Advinia Care At Venice

Based on observation, review of facility policy and procedure and staff interviews, the facility failed to prepare, and store food in a sanitary manner by failing to cover and date food in 1 reach-in refrigerator, failed to use proper hand hygiene during dish washing procedure, and failed to ensure hair restraints were used to cover facial hair. Additionally, the facility failed to properly assist residents during meals to prevent cross contamination. The lack of sanitation in the kitchen and dining services had the potential to affect all residents and staff.
The findings included:
The facility policy Food Safety and Sanitation initiated 2021 documented Beard nets are required when facial hair is visible are we cried when facial hair is visible. Employees will wash their hands just before they start to work in the kitchen and after smoking, sneezing, using the restroom, handling poisonous compounds or dirty dishes, and touching their face, hair, other people or surfaces or items with potential for contamination. All time and temperature control for safety foods including leftovers should be labeled, covered and dated it when stored.
On 7/8/24 at 9:03 a.m., during an initial tour of the kitchen with the Director of Hospitality, the following observations were made:
1. In the kitchen there were employee personal drinks and items on the counters where food is stored and prepared.
Photographic evidence obtained.
2. There was a thick layer of food, dust and debris on top of the dishwasher.
Photographic evidence obtained.
3. Dietary Aide Staff O was observed using the high temp dishwasher. He was wearing disposable gloves, and placing dirty plates in the machine to be washed and sanitized. Staff O removed the clean and sanitized plates from the dishwasher with the same gloves used to load the dirty dishes in the machine. Staff O removed and held the clean plates against his body with the plates touching his dirty apron. Staff O placed the clean plates in the clean dish racks.
4. The trash cans in the kitchen were uncovered. The Director of hospitality verified the observation, grabbed the lids and covered the trash cans.
Photographic evidence obtained.
5. In the reach-in refrigerator there was a tray of uncovered and undated desert fruit cups, and a covered plate of unlabeled and undated foods. The Director of hospitality said he could not identify the food on the plate.
Photographic evidence obtained.
6. There was a tin of fruit dated 6/26/24. The Director said the fruit was to be kept for three days. He removed and discarded the fruit.
Photographic evidence obtained.
7. On the serving area where the toaster was located there were employee personal drinks and cups. The Director said, it's ok they are covered and have a lid. There was a wrapped sandwich on the shelf the of the serving area and the Director said it was for the staff.
Photographic evidence obtained.
8. The floor drain in the main kitchen had dust, debris on the racks and a slimy bio-film in the bottom of the drain. The Director of hospitality said the maintenance department was responsible to clean the drains, but did not know when it was done. He said, I have only been here seven weeks now. Come on, this is a working kitchen.
Photographic evidence obtained.
9. The walk-in refrigerator had there was a large plastic bin with lettuce/kale dated 5/8/24. The Director of hospitality said he did not have a chance to change the sticker yet.
Photographic evidence obtained.
10. The clean plates in the plate warmers had no covers to protect the clean plates from dust and food particles. The Director of hospitality retrieved the covers and placed them on the clean plates.
11. There was a two-compartment sink in the prep section of the kitchen. Both sinks had grim, food and debris. The Director of hospitality said staff was not currently using the sink.
The drain on the bottom of the sink had lettuce and other foods in the floor drain catch. The Director said, I never said they are not using it, they might throw something in there to rinse it out.
Photographic evidence obtained.
12. In the walk-in refrigerator two turkeys were observed thawing on a tray in a rolling rack. Two dead insects were observed on the tray.
Photographic evidence obtained.
13. On 7/8/24 at 12:07 p.m., during an initial observation in the main dining room the following observations were made:
a. One resident was served her meal while the other three residents waited to be served because they required assistance with the meal. Over 10 minutes had passed before the other residents were served their meals.
b. Observed Registered Nurse Staff M providing feeding assistance to two residents at the same table. Staff M did not wash her hands in between using one residents' utensil and placing food into her mouth as she rubbed the residents back, and then picking up the other resident's spoon to assist her to place food into her mouth. Staff M would periodically stand as she moved around the table to assist the other residents at the table. Staff M was observed taking an empty glass from a resident who requested more juice and went to the juice machine and with the rim of the used and dirty glass pressed it against the dispensing nozzle to fill the glass with juice. Clean glasses were available next to the juice dispenser.
c. Observed certified nursing assistant (CNA) Staff J providing feeding assistance to two residents at the same time, giving one resident a back rub as she assisted her and repositioning her in the wheelchair and then turning to provide feeding assistance to the other resident without performing proper hand hygiene to prevent cross contamination.
d. Observed CNA Staff K feeding residents while standing and going from one resident to another picking up glasses and utensils and offering assistance without performing hand hygiene.
e. CNA Staff L was observed standing beside a resident who was in a reclining wheelchair and reaching across the resident to access the residents' utensils and food. Staff L continued to stand on the side of the resident, and reaching across the resident to provide assistance throughout the meal.
On 7/9/24 at 1:37 p.m., during an interview with the Director of Nursing she said the staff did inform her of the concerns with staff standing to assist residents with meals and feeding more than 1 resident without sanitizing their hands. She said she had instructed the staff on proper hand hygiene when assisting the residents but had no written policy for assisting residents with their meals.
On 7/10/24 at 11:00 a.m., in an interview the Maintenance Director said the kitchen floor drain traps were cleaned every three months and as needed. He said pest control comes monthly and sprays the drain traps.
On 7/10/24 at 12:00 p.m., during a second observation of the main kitchen with the Director of Hospitality, Dietary [NAME] Staff P had no facial covering on his beard and mustache as he prepared the food. The Dietary Manager was present and did not instruct him to put one on. Staff P was observed touching trays of meatballs without gloves. Staff P walked to the trash can and lifted the lid to throw away garbage, and then went to grab a clean tin container from the shelf and went back to preparing food. He did not wash his hands and did not have on gloves. The Director did not instruct the cook on hand hygiene to prevent cross contamination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of an admission Record indicated the facility admitted Resident #16 to the facility on 1/10/24 with the following diagnoses: Cerebrovascular disease, Hemiplegia and hemiparesis following a stroke, right sided weakness, dysphagia, Aphasia, mood disorder, muscle spasm, atrial fibrillation, seizures and a chronic subdural hemorrhage.
The Quarterly Minimum Data Set (MDS) assessment dated [DATE] noted Resident #16 had a Brief Interview for Mental Status (BIMS) score of 00 indicating the assessment could not be done due to the resident's severe cognitive impairment. The assessment indicated the resident was dependent for all Activities of Daily Living (ADLs). The resident was unable to use his right arm and hand. Resident #16 was dependent for all transfers from bed to reclining high back wheelchair.
Review of Resident #16 Care Plan initiated 1/29/24. revealed no plan of care for Activities of Daily Living (ADLs) such as bathing, shaving, oral hygiene.
On 7/8/24 at 9:52 a.m., Resident #16 was observed sitting in the hallway in front of the nurses station in a high back wheelchair. Resident #16 had a two to three days facial hair growth. His fingernails extended approximately 1/4 inch past his fingertips with a brown substance under his nails.
On 7/9/24 at 1:53 p.m., Resident #16 was observed in the hallway in the high back wheelchair. Resident #16 did not answer any questions. The resident's fingernails remained long, extending 1/4 inch past the fingertips with a brown substance under the nails. The resident had a three to four days facial hair growth.
On 7/10/24 at 10:20 a.m., in an interview Resident #16's wife said she was very concerned about the lack of bathing, shaving and nail car for her husband. The wife said he's frequently not shaved when she visits. She said she tries to trim his nails as he likes to reach in his incontinent briefs when he's soiled. She said it was very frustrating and he had voiced her concerns several times to the staff.
Review of the shower assignments revealed Resident #16 was scheduled for showers on the evening shift on Mondays and Thursdays.
Review of the Certified Nursing Assistants (CNAs) documentation revealed Resident #16 received four showers in the last 30 days. The most recent shower was dated 7/8/24 when the resident was observed unshaved, with a brown substance under the fingernails.
On 7/10/24 at 11:14 a.m., in an interview Licensed Practical Nurse Staff A said Resident #16's showers were scheduled on Mondays and Thursdays. She said the CNAs are required to notify the nurse if the resident did not receive the scheduled shower.
Based on observation, review of facility policy and procedure, review of the clinical record and resident and staff interview, the facility failed to provide the necessary care and services to maintain personal hygiene for 2 (Residents # 11 and #16) of 2 residents reviewed for ADLs (activities of daily living).
The findings included:
1. The facility policy CA-12 ADL Support initiated 7/2019 (revised 10/2022) documented Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care including appropriate support and assistance with hygiene (bathing, dressing, grooming and oral care).
Review of the clinical record revealed Resident #11 had a readmission date of 6/13/24 with diagnoses including falls, acute respiratory failure, heart failure and anxiety.
The admission Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 6/17/24 documented the resident was dependent on staff for bathing.
The MDS noted Resident #11's cognitive skills for daily decision making were moderately impaired.
The plan of care identified Resident #11 had an ADL self-care performance deficit related to weakness and infection. The interventions included, The resident is able to provide upper body hygiene with supply set up.
On 7/8/24 at 10:50 a.m., Resident #11 was in his room in a wheelchair (w/c). He was unshaven approximately 2 days growth. His fingernails extended approximately 1/2 inch in length with a brown and black substance under the nails. In an interview Resident #16 said, I don't like them this long; they need to be cut. I will have to find someone to cut them for me. The resident said he did not remember if he was receiving his scheduled showers.
On 7/9/24 at 10:24 a.m., during an observation Resident #11 remained unshaven.
On 7/9/24 at 1:50 p.m., in an interview Certified Nursing Assistant (CNA) Staff N said she was assigned to assist Resident #11. The CNA said men are shaved on the shower days and there was a schedule at the desk. The CNA said the residents are showered and shaved twice a week and as needed.
On 7/9/24 at 2:03 p.m., Resident #11 was observed in his room in a wheelchair. He was noted to have crumbs of food covering the front of his shirt and pants from the noon meal. He was unshaven. Resident #11 said his wife usually shaved him but she was ill and could not visit at this time.
Review of the shower assignments revealed Resident #11 scheduled showers were on Tuesdays and Fridays.
Review of the CNA documentation for the previous 30 days revealed the resident received a shower on 6/14/24, 6/18/24, 6/21/24, 7/2/24 and 7/5/24. Resident #11 received 5 showers since his admission. The resident was scheduled for a shower on 7/9/24.
On 7/10/24 at 10:01 a.m., Resident #11 was observed in his room in clean clothing. He remained unshaven. Licensed Practical Nurse Staff A was assisting the resident with his medications. Staff A confirmed the resident had not been shaved for several days. Staff A said shaving is to be done with daily care.
On 7/10/24 at 1:49 p.m., in an interview CNA Staff N said Resident #11 was scheduled for a shower on 7/9/24. The CNA had documented not applicable on the documentation for 7/9/24. CNA Staff N said, the nurse wrote the wrong shower on the assignment sheet, and I showered another resident. When I realized the error, it was the end of my shift and I did not have time to shower or shave him.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility policy and procedure, record review and resident and staff interview, the facility failed to ensure they provided an ongoing program to support the residents in their choice of activities which are designed to meet the resident's interests and support the resident physical, mental and psychosocial well-being for 2 (residents #11, and #190) of 3 residents reviewed for involvement in activities. The lack of an ongoing activity program could lead to a decline in the residents' self-esteem, physical, mental, and psychosocial well-being.
The findings included:
The facility policy Activities effective 7/1/18 (revised 2/3/21) documented Activities refer to any endeavor, other than routine ADL's in which a resident participates that is intended to enhance her/his sense of well-being and to promote self-esteem, pleasure, comfort, education, creativity, success and independence. The facility shall provide, based on the comprehensive assessment and care plan and the preferences of each resident, an on-going program to support residents in their choice of activities, designed to meet the interests and need of the residents.
The resident shall be involved in an ongoing program of activities that is designed to appeal to his or her interests and to enhance the residents highest practicable level of physical, mental and psychological well-being.
1. Review of the clinical record revealed Resident #11 had a readmission date of 6/13/24 with diagnoses including falls and anxiety.
The admission Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 6/17/24 documented it was very important for the resident to go outside to get fresh air, to participate in religious services or practices, keep up with the news, have animals around and to have books, newspapers to read.
The MDS noted Resident #11's cognitive skills for daily decision making were moderately impaired.
Review of the plan of care failed to show documentation of a care plan to address the resident's activity needs.
On 7/8/24 at 2:11 p.m., Resident #11 was observed in his room in his wheelchair, he had the television (TV) on but he was not watching it, and said he taking a nap. He said he attends activities when they have them, but they do not always have any.
On 7/9/24 at 2:00 p.m., Resident #11 was in his room, the activity calendar at 2:00 p.m., specified chair exercises.
On 7/11/24 at 2:04 p.m., Resident # 11 was observed sitting alone in his room, the TV was off and there was no music playing. The activity calendar specified at 1:15 p.m., candy dice game and at 2:30 p.m., pretty nails.
2. Review of the clinical record revealed Resident #190 had an admission date of 5/24/24 with diagnoses including dementia, Alzheimer's disease and depression.
The Admissions MDS dated [DATE], documented the activities identified as very important to the resident included going outside, religious services, being involved in groups and keeping up with the news. The MDS noted Resident #190's cognitive skills for daily decision making were severely impaired.
Review of the plan of care failed to show documentation of an activity care plan to address the resident's activity needs.
On 7/8/24 at 11:21 a.m., Resident #190 was observed sitting in the hallway in her w/c in front of the nursing desk. She smiled when greeted but did not respond appropriately to any questions asked.
Review of the activity calendar specified the activities at 11:00 a.m., were room visits and BINGO.
On 7/9/24 at 10:41 a.m., Resident #190 was observed sitting in her w/c in the hallway in front of the nursing desk since 9:00 a.m. There was a bedside table next to her with a book on top of it. The resident was not engaged, and she paid no attention to the book. Several other residents were in the hallway, sitting in w/c's.
Review of the activity calendar specified hangman at 9:45, mind games and Resident Council at 11:00 a.m.
On 7/9/24 at 1:34 p.m., Resident #190 was observed in her w/c in the hallway in front of the nurse's desk.
Review of the activity calendar specified canines 4 Christ at 1:30 p.m.
On 7/10/24 at 9:08 a.m., in an interview the Activities Director said my assistants do 1-1 room visits daily and the certified nursing assistants will bring resident's out for group activities. The Activity Director said there was a TV room in the dining room of the unit and she puts on music for the residents. The Activity Director said for the residents sitting in the hallway by the nursing station she does activities such as play ball, trivia, hand massages and interacts with them for 15 to 30 minutes a day. The Activity Director said she had a TV installed in the dining room so the residents can watch the TV and she will put calming animal videos on for the residents. She said she identifies the residents who would like to come to the activity programs by the initial activity assessment completed. The Activity Director said she asks the residents what they like and if they can't express that she asks the family members. I do the MDS and put in a care plan. The Activity Director said she had a binder for 1-1 room visits provided. The binder was reviewed with the Activity Director and only 4 residents were listed to receive the 1-1 room visits. Resident's #11 and #190 were not included on the 1-1 visit list. The Activity Director said she keeps a log of the activities the residents attend each day. Review of the daily activity log did not show a daily form for Resident #11 or #190. The Activity Director confirmed there was no documentation Resident #11 and #190 attended any activities since July 1, 2024.
On 7/10/24 9:22 a.m., Resident #190 was in the hallway in front of the nurse's desk facing the nurse's station. The TV in the dining room was off. There was no music and no activity in progress for the residents.
On 7/10/24 at 9:43 a.m., Resident #190 remained in the hallway in front of the nurse's desk with no activity in progress. Resident #190 was observed attempting to get out of her w/c unassisted and was verbally encouraged by staff to sit down.
On 7/11/24 at 1:51 p.m., Resident #190 was observed sitting in her w/c in the hall in front of the nurses station. There was no activity in progress on the unit. The activity calendar specified at 1:15 p.m., candy dice game in the activity room and 2:30 p.m., pretty nails.
Review of the nursing progress note revealed a behavior note dated 7/6/2024 at 5:00 p.m., documented Patient is crying and seems she cannot express verbally what's the reason. Reassured the resident and diverted her attention which is effective. Antidepressant medication started.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and family interview, and record review, the facility failed to revise and update the plan of care for 1 (Resident #16) of 2 residents reviewed for fall. Reviewing and updating of a resident's plan of care by the interdisciplinary team ensured the residents reached and maintained the highest practical safety measures and wellbeing.
The findings included:
Review of a facility policy titled, Falls Management Program, dated 2/7/21 indicates that the fall response steps are a comprehensive approach that forms the backbone of the falls Management Program (FMP). It includes the following eight steps:
1. Evaluate and monitor resident for 72 hours after the fall.
2. Investigate fall circumstances.
3. Record circumstances, resident outcome, and staff response.
4. Fax alert to primary care provider.
5. Implement immediate intervention within the first 24 hours.
6. Complete falls assessment.
7. Develop plan of care.
8. Monitor staff compliance and resident response.
During an interview on 7/10/24 at 10:20 a.m., Resident #16 wife stated that she was very concerned about the falls with injuries her husband has had since admission to the facility. Resident #16's spouse said the resident fell from the bed, two of the three falls resulted in a transfer to the hospital. The wife said she was concerned her husband's room was the farthest from the nurses desk.
Review of the clinical record revealed Resident #16 was admitted to the facility on [DATE] with the following diagnoses: Cerebrovascular disease, Hemiplegia and hemiparesis following a stroke, right sided weakness, dysphagia, Aphasia, mood disorder, muscle spasm, atrial fibrillation, seizures and a chronic subdural hemorrhage.
The quarterly Minimum Data Set (MDS) assessment dated [DATE] noted Resident #16 scored 00 on the Brief Interview for Mental Status (BIMS) indicating the assessment could not be done due to the resident's severe cognitive impairment. The assessment indicated that the resident had a fall with injury since admission and that the resident was dependent for all Activities of Daily Living (ADLs). Resident #16 was unable to use his right arm and hand which was contracted. The resident required the use of a mechanical lift and was dependent for all transfers from bed to reclining high back wheelchair.
Review of the care plan initiated on 1/29/24 noted Resident #16 was at risk for falls. the goal was for the resident not to sustain serious injury through the review date.
Review of the Order Summary Report revealed a physician's order dated 4/7/24 for Fall Mats at bedside while resident is in bed.
The care plan was not updated with the order for fall mats at bedside while resident is in bed until 4/24/24 for Bilateral Floor mats to both sides of bed when resident in bed.
Review of the clinical record revealed Resident #16 sustained a fall on 4/9/24, 4/26/24 and 5/4/24.
Review of the incident investigations revealed on 4/9/24 Resident #16 was found face down on the floor in his room to the right side of his bed. A fall mat was in place on the left side of the bed, but not on the right side. Resident #16 sustained a laceration and swelling to his forehead resulting in a transfer to the local emergency room for evaluation and treatment of his injuries.
On 7/10/24 at 3:10 p.m., in an interview the Director of Nursing (DON) confirmed that Resident #16 fall mats order was not initiated on the care plan until 4/24/24 and the resident only had one floor mat in place when he was found on the floor on right side of the bed on 4/9/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews, the facility failed to coordinate care and services for 1 (Resident #13) of 1 sampled resident's receiving dialysis by failing to ensure medications related to dialysis were administered as ordered by the physician.
The findings included:
Review of a facility policy titled; Dialysis Management dated 10/2022 indicates that the nurse will obtain orders for Medication as ordered to dialysis schedule.
A review of an admission Record indicated the facility admitted Resident #13 on 2/19/24 with the following diagnosis: End stage renal disease and dependence on renal dialysis.
The quarterly Minimum Data Set (MDS) dated [DATE] indicated that the Resident #13 had a Brief Interview for Mental Status (BIMS) score of 15, cognitively intact. MDS also indicated that the resident was currently receiving dialysis for end stage renal failure.
Review of Resident #13's Care Plan initiated 2/28/24 indicated Resident #13 needed dialysis related to end stage renal disease and that Tuesday, Thursday and Saturday was her dialysis days. The comprehensive Care Plan did not address the resident need to receive her Phosphorus. binding medication sent with her to dialysis unit to be taken with breakfast.
A review of Resident #13 physicians orders indicate the resident is to have dialysis 3 times a week on Tuesdays, Thursdays and Saturdays. Pick up time between 5:50 am and 6:20 am for a treatment time of 6:55 am. The resident was also ordered Sevelamer Carbonate 800 mg (to prevent high phosphate levels in dialysis patients) 1 tab three times a day with meals. to be given with meals. The medication was scheduled for 8:00 a.m. to be given with the breakfast meal.
During an interview on 7/10/24 at 10:30 am Resident #13 said that she went to dialysis very early in the morning and was picked up before 6:00 a.m., most of the time. She said that she gets a bagged breakfast to take with her to dialysis but is not given any medication to take with her to take with her breakfast.
A review of Resident #13 Medication Administration Record (MAR) revealed that resident did not receive the ordered Sevelamer Carbonate on 7/2/24, 7/4/24, 7/9/24 and 7/11/24. The medication is noted to be ordered for 8:00 a.m., each morning with breakfast but the resident is not in the facility at that time on Tuesdays, Thursday and Saturday, but at the dialysis unit.
On 7/11/24 at 9:26 a.m., Licensed Practical Nurse (LPN) Staff A stated that she did not give the medication at 8:00 a.m., because the Resident #13 was not in the facility. She said the resident leave very early prior to her coming on shift.
On 7/11/24 at 3:20 p.m., in an interview the Director of Nursing (DON) said that she was unaware the medication was not being given or had not been placed on the MAR to match the time resident was given breakfast and sent to dialysis. The DON acknowledged the medication should have been ordered to be sent with Resident #13 to dialysis to be taken with her breakfast.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff and family interview the facility failed to document a thorough investigation including root cause analysis to prevent future falls for 1 (Resident #16) of 2 residents reviewed for falls. The facility also failed to coordinate care and implement interventions to minimize the risk of avoidable fall and fall related injuries for Resident #16 with a history of multiple falls.
The findings included:
Review of a facility policy titled, Falls Management Program, dated 2/7/21 indicates that the fall response steps are a comprehensive approach that forms the backbone of the falls Management Program (FMP). It includes the following eight steps:
1. Evaluate and monitor resident for 72 hours after the fall.
2. Investigate fall circumstances.
3. Record circumstances, resident outcome, and staff response.
4. Fax alert to primary care provider.
5. Implement immediate intervention within the first 24 hours.
6. Complete falls assessment.
7. Develop plan of care.
8. Monitor staff compliance and resident response.
During an interview on 7/10/24 at 10:20 a.m., Resident #16 wife stated that she was very concerned about all the falls with injuries her husband has had since admission. The wife stated that his falls were from his bed and his room was one of the farthest from the nurses desk.
A review of admission Record was admitted to the facility on [DATE] with the following diagnoses: Cerebrovascular disease, Hemiplegia and hemiparesis following a stroke, right sided weakness, dysphagia, Aphasia, mood disorder, muscle spasm, atrial fibrillation, seizures and a chronic subdural hemorrhage.
The quarterly Minimum Data Set (MDS) dated [DATE] indicates that resident #16 had a Brief Interview for Mental Status (BIMS) score of 00 because the assessment could not be done due to the resident severe cognitive impairment. The assessment indicated that the resident had a fall with injury since admission and that the resident was dependent for all Activities of Daily Living (ADLs). The Resident was unable to use his right arm and hand which was contracted. Resident #16 used a mechanical lift and was dependent on staff for all transfers from bed to reclining high back wheelchair.
Review of the care plan initiated on 1/29/24 noted Resident #16 was at risk for falls. the goal was for the resident not to sustain serious injury through the review date.
Review of the Order Summary Report revealed a physician's order dated 4/7/24 for Fall Mats at bedside while resident is in bed.
Review of a facility incident investigations revealed on 4/9/24 at 4:07 p.m., Resident #16 was found face down on the floor in his room to the right side of his bed. No fall mat was in place on the right side of the bed where he was found. The resident sustained swelling and a laceration to his forehead requiring a transfer to the hospital for evaluation and treatment.
The clinical record lacked documentation of a fall assessment risk upon the resident's return to the facility.
The care plan was not updated with the order for fall mats at bedside while resident is in bed until 4/24/24 for Bilateral Floor mats to both sides of bed when resident in bed.
On 4/26/24 at 4:40 p.m., documentation in the clinical record revealed Resident #16 was found on the floor in his room. The resident sustained a laceration to the left elbow, swelling and bump on top of his left eye. Resident #16 was transferred to the hospital for evaluation and treatment of his injuries.
The incident investigation did not document which fall preventive measures, including fall mats were in place at the time of the incident.
The clinical record lacked documentation of a fall assessment risk upon return to the facility.
On 5/4/24 at 4:45 p.m., documentation in the clinical record revealed Resident #16 was found on the floor in his room. When the nurse arrived, the resident was on the fall mat on the side of the bed. the bed was in its lowest position.
On 7/10/24 at 3:10 p.m., in an interview the Director of Nursing verified the physician's order for bilateral floor mats dated 4/7/24 was not added to the care plan until 4/24/24. She verified the fall mats were not in place as ordered on 4/9/24 when Resident #16 was found on the right side of the bed and sustained a laceration to the forehead. The DON also verified the lack of documentation the resident's falls were reviewed to determine the root cause of the falls. She said on 6/7/24 the care plan was updated to include a review of the past falls and attempt to determine the cause of the resident's multiple falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Interview and record review, the facility failed to provide appropriate care and services to prevent a decline in urinary continence for 1 Resident (#21) of 2 incontinent residents reviewed.
The findings included:
Review of the facility policy for bladder and bowel evaluation revised 1/2023: Residents are evaluated for continence on admission/readmission, quarterly, and with significant change in status. Residents who have been determined to be incontinent without a documented irreversible cause, presenting with a significant change in continence, will be further evaluated for potential bowel or bladder management. On admission, residents without a documented reversible cause for bowel or bladder incontinence will be assessed for the potential of bladder/bowel retraining program. Quarterly those residents with a significant change decline in bowel or bladder continence, that is not transient and self-limiting, will have a bowel and bladder evaluation completed, and will have bowel and bladder diary completed. Based on data collected from the patterning evaluation, residents will be provided a resident centered individualized continence management program. Scheduled toileting programs, retraining programs, and routine incontinent care will be added to the resident care plan.
Review of the facility policy for Bladder Incontinence Assessment and Management revised on 1/2023: The staff and practitioner will appropriately screen for and manage individuals with urinary incontinence. The physician and staff will provide appropriate services and treatment to help residents restore or improve bladder function .As part of its assessment, nursing staff will seek and document details related to continence. The nursing staff and physician will identify risk factors for becoming incontinent or for worsening of current incontinence, including diabetes, urinary tract infections, caffeine use, and excessive fluid intake. The physician and staff will address treatable causes or contributing factors related to urinary incontinence, including: changing medications that cause or exacerbating incontinence; treating underlying conditions that may impair continence .; implementing a fluid and/or bowel management program to meet assessed needs .If the individual remains incontinent despite treating transient causes of incontinence, the staff will initiate a toileting plan .The staff will provide scheduled toileting, prompted voiding, or other interventions to try to manage incontinence.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had a Brief Interview for Mental Status (BIMS) score of 10 indicative of moderately impaired cognition. The MDS revealed Resident #21 was occasionally incontinent of bladder (less than 7 episodes of incontinence).
Record review of the Quarterly MDS assessments dated 3/1/24, and 6/1/24 revealed Resident #21 was frequently incontinent of bladder.
Review of the Certified Nursing Assistant's (CNA) task sheet for bladder continence from 6/9/24 through 7/8/24 revealed 54 episodes of incontinence and 2 episodes of continence.
Review of the resident's progress notes from 12/1/23 to 6/29/24 revealed no documentation the facility addressed the resident's decline in bladder continence. There was no documentation the physician was notified of the decline in continence status. There was no documentation of a bladder evaluation, including a voiding diary or patterning.
Review of Resident #21's care plan with focus on incontinence revealed the resident had potential for incontinence complications and was created on 12/10/23. The goal for the care plan was not developing complications associated with incontinence. The interventions included reporting lab results to the physician; providing incontinent care after all incontinent episodes; and reporting changes in bladder status to the physician. The three interventions were initiated on 12/10/23 with no care plan updates after the decline was identified.
On 7/8/24 at 4:27 p.m., in an interview Resident #21 said she knows when she needs to urinate. She said she has the sensation that it is time to urinate and uses the call bell, but it can take an hour for staff to get to her. This forces her to urinate in her incontinent brief. Resident #21 stated it made her feel embarrassed.
On 7/9/24 2:45 p.m., in an interview Certified Nursing Assistant (CNA) Staff R said Resident #21 was incontinent and did not like to go in the incontinent brief. She said she needed assistance for toileting. She said she checks the resident every two hours and she is usually wet. She said Resident #21 drank a lot of coffee and maybe that made her go. She said Resident #21 was with it and can hold a conversation.
On 7/9/24 at 3:06 p.m., CNA Staff I said he checks residents every two hours. He said Resident #21 was mostly incontinent. He said she uses the call bell for water but is usually wet when he helps her with toileting.
On 7/9/24 at 3:31 p.m., Licensed Practical Nurse (LPN) Staff B said staff check residents every two hours. She said when they check on Resident #21 she is already wet. She said the only thing in her history to make her incontinent would be the Metformin (a medication used to treat diabetes).
On 7/10/24 at 8:54 a.m., in an interview Resident #21 said staff assist her with toileting, but when she needs to go she cannot wait. She said staff do not offer toileting throughout the day, when they do she has already wet herself.
On 7/10/24 at 9:24 a.m., in an interview the MDS coordinator said Resident #21's continence status declined in the first three months she was at the facility. She said she would automatically be aware of that because the MDS system produces side by side results. She said she was responsible for updating the care plan interventions after changes, but she did not do that for the resident's incontinence decline. She said she does not know if anyone made the physician aware of the change in bladder status as instructed in the care plan. She said she could see an irreversible clinical condition for the resident's decline of continence. She said the resident was never assessed for a bladder retraining program and there was no bladder diary in the record. She said the facility did not attempt a toileting program or individualized voiding schedule to help decrease incontinence episodes.
On 7/10/24 at 10:22 a.m., in an interview the Director of Nursing (DON) said after the resident's continence decline was identified the facility should have completed a patterning assessment and notified the doctor to help identify possible causes. She said she did not know why it was not done. She said the decline was not discussed in the morning meetings and she was not aware of the problem.

Based on observation, interview and record review, the facility failed to have a process in place to minimize loss or diversion of controlled narcotic medications.
The findings included:
Review of the facility policy for Controlled Substances: Documentation/Destruction/Storage revised 6/5/21: Once removed from count, discontinued drugs are stored in a double-locked area which is secure and accessible to the director of nursing and administrator only.
On 7/1/24 at 12:36 p.m., Licensed Practical Nurse (LPN) Staff F said she gives the unused controlled substances from the medication cart to the Director of Nursing (DON) for destruction. She said the DON locks them in her drawer.
On 7/11/24 at 12:36 p.m., observed the DON open her desk drawer with her key to reveal multiple narcotic drug packs and controlled substance record sheet.
On 7/11/24 at 12:36 p.m., the DON was interviewed in her office. She said the unused controlled substances are stored in her desk in the left-hand side drawer. She said does not know which narcotics are in her drawer and does not have a list for which she could reconcile the narcotics with to make sure they were all there and accounted for.
On 7/11/24 at 1:06 p.m., in a telephone interview the consultant pharmacist said he visits the facility for controlled substance disposal. He said he does not bring a list to reconcile the narcotics that should be at the facility ready for disposal. He said with the DON together they create the Controlled Substance Prescription Disposition list.
He said the controlled substances in the DON's drawer are added to the list. He said the facility did not keep a list of narcotics that should be in the drawer. He said it would be nice if they kept a log of what was in the drawer so he would know all the controlled substances were accounted for, but they do not. He said he did not believe a log was a part of the regulation, but it would be nice if they had one.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, the facility failed to ensure ongoing communication between the nursing facility and the dialysis center related to the phyiscal assessment of a dialysis resident before, during, and after each dialysis treatment for 1 (Resident #17) of 1 resident receiving dialysis.
The findings included:
The facility policy CD-3, Dialysis Management revised 10/2022 stated Residents receiving hemodialysis treatments [a procedure whree a dialysis macing and a special filter called an artificial kidney, or a dialyzer, are used to clean the blood] will be assessed and monitored to ensure quality of life and well-being.
The procedure included the following information. On admission the resident will be assessed to determine [hemodialysis] access type. The site will be observed for function and signs and symptoms of infection.
The nurse will obtain orders for monitoring of site, and interventions as appropriate.
Facility will establish open communication with the Residents Dialysis center utilizing a Dialysis Communication Book completing the Dialysis Communication form CD-3A.
The nurse will establish pre-dialysis vital signs (Blood pressure, pulse, temp, respirations).
On return from the Dialysis Center, the nurse will review the communication returning from the Dialysis Center. The nurse should review specifically, pre and post vital signs, treatment tolerance, any medications given and any new orders for resident care.
The nurse will evaluate the resident post dialysis for mental status, pain, access site condition and response to treatment.
The nurse will document findings in the nurses note.
The facility policy CW-3, Weight assessment and interventions revised 5/2019 stated Residents receiving Hemodialysis treatment should be weighed pre and post treatment at dialysis. Post weights should be recorded in the Residents' medical record (Electronic Health Record) upon return from hemodialysis by their licensed nurse.
On 7/11/23, clinical record review noted Resident #17 was admitted to the facility on [DATE]. The diagnoses included End Stage Renal (kidney) Disease and required Hemodialysis, Anemia, Stroke, Stage 4 pressure ulcer of the sacrum.
The admission Minimum Data Set with a target date of 6/18/23 noted the resident's cognition was intact with a Brief Interview for Mental Status of 15. Resident #17 required the assistance of one person for transfer and mobility.
The Physician order with an effective date of 6/13/23 noted the resident required Dialysis every Tuesday, Thursday, and Saturday (the resident received dialysis at a dialysis center).
Resident #17's care plan initiated on 6/13/23 for hemodialysis included the following interventions to be completed by nursing staff.
Potential for complications related to hemodialysis for diagnosis of End Stage Renal Failure.
Coordinate resident's care in collaboration with dialysis center.
Observe and report to physician complications related to renal failure: Edema/fluid overload; Respiratory difficulty/shortness of breath; Increased weakness, changes in mental status; changes in vital signs.
Weigh resident as ordered and notify physician of significant weight changes.
The Electronic Health Record review revealed Hemodialysis Communication Forms were not completed for the resident on 6/13/23, 6/15/23, 6/20/23,6/22/23,6/24/23 and 6/29/23. The dialysis center did not document Resident #17's pre and post dialysis vital signs, any resident complications during dialysis, nutritional concerns, medication given during dialysis treatment, laboratory values, post-dialysis instructions and any new physician orders for those treatment days.
On 7/10/22 at 4:54 p.m., Resident #17 said she goes to the dialysis center on Tuesday, Thursday, and Saturday. She said the nursing facility and dialysis center do not always communicate with each other. She said she did not carry a dialysis binder or bring any hemodialysis communication form from the dialysis center and back to the nursing facility after dialysis.
On 7/12/23 at 12:00 p.m., Staff P, Licensed Practical Nurse (LPN) stated Resident #17 goes to dialysis on Tuesday, Thursday, and Saturday. She did not know about a dialysis book but does send the resident to dialysis with a face sheet. She verified the resident had not returned with any communication forms from the dialysis center.
On 7/12/23 at 12:01 p.m., Staff W, Registered Nurse (RN) stated she was not sure but there should be a dialysis book, every facility has one.
On 7/12/23 at 4:50 p.m., the Director of Nursing (DON) stated there was no contract between the facility and the dialysis center. Dialysis is coordinated by nephrologist, dialysis, and patient. We are not involved in it. The care coordination with dialysis is confirmed prior to admission and transportation is arranged by us for Tuesday and Thursday and she takes the public bus on Saturdays. There is a dialysis hand off sheet that is done during the week but there is no copy retained for the record and it is not completed on Saturdays. Dialysis does not send any updates back. The DON said she has not done any training with the nurses regarding dialysis access site assessment, dressing removal, assessing for bruit or thrill [a whooshing or swishing sound caused by turbulent blood flow through an artery], it is not part of a competency assessment or skills check. If the dressing is soiled or saturated, we call 911. I've never checked to see if nurses have documented they assessed the access site for bleeding or complications after dialysis. The DON stated Resident #17 does not have a book to take back and forth to dialysis for communication. The DON verified the Dialysis center has not called to give any updates on resident #17 since admission to the facility.
On 7/13/23 at 11:34 a.m., The Registered Dietitian (RD) stated she left a message for the Dialysis Dietitian on 6/30/23. The RD stated there was no communication with the dialysis center between 6/12/23 to 6/30/23 when the first message was left. I was not working because dietary services had been stopped at the nursing facility.
On 7/13/23 at 2:08 p.m., Resident #17 stated she had been back from dialysis since 12:30 p.m. The resident stated her vitals and dressing were not checked prior to going to dialysis and since being back no one had checked her vital signs or dressing.
On 7/14/23 at 11:50 a.m., The DON stated no specific order had been entered for the dialysis access site monitoring and assessment. The DON stated her expectation was that vital signs be checked for a resident both pre and post dialysis visits and confirmed the nurses have not checked the vital signs for this resident both prior to and following dialysis. The DON confirmed post dialysis weights have not been recorded in the electronic health record. The DON verified these items are listed in the dialysis management and weights policy.

Based on interview, and record review the facility failed to complete performance reviews for 3 (Certified Nursing Assistants Staff G, Staff E, and Staff F) of 3 Certified Nursing Assistants (CNAs) surveyed for performance review.
The findings included:
Review of the current staff list provided by the facility revealed CNA Staff G had a date of hire of 9/16/21, CNA Staff E had a date of hire of 5/6/21, and CNA Staff F had a date of hire of 5/20/21.
On 7/14/23 at 12:00 p.m., 2:00 p.m., a request was made to the Administrator for documentation of the annual performance review for CNAs Staff G, E, and F.
On 7/14/23 at 4:00 p.m., an additional request was made to the Administrator in training for documentation of the annual performance review for CNAs. Staff G, E, and F.
As of the exit date of 7/16/23, the facility's administration did not provide documentation verifying CNAs. Staff G, E, and F had an annual performance review completed.

5. On 7/12/23 a review of the Medication Regimen Review for Resident #13 revealed a consultant pharmacist's recommendation dated 6/13/23 that read, The resident is receiving both Escitalopram and Bupropion for depression. Could you please consider a gradual dose reduction of Bupropion with the hopeful possibility of eventually eliminating this drug?
On 6/30/23 the APRN agreed with the recommendation.
On 7/12/23, a review of Resident #13's medical record revealed the resident was still receiving Bupropion 75 mg once daily.
On 7/12/23 at 10:18 a.m., the DON confirmed the APRN agreed to the dose reduction of the Bupropion recommended by the consultant pharmacist, but it had not been changed in the Resident #13's medical record.
Based on record review, policy review, and staff interviews, the facility failed to ensure medication irregularities and/or concerns were addressed in a timely manner when the consultant pharmacist identified irregularities and/or medication concerns, for 3 (Residents #11, #13 and #25) of 5 resident's medication regimens which were reviewed.
The findings included:
1. On 7/12/23 a review of the consultant pharmacist's monthly medication review for Resident #25 revealed on 5/16/23 he recommended a GDR (gradual dose reduction) be attempted for Buspirone 10 milligrams (mg) once daily for anxiety to Buspirone 7.5 mg once daily for anxiety.
On 6/13/23 the consultant pharmacist recommended a GDR be attempted for Escitalopram 10 mg once daily for depression to Escitalopram 5 mg once daily for depression for Resident #25.
On 6/30/23 Resident #25's Advanced Practice Registered Nurse (APRN) agreed with the consultant pharmacist's recommendation to lower the Escitalopram to 5 mg daily for depression.
A review of Resident #25's medical record revealed Resident #25 was currently receiving Buspirone 10 mg once daily for anxiety and Escitalopram 10 mg once daily for anxiety.
Further review of Resident #25's medical record revealed no documentation Resident #25's primary care physician (PCP) had reviewed and acted upon the consultant pharmacist's recommendation for a GDR of Buspirone 10 mg on 5/16/23. The facility did not decrease Escitalopram to 5 mg as recommended by the consultant pharmacist and agreed upon by the APRN on 6/30/23.
2. On 7/12/23 a review of the consultant pharmacist's monthly medication review for Resident #11 revealed on 2/14/23 he recommended a GDR be attempted for Sertraline 100 mg in the afternoon for depression once daily to Sertraline 75 mg in the afternoon for depression.
On 3/14/23 the consultant pharmacist recommended the Benzonatate Pearls 100 mg by mouth every 8 hours, as needed for cough be discontinued to minimize the potential of unwanted side effects which could be severe drowsiness or dizziness, confusion, hallucinations, ongoing numbness or tingling in your mouth, throat, or face, numbness in your chest or a choking feeling.
Further review of Resident #11's medical record revealed Resident #25 was currently receiving Sertraline 100 mg for depression and Benzonatate Pearls 100 mg as needed for cough. There was no documentation Resident #11's PCP (Primary Care Physician) had reviewed the consultant pharmacist's recommendations for a GDR for the Sertraline 100 mg on 2/14/23 and the discontinuation of the Benzonatate Pearls on 3/14/23 as required.
3. Review of the Pharmacy Consultant Medication Review, Policy # C_MED_27 created on 7/2018 and revised 1/2023 stated a licensed pharmacist (pharmacy consultant), would review the medication regimen review (MRR) for each resident at least monthly and more frequently, as needed. The consultant pharmacist would review each medication regimen of all residents in the facility once per month for supporting diagnosis, allergy conflicts, pertinent orders, contraindications between medications, identifying adverse consequences . and gradual dose reductions attempted. The Pharmacy Consultant should report irregularities to the attending physician, medical director, and Director of Nursing (DON) with the resident's medication regimen review. The DON would give the Unit Manager/designee a copy of the monthly pharmacy consultant reports. The Unit Manager/designee was responsible to ensure all recommendations are acted upon, all recommendations are reported to the resident physicians, there was documentation in the resident medical record that notification and follow-up occurred, notify the resident's physician of the pharmacy consultant's recommendations and document in the resident's medical record that the recommendation was completed, and remind the resident's physician to sign the resident's consultant report that was filed in the resident's medical record. The Unit Manager/designee would return the copy of the consultant's report to the DON when notifications, follow-ups, and documentation had been completed. The DON would notify the facility's medical director if the resident physician did not follow through on the consultant's recommendations.
4. On 7/11/23 at 4:10 p.m., the Director of Nursing (DON) said she was responsible to print all the monthly consultant pharmacist recommendations and give them to the residents' PCP for their review and ensure any physician orders related to the consultant pharmacist recommendations were implemented timely.
On 7/12/23 at 10:12 a.m., the DON confirmed, after reviewing Resident #11's medical record, the consultant pharmacist had recommended on 2/14/23 for a GDR be attempted for Sertraline 100 mg for depression and on 3/14/23 the discontinuation of Benzonatate Pearls 100 mg as needed for cough. The DON confirmed Resident #11 was currently receiving those medications and the GDR was not done for the Sertraline 100 mg and the Benzonatate Pears 100 mg was not discontinued as requested.
The DON said she was unable to find documentation the consultant pharmacist recommendations on 2/14/23 and 3/14/23 were reviewed by Resident #11's physician, the pharmacy consultant report was signed by the physician as reviewed, and a copy of the signed report was placed in the resident's medical record as required.
The DON confirmed the consultant pharmacist had written on 5/16/23 for a GDR to be attempted for Buspirone 10 mg once daily for anxiety to Buspirone 7.5 mg once daily for anxiety.
On 7/12/23 at 10:18 a.m., the DON confirmed, after a review of Resident #25's medical record, the consultant pharmacist had recommended on 6/13/23 for a GDR to be attempted for Escitalopram 10 mg once daily for depression to Escitalopram 5 mg once daily for depression, which the APRN confirmed and wrote to lower the Escitalopram to 5 mg on 6/30/23.
The DON said she was unable to find documentation the consultant pharmacist recommendations on 5/16/23 were reviewed by Resident #25's physician, the pharmacy consultant report was signed by the physician as reviewed, and a copy of the signed report was placed in the resident's medical record as required. The DON said the pharmacist consultant's recommendation to lower the Escitalopram to 5 mg and signed by the APRN on 6/30/23 to lower the Escitalopram to 5 mg was not implemented on 6/30/23 as ordered by the APRN.
On 7/12/23 at 11:18 a.m., during an interview with the Consultant Pharmacist, he said he reviewed all facility resident's medication regimes at least every month to include supporting diagnoses for each medication, allergy conflicts, pertinent orders, contraindications between medications, identifying adverse consequences . and request for a gradual dose reduction as per federal and state guidelines. He said he met with the DON every month and she was responsible to ensure each resident's primary care physician reviewed all recommendations, ensured the physician signed the recommendations, and placed the physician signed review of the recommendation into the resident's medical record. He said if there were any physician orders and/or recommendations, the DON was responsible to ensure they were acted upon in a timely manner.
The consultant pharmacist confirmed he had recommended a GDR for Resident #25 on 5/16/23 and 6/13/23, and he had recommended a GDR for Resident #11 on 2/14/23 and a recommendation to discontinue medication on 3/14/23. He said he was not informed by the DON that his recommendations for Residents #11 and #25 were not reviewed by their physician and/or implemented as ordered by their physician.
On 7/14/23 at 9:40 a.m., in an interview with the facility's Medical Director, he said the DON was responsible to ensure all consultant pharmacy medication review recommendations were given to the resident's primary care physician for review and to ensure all physician orders and/or physician request were implemented in a timely manner as required in their Pharmacy Consultant Medication Review, policy #C-Med-27.

Based on staff interviews, and record reviews, the facility failed to ensure the Dietary Manager possessed the necessary qualifications and to ensure frequently scheduled consultation by a qualified dietitian.
The findings included:
On 7/11/23 at 11:45 a.m., the Director of Food and Nutrition Services said she had completed a course work on June 28, 2019, at a university for Nutrition and Food service Professional training.
She said the completed course allowed her to take the certification exam but has not done so yet. She stated the Registered Dietician (RD) worked offsite but came in once a month.
The Director of Food and Nutrition Services provided a certificate of completion dated June 28, 2019 which noted she had, Satisfactorily completed the requirement for the Professional Development pre-certification course. Nutrition and foodservice [sic] Professional Training.
On 7/12/23 at 4:13 p.m., the regional RD said he visits the facility monthly to monitor the food and nutrition services. He said the facility RD normally does the clinical part of the assessments, including readmissions, quarterly, Minimum Data Set assessments, care plan and addresses any weight loss.
He said the current Director of Food and Nutrition Services started in April 2023, and he was aware the Directof of Food and Nutrition Services was not qualified and verbalized concerns about changes in the regulations she may not be aware of which could impact her ability to pass the certification exam.
On 7/12/23 at 3:13 p.m., the Human Resources Assistant said the Director of Food and Nutrition Services was hired in January 2023 as a cook. She was promoted to Director of Food and Nutrition Services on April 3, 2023. She verified the employment application was incomplete and did not list dates of prior work experience, employment title or documented references. She stated she was not aware of the regulations required for a Director of Food and Nutrition Services.
On 7/13/23 at 11:20 a.m., during a telephone interview the RD stated she was contracted by the facility to work remotely one day per week.
On 7/13/23 11:34 a.m., the RD stated she did not work from 5/30/23 until 6/29/23.
On 7/13/23 at 5:18 p.m., the administrator stated he was not aware of the regulatory requirement for Director of Food and Nutrition Services qualifications.

Based on resident and staff interview, record review, and observation, the facility failed to provide palatable food at appropriate temperatures for 3 (Residents #7, #17 and #385) of 4 residents interviewed for food palatability. Poor food quality may cause resident to eat less of their food or not at all, which can lead to weight loss and impaired nutrition.
The findings included:
On 7/10/23 at 9:55 a.m., Resident #385 stated the food is cold. She said, the vegetables don't have any seasoning, are over cooked, no fruit, no soda. The oatmeal is dried and hard, no sugar or milk in it and the eggs are cold.
On 7/11/23 at 10:30 a.m. Resident #7's private duty Certified Nursing Assistant (CNA) was interviewed. She stated she worked with Resident #7 two days a week. She stated, The food is often cold or just lukewarm. The staff will warm it if someone is here to ask them.
On 7/11/23 10:55 a.m., Resident #385 stated she just can't eat cold eggs, the food is cold no matter what they bring.
On 7/11/23 at 12:15 p.m., food was observed being delivered from the main kitchen to the satellite kitchen and placed on the steam table.
The assistant kitchen manager was observed plating the food on room temperature plates. She stated the plate warmer had not been in service for a couple of weeks.
Tray line was stopped after serving four bowls of soup for a staff member to go to the main kitchen and return with enough bowls to serve everyone in the dining area.
On 7/11/23 at 1:10 p.m., tray line was paused again when staff ran out of plates. Staff returned to the kitchen to obtain additional plates for the residents. The assistant kitchen manager stated the area was not stocked with dishes for lunch service.
On 7/11/23 at 1:19 p.m., a test tray was requested for the back hall.
The test tray was done after the last tray was distributed in the back hall. The turkey was barely warm when tasted, and the temperature was 109 degrees Fahrenheit. The green beans and sweet potato were warm when tasted, not hot.
On 7/12/23 at 1:30 p.m., Resident #17 stated the food does not have much taste, at best, the hot food is only lukewarm. It's just not hot.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure 2 (Residents #15, and #21) of 2 sampled residents of 25 residents requiring assistance with eating received the necessary assistive devices during dining.
The findings included:
1. Resident #15 was admitted to the facility on [DATE] with diagnoses including hemiplegia (Paralysis on one side of the body), and Parkinson's disease. Resident #15 had contractures (deformity) of both hands. Resident #15 received a pureed diet.
On 7/11/23 at 12:30 p.m., Resident #15 was observed eating a pureed lunch in the dining room with a regular spoon. The resident had difficulty getting the food to his mouth, spilling the content of the spoon on the plate.
On 7/12/23 at 11:48 p.m., the Director of Physical Therapy stated Resident #15 should have a weighted utensil when he was eating his meals.
Review of the care plans for activities of daily living and nutrition showed no intervention to provide the resident with weighted utensils for meals.
On 7/12/23 at 12:45, Resident #15 was observed eating in the dining room. No weighted utensils were provided for him during his meal.
On 7/14/23 at 4:00 p.m., the Restorative Aide said Resident #15 uses three weighted utensils and she keeps them rolled up in a towel in the skilled nursing kitchen. She stated she made sure when she was working the resident had the utensils. She stated she was not sure how the resident got the utensils when she was not working.
On 7/14/23 at 4:30 p.m., the Director of Nursing said the weighted utensils should be listed on the meal ticket to alert the staff assisting with the meals.
On 7/14/23 Resident #15's lunch meal ticket was observed. It did not list the weighted utensils.
2. Resident #21 was admitted to the facility from the hospital on [DATE]. Diagnoses included Cerebral vascular Accident (Stroke), hypertension, Diabetes Mellitus, depression and anxiety.
The Quarterly Minimum Data Set (MDS) assessment dated [DATE] noted Resident #21's cognition was intact with a Brief Interview for Mental Status (BIMS) of 13. Section E of the assessment shows Resident #21 had no rejection of care behaviors. Section G showed Resident #21 had function limitations on one side on both his upper and lower extremities.
On 7/10/23 at 12:30 p.m., Resident #21 was observed in bed eating a peanut butter and jelly sandwich. The resident also had a regular small bowl of pudding.
The meal ticked for the lunch meal of 7/10/23 noted the use of a divided plate (keeps food separated).
Review of Resident #21's care plans showed no intervention listed for a divided plate.
On 7/12/23 at 11:50 a.m., the Director of Physical Therapy (PT) said she will provide the kitchen with a divided plate. The Director of Physical Therapy opened a cabinet in her office which contained a supply of divided plates.
On 7/13/23 at 12:40 a.m., Resident #21 was observed in bed. The resident's lunch was on his bedside table, it was not on a divided plate.
On 7/14/23 at 12:30 p.m., Resident #21 was observed in the dining room having lunch. The meal was not served on a divided plate.
On 7/14/213 at 2:20 p.m., the Director of PT verified she had not yet provided the kitchen with a divided plate for Resident #21.
On 7/14/23 at 4:30 p.m., the Director of Nursing said the adaptive equipment, including divided plates should be listed on each resident's meal ticket.
Resident #21's meal ticket for 7/14/23 was observed. It did not list the divided plate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility's administration failed to utilize its resources effectively to ensure a safe environment, including adequate supervision of cognitively impaired residents with known exit seeking behaviors to prevent unsafe wandering and elopement.
On 4/1/23 at approximately 4:30 p.m., Resident #386 who was cognitively impaired, and wheelchair bound was not adequately supervised. The resident wheeled herself through an unsecured door of the skilled nursing facility into a hallway leading to the adjoining Assisted Living Facility.
Resident #386 left through the front door of the Assisted Living Facility, and traveled unsupervised in her wheelchair, approximately three tenths of a mile, and crossed two streets.
On 4/1/23 at 5:45 p.m., a staff member from a neighboring skilled nursing facility found Resident #386 wandering the streets.
Resident #386 had a likelihood for serious harm, injury, or death due to the risk for serious injury from a fall, getting lost or getting hit by a car.
The failure of the facility's Administration to provide the necessary care and services to prevent neglect, unsafe wandering, and elopement of cognitively impaired residents at risk for elopement resulted in the determination of Immediate Jeopardy at a scope and severity of isolated (J) starting on 4/1/23.
On 7/14/23 at 4:00 p.m., the facility's Administrator was informed of the determination of Immediate Jeopardy (IJ) and provided the IJ templates.
The facility census was 37 with five residents at risk for unsafe wandering and elopement.
The findings included:
Cross reference to F600, F689, and F867.
The Executive Director's job description signed on 3/31/23 specified the Executive Director is totally responsible for the management of the skilled nursing facility, ensures high quality resident care services. The job description read, . Monitor resident care on a daily basis; conduct daily rounds . Directs community safety and loss prevention program; monitors adherence to safety rules and regulations and takes remedial action when necessary .
Review of signed, not dated Director of Nursing responsibilities revealed the Director of Nursing is responsible for managing the care of residents from admission through discharge and for maintaining the delivery of quality care. Direct nursing department in the delivery of the individual patient's plan of care as well as identifying interdisciplinary needs and coordination of health care clinicians. The Director of Nursing, Understands and implements rules and regulations under Medicare . understands and implements adequate clinical patient assessments identifying specific needs of residents in the facility . Demonstrates sound, logical and timely decision making skills . Oversees incidents/accident of patients. Provides in-services as needed in areas of expertise . Scheduling ongoing training of employees .
The facility's policy for Elopement Prevention with a revised date of 6/22/2021 noted, When a resident is deemed to be an elopement risk the following measures should be put in place:
Resident should be placed in a secured unit.
A wander guard bracelet should be placed on the resident.
A Physicians order should be written to check placement of the wander guard every shift and function of bracelet daily.
Photos should be taken of the resident to be placed in the Elopement Risk book.
Communication to all staff on duty should be completed and carried on from shift to shift.
Documentation of the Elopement Risk should be made . facility Elopement Book, placed at nursing station and front entry . Elopement concerns and resident at risk should be reviewed monthly and discussed at the facility QAPI (Quality Assurance and Performance Improvement) meeting to discuss trends and concerns.
Elopement Risk Book should be reviewed daily and discusses at change of shift. Photos should be current with description of resident along with any other pertinent information that may help with locating the resident in an elopement situation.
Review of the facility's incident investigations revealed on 4/1/23 Resident #386 who was cognitively impaired, and wheelchair bound, wheeled herself through an unsecured door into a hallway leading to the adjoining Assisted Living Facility (ALF). Resident #386 left through the front door of the ALF.
The resident was last seen at the nurse's station of the skilled nursing facility at approximately 4:30 p.m.
Resident #386 traveled alone, and unsupervised in a wheelchair three tenths of a mile and crossed two streets. On 4/1/23 at 6:00 p.m., a staff member from a neighboring facility found the resident wandering the streets. Resident #1 was returned unharmed to the skilled nursing facility.
Review of the facility's investigation, and analysis of the incident revealed documentation, Upon investigation it was apparent that she (Resident #386) traveled in her wheelchair down the back hallway where the wander guard was alarming outside room [ROOM NUMBER] outside door, she then went through the double doors into the ALF. She then exited the building through the main entrance and to the road where she turned left and proceeded down Pinebrook Ave (Avenue) in her wheelchair .
Resident #386 was placed on one to one supervision and discharged to a secured unit ALF on 4/4/23.
Review of the corrective actions implemented by the facility revealed on 4/3/23 (two days after the elopement) the Regional Director of Clinical Operations educated staff for 10 minutes on responding to the wander alarm, including not turn off the alarm until all residents are accounted for.
There was no documentation Licensed Practical Nurse Staff X, Certified Nursing Assistants (CNAs) Staff CC, DD, EE, and FF who were on duty when Resident #386 eloped were educated.
On 7/11/23 the Director of Nursing provided a handwritten list of current residents identified to be at risk for unsafe wandering and elopement and wore wander guards including Residents #8, #26, #11, #287, and #288.
On 7/11/23 at approximately 3:00 p.m., the elopement book at the receptionist desk at the entrance of the skilled nursing facility, and the entrance of the adjoining Assisted Living Facility were reviewed.
The elopement books did not include Resident #26, #288, and #287.
On 7/12/23 at 11:11 a.m., CNA Staff K said she would refer to the elopement risk book at the nurse's station to identify residents at risk for unsafe wandering and elopement. She said Residents #26, #11, and #287 had wandering behaviors.
On 7/12/23 at 11:21 a.m., CNA Staff L said Residents #26, #11, and #287 had wandering behaviors. She the nurses would tell them if someone has a potential for elopement and they would have a wander guard on.
On 7/12/23 at approximately 4:00 p.m., Resident #288 was observed on the unit. He did not have a wander alert bracelet.
LPN Staff P verified Resident #288 was not wearing a wander alert bracelet as ordered. She said the resident had removed the wander alert bracelet.
Review of the clinical record for Resident #288 revealed a physician's order dated 7/11/23. Resident #288's diagnoses included Alzheimer's, and Dementia. Resident #288 did not have a care plan alerting the staff of the risk for elopement.
Review of the clinical record for Resident #26 revealed an admission date of 6/15/23 with diagnoses including Dementia. There was no care plan alerting the staff of the risk for elopement.
On 7/11/23 at approximately 4:30 p.m., the resident was observed in a wheelchair wandering in the hallways.
On 7/12/23 at 9:00 a.m., the Director of Nursing (DON) said she recommended installing a wander alert system which would automatically lock the doors when a resident with a wander alert bracelet came near an exit door. She said she did not know what the plan was for the unsecured door between the skilled nursing facility and the ALF. The DON said although she has been employed at the facility for over a year, she was not the DON at the time of the incident. She said on 5/1/23 she became the DON at the facility.
On 7/12/23 at 10:30 a.m., the Director of Nursing verified Resident #26 was at risk for unsafe wandering and elopement. She said the Activities Staff was responsible to update the elopement book and ensure all residents identified to be at risk for elopement were in the books.
Review of the Agency For Health Care Administration Background Screening Clearing House revealed the Activities Director had a date of hire of 5/8/23.
On 7/12/23 at 10:50 a.m., the Activities Director said she did not know her responsibilities included updating the elopement books.
On 7/14/23 at 10:30 a.m., the Director of Nursing verified no one ensured the elopement book risk was updated.
Review of the facility's policy and procedure for Elopement-Missing Resident revised on 10/22 noted if an employee discovers that a resident is missing from the facility, he/she should announce on the overhead paging system, Code Orange three times, the unit/area involved or the room number of the missing resident, the time the resident was determined missing.
On 7/14/23 at 10:57 a.m. Staff Q, Transporter said he did not know the overhead code for elopement.
On 7/14/23 at 11:00 a.m. Staff R, Activities Assistant said Code Orange was an emergency, You make sure everyone is in their rooms and shut the doors.
On 7/14/23 at 10:30 a.m., during a review of the facility's Quality Assurance and Performance Improvement process review, the Administrator said he did not have any additional information related implementation of processes to ensure a safe environment, including adequate supervision of cognitively impaired residents with known exit seeking behaviors to prevent unsafe wandering and elopement.

Based on interview, and record review the facility failed to have documentation of a comprehensive facility-wide assessment, including an evaluation of the resident population and resources needed to provide the necessary care and services.
The findings included:
On 7/10/23 at 9:20 a.m., and on 7/14/23 at 12:00 p.m., a request was made to the administrator to provide documentation of a facility assessment.
On 7/14/23 at 2:00 p.m., the Administrator provided an 18 page document titled, Facility's Quality Assessment and Assurance which he said was the facility assessment.
The document a clinical systems scorecard summary, and a long term care essentials clinical assessment test which noted individuals scoring less than a 70 on assessments will be given the opportunity to retest at a later time and/or date.
The document did not include an evaluation of the resident population, including diseases, conditions, physical, functional or cognitive status, acuity of the resident population, and any other pertinent information about the residents that may affect and plan for the services the facility must provided. and resources needed to provide the necessary care and services the residents require.
The form did not list the facilities resources and daily needs to ensure the care of the residents.
On 7/14/23 at 12:01 p.m., the Administrator said this document was all he could provide as a facility assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility's policies and procedures, and staff interviews the facility failed to develop and implement appropriate corrective actions related to adequate supervision of cognitively impaired residents at risk for unsafe wandering, elopement and exit seeking behaviors.
On 4/1/23 at approximately 4:30 p.m., Resident #386 who was vulnerable, cognitively impaired, and wheelchair bound was not adequately supervised. The resident wheeled herself through an unsecured door of the skilled nursing facility into a hallway leading to the adjoining Assisted Living Facility.
Resident #386 left through the front door of the Assisted Living Facility, setting off a wander alarm, and traveled unsupervised in her wheelchair, approximately three tenths of a mile, and crossed two streets.
On 4/1/23 at 6:00 p.m., a staff member from a neighboring skilled nursing facility found Resident #386 wandering the streets.
Resident #386 had a likelihood for serious harm, injury, or death due to the risk for serious injury from a fall, getting lost or getting hit by a car.
The facility failure to implement appropriate corrective actions to prevent further incidents of unsafe wandering and elopement of cognitively impaired residents identified at risk for elopement and unsafe wandering resulted in the determination of Immediate Jeopardy (IJ) at a scope and severity of isolated (J) beginning on 4/1/23.
The Immediate Jeopardy was ongoing.
On 7/14/23 at 4:00 p.m., the facility's Administrator was informed of the determination of Immediate Jeopardy (IJ) and provided the IJ templates.
The facility census was 37 with five residents at risk for unsafe wandering and elopement.
The findings included:
Cross reference to F600, F689, and F835
The facility's Quality Assurance and Performance Improvement (QAPI) plan reviewed 2/7/2021 noted, The organizational program, established by the Medical Director and Director of Nursing and interdisciplinary Performance Improvement Committee, with support and approval from the Governing Body, shall have the responsibility for monitoring every aspect of resident care and service (including contracted services) from the time the resident enters the facility through diagnosis, treatment, recovery and discharge in order to identify and resolve any breakdowns that may result in suboptimal resident care and safety, while striving to continuously improve and facilitate positive resident outcomes . The committee shall identify quality deficiencies and develop and implement plans of action to correct these quality deficiencies, including monitoring the effect of implemented changes and making needed revisions to the action plans .
The Executive Director's job description signed by the Administrator on 3/31/23 noted the Executive Director (Administrator) oversees and monitors nursing services to ensure high quality nursing delivery systems.
The Director of Nursing Job Performance, signed (undated) noted the Director of Nursing participates in quality assurance performance improvement set and meet department goals to meet expectations of quality. Maintains knowledge and skills required to perform job.
Review of the facility's incident investigations revealed on 4/1/23 Resident #386 who was cognitively impaired, and wheelchair bound, wheeled herself through an unsecured door into a hallway leading to the adjoining Assisted Living Facility (ALF). Resident #386 left through the front door of the ALF. The resident was last seen at the nurse's station of the skilled nursing facility at approximately 4:30 p.m. Resident #386 traveled alone, and unsupervised in a wheelchair three tenths of a mile and crossed two streets. On 4/1/23 at 6:00 p.m., a staff member from a neighboring facility found the resident wandering the streets. Resident #1 was returned unharmed to the skilled nursing facility.
Review of the analysis of the incident revealed documentation, Upon investigation it was apparent that she (Resident #386) traveled in her wheelchair down the back hallway where the wander guard was alarming outside room [ROOM NUMBER] outside door, she then went through the double doors into the ALF. She then exited the building through the main entrance and to the road where she turned left and proceeded down Pinebrook Ave (Avenue) in her wheelchair.
Review of the corrective actions implemented by the facility to prevent recurrence of unsafe wandering and elopement revealed:
Resident #386 was placed on one to one supervision and discharged to a secured unit ALF on 4/4/23.
On 4/3/23 (two days after the elopement) the Regional Director of Clinical Operations educated staff for 10 minutes on responding to the wander alarm, including not turn off the alarm until all residents are accounted for. There was no documentation Licensed Practical Nurse Staff X, Certified Nursing Assistants (CNAs) Staff CC, DD, EE, and FF who were on duty when Resident #386 eloped were educated.
There was no documentation the facility-initiated elopement drills on all shifts, including weekends to verify staff understood the education and responded appropriately to the wander alarm when activated.
On 7/11/23 at approximately 5:50 p.m., the door connecting the skilled nursing facility to the ALF remained unsecured. It was not equipped with an alarm to alert staff to unsafe wandering.
On 7/11/23 at approximately 10:35 a.m., the Director of Nursing provided a handwritten list of current residents identified to be at risk for unsafe wandering and elopement, including Residents #8, #26, #11, #287, and #288. She said residents #8, #26, #11, #287, and #288 wore a wander alert bracelet to alert staff of unsafe wandering and attempt at elopement.
Review of the clinical record for Resident #26 revealed an admission date of 6/15/23 with diagnoses including Dementia. There was no care plan alerting the staff of the risk for elopement. On 7/11/23 at approximately 4:30 p.m., the resident was observed in a wheelchair wandering in the hallways.
On 7/11/23 at 5:54 p.m., the alarm of a door equipped with a wander alarm system was triggered to observe the staff response to the alarm.
On 7/11/23 at 5:57 p.m., CNA Staff AA started closing all residents' bedroom doors in response to the alarm. She said, I thought it was a fire alarm. Staff AA did not investigate or look around to see if Residents #11, #287, and #288 identified to be at risk for elopement and wore a wander alarm had left the facility.
Review of the 10 minutes in-service related to wanderguards dated 4/3/23 lacked documentation CNA AA with a date of hire of 1/12/23 attended the in-service which specified, If anyone hears this alarm they are to investigate it immediately. Look around do you see a resident with a white bracelet and alarm? Look outside, if there is a resident outside who has on a white bracelet and alarm.
On 7/11/23 at 6:00 p.m., five minutes after the alarm was triggered, Licensed Practical Nurse (LPN) Staff P turned off the alarm, and said, The alarm means it is an elopement risk. She looked out the door and said she did not see anyone. She did not initiate a count of the residents to ensure all cognitively impaired residents including Residents #8, #26, #11, #287, and #288 were accounted for. Staff P said she did not respond to the alarm quickly because she could barely hear anything, especially in the dining room with the clanking of the dishes.
LPN Staff P attended the in-service on 4/3/23 and did not follow the procedure outlined in the in-service which specified, You can not turn [sic] off the alarm until you know that all residents are accounted for.
No staff present on the unit looked at the unsecured double door leading to the ALF where Resident #386 eloped from.
Review of the facility's policy for Elopement Prevention with a revised date of 6/22/2021 noted photos of residents at risk for elopement should be taken and placed in the Elopement Risk book.
On 7/11/23 at approximately 3:00 p.m., the elopement book at the receptionist desk at the entrance of the skilled nursing facility, and the entrance of the adjoining Assisted Living Facility were reviewed. The elopement books did not include Resident #26, #288, and #287.
On 7/12/23 at 9:00 a.m., the Director of Nursing said she recommended installing a wander alert system which would automatically lock the doors when a resident with a wander alert bracelet came near an exit door. She said she did not know what the plan was for the unsecured door between the skilled nursing facility and the ALF.
On 7/12/23 at 9:31 a.m., the DON said she was the designated Risk Manager. She said she was not involved in developing a performance improvement plan for elopement. She said, The Administrator would know that. She said, I told them I thought the doors were the cause of the elopement in the QAPI (Quality Assurance and Performance Improvement) meetings.
On 7/12/23 at 10:30 a.m., the Director of Nursing said the Activities Staff was responsible to update the elopement book and ensure all residents identified to be at risk for elopement were in the books.
On 7/12/23 at 10:50 a.m., the Activities Director who had a date of hire of 5/8/23 said she did not know her responsibilities included updating the elopement books.
On 7/12/23 at approximately 4:00 p.m., Resident #288 who had a physician's order for a wander alert bracelet was observed on the unit. He did not have a wander alert bracelet.
On 7/14/23 at 10:30 a.m., during a review of the facility's Quality Assurance and Performance Improvement (QAPI) process review, the Administrator presented an elopement drill QAPI worksheet dated 4/1/23 which noted, Time in: 6:00 p.m. There was no Time out noted on the worksheet. The comment noted Education on door alarms for all SNF (Skilled Nursing Facility), ALF (Assisted Living Facility) and entire building staff and elopement
At the time of the survey there were 39 active nursing staff (Licensed Nurses and Certified Nursing Assistants) employed at the facility. There was no documentation 24 of the 39 had received elopement prevention training since the elopement incident of 4/1/23.
An elopement Drill QAPI worksheet dated 5/23/23 at 11:20 a.m. to 11:32 a.m. consisted of a check mark placed next to each item on the list. The form noted after the drill is completed, review drill with staff, provide feedback and answer questions, staff to sign in-service sheet. There was no documentation the drill was reviewed, who participated and feedback.
Review of the QAPI minutes for the May 2023 meeting noted an elopement drill was held on 5/23/23 on the day shift with 100% accuracy in action and response time. There was no discussion of the unsecured SNF door to prevent further incidents of unsafe wandering into the ALF and elopement.
The Administrator presented an undated document titled, Performance Improvement Plan-Life Safety and Clinical Operations
The document listed the following Issues:
Elopement Drills and Process. Solution: Life Safety Director and Clinical Director will work together in submitting Elopement audits to QAPI Committee monthly. The project was ongoing and X entered on the Completed column.
Monitoring. Monthly education will be provided to staff on the elopement procedures with an X entered in the column, indicating the monthly education was completed.
QAPI. Audit results will be brought to QAPI had an X entered indicating the audit results were brought to QAPI. The Administrator only had documentation of the check off Elopement drill QAPI worksheet completed on 5/23/23. There was no sign in sheet making it impossible to determine who participated in the drill.
On 7/14/23 at 10:30 a.m., the Administrator said he did not have any additional information related implementation of processes to ensure a safe environment, including adequate supervision of cognitively impaired residents with known exit seeking behaviors to prevent unsafe wandering and elopement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure they had an updated transfer agreement with one or more hospitals approved for participation under the Medicare and Medicaid programs. The transfer agreement was to be used to ensure a safe and appropriate transfer of a resident between the facilities.
The findings included:
A review of the Facility Transfer Agreement (Revised on 01-2009) between the long-term care facility/nursing home and the hospital revealed it was signed on [DATE] with an end date of [DATE]. Further review of the Facility Transfer Agreement noted it was not renewed after the [DATE] end date.
On [DATE] at 1:50 p.m., in an interview with the Administrator, he said the current transfer agreement between the nursing home and the hospital expired on [DATE]. He said he was unable to find documentation the facility had renewed the transfer agreement with the hospital or had attempted to secure a new transfer agreement with a hospital as required per federal regulation.

Based on observations, record review, and staff interviews, the facility failed to ensure no greater than 5% medication error rate. 38 opportunities with 5 errors were observed resulting in a 13.16% medication error rate.
The findings included:
On 7/14/23 at 8:15 a.m., Licensed Practical Nurse (LPN) Staff P was observed administering 13 different medications to Resident #16.
Upon reconciliation of the observation with the physician's orders, it was revealed in addition to the 13 medications administered, an order to administer Lorazepam (medication used for anxiety) 0.5 milligram (mg) one tablet by mouth two times a day, hold for sedation.
The morning Lorazepam was scheduled for 9:00 a.m. Staff P was not observed administering the Lorazepam to Resident #16 as ordered.
The physician's orders also included Cyanocobalamin (Vitamin B12) 1000 micrograms (mcg) one tablet by mouth one time a day for supplement. Staff P was not observed administering the Cyanocobalamin to Resident #16.
On 7/14/23 at 8:26 a.m., LPN Staff P documented in a progress note she held the Lorazepam since, Daughter prefers that patient not have it in the morning.
On 7/14/23 at 8:30 a.m., LPN Staff P verified she did not administer the Cyanocobalamin as ordered to Resident #16. She said the Cyanocobalamin has not been available for two months, and Administration said, It's on order.
On 7/14/23 at 2:00 p.m., LPN Staff P verified she held the Lorazepam at the daughter's request but had not notified the Advanced Practice Registered Nurse who ordered the medication.
On 7/15/23 review of the Medication Administration Record (MAR) showed Resident #16 did not receive the Cyanocobalamin on 7/14/23.
2. On 7/14/23 at 9:15 a.m., LPN Staff U was observed administering medications to Resident #85, including two tablets of Magnesium Oxide 400 mg for a total of 800 mg.
LPN Staff U said Resident #85 had an order for Co Q-10 (supplement)100 mg, but she was not able to locate the medication. She did not administer the Co Q-10.
Reconciliation of the observation of the medication administration with the physician's orders revealed an order for Co Q-10 oral capsule 100 mg by mouth daily for supplement and Magnesium Oxide 250 mg, give two tablets (500 mg) one time a day.
LPN Staff U documented on the MAR she administered Magnesium Oxide 500 mg as per the physician's order, and the Co Q-10 was not available.
On 7/14/23 at 5:10 p.m. The Director of Nursing (DON) said CO Q-10 was on order and not available.
On 7/14/23 at 12:00 p.m., LPN Staff U verified she administered 800 mg of Magnesium Oxide to Resident #85 instead of Magnesium Oxide 500 mg as per the physician's order.
On 7/14/23 at 4:35 p.m., the DON said the facility did not have Magnesium Oxide 250 mg. She said the nurse who took the verbal order on 7/5/23 for the Magnesium Oxide should have informed the practitioner the Magnesium Oxide was not available in that strength.
5. On 7/14/23 at 2:00 p.m., LPN Staff P was observed administering four different medications to Resident #24.
Reconciliation of the observation with the physician's orders revealed an order to administer Miralax (laxative) 17 grams mixed in eight ounces of water once a day for constipation.
LPN Staff P was not observed to offer or administer the Miralax. She documented on the MAR Resident #24 refused the Miralax.
On 7/14/23 at 3:30 p.m., LPN Staff P verified she did not offer or administer the Miralax to Resident #24 and documented the resident refused the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, review of facility's policies and procedures, and staff interview the facility failed to protect residents' rights to be free from neglect.
The facility neglected to develop a care plan and ensure adequate supervision to prevent unsafe wandering and elopement for 1 (Resident #386) of 5 sampled cognitively impaired residents with active exit seeking behaviors.
On 4/1/23 at approximately 4:30 p.m., Resident #386 who was cognitively impaired, and wheelchair bound was not adequately supervised. The resident wheeled herself through an unsecured door of the skilled nursing facility into a hallway leading to the adjoining Assisted Living Facility.
Resident #386 left through the front door of the Assisted Living Facility, and traveled unsupervised in her wheelchair, approximately three tenths of a mile, and crossed two streets.
On 4/1/23 at 5:45 p.m., a staff member from a neighboring skilled nursing facility found Resident #386 wandering the streets.
Resident #386 had a likelihood for serious harm, injury, or death due to the risk for serious injury from a fall, getting lost or getting hit by a car.
The facility's failure to provide the necessary care and services to prevent neglect resulted in the determination of Immediate Jeopardy level at a scope and severity of isolated (J) starting on 4/1/23.
On 7/14/23 at 4:00 p.m., the facility's Administrator was informed of the determination of Immediate Jeopardy (IJ) and provided the IJ templates.
The facility census was 37 with five residents at risk for unsafe wandering and elopement.
The findings included:
Cross reference to F689, F835 and F867.
The facility's policy and procedure for abuse with a revised date of 10/23/22 noted, Neglect. Failure to provide goods or services necessary to avoid physical harm, mental anguish, or mental illness . Prevention. Identify, correct, and intervene in situations where . neglect, and/or mistreatment are more likely to occur. This includes, but is not limited to, identification/analysis of:
a.
Secluded areas of the facility.
b.
Sufficient staffing on each shift to meet the needs of the residents/patients.
c.
Assigned staff demonstrating knowledge of individual resident/patient needs.
d.
Sufficient and appropriate supervisory staff to identify inappropriate behaviors.
e.
Residents/patients with needs and behaviors which might lead to . neglect.
.The facility will take all necessary corrective actions depending on the results of the investigation . Occurrences will be analyzed to determine if any changes in policy and procedures should be implemented to prevent future occurrences .
Review of the clinical record revealed Resident #386 was an [AGE] year-old female admitted to the facility from an acute care hospital on 1/17/23 with diagnoses including Alzheimer's disease, history of intracranial hemorrhage (bleeding), visual loss in both eyes, traumatic brain injury, and seizures.
Review of the progress notes showed on 1/21/23 Resident #386 was up wandering in the hallway, attempting to go out exit door. The resident stated she was looking for the kitchen. The resident was reoriented and assisted back to her room and to bed.
The admission Minimum Data Set (MDS) Assessment with a target date of 1/23/23 noted the resident's cognition was severely impaired with a Brief Interview for Mental Status of 05. The MDS did not document Resident #386's wandering behaviors.
On 2/7/23 the physician ordered to apply a wanderguard (Brand name wander alert to notify staff when the resident leaves a safe area), and check the placement of the wanderguard every shift.
Resident #386 was discharged to an acute care hospital on 3/9/23 and returned to the facility on 3/20/23.
The elopement evaluation completed on 3/20/23 upon return to the facility noted Resident #386 was exhibiting exit-seeking searching behaviors such as standing by the exit door, looking for someone, asking to go home et cetera.
Review of the Medication Administration Record for 3/2023, and 4/2023 noted a physician's order dated 3/21/23 for a wanderguard.
The 5-Day Minimum Data Set (MDS) Assessment with a target date of 3/26/23 noted the resident's cognition was severely impaired with a Brief Interview for Mental Status of 01. The MDS noted Resident #386 exhibited wandering behaviors, one to three days. The MDS was inaccurate and did not reflect the use of the wander/elopement alarm. Resident #386 used a wheelchair and required extensive physical assistance of one person for locomotion off unit (How resident moves to and returns from off-unit locations), if in wheelchair, self-sufficiency once in a chair.
The care plan was not revised to reflect the risk for elopement and interventions to prevent unsafe wandering and elopement.
On 4/1/2023 at 6:56 p.m., a nursing progress note read, Resident was last seen during med pass by nurse in W/C (wheelchair) at nurses station at 1630 (4:30 p.m.). CNA (Certified Nursing Assistant) notified nurse as 1755 (5:55 p.m.) that resident was no longer in nurses station area nor in dining area. Head count completed and noticed that the resident was no longer on grounds. Absence of alarms did not notify facility that resident had exited the building. Found at near [sic] by facility . Family, MD, and DON (Director of Nursing) notified of elopement.
Review of the facility's investigation, and analysis of the incident revealed on 4/1/23 at 4:30 p.m., Resident #386 was seen at the nurses station. Upon investigation it was apparent she then traveled in her wheelchair down the back hallway where the wander guard was alarming outside room [ROOM NUMBER] outside door.
There was no documentation staff increased supervision when Resident #386 attempted to leave the facility and triggered the wander alarm.
The investigation noted after triggering the wander alarm to the outside door close to room [ROOM NUMBER], Resident #386 when through the double doors into the Assisted Living Facility (ALF), traveled that hallway until she made a right heading to the main entrance of the facility where the wander guard in that hallway was also triggered. She then exited the building through the main entrance and to the road where she turned left and proceeded down Pinebrook Avenue in her wheelchair. The elopement occurred during mealtime for both sides of the house and staff were either serving in their perspective dining rooms or on break in the ALF. Resident #386's family typically visit her daily between 4:00 p.m., and 5:00 p.m., and take her outside to visit and enjoy fresh air. On 4/1/23, Resident #386's family did not come. Upon interviewing staff who were on shift, they did not think her absence was unusual during this time because she is routinely outside at this time to visit with family.
The facility's immediate corrective action was to place the resident on one to one supervision to prevent further incidents of unsafe wandering and elopement.
On 4/4/23 Resident #386 was discharged to a secured memory care unit.
On 4/1/23 Registered Nurse Staff Y documented in a witness statement, On 4/1/23 I did not see (Resident #386) in the dining room or in the facility from the time I came on to the floor at 3:00 pm today. (Facility name) called Advinia Care at 6 pm asking if we were missing a resident. (Resident #386) was found at (facility name) and her nurse brought resident back. She was in her wheelchair.
The facility provided documentation on 4/3/23 (two days after the elopement) they educated staff for 10 minutes on responding to the wander alarm, including not turn off the alarm until all residents are accounted for.
There was no documentation five staff members on duty when Resident #386 eloped were educated.
There was no documentation the facility-initiated elopement drills on all shifts, including weekends to verify staff understood the education and responded appropriately to the wander alarm when activated.
On 7/11/23 the facility provided a list of current residents identified to be at risk for unsafe wandering and elopement, including Residents #8, #26, #11, #287, and #288.
On 7/11/23 at approximately 5:50 p.m., the door connecting the skilled nursing facility to the ALF remained unsecured. It was not equipped with an alarm to alert staff to unsafe wandering.
On 7/11/23 at 5:54 p.m., the surveyor used the fob provided by the facility to trigger the alarm of a door equipped with a wander alarm system at the skilled nursing facility to observe the staff response to the alarm.
On 7/11/23 at 5:57 p.m., CNA Staff AA started closing all residents' bedroom doors in response to the alarm. She said, I thought it was a fire alarm. Staff AA did not investigate or look around to see if Residents #8, #26, #11, #287, and #288 identified to be at risk for elopement and wore a wander alarm had left the facility.
Review of the Agency For Health Care Administration Background Screening Clearing house revealed Staff AA permanent hire date was 1/12/23.
Review of the in-service related to wanderguards dated 4/3/23 lacked documentation CNA AA attended the in-service which specified, If anyone hears this alarm they are to investigate it immediately. Look around do you see a resident with a white bracelet and alarm? Look outside, if there a resident outside who has on a white bracelet and alarm.
On 7/11/23 at 6:00 p.m., Licensed Practical Nurse (LPN) Staff P turned off the alarm, and said, The alarm means it is an elopement risk. She looked out the door and said she did not see anyone. She did not initiate a count of the residents to ensure all cognitively impaired residents at risk for elopement, including Residents #8, #26, #11, #287, and #288 were accounted for.
LPN Staff P attended the 10 minutes in-service on 4/3/23 and did not follow the procedure which specified, You can not [sic] turn off the alarm until you know that all residents are accounted for.
The facility's policy on Elopement Prevention effective 2/10/21 and revised on 6/22/23 noted when a resident is deemed to be an elopement risk, photos of the resident should be taken and placed in the elopement risk book. Documentation of the elopement risk should be made on the Facility elopement Book, placed at nursing station and front entry.
On 7/11/23 at approximately 3:00 p.m., the elopement book at the receptionist desk at the entrance of the skilled nursing facility, and the entrance of the adjoining Assisted Living Facility were reviewed. The elopement books did not include Resident #26, #288, and #287.
On 7/12/23 at 9:00 a.m., the Director of Nursing stated not all current employees had completed the Inservice. She verified the skilled nursing unit was not a secured unit. She stated the elopement book was updated with each resident added. The DON said she did not know what was going to be done about the unsecured door between the assisted living facility and the skilled unit.
On 7/14/23 at 10:30 a.m., the Administrator said he did not have any additional information related implementation of processes to ensure a safe environment, including adequate supervision of cognitively impaired residents with known exit seeking behaviors to prevent unsafe wandering and elopement.

Based on record review, review of the facility's policies and procedure, and staff interviews the facility failed to submit an immediate report for an elopement, which could be considered neglect, to the State Survey Agency and adult protective services in accordance with State law for 1 (Resident #386) of 3 incidents reviewed.
The findings included:
Cross reference to F600 and F689
The facility's abuse policy, section resident rights, revised 10/23/22 noted, The facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient . neglect . Neglect. Failure to provide goods or services necessary to avoid physical harm, mental anguish, or mental abuse . Reporting . Notify the local law enforcement and appropriate State Agency(s) immediately (no later than 2 hours after allegation/identification of allegation) by Agency's designated process after identification of alleged/suspected incident .
Review of the facility's incidents investigations on 4/1/23 at approximately 4:30 p.m., revealed Resident #386, who was cognitively impaired, identified to be at risk for unsafe wandering and elopement, and wheelchair bound was not adequately supervised.
The resident wheeled herself through an unsecured door of the skilled nursing facility into a hallway leading to the adjoining Assisted Living Facility.
Resident #386 left through the front door of the Assisted Living Facility, and traveled unsupervised in her wheelchair, approximately three tenths of a mile, and crossed two streets.
Staff was not aware the resident was missing for approximately one hour and 45 minutes.
On 4/1/23 at 5:45 p.m., a staff member from a neighboring skilled nursing facility found Resident #386 wandering the streets.
There was no documentation the facility reported the neglect to the State Survey Agency within 24 hours as required, or Adult Protective Services.
On 7/12/23 at 10:30 a.m., the Director of Nursing said she had no idea why Adult Protective Services was not notified of the elopement incident.
On 7/14/23 at 3:24 p.m., the Director of Nursing said, a federal report for elopement should have been done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, the facility failed to ensure resident care plan meeting/conference was conducted with the resident and/or their representative after completion of the comprehensive admission Minimum Data Set (MDS) assessment for 2 (Resident #29 and #25) of 5 sampled residents. This did not allow the resident and/or their representative to participate in decision-making related to their plan of care and ensure the resident's care plan had the required information.
The findings included:
1. On 7/10/23 at 10:26 a.m., during an interview with Resident #29, he said he was not invited to his care plan meeting. Resident #29 said because he was not invited to his plan of care meeting, he did not know what the Interdisciplinary Team (IDT) had determined his plan of care would be while he is at the facility.
On 7/12/23 a review of Resident #29's medical records revealed he was admitted to the facility on [DATE] with a diagnosis of pathological left femur fracture, and abnormalities of gait and mobility. The Comprehensive admission Assessment was completed and finalized on 6/28/23. A review of Resident #29's plan of care revealed they were completed by 7/6/23. Further review of Resident #29's medical records revealed no documentation Resident #29 had attended or was invited to participate in decision-making related to the completion of his plan of care.
2. On 7/10/23 at 11:01 a.m., during an interview with Resident #25's husband, he said since his wife's admission to the facility, he had asked multiple staff members about the plan of care related to his wife's stay at the facility. He said no one had kept them updated about the plan of care for his wife and he told them he wanted to meet with the case manager and the IDT related to his concerns about his wife's care at the facility.
On 7/12/23 a review of Resident #25's medical records revealed she was admitted to the facility on [DATE] with a diagnosis of fracture to left hip, joint replacement surgery, infection of the left hip, Hypertension, abnormalities of gait and mobility, altered mental status and unspecified dementia. An Attestation of Incapacity form was completed and signed by the physician on 6/19/23 for Resident #25.
Further review of Resident #25's plan of care revealed they were reviewed and initiated by the IDT on 6/20/23 and 6/26/23. Resident #25's medical records revealed no documentation Resident #25 and/or Resident #25's husband had attended or were invited to attend Resident #25's IDT care plan meeting on 6/26/23.
3. On 7/13/23 review of the Clinical Operations for Care Plans, policy #CC-21 created 7/2018 and last revised 1/2023 stated each resident of the facility shall be involved in the development and review of their plan of care along with their family member. Residents, family members or other responsible people should be invited to attend the interdisciplinary conference.
4. On 7/13/23 at 9:44 a.m., in an interview with the Minimum Data Set (MDS)/Care Plan Coordinator, she said she liked to complete the resident's baseline care plan within 48 hours of admission and tried to meet with the IDT to finalize the resident's full care plan within 7 to 10 business days of the resident's admission to the facility. The MDS Coordinator said the comprehensive plan of care is required to be developed within 7 days after the completion of the comprehensive assessment. The MDS Coordinator confirmed the facility's Care Plans policy stated each resident or family member or responsible people should be invited to attend the development and review of the resident's plan of care while at the facility.
On 7/13/23 at 9:50 a.m., the MDS Coordinator reviewed Resident #25's medical record and confirmed Resident #29's last admission to the facility was on 6/09/23. She said Resident #25's baseline care plan was completed on 6/12/23 and the full care plan was finalized by the IDT on 6/26/23. She said she was unable to find documentation Resident #25 and/or her husband were invited and participated in the development of the plan of care for Resident #25 on 6/26/23 as required.
On 7/13/23 at 10:08 a.m., the MDS Coordinator, after she reviewed Resident #29's medical record, confirmed the resident was admitted to the facility on [DATE]. She said Resident #29's baseline care plan was completed on 6/22/23 and she completed the Comprehensive admission Assessment on 6/28/23. The MDS Coordinator said Resident #29's plan of care was completed within seven days of the Comprehensive admission Assessment, but she was unable to find documentation Resident #29 was invited and/or participated in the development of his plan of care as required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to implement individualized, care planned interventions to prevent the decline in range of motion for 2 (Resident #15, and #21) of 2 sampled residents with limited range of motion.
The findings included:
1. Resident #15 was admitted to the facility on [DATE]. Diagnoses included as of 8/11/22 hemiplegia (Paralysis on one side of the body) related to a cerebral vascular accident (stroke), and Parkinson's disease as of 2/22/19.
Observation on 7/11/23 at 12:15 p.m., showed Resident #15's fourth and fifth fingers of both hand were contracted, pointing downwards toward the palm of his hands.
Resident #15 said he did not have any splints or other device to keep his hands open.
Clinical Record review showed the admission Minimum data Set (MDS) assessment dated [DATE] noted Resident #15 was admitted from an acute care hospital. Resident #15's cognition was moderately impaired with a Brief Interview of Mental Status (BIMS) score of 11. The MDS noted Resident #15 had no functional limitation in Range of Motion to his upper extremities and started physical therapy on 5/1/23.
Review of Resident #15's care plan initiated on 5/5/23 showed Resident #15 has a deficit in his activities of daily living self-care with performance deficit related to limited mobility. Interventions as of 6/9/23 included applying a palm roll in the left hand to prevent contractures.
On 7/12/23 at 11:48 a.m., the Director of Physical Therapy (PT) said she started employment at the facility a month ago. She verified Resident #15's hands were both contracted. The Director of Physical Therapy said Resident #15 was supposed to wear an orthotic device (An artificial appliance that supports the body part for the purpose of stabilization, support, or movement reminder) to both hands.
On 7/12/23 at 11:55 a.m., The PT director said Resident #15's orthotic devices were shaped and looked like carrots. The PT director searched the resident's room and was not able to locate the orthotic devices.
On 7/13/23 at 1:00 p.m., Resident #15's nephew said he was concerned because the facility was not doing anything to keep his hands functioning. The nephew said Resident #15 used to have splints for his hands when he resided at an Assisted Living Facility. He said since his admission to the nursing home, he has not been wearing any splints.
On 7/14/23 at 10:00 a.m., the Medical Director verified Resident #15 had contractures in both his hands and he should be receiving services to prevent further decline to his hands.
On 7/14/23 at 3:00 p.m., the MDS Coordinator verified Resident #15 had not been assessed and care planned appropriately for the contractures of his hands.
On 7/14/23 at 4:00 p.m., the Restorative Aide said she had seen the resident with carrots (orthotic device) in his hands a month ago.
2. Resident #21 was admitted to the facility from the hospital on [DATE]. Resident #21 has a history of Cerebral vascular Accident (Stroke), hypertension, Diabetes Mellitus, depression and anxiety.
The Quarterly MDS dated [DATE] showed Resident #21 has a BIMS of 13 which show intact cognition. Resident #21 had no rejection of care behaviors. Resident #21 had function limitations in range of motion on one side on both his upper and lower extremities.
On 7/10/23 at 4:12 p.m., Resident #21 was observed in his bed. The resident was observed to have contractures to his right hand. Resident #21 was not to able to straighten the fourth and fifth finger of his right hand. The resident had some movement observed on the first and second fingers of the right hand. The resident stated his right leg was contracted. The resident said he did not get assistance from staff with range of motion exercises. The resident stated he did not have a splint for his hand. The resident stated if he had a splint he would wear it.
Resident #21's Care plan read, The resident has limited physical mobility r/t [related to] Stroke. Has right sided weakness. Receives restorative nursing to maintain abilities. Res [Resident] has refused restorative program DC'd [discontinued] Date initiated:11/21/20 Revision on:10/16/22.
The last intervention listed in the care plan was to report any decline or pain which was initiated on 4/27/21. The care plan did not list any orthotics to the resident's right hand or leg. There was no revision to the interventions since 5/20/21. The goal listed in the care plan was, The resident will demonstrate improved performance ADL (activities of daily living) ability as he regains strength. This goal was initiated on 11/21/20 and was revised on 4/14/23 with a target date of 7/10/23.
On 7/12/23 at 12:20 p.m., the Director of PT said Resident #21 should be receiving restorative. The PT director stated the resident should have a splint for his hand and a brace for leg in place. She stated Occupational Therapy was going to pick up the resident for services and they would be assessing the resident's mobility needs.
An active physician's order dated 12/28/20 reads, apply right wrist brace No directions were specified in the order.
Documentation provided by the facility listed as Nursing Rehab/Restorative Program Record showed the restorative program was discontinued on 5/3/21 due to resident refusal of care.
Further documentation showed Restorative continued from 1/12/22 through 7/21/22. The documentation showed the resident was declining to participate in restorative and to wear wrist splint and leg brace. There was no nursing assessment related to the resident's refusal of care.
On 7/14/23 at approximately 10:00 a.m., Resident #21 was observed coming out of the therapy room in his wheelchair. He was wearing a right leg brace. The resident appeared comfortable and compliant with the brace.
On 7/14/23 at 2:45 p.m., the PT director said staff found the resident's wrist brace, but it was not unusable, and another brace had been ordered.
On 7/14/23 at 4:00 p.m., the Restorative Aide said she knew Resident #21, and he was compliant with restorative, but he got to where he would not let her touch him. She stated the resident would be in pain with any movements. She stated she reported this to the nursing staff. They finally ended up discontinuing restorative. The Restorative Aide said she did not know if nursing put any interventions in place to reduce the resident pain during restorative.
On 7/14/23 at 4:30 p.m., the Director of Nursing (DON) said the resident's restorative had been stopped due to noncompliance. She was not the DON at the time the restorative was stopped, and she could not say if nursing assessed the reason for refusal of restorative services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews, the facility failed to implement processes to ensure adequate supervision of 1 (Resident #386) of 5 cognitively impaired residents at risk for elopement to prevent unsafe wandering and elopement.
On 4/1/23 at approximately 4:30 p.m., Resident #386 who was a vulnerable cognitively impaired, wheelchair bound resident with known wandering behavior was not adequately supervised. The resident wheeled herself through an unsecured door of the skilled nursing facility into a hallway leading to the adjoining Assisted Living Facility. Resident #386 wore a wander alarm and triggered the alarm of two doors without staff response.
Resident #386 left through the front door of the Assisted Living Facility, and traveled in her wheelchair, approximately three tenths of a mile, and crossed two streets.
Resident #386 was missing for approximately one hour and 30 minutes without staff knowledge.
On 4/1/23 at 5:45 p.m., a staff member from a neighboring skilled nursing facility found Resident #386 wandering the streets.
Resident #386 had a likelihood for serious harm, injury, or death due to the risk for serious injury from a fall, getting lost or getting hit by a car.
The failure to ensure adequate supervision to protect vulnerable residents from unsafe wandering and elopement resulted in a determination of Immediate Jeopardy (IJ) at a scope and severity of isolated (J) starting on 4/1/23 when Resident #386 left the building without staff knowledge.
On 7/14/23 at 4:00 p.m., the facility Administrator was notified of the Immediate Jeopardy and provided the IJ templates.
The immediate Jeopardy was ongoing.
The facility census was 37 with five residents at risk for elopement.
The findings included:
Cross reference to F600, F835 and F867
The facility's policy for Elopement Prevention with a revised date of 6/22/2021 noted, When a resident is deemed to be an elopement risk the following measures should be put in place:
Residents should be placed in a secured unit.
A wander guard bracelet should be placed on the resident.
A Physicians order should be written to check placement of the wander guard every shift and function of bracelet daily.
Photos should be taken of the resident to be placed in the Elopement Risk book.
Communication to all staff on duty should be completed and carried on from shift to shift.
Documentation of the Elopement Risk should be made . facility Elopement Book, placed at nursing station and front entry . Elopement concerns and resident at risk should be reviewed monthly and discussed at the facility QAPI (Quality Assurance and Performance Improvement) meeting to discuss trends and concerns.
Elopement Risk Book should be reviewed daily and discussed at change of shift. Photos should be current with description of resident along with any other pertinent information that may help with locating the resident in an elopement situation.
The Elopement-Missing Resident Policy CE-2, Revised 10/2022 noted the facility administration should complete a thorough investigation including the wanderguard (wander alarm to alert staff when a resident leaves a safe area) system and evaluating any preventative measure that may have been in place.
Resident #386 was an [AGE] year-old female admitted to the facility from an acute care hospital on 1/17/23 with diagnoses including Alzheimer's disease, history of intracranial hemorrhage (bleeding), visual loss in both eyes, traumatic brain injury, and seizures.
The elopement evaluation completed on 3/20/23 noted Resident #386 was exhibiting exit-seeking searching behaviors such as standing by the exit door, looking for someone, asking to go home et cetera.
The physicians orders dated 3/21/23 included the use of a wander guard for Resident #386.
The care plan was not revised to reflect the risk for elopement and interventions to prevent unsafe wandering and elopement.
The 5-Day Minimum Data Set (MDS) Assessment with a target date of 3/26/23 noted the resident's cognition was severely impaired with a Brief Interview for Mental Status of 01. The MDS noted Resident #386 exhibited wandering behaviors, one to three days. The MDS was inaccurate and did not reflect the use of the wander/elopement alarm that was used during the assessment observation period.
A nursing progress note dated 4/1/23 (Saturday) read, Resident (Resident #383) was last seen during med pass by nurse in W/C (wheelchair) at nurses station at 1630 (4:30 p.m.). CNA (Certified Nursing Assistant) notified nurse as 1755 (5:55 p.m.) that resident was no longer in nurses station area nor in dining area. Head count completed and noticed that the resident was no longer on grounds. Absence of alarms did not notify facility that resident had exited the building. Found at near [sic] by facility . Family, MD, and DON (Director of Nursing) notified of elopement.
Review of the facility's investigation, and analysis of the incident revealed on 4/1/23 at 4:30 p.m., Resident #386 was seen at the nurses station. Upon investigation it was apparent she then traveled in her wheelchair down the back hallway where the wander guard was alarming outside room [ROOM NUMBER] outside door.
The investigation noted after triggering the wander alarm to the outside door, close to room [ROOM NUMBER], Resident #386 went through the double door into the Assisted Living Facility (ALF), traveled that hallway until she made a right heading to the main entrance of the facility where the wander guard in that hallway was also triggered. She then left the facility through the main entrance where that alarm was also triggered. She then exited the building through the main entrance and to the road where she turned left and proceeded down Pinebrook Avenue in her wheelchair.
All wander guard checks have shown no fault in the system alerting when triggered. The elopement occurred during mealtime for both sides of the house and staff were either serving in their perspective dining rooms or on break in the ALF.
Resident #386's family typically visited her daily between 4:00 p.m., and 5:00 p.m. and took her outside to visit and enjoy fresh air. On 4/1/23 the family did not come. Upon staff interview, staff who were on shift and knew Resident #386 said they did not think the resident's absence was unusual during this time since she was routinely outside at that time of the day to visit with family.
Resident #386 was discovered down Pinebrook Avenue on 4/1/23 at approximately 6:00 p.m., by a member of a nearby skilled nursing facility who contacted the facility and asked if they were missing a resident.
There was no documentation staff increased supervision after Resident #386's first attempt to leave the facility when she triggered the wander alarm of the door leading to the outside near room [ROOM NUMBER].
The facility's immediate corrective action was to place Resident #386 on one-to-one supervision to prevent further incidents of unsafe wandering and elopement.
On 4/4/23 Resident #386 was discharged to a secured memory care unit.
Resident #386's care plan was not updated with interventions to prevent further incidents of unsafe wandering and elopement until 4/6/23, two days after discharge.
On 4/1/23 Registered Nurse Staff Y documented in a witness statement, On 4/1/23 I did not see (Resident #386) in the dining room or in the facility from the time I came on to the floor at 3:00 pm today. [Facility name] called Advinia Care at 6 pm asking if we were missing a resident. (Resident #386) was found at Orchid Cove and she was brought back to the facility.
The facility provided documentation on 4/3/23 (two days after the elopement) they educated staff for 10 minutes. The topic of the education was Wanderguards, and included responding to the wander alarm, including not turning off the alarm until all residents are accounted for.
There was no documentation Licensed Practical Nurse Staff X, Certified Nursing Assistants (CNAs) Staff CC, DD, EE, and FF who were on duty when Resident #386 eloped were educated.
There was no documentation the facility-initiated elopement drills on all shifts, including weekends to verify staff understood the education and responded appropriately to the wander alarm when activated.
On 7/11/23 the facility provided a list of current residents identified to be at risk for unsafe wandering and elopement, including Residents #8, #26, #11, #287, and #288. Residents #11, #287, and #288 wore a wander alert bracelet.
On 7/11/23 at 5:00 p.m., the Administrator in training provided the surveyor a fob to trigger the wander alarm from front entrance door of the Assisted Living Facility to observe staff response. The Administrator in training was present when the alarm was triggered.
The ALF receptionist and business office manager said they were new employees and had completed their orientation. Both staff members said they did not receive education about the wander alarm system.
A staff member from the skilled nursing facility started educating the receptionist and the business office manager on response when the wander alarm is triggered.
On 7/11/23 at approximately 5:50 p.m., the door connecting the skilled nursing facility to the ALF remained unsecured. It was not equipped with an alarm to alert staff to unsafe wandering.
On 7/11/23 at 5:54 p.m., the surveyor used the fob to trigger the alarm of a door equipped with a wander alarm system at the skilled nursing facility to observe the staff response to the alarm.
On 7/11/23 at 5:57 p.m., CNA Staff AA started closing all residents' bedroom doors in response to the alarm. She said, I thought it was a fire alarm. Staff AA did not investigate or look around to see if Residents #11, #287, and #288 identified to be at risk for elopement and wore a wander alarm had left the facility.
Review of the Agency For Health Care Administration Background Screening Clearing House website revealed Staff AA's permanent hire date was 1/12/23.
Review of the in-service related to Wanderguards dated 4/3/23 lacked documentation CNA AA attended the in-service which specified, If anyone hears this alarm they are to investigate it immediately.
On 7/11/23 at 6:00 p.m., Licensed Practical Nurse (LPN) Staff P turned off the alarm, and said, The alarm means it is an elopement risk. She looked out the door and said she did not see anyone. She did not initiate a count of the residents to ensure all cognitively impaired residents including Residents #8, #26, #11, #287, and #288 were accounted for.
On 7/12/23 at approximately 4:00 p.m., Resident #288 was observed on the unit. He did not have a wander alert bracelet.
LPN Staff P verified Resident #288 was not wearing a wander alert bracelet as ordered. She said the resident had removed the wander alert bracelet.
Review of the clinical record for Resident #288 revealed a physician's order dated 7/11/23. Resident #288's diagnoses included Alzheimer's, and Dementia. Resident #288 did not have a care plan alerting the staff of the risk for elopement.
Review of the clinical record for Resident #26 revealed an admission date of 6/15/23 with diagnoses including Dementia. There was no care plan alerting the staff of the risk for elopement. On 7/11/23 at approximately 4:30 p.m., Resident #26 was observed in a wheelchair wandering in the hallways.
On 7/11/23 at approximately 3:00 p.m., the elopement book at the receptionist desk at the entrance of the skilled nursing facility, and the entrance of the adjoining Assisted Living Facility were reviewed. The elopement books did not include Resident #26, #288, and #287.
On 7/12/23 at 9:00 a.m., the Director of Nursing said she recommended installing a wander alert system which would automatically lock the doors when a resident with a wander alert bracelet came near an exit door. She said she did not know what the plan was for the unsecured door between the skilled nursing facility and the ALF.
On 7/12/23 at 10:30 a.m., the Director of Nursing verified the elopement books were not updated. She said Resident #26 was at risk for unsafe wandering and elopement and should have been in the book. She said the Activities Staff was responsible to update the elopement book and ensuring all residents identified to be at risk for elopement were in the books.
On 7/12/23 at 10:50 a.m., the Activities Director said she did not know her responsibilities included updating the elopement books.
On 7/14/23 at 10:30 a.m., the Administrator said he did not have any additional information related implementation of processes to ensure a safe environment, including adequate supervision of cognitively impaired residents with known exit seeking behaviors to prevent unsafe wandering and elopement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff, resident, and family interview, the facility failed to provide nutritional interventions and physician's orders to prevent weight loss for 1 (Resident #7) of 1 resident identified at risk for compromised nutrition and weight loss.
The findings included:
Clinical record review revealed Resident #7 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment dated [DATE] noted diagnoses of non-Alzheimer's dementia, hypertension, Parkinson's Disease, Dysphagia (swallowing difficulties), and cognitive communication deficit. The MDS noted the resident was receiving a mechanically altered diet (change in texture of food and/or liquids).
The clinical record noted Resident #7 had an allergy to shellfish which was not listed on the meal ticket.
The Care area assessment dated [DATE] indicated Resident #7's BMI (Body Mass Index) was too low (17) (Body Mass Index less than 18.5 indicates the resident is at nutritional risk), and the resident required a therapeutic diet.
The Care plan initiated 6/9/2023 indicated the resident has a nutritional problem related to diagnoses of dementia, altered mental status, Parkinson's disease, required a therapeutic diet, history of weight loss. The goal initiated 6/9/2023 was The resident will maintain adequate nutritional status as evidenced by maintaining weight without significant weight changes.
Interventions included to record/report signs or symptoms of malnutrition, significant weight loss: 3 pounds (lbs.) in 1 week, greater than 5% in 1 month, greater than 7.5% in 3 months, greater than 10% in 6 months; Provide and serve supplements as ordered; Provide, serve diet as ordered; Monitor intake and record every meal; RD (Registered Dietitian) to evaluate and make diet change recommendations.
The resident weight flow sheet revealed on 5/2/23 Resident #7 weight was 97.0 lbs.
The admission Minimum Data Set (MDS) assessment dated [DATE] noted the resident's height to be 5 feet, 3 inches.
On 5/5/23 the physician ordered a house shake supplement, 90 milliliters (ml's.) three times daily.
On 6/4/23 the resident's weight was documented to be 90.0 lbs. which indicated a significant weight loss of 7.2 % in 30 days.
The Registered Dietitian (RD) documented in a progress note date 6/9/23, Resident #7 weight triggered for loss for 1 week, 1 month. RD to increase house shake from three times daily to four times daily and discuss potential for appetite stimulant with physician.
On 6/10/23 the house shake was increased to four times a day.
On 7/5/23, the resident's weight was documented as 88.5 lbs.
The RD quarterly evaluation dated 7/7/23 noted resident remained underweight and triggered for significant weight loss x 3 months. Resident #7 was dependent on staff for meals.
On 7/11/23 at 1030 a.m., Resident #7's private duty Certified Nursing Assistant (CNA) stated she works with the resident two days a week. She feeds Resident #7, offers food, and fluids. Resident #7 will eat at least half of what the facility provides for meals and is offered extra fruits and vegetables that she likes and eats all of. The CNA said, I used to see the supplement on her tray but have not seen it for a couple of months. She's lost a lot of weight.
On 7/12/23 at 11:44 a.m., Resident #7 was observed in bed, dressed in a hospital gown. There was no food or drink at the bedside. The resident looked thin.
On 7/12/23 at 3:11 p.m., Licensed Practical Nurse (LPN) Staff P stated we have been out of the house shake for about three weeks. She stated she has been documenting it in the records but has not had any for some time.
On 7/12/23 at 3:29 p.m., the Director of Food and Nutrition Services said no one had provided house shakes to the nursing unit. Anyone can take them, but no one has for a while.
On 7/13/23 at 11:16 a.m., the physician stated he had not been informed the resident was not receiving the supplements and would have liked to have known.
On 7/13/23 at 11:20 a.m. during a telephone interview, the RD stated she works remotely one day per week, she does not physically come to the facility. The RD verified Resident #7 had lost weight. She confirmed resident #7 had lost 9.5 pounds or 8.76 percent. The RD stated, I let the Director of Nursing know on 6/28/23, last week, and on July 7th, the nurses were charting the supplement was not available, or on order, so the resident was not getting it.
On 7/13/23 5:55 p.m., CNA Staff T was observed feeding the resident while in bed. There was no house shake on the tray, as listed on the meal ticket. Staff T, CNA stated she just gets it at lunch not dinner.
On 7/13/23 at 5:58 p.m., Dietary Aide staff V said she didn't know what the house shakes were. She opened the pantry refrigerator, held a house shake container and asked, this is it? while holding the house shake container. She stated she did not put house shakes on any trays.
On 7/13/23 at 6:00 p.m., the DON was observed checking trays and tickets and stated she has not put any house shakes on trays. She stated she did not see it on the meal ticket and did not realize it had been added to the meal tickets.
On 7/14/23 at 9:38 a.m., the physician stated during a follow up telephone interview the lack of shakes may not have caused the weight loss, but it definitely did not help that she did not receive the shakes.

Based on observation, review of facility's policy and procedure and staff interview the facility failed to maintain safe food temperature during preparation of meal, and failed to discard expired food items to prevent their use beyond the manufacturer's specified safe use date.
The findings included:
The facility's policy for Meal Service and Snacks with a revision date of 1/2021 read, . The Dietary department shall be responsible for food preparation for all meals and snacks .
On 11/8/21 at 12:30 p.m., observation of the food prep area showed one tray of egg salad sandwiches on a table in the food preparation area.
Upon request the Certified Dietary Manager (CDM) measured the temperature of the egg salad sandwiches which measured at 54 degrees Fahrenheit (F).
The CDM verified the cold food should be held at 41 degrees F or lower. He placed the sandwiches back in the refrigerator.
On 11/8/21 at 12:40 p.m., observation of the satellite kitchen with the CDM revealed the following:
An opened, undated bottle of honey mustard sauce with a large accumulation of black/greenish substance around the lid. Resident #2's name was written on the bottle.
Photographic evidence obtained
An opened bottle of chocolate syrup with an expiration date of 9/6/21. A large accumulation of green and black growth was observed around the cap.
Photographic evidence obtained
On 11/8/21 at approximately 12:40 p.m., in an interview dietary aide staff E said she was responsible to check the expiration date of refrigerated product. She said, I know but haven't had the time to get to it.
On 11/8/21 at 12:45 p.m., the CDM verified the observation and said residents' food items should not be stored in the satellite kitchen's refrigerator. The CDM discarded the chocolate syrup and the honey mustard sauce.
On 11/10/21 at 10:15 a.m., observation of the medication room with Licensed Practical Nurse (LPN) Staff C showed 98 packages of soft baked cookies with an expiration date of 7/2021 which she said were residents' snacks.
On 11/10/21 at 11:03 a.m., in an interview the Registered Dietitian (RD) said the dietary department had the responsibility to verify the expiration date of foods and snacks. The RD said the egg salad sandwiches should not have been used and residents should have been given a new sandwich.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to have documentation of a baseline care plan for 2 (Resident #26 and #80) of 2 residents reviewed for baseline care plans.
The findings included:
On 11/9/21, review of the clinical records revealed Resident #26 was admitted to the facility on [DATE]. The clinical record lacked documentation of a baseline care plan.
On 11/9/21, review of the clinical record revealed Resident #80 was admitted to the facility on [DATE]. The clinical record lacked documentation of a baseline care plan.
On 11/9/21 at 1:30 p.m., in an interview the Minimum Data Set (MDS) coordinator verified the lack of documentation a baseline care plan was developed for Resident #26 and #80 to reflect interventions to address their needs. The MDS coordinator said, No residents at this facility have a baseline care plan in their records.

Based on observation, record review and staff interview the facility failed to provide assistance for grooming and nail care for 2 (Resident #15 and #18) of 2 dependent residents reviewed for activities of daily living.
The findings included:
1. On 11/8/21 review of Resident #15's care plan noted the resident has limited physical mobility related to exacerbation of Parkinson's, dementia. The care plan revised on 4/2021 also noted the resident required assistance of one to two with all activities of daily living.
On 11/8/21 at 3:23 p.m., Resident #15 was observed in a wheelchair. Resident was not able to answer questions. The Resident's fingernails were uneven and extended approximately half centimeter from the base with a large accumulation of brown substance underneath the nails. Resident #15 was observed scratching her arms and shoulders.
The same observation was made on 11/9/21 at 2:20 p.m., and 11/10/21 at 9:00 a.m.
2. On 11/8/21 review of Resident #18's care plan dated 10/24/21 noted the resident had limited physical mobility related to weakness and poor sight. The care plan also noted Resident #15 had impaired cognitive function, dementia and impaired thought process related to dementia.
On 11/8/21 at 3:25 p.m., Resident #18 was observed in a wheelchair. Resident was not able to answer any questions. The resident's hair had a large amount of white flakes. The resident's nails were uneven and extended approximately half centimeter from the base with brown substance observed underneath the nails.
The same observation was made on 11/9/21 at 2:20 p.m., and 11/10/21 at 9:00 a.m.
Complete record review for Resident #18 and #15 failed to show documentation of nail care.
On 11/10/21 at 9:30 a.m., in an interview the Director of Nursing (DON) said CNA Staff G and the restorative nurse oversee nail care. She said there is no written policy or process for nail care but the need for nail care should be documented on a skin care sheet. The DON verified Resident #15 and #18's nails needed to be trimmed and cleaned.
On 11/10/21 at 10:00 a.m., in an interview Certified Nursing Assistant (CNA) Staff G said she trims nails as needed but there was no process for routine nail care for residents.