone 4 (400 Hall) should be on constantly. 4. The ALARM for end exit on Zone 3 (300 Hall) should be on constantly. (Exits are marked by EXIT signs). 5. The ALARM for the side door on Zone 5 (500 Hall) should be on constantly. 6. The ALARM for the side door on Zone 4 should be on constantly. 7. The ALARM for the door in the dining room (Zone 6) should be on constantly. 8. The ALARM for the left end door on Zone 3 should be on constantly. 9. The ALARM for the side door on Zone 3 should be on constantly. 10. The ALARM for the exit to laundry should be turned on from 9:00 PM to 6:00 PM. 11. The ALARM for entering Zone 2 should be on at all times. The facility's Plan of Removal was accepted on 4/5/12 at 7:30 AM. Observation on 4/3/12 at 2:55 PM revealed Resident #8 on 1:1 staff monitoring. Observation on 4/3/12 at 4:40 PM revealed staff in-servicing taking place. Observation on 4/4/12 at 8:00 AM revealed alarms on all exit doors and the Fire Doors entering the 200 Hall. Observations on 4/4/12 from 8:00 AM through 4/6/12 at 3:40 PM revealed staff monitoring alarms on doors and the security of exit doors. On 4/6/12 at 4:00 PM, the Administrator and Corporate staff were informed that the IJ was removed. However, the facility remained out of compliance at a pattern with the potential for more than minimal harm that is not Immediate Jeopardy. The facility had not had time to implement, monitor and evaluate the effectiveness of their Plan of Removal. Source of the Facility's 672 reflected a census of 44 residents. The facility provided Elopement Risk Assessments for all residents on 4/4/12 that reflected 3 wandering Residents and 12 Residents at risk for elopement.

Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible when they failed to maintain proper function of 7 of 13 exit doors that failed to close properly in order to secure the facility from potential outside intruders; and failed to ensure 1 of 1 known wandering resident (Resident #8) received adequate supervision to prevent accidents when they failed to monitor, adequately supervise and develop interventions to prevent Resident #8 from wandering into an unoccupied and unmonitored hallway separated from the general population by Fire Doors and exiting the facility, unsupervised, into a courtyard on 3/20/12 This failure resulted in an identification of an Immediate Jeopardy (IJ) on 4/3/12. While the IJ was lowered on 4/6/12, the facility remained out of compliance at a pattern with the potential for more than minimal harm that is not an IJ. This deficient practice could result in injury due to falls or exposure to environmental elements for Resident #8 and 2 (two) additional wandering residents identified by the facility. Findings include: Review of the Facesheet reflected Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the hospital History and Physical dated 7/7/11 reflected Resident #8 had a history of [REDACTED]. A neighbor found him lying in the street and called 911. He had wandered 8 (eight) blocks from home where he fell in the street. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] reflected Resident #8's ability to see in adeguate light was impaired. His skills for daily decision making were severely impaired. He had long term and short term memory impairment. He had trouble concentrating and was short-tempered and easily annoyed. He was totally dependant on staff for transfers. He required supervision for locomotion throughout the facility. He used a wheelchair for mobility. He had limited range of motion to his lower extremeties. He had falls since admission. He received antipsychotic and antianxiety medication. Review of the Care Plan dated 8/30/11 reflected Resident #8 is calmer, but still occasionally tries to leave the facility and has periods of agitated behavior. Review of the Care Plan dated 3/29/12 reflected Resident #8 had severe Alzheimer's Dementia. He was confused and disoriented; mentally wanders; unable to express his needs or thoughts. Resident #8 had a history of [REDACTED]. He required total assistance with transfers due to severe confusion. He had no safety awareness. There was no plan of care or interventions for Resident #8's wandering and exit seeking behavior. Review of a Fall Risk assessment dated [DATE] reflected Resident #8 scored a 25 where 10 or above represents High Risk; and 3/26/12 reflected Resident #8 scored a 24. Review of Resident 8 's Clinical Record reflected there were no Wandering/Elopement Risk assessments for the resident. Observation on 4/4/12 at 8:13 AM revealed Resident #8 holding the hand rail and pulling himself up the 300 Hall. He had a self-release safety belt in place and Hoyer (mechanical lift) lift sling underneath him in his wheelchair. Observation on 4/4/12 at 2:45 PM revealed Resident #8 scooting himself in his wheelchair with his feet, near the Nurses ' Station. He had a personal alarm, a self-release safety belt in place and a Hoyer lift sling underneath him in his wheelchair. Observation on 4/5/12 at 12:09 PM, revealed two unidentified Certified Nurse Aide (CNAs) pushing Resident #8, in his wheelchair, to the dining room. In an interview on 4/3/12 at 1:20 PM the Administrator stated that Resident #8 was the only wandering resident in the facility. Review of Nurses' Notes revealed the following: 8/3/11-Up in wheelchair wandering facility-kept going to door at end of hallway wanting to leave facility. 8/31/11-Confused and forgetful. Wandering aimlessly up and down halls. Personal alarm on at all times. Does not ask for help when wanting to stand or transfer. 9/1/11-Up in wheelchair propelling self freely in hallway. Remains confused. Looking for a way to leave. 9/2/11-Propelling self-up and down hallway in his wheelchair with his feet. 9/7/11-Up in wheelchair propelling self freely in hallway. Wanders aimlessly throughout the day, opening doors. 9/15/11-Up in wheelchair. Propels with his feet. Wanders about the facility. Will wander away from supper while eating. 9/17/11-Up in wheelchair propelling self-up and down hallways. Roams about facility. Wanders into other Resident 's rooms. Poor safety awareness. 2/22/12-Propels self in wheelchair up and down halls. 3/17/12-Found on floor in hall. 3/20/12-6:00 PM-Found outside of 200 Hall Stuck in the mud, by a CNA. Incident Report done. Family and Physician notified. Review of the Incident/Accident report dated 3/20/12 at 6:00 PM reflected an attempted elopement by Resident #8 who had memory and decision making impairment. The report, documented by LVN A, reflected that Resident #8 was located beside the porch of the 200 Hall. It was described that an unidentified CNA found Resident #8 outside the 200 Hall right next to the porch and was brought back in without incident. The recommended steps to prevent recurrence, documented on 3/21/12 by the Director of Nurses (DON), reflected only to "be sure doors are closed to 200 Hall especially in the PM (evening) when there is less staff activity." The Incident/Accident report was signed by the DON and the Administrator on 3/21/12. There was no documentation that the incident had been investigated or that any other interventions were put in place for Resident #8. Review of a Progress Note dated 3/20/12 reflected Resident #8 was pushing himself backwards in his wheelchair in the hallway. He was confused and had decreased cognition. Review of a Fax to the physician dated 3/20/12 reflected Resident #8 was "found outside of 200 Hall just off porch. No injuries." Review of the consolidated physician's order [REDACTED]. Alarm sounds when resident tries to remove seat belt. Personal alarm on at all times. Use Mechanical Lift with three-person assist for transfers. Mobility per wheelchair. May have Lap Buddy when up in wheelchair to enable resident to safely propel self in wheelchair and as a reminder to not get up out of wheelchair unassisted due to resident will stand up out of wheelchair and forget to lock breaks-has no safety awareness. " In an Interview 4/3/12 at 2:00 PM Administrator stated she did not know much about Resident #8 ' s attempted elopement. She stated Resident #8 will go up to door and "fiddle with knobs" and we have told the staff to watch him more closely. They take residents onto the 200 Hall to weigh them, he had never done that before, that's why we watch him more closely. No investigation report was done; she stated she just made "mental notes." She stated she did sign off on the Incident/Accident report, but didn't know much about it. She stated that the DON was to tell nurses to watch Resident #8 more closely, to make sure doors were closed, and that nurses unlock doors in the morning and lock them at night. The panic bar is supposed to stay locked during the day, and unlocked at night. She stated that if residents go outside, its ok, they won't get hurt, residents are allowed to go out to the "gazebo." In an interview on 4/3/12 at 3:27 PM the Administrator stated that they discussed Resident #8's attempted elopement in the morning "Stand Up" meeting. She stated, "I knew we had talked about it." Review of the Stand Up Agenda which was dated 4/3/12 reflected that Resident #8 was "out onto 200 Hall porch--to keep 200 Hall doors closed." In an Interview 4/3/12 at 4:02 PM Licensed Vocational Nurse (LVN) A stated that it was a normal day, Resident #8 was going up and down halls like he usually did. She stated that they were weighing residents on the scale inside the 200 Hall and that he got past everyone to go to the outside patio off of the 200 Hall. His wheelchair was stuck in mud outside of the patio. She stated that a CNA found him and brought him back in, but she couldn't remember who the CNA was. LVN A stated that residents don't go outside alone. They should only go outside with a responsible party. In an interview on 4/4/12 at 2:30 PM CNA B stated that Resident #8 had no sense of where he was. She stated that Resident #8 was always trying to leave the facility. He was always trying to open the kitchen doors and the doors to other resident rooms. She stated that Resident #8 tried to leave through the front door one evening but they were always able to catch him before he got out the door. She stated, " We always watched him very close because he was always trying to go home. " She stated that she was not aware that Resident #8 had gotten outside at all until " You guys came. " She stated that she then heard that Resident #8 had gotten out the 200 Hall. She stated that the 200 Hall Fire Doors were always closed since there were no residents down that hall, but Resident #8 could open those doors. "I've seen him do it." CNA B stated that on the evening shift (2:00 PM to 10:00 PM) they used to have a resident on the 500 Hall that kept trying to leave the facility. That resident had been recently discharged from the facility. She stated that the facility never had alarms on the doors. To protect the wandering resident and let them know if she tried to leave, they attached Personal Alarms to the exit doors on the 500 Hall by setting the alarming device in the handrail and the magnet on the Panic Bar. CNA B stated that when that resident would try to go out the door, the magnet would detach from the device and alarm. She stated that she thinks the DON and Administrator came up with the idea to protect the resident. CNA B stated that the alarms were only placed on the 500 Hall because the 300 and 400 Hall exits could be seen from the Nurses' Station but the 500 Hall exits could not. She stated that she never really checked any of the doors to see if they were locked from the outside or to see that they were comlpetely closed. CNA B stated that if they went on break, they always came in the 300 Hall door or the front door that were just left unlocked. She stated that she was not aware of anyone locking or securing the exit doors to the outside, she just assumed the nurses locked the doors. CNA B further stated that if anyone came in or went out a door, they would know because the Personal Alarm that they placed on the Panic Bar in the evening would go alarm. She stated that she never payed attention to whether the exit doors actually closed or locked. In an interview on 4/5/12 at 9:50 AM, CNA D stated that she and another CNA stepped outside at the end of 300 Hall around 6:00 PM. She stated that the other CNA walked to the corner of the patio area outside the 300 Hall and called her over to see Resident #8 outside the middle door on the 200 Hall, in his wheelchair with the door closed behind him. The front right wheel of his wheelchair was off the sidewalk in the grass. CNA D stated that she brought Resident #8 back in the same door on the 200 Hall. She stated that the door was closed but not locked from the outside. She stated that Resident #8 had gone into the 200 Hall through the Fire Doors on his own before, so she knew he was capable of doing it. She stated that no one ever went down the 200 Hall because there were no residents there. She stated she was not sure if the exit doors on 200 Hall or any hall were ever locked to the outside but the door was not locked to the outside when she brought Resident #8 back in. She stated that she had worked at the facility for approximately a year and a half but had worked at the facility in the past and never remembered alarms being on the doors. She stated that if there had been alarms on the doors she would remember. She stated that she knew that the front door, the exit door on the 300 Hall where the ambulance came in and the exit on the 300 Hall to the laundry building were never locked to the outside. In an interview on 4/5/12 at 3:30 PM CNA C stated that she had worked at the facility for approximately six months. She stated that she worked the evening Resident #8 was found outside but she did not find him. She stated that CNA D found Resident #8 outside. She stated that Resident #8 wandered a lot. He wandered throughout the entire facility, especially into other resident's rooms, into the dining room and anywhere he could get into as long as he was out of bed. She stated that Resident #8 got around on his own pretty well in his wheelchair by pushing himself with his feet or pulling himself down the halls using the handrails. She stated that Resident #8 was sometimes seen pushing on doors. She stated that he tried to leave the facility at times but they were always able to catch him in the past. CNA C stated that on the evening shift the CNAs or the Charge Nurse would put Personal Alarms on the exit doors at the end of 500 Hall, 400 Hall and the dining room exit so if a resident attempted to leave, the alarm would go off. She stated that the facility had an alarm system for the doors but it was never used because no one knew how to work it. She stated that she was not aware of anyone ever locking or securing the exit doors to the outside. She stated she thought the nurses locked the doors but she was not sure because she had never seen anyone do it. Observation on 4/3/12 at 10:46 AM revealed that the 200 Hall was unoccupied by residents. The Fire Doors at the front of the hall were closed. The Southwest exit door located midway down the hall exited to a grassy, empty courtyard between the 200 and 300 Halls. There was a narrow sidewalk that ran between the 200 Hall central door and 300 Hall central door. At the end of the 200 Hall there was an exit door that lead to a covered patio area toward the front of the building (Southeast exit door). The door did not close automatically with the pneumatic door closer. There was a three foot high rod iron fence around the patio area that extended 3/4 of the way to the 300 Hall exit and patio area. Observation on 4/3/12 at 12:15 PM revealed that the 400 Hall Southwest, and Northeast exit doors were unlatched and open approximately 1 ? to 2 inches and did not close automatically with the pneumatic door closer. The doors were able to be pushed open without use of the Panic Bar. The Southwest door had to be manually forced close. The Northeast exit door would not close even by force. Observation on 4/3/12 at 1:30 PM on the 300 Hall revealed that the South door would not close properly with the pneumatic door closer. The Southeast and Northeast doors were locked into the open position making doors unlocked from the outside and did not close properly with the pneumatic door closer. There were no alarms on the doors. The facility was located in a rural area with a house on the North and a pasture on the South. There was a parking lot and a pasture to the West and a parking lot and street to the East. In an interview on 4/3/12 at 1:30 PM, the Maintenance Supervisor stated the building is shifting and they have had a lot of rain. He stated that he was not aware how long doors had not been shutting because he had only been there for one month. He was not sure who secured the doors. Observation on 4/3/12 at 2:30 PM Housekeeper E entered Hall 400 Southwest door. The door did not close behind her. In an Interview on 4/3/12 at 2:30 PM Housekeeper E stated she never pays attention to doors closing. Review of the Resident Council Minutes dated 3/7/12 documented that the Activity Director explained to residents of the need to keep the 500 hall patio door locked (from outside) and temporary alarm due to some confused residents and their safety. In an Interview 4/5/12 at 12:29 PM the Activity Director stated that a resident had attempted to get out, but that the resident was no longer here. The door had a personal alarm like the one you put on a wheelchair. Observation on 4/3/12 at 2:15 PM revealed a perimeter alarm box mounted on the wall at the nurses' station. Posted near the alarm box was a sign with instructions on how "to disarm the entire system" and "to alarm the system." The A/C light was lit up in red. The instructions reflected that when the system was disarmed the A/C light should be on. In an interview on 4/3/12 at 2:30 PM the Regional Director of Operations stated that it would not be alright for a confused resident with Alzheimer's and impaired decision making to go outside unsupervised. He stated that the facility should try to prevent that. He further stated that the facility's doors should be locked by the staff at night. He stated that the facility also had a perimeter alarm that was to be activated. He stated that he was not sure what the perimeter alarm monitored but he would find out. In an interview on 4/3/12 at 2:55 PM the Regional Director of Operations stated that they discovered that the perimeter alarm did not monitor all exit doors. He stated that the perimeter alarm was not activated and the instructions that were posted were not all correct. In an interview on 4/3/12 at 4:23 PM the Regional Director of Operations stated that they "abandoned the perimeter alarm because it gets to confusing." He stated that they planned to purchase an alarm for each door instead of using the perimeter alarm system. In an interview on 4/3/12 at 4:23 PM LVN H stated that she had never used the perimeter alarm. She stated, "I wasn't even aware it existed." Review of the facility 's Policy and Procedure titled Abuse Investigation, revised December 2009, reflected the following: Recognizing Signs and Symptoms of Abuse/Neglect 2. " Neglect " is defined as failure to provide goods and services as necessary to avoid physical harm. 3. b#9 Leaving someone unattended who needs supervision. Review of the facility's Policy and Procedure for Wandering, Unsafe Resident, revised December 2007, reflected the following: Wandering, Unsafe Resident Policy Interpretation and Implementation 1. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). 2. The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering. 3. The resident ' s care plan will indicate the resident is at risk for elopement or other safety issues. 4. Interventions to try to maintain safety will be included in the resident ' s care plan. 5. Nursing staff will document circumstances related to unsafe actions, including wandering, by the resident. 6. Staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behavior. According to Weather Underground the temperature on 3/20/12 at 5:55 PM was 62.6 degrees Fahrenheit. The facility's Administrator, Director of Nurses, Assistant Director of Nurses, Regional Nurse Consultant and Regional Director of Operations were notified that an IJ existed on 4/3/12 at 4:45 PM due to the facility's failure to adequately monitor, supervise and implement preventive interventions for Resident #8, a known cognitively impaired, wandering, exit seeking, high fall risk resident to prevent his wandering onto an unoccupied/unmonitored hallway separated from the general facility population by closed Fire Doors and exiting the facility unsupervised and failed to ensure that facility staff secured the building from outside intruders by securely closing and locking facility doors. The facility provided the following plan of removal on 4/4/12 at 7:30 AM: Plan of Removal Resident #8 was placed on one on one constantly while his plan of care was being evaluated. The IDT (Interdisciplinary Team) has determined that alarms on all doors will prevent any elopements from Resident #8 in the future. All residents have the potential to be affected by the alleged deficient practice. Every resident in the building had an elopement assessment completed by the nursing staff, led by regional staff, to determine their current safety. Any residents at risk for elopement will have their plan of care evaluated and adapted accordingly. This will be completed by the end of the day 4/3/2012 by qualified nursing staff. The Minimum Data Set (MDS)/Care Plan Coordinator will update the care plan of each resident identified to be an elopement risk. The Medical Director was initially made aware of the immediate jeopardy, and has been involved in the development of the plan to remove. These conversations are considered a part of the Quality Assurance (QA) process. Facility staff will be in-serviced on elopement and building security as well as appropriate follow up for any accident/incident report by regional clinical staff. All in-servicing began 4/3/2012 and will be completed by end of the day 4/4/2012 to ensure all staff are in-serviced, regardless of their work schedule. The system for building security is as follows: 1. The front door will be locked from 9:00 PM to 6:00 AM every night. The front door bell will be used for any permitted visitors. 2. The exit door to the laundry department will be alarmed from 9:00 PM to 6:00 AM every night. 3. All other exits from the building will be alarmed constantly. 4. The entrance to Zone 2 (200 Hall) will be alarmed constantly. 5. All staff have been in-serviced on the alarm procedure. 6. The Maintenance Supervisor and/or designee will check each alarm weekly to ensure they are in good working condition and the batteries are operable. 7. All Administrative Staff have in-serviced on proper follow up for accident/incidents. Following is a list of all in-servicing completing pertaining to the alleged deficient practice: 1. All staff have been in-serviced to lock the front door from the hours of 9:00 PM to 6:00 AM. Any permitted visitors can use the doorbell. 2. All staff has been in-serviced on securing the building at night. This includes instructions on how to alarm and reset each one. 3. The Maintenance Supervisor has added checking the door alarms weekly to the preventative maintenance system. 4. All nursing staff and administrative staff have been in-serviced on proper accident/incident follow up. To monitor for compliance, the Administrator and/or designee will run a weekly Standards of Care meeting to include monitoring of all incident and accidents. In this meeting all incident reports from the past week will be reviewed for completion, accuracy, appropriate interventions, reportability, and the final disposition. In addition, tracking and trending of incidents and accidents will be completed and analyzed. Members of this meeting are to include the Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Social Worker, and Therapy Representative. Any negative findings will be forwarded to the Administrator and the QA committee. The next QA meeting is scheduled for 4/25/2012. This plan was initially implemented 4/3/2012 and will be monitored, through personal observation, through completion by Regional Director of Operations, Regional Directors of Reimbursement, and President. All staff will be in-serviced before returning to work Addendum: 4/4/12 The facility will also complete the following: 1. Checking all exit alarms will be placed on the 24 hour report for the nurse on duty to document when completed. All nursing staff has been in-serviced on April 5, 2012 to check all exit alarms at the beginning of their shift. 2. All exit doors have been checked as of April 4, 2012 and are in good working condition. The Maintenance Supervisor will add checking those doors to the weekly Preventative Maintenance System. Securing Building: 1. The front door should be locked between the hours of 9:00 PM and 6:00 AM. The doorbell can be used for any permitted visitors. 2. The ALARM on both exit doors on the end of Zone 5 should be on constantly. 3. The ALARM for the two exits on the end of Zone 4 (400 Hall) should be on constantly. 4. The ALARM for end exit on Zone 3 (300 Hall) should be on constantly. (Exits are marked by EXIT signs). 5. The ALARM for the side door on Zone 5 (500 Hall) should be on constantly. 6. The ALARM for the side door on Zone 4 should be on constantly. 7. The ALARM for the door in the dining room (Zone 6) should be on constantly. 8. The ALARM for the left end door on Zone 3 should be on constantly. 9. The ALARM for the side door on Zone 3 should be on constantly. 10. The ALARM for the exit to laundry should be turned on from 9:00 PM to 6:00 PM. 11. The ALARM for entering Zone 2 should be on at all times. The facility's Plan of Removal was accepted on 4/5/12 at 7:30 AM. Observation on 4/3/12 at 2:55 PM revealed Resident #8 on 1:1 staff monitoring. Observation on 4/3/12 at 4:40 PM revealed staff in-servicing taking place. Observation on 4/4/12 at 8:00 AM revealed alarms on all exit doors and the Fire Doors entering the 200 Hall. Observations on 4/4/12 from 8:00 AM through 4/6/12 at 3:40 PM revealed staff monitoring alarms on doors and the security of exit doors. On 4/6/12 at 4:00 PM, the Administrator and Corporate staff were informed that the IJ was removed. However, the facility remained out of compliance at a pattern with the potential for more than minimal harm that is not Immediate Jeopardy. The facility had not had time to implement, monitor and evaluate the effectiveness of their Plan of Removal. Source of the Facility's 672 reflected a census of 44 residents. The facility provided Elopement Risk Assessments for all residents on 4/4/12 that reflected 3 wandering Residents and 12 Residents at risk for elopement.