Based on interviews and record review the facility failed to ensure the physician was notified when residents on the second and third floors did not receive their medications and treatments as ordered when the facility experienced an internet outage preventing access to the Electronic Health Record (EHR) system on 01/21/2025 and 01/22/2025. Nurses did not have access to pre-printed paper documentation forms such as physician orders and MARs (Medication Administration Record) to administer medications on 01/21/2025 and 01/22/2025. The facility staff failed to notify the Director of Nursing (DON), residents, and resident representatives of residents not receiving their ordered medications and treatments on 01/21/2025 and 01/22/2025. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death. The Immediate Jeopardy (IJ) was cited in reference to 483.10 Resident Rights. On 03/25/2025 at 4:15 PM, the Administrator (ADM), the Director of Nursing (DON), the Assistant Director of Nursing (ADON) and Executive Director of Operations were provided a copy of the IJ template and, notified of the finding of immediate jeopardy in the area of Resident Rights at F580-Notify of Changes (Injury/Decline/ Room, Etc.). The IJ began on 01/21/2025 and continued until 03/26/2025 when the facility implemented corrective action to remove the immediacy. On 03/27/2025 the immediate jeopardy was removed, F580 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficient practice affected residents on the second and third floors at the facility who were receiving medications. This deficiency was cited as the result of the investigation of complaint/report number AL00050173. Findings Include: Cross-Reference F600, F658 and F760. Review of the facility's After Action Report for the snowstorm January 21 to 23, 2025, documented the following: Knollwood Healthcare experienced an unusual snowstorm on January 21 to January 23, 2025 . We did have the modem go out for the computer Internet . On 03/19/2025 at 3:53 PM, a telephone interview was conducted with Licensed Practical Nurse (LPN) #11, who was identified as a supervisor during the snowstorm on 01/21/2025. LPN #11 said she did remember when the facility's computer system was down during the snowstorm. LPN #11 said she was not sure if the residents received their medications or not. When asked if the DON or ADM knew the system was down, LPN #11 said she could not say yes or no whether they knew. When asked who would have been responsible for notifying them, LPN #11 said the supervisor. On 03/20/2025 at 11:00 AM, the surveyor conducted an interview with the DON. When asked what she could tell the surveyor about the medication system being down on 01/21/2025 and 01/22/2025 when there was a snowstorm, the DON said she was not at the facility during that time and did not recall anyone informing her the system was down. The DON said she was not notified the residents did not receive their medications on those days. The DON said on 01/22/2025 she sent a text to LPN #11 asking LPN #11 how things were going and LPN #11 texted back going, no issues. The DON said she did not know that the residents did not receive their medications during the snowstorm until 03/20/2025. On 03/21/2025 at 10:23 AM, the surveyor conducted an interview with the ADM. The ADM said the internet was down during the snowstorm back in January 2025. The ADM said he did not remember who informed him of this, but he told them to use the paper MARs. The ADM said he was not aware the residents did not receive their medications until he was made aware of this by the survey team. When asked if he should have been made aware that the residents did not receive their medications, the ADM said absolutely. On 03/22/2025 at 9:42 AM, a follow-up interview was conducted with the DON. The DON said she should have been notified when the residents did not receive their medications on 01/21/2025 and 01/22/2025. When asked who would have been the supervisor on 01/21/2025 and 01/22/2025, the DON said LPN #11. The DON said the physician also should have been notified. On 03/22/2025 at 10:18 AM, a telephone interview was conducted with the Physician/Medical Director (MD). The MD said back in January (2025) when there was a snowstorm in the area he was not informed that the facility's computer system was down and the residents did not receive their mediations. The MD said he would have liked to have been informed of this. When asked what were some of the things residents could potentially face when residents did not receive their medications as prescribed by their physician, the MD said it could be a blood pressure issues if the medication missed was for the blood pressure; it could be a clotting issues if the resident was on blood thinners; pain control could be an issue if the resident was on pain medication; and the blood sugar may be affected if insulin was not given as ordered. ********************************************************* On 03/26/2025, the facility submitted an acceptable removal plan, which documented: ********************************************************* 1) Process: To ensure that in the event of a power/internet outage the most updated Medical Record Administration (MAR) will be available for nurses that provide care to the residents: The medication administration Record (MAR) will be printed monthly by the Director of Nursing Assistant Director of Nursing or Unit Manager, by the 1st of each month. The paper MAR will be updated at the time the order is received or confirmed for all current resident and new admits by the RN/LPN who receives the order or confirms the new order for any medication changes including all new orders for new admits. The updated MAR will be located by the nursing stations. All, 100% of LPNs and RNs were in-serviced and completed on March 26th, 2025. Inservice was to ensure nurses know where the paper MAR is located and to update it as soon as a new admission or whenever the physician changes an order in the MAR. 2) In services On 3/20/2025 - 03/26/2025 the Director of Nursing and Assistant Director of Nursing began to educate all nurses, all physical therapy staff and administrative staff (receptionist, Admissions Coordinator, Staffing Coordinator and Human Resources) and provided the education with 1:1 in-service to LPN #14, RN #15, LPN #11, RN #20, and RN #16. The in-services included: a) the policy titled Policy on Computer or Internet Downtime and EHR, b) the standard of practice to: i) administer medication, ii) monitor blood glucose, iii) the implementation of the prescribing physicians' orders iv) the importance of documenting medication administration at the time of administration. c) Inservice included calling the physician as well as notify the Director of Nursing or Designee if staff including nurses are unable to carry out a physician's order. d) Inservice included how it led to neglect and the facility's Abuse Policy titled Abuse Policy. The in-service was completed on March 26th, 2025 for 21 of 21 nurses, 9/9 PT staff, 16/16 of administrative staff. On 3/26/2025, 21 of 21 of the nursing staff were all educated by the Director of Nursing or Assistant Director of Nursing and 1:1 in-service to LPN #14, RN #15, LPN #11, RN #20, and RN #16. The in-service included that a printed MAR will be ready for the 1st of each month. A copy of the paper MAR will be kept at each nurses' station for use during downtime. Education included that RNs and LPNs who receives an order or confirms a new order for any medication changes including all new orders for new admits will update the paper medication administration records at the time the order is received or confirmed for all current resident and new admits. The Administrator educated the Director of Nursing and the Assistant Director of Nursing on 03/26/2025 that both of them are responsible to print the paper MAR to be ready for the 1st of each month and will be placed by each of the nurse's station. A monthly MAR print out schedule was created for clarity. The education included that the DON and the ADON will confirm that an accurate MAR for all residents is printed and available for use in the event of a forecasted severe storm such as tropical depression, tropical storm, hurricane, or winter snow storm or other reason to expect downtime. A mock drill was conducted on 3/21/25 for the nursing personnel on shift. 2) Assessment Due to the failure of functionality of the router which caused the internet outage in the facility, the facility replaced the router on January 30th, 2025 through its internet provider. On 3/26/25 The entire Medical Record Administration was reprinted in the event of outage and nurses were all educated that any medication changes or new admissions will need to be updated in the paper medical administration records. All residents that had the potential of being affected by this deficient practice from January 21st 2025 to January 22nd 2025. A report was generated from the electronic medical records to see which residents could have been affected during 1/21/25 - 1/22/25. There was a total of 56 of 56 residents were assessed by the medical director and completed on March 26th, 2025. No adverse effects were identified by the physician due to this deficient practice and no recommendations were made. 2) Quality Assurance An ad-hoc Quality Assurance meeting which included the entire IDT team ( Director of Nursing, Administrator, Rehab Director, Business Office Manager, Social Worker Director, Governing Body, Medical Director, Business Office Manager, Assistant Director of Nursing, Staffing Coordinator, Unit Manager, Dietary Director, Admissions Director) was conducted on March 25, 2025 in response to F600, F658, F580, and F760 to discuss the deficient practice and plan of correction. The nurses that were responsible were immediately educated about the in-proper practice that led to F600, F658, F580, and F760 and on the Policy on Computer or Internet Downtime and EHR access. The QA team discussed the needed in services/education for LPN #14, RN #15, LPN #11, RN #20, and RN #16. This plan was completed on March 26th, 2025. ******************************************************* After review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team determined the facility implemented the immediate corrective actions as of 03/26/2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review and review of facility policies titled, Abuse Policy and Policy on Computer or Internet Downtime and EHR (Electronic Health Record) Access, the facility failed to protect the resident's right to be free from neglect when systems were not in place to ensure continuity of care and operations when the facility experienced a forecasted winter storm which caused internet outage preventing access to the EHR system on 01/21/2025 and 01/22/2025. The facility failed to ensure pre-printed paper documentation forms such as physician orders and MARs were available and accessible for the licensed nursing staff to utilize for resident care, treatment, and medication administration prior to the internet outage. The nurses and nurse supervisor on duty during that time failed to ensure residents received medications as ordered by the physician. Residents residing on the second floor and third floor did not receive their medications on 01/21/2025 and 01/22/2025 as ordered. The staff further failed to notify management staff or the residents' physician of their inability to safely administer. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death. The Immediate Jeopardy (IJ) was cited in reference to 483.12 Freedom from Abuse, Neglect, and Exploitation. On 03/25/2025 at 4:15 PM, the Administrator (ADM), the Director of Nursing (DON), the Assistant Director of Nursing (ADON), and Executive Director of Operations were provided a copy of the IJ template and notified of the finding of immediate jeopardy substandard quality of care in the area of Freedom from Abuse, Neglect, and Exploitation at F600- Free from Abuse and Neglect. The IJ began on 01/21/2025 and continued until 03/26/2025 when the facility implemented corrective action to remove the immediacy. On 03/27/2025 the immediate jeopardy was removed, F 600 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficient practice affected all residents at the facility who received medications. This deficiency was cited as the result of the investigation of complaint/report number AL00050173. The facility further failed to protect Resident Identifier (RI) #15's right to be free from verbal abuse perpetrated by Certified Nursing Assistant (CNA) #10. Specifically, on 01/30/2025, the facility failed to ensure RI #15 was not verbally abused by CNA #10, who stated she was tired and frustrated from working a double the day before, and who called RI #15 a stupid mother fucker while providing assistance to RI #15 who needed assistance to stand. RI #15 said, he/she was shocked when CNA #10 spoke to him/her that way. This deficient practice was cited as the result of the investigation of complaint/report number AL00050214 and affected RI #15, one of three residents sampled for abuse, and did not rise to the jeopardy level. Findings Include: 1) Cross-Reference F580, F658 and F760. Review of the facility's policy titled, Abuse Policy, updated 08/2022, revealed the following: Our residents have the right to be free from . neglect . Policy Interpretation and Implementation Definitions . 9. Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident(s) requires but the facility fails to provide them to the resident(s) . Neglect includes cases where the facility's indifference or disregard for resident care, comfort, or safety, resulted in or could have resulted in, physical harm, pain, mental anguish, or emotional distress. Neglect may be the result of a pattern of failures or may be the result of one or more failures involving one resident and one staff person. Examples of individual failures include, but are not limited, to the following: . Failure to provide supervision and/or monitoring of the delivery and implementation of care; . Failure to provide orientation and/or training to staff; Failure to provide trained on . new procedures . required for the care of a specified resident or required due to changes in standards of practice; Failure to oversee the implementation of resident care policies; Failure to identify, assess, and/or contact a physician and/or prescriber for an acute change in condition, and/or a change in condition that require the plan of care to be revised to meet the resident's needs in a timely manner; Failure to implement effective communication systems across all shifts for communicating necessary care and information between staff, practitioners, and resident representatives . On 03/19/2025 at 3:09 PM, a telephone interview was conducted with Licensed Practical Nurse (LPN) #14, the licensed staff member assigned to work the Second Floor (back hall cart) on 01/21/2025 on the 2:00 PM to 10:00 PM shift. LPN #14 said one specific night the computer system at the facility was not working and was down because of a storm. When asked how she passed medications that evening, LPN #14 said she was not able to pass medications. LPN #14 said LPN #11 was the Second Floor supervisor at that time and when she informed LPN #11 that she was not able to pass medications, LPN #11 said she did not know what to do. On 03/21/2025 at 11:33 AM a follow-up interview was conducted with LPN #14 who said she was not aware the facility had paper MARs at the time of the storm on 01/21/2025. On 03/22/2025 at 1:43 PM, a follow-up telephone interview was conducted with LPN #14. LPN #14 said in addition to not being able to pass medications when the internet was down on 01/21/2025, she was not able to perform capillary blood glucose (CBG) monitoring checks because she did not know who needed them. LPN #14 said she did not feel comfortable to administer anything without the MAR. When asked about how many CBG checks she thought she had on her cart, LPN #14 said two to four. On 03/19/2025 at 9:50 AM an interview was conducted with RI #308's family member (FM). The FM said RI #308 did not receive his/her seizure medication as ordered while a resident. The FM said it was concerning because RI #308 had a very short window to take his/her seizure medications. The FM said before RI #308 was admitted to the facility he/she had received all of his/her medications for seizures except for two since his/her accident in 2019. The FM identified LPN #14 as the nurse that did not administer RI #308's medications as ordered. On 03/21/2025 at 11:58 AM, a telephone interview was conducted with Registered Nurse (RN) #15, the licensed staff member assigned to work the Second Floor (front hall cart) on 01/21/2025 on the 6:00 AM to 2:00 PM and 2:00 PM to 10:00 PM shift. RN #15 said she was able to pass medications that morning, but something happened that she could not administer medications that evening. RN #15 said she was hired in January and was not told to use the paper MARs if there was an internet outage. RN #15 said she informed LPN #11 she was not able to administer medications to residents. RN #15 said LPN #11 did not tell her what to do. RN #15 said when the snowstorm occurred back in January 2025, LPN #11 did not inform her to use the residents' paper MARs. On 03/19/2025 at 3:53 PM, a telephone interview was conducted with LPN #11, the LPN supervisor. LPN #11 said she did remember when the facility's computer system went down back in January of 2025 when a snowstorm hit. The surveyor asked LPN #11 if the system was down, how did the residents receive their scheduled medications. LPN #11 said on that shift there were new nurses and nothing could be printed out for the new nurse to use to give the medications by. When asked did the residents receive their medications, LPN #11 said she was not sure. LPN #11 said she did not recall anyone reporting to her that the residents did not get their medications. LPN #11 said there should have been a backup plan in place to ensure the residents received their medications. When asked did the DON and ADM know the system was down, LPN #11 said she could not say yes or no if they knew. On 03/21/2025 at 12:36 PM, a follow-up telephone interview was conducted with LPN #11 who said she could not get into the computer to print the paper MARs to give to the nurses and she could not find the paper MARs in the binder. LPN #11 said she did not recall telling the new nurses about the paper MARs because she could not print them. When asked who would have been responsible for ensuring the paper MARs were in the binder, LPN #11 said the unit manager. LPN #11 said it would be important to ensure the paper MARs were in the binders to make sure the nurses had something to give medications by if there was an internet outage. On 03/24/2025 at 11:16 AM, a telephone interview was conducted with RN #16, the licensed staff member working on the Third Floor on 01/21/2025 on the 2:00 PM to 10:00 PM and 10:00 PM to 6:00 AM shifts; and working on the Second Floor on 01/22/2025 on the 2:00 PM to 10:00 PM and 10:00 PM to 6:00 AM shifts. RN #16 said the paper MARs were kept on the unit near the nurses' station and during the downtime she did not see the paper MARs. When asked did she report to anyone that she could not find the paper MARs, RN #16 said she could not remember if she did or not. RN #16 said if anyone CBG required monitoring such as a sliding scale, she could not provide that because she did not have the paper MAR or eMAR to see who needed CBG checks. When asked what was the rationale for having preprinted MARs, RN #16 said in case of an emergency like the internet going down of if there was a power outage the nurses would have a place to document that the medications had been given. On 03/20/2025 at 4:49 PM an interview was conducted with LPN #18 who recalled that the DON was at home and LPN #11 was the supervisor. LPN #18 said LPN #11 told her to pass medications using the prepackaged medications that had the residents' name, medication name, dosage, and the time it was to be given. LPN #18 said she always checked those things against the MAR as well. LPN #18 said she asked LPN #11 where were the paper MARs and LPN #11 said she did not know. LPN #18 said each floor should have had a book with monthly paper MARs and she thought there should be a policy about that. LPN #18 said there should be something in place for giving medications when there was a power outage or computers go down or anything like that. On 03/22/2025 at 6:26 PM an interview was conducted with RN #17, Unit Manager for the Third Floor. RN #17 said that in preparation for the storm the ADM informed staff that everyone needed to be prepared to come to work if it was safe. RN #17 said when she left around 2 PM she thought the internet was still up. RN #17 said no one informed her that the residents did not get their medications because the internet was down. RN #17 said she did not know how nurses passed medications after the internet went down because she was not there and she did not know who the Supervisor was on those days. RN #17 said staff should have gotten the paper MAR and passed medications from it, and then once the internet was back up the staff should have transferred the information onto the eMAR (Electronic Medication Administration Record). RN #17 had no idea why that was this not implemented when there was an internet outage on 01/21/2025 and 01/22/2025. RN #17 said the Unit Manager or anybody in Administration can place the printed MARs in the binders on each floor. RN #17 said she did not know if the printed MARs were on the Second Floor at the time of the storm, and said they should have been on the Third Floor. On 03/21/2025 at 10:54 AM, an interview was conducted with the DON. The DON said the facility's computer system was run by the internet. The DON said the facility's policy indicated that staff should initiate downtime procedures when the outage is more than 30 minutes. The DON said paper documentation should occur during downtime and this would include the MAR as well. The DON said pre-printed downtime forms should be kept at the nurses' station in the binders behind the nurses station. When asked where would there be evidence these forms were used on 01/21/2025 and 01/22/2025 when the internet was down, the DON said the evidence would be on the paper MAR where the nurses signed their initials. The DON said she had not seen any paper MARs from January 2025 with initials that medications had been administered. The DON said all nurses should have had knowledge of the downtime procedure before 01/21/2025. On 03/22/2025 at 9:42 AM during a follow-up interview with the DON she said she should have been notified when residents did not receive their medications on 01/21/2025 and 01/22/2025. The DON said she would have asked them where was the paper MARs. The DON said anybody, like DON, ADON, unit managers could place the MARs in the book/binders. On 03/23/25 at 4:42 PM a follow-up interview was conducted with the DON. The DON was asked about a previous interview when she stated the ADON, the unit manager or the supervisor could print and place the printed MAR in the binders on the floors, and who would be responsible for verifying the MARs had been printed and placed in the binders. The DON said, no one in particular, it was just a team effort. On 03/21/2025 at 10:23 AM an interview was conducted with the ADM. The ADM said he first became aware during the survey that residents' medications had not been administered during the internet downtime on 01/21/2025 and 01/22/2025. ***************************************************** On 03/26/2025, the facility submitted an acceptable removal plan, which documented: ****************************************************** On January 21st, 2025 in the afternoon, we encountered a major snow storm and our modem was not functioning. Due to the impact of the storm, we were unable to get a technician into the facility to restore the internet until January 22nd, 2025 at approximately 6:00 pm. Unfortunately, the facility failed to ensure residents were free of significant medications when licensed nursing staff failed to administer medications including insulin and other significant medications. Deficiencies The facility failed to protect the resident's right to be free from neglect when systems were not in place to ensure continuity of care and operations when the facility experienced a forecasted winter storm which caused internet outage preventing access to EHR system on 01/21/2025 and 01/22/2025. The facility failed to ensure pre-printed paper documentation forms such as physician orders and MARs were available and accessible for the Licensed Nursing Staff to utilize for resident care, treatment, and medication administration prior to the internet outage. This affected all residents in the facility. The nurses and nurse supervisor on duty during that time failed to ensure residents received medications and treatments as ordered by physician. Residents residing on the second floor and third floor did not receive their medications and treatments on 01/21/2025 and 01/22/2025 as ordered. The staff further failed to notify management staff or the residents' physician of their inability to safely administer medication which contributed to medications and other resident care not being performed for greater than 24 hours. All the residents had the potential to be affected by this deficient practice. 1) Process: To ensure that in the event of a power/internet outage the most updated Medical Record Administration (MAR) will be available for nurses that provide care to the residents: The medication administration Record (MAR) will be printed monthly by the Director of Nursing Assistant Director of Nursing or Unit Manager, by the 1st of each month. The paper MAR will be updated at the time the order is received or confirmed for all current resident and new admits by the RN/LPN who receives the order or confirms the new order for any medication changes including all new orders for new admits. The updated MAR will be located by the nursing stations. All, 100% of LPNs and RNs were in-serviced and completed on March 26th, 2025. Inservice was to ensure nurses know where the paper MAR is located and to update it as soon as a new admission or whenever the physician changes an order in the MAR. 2) In services On 3/20/2025 - 03/26/2025 the Director of Nursing and Assistant Director of Nursing began to educate all nurses, all physical therapy staff and administrative staff (receptionist, Admissions Coordinator, Staffing Coordinator and Human Resources) and provided the education with 1:1 in-service to LPN #14, RN #15, LPN #11, RN #20, and RN #16. The in-services included: a) the policy titled Policy on Computer or Internet Downtime and EHR, b) the standard of practice to: i) administer medication, ii) monitor blood glucose, iii) the implementation of the prescribing physicians' orders iv) the importance of documenting medication administration at the time of administration. c) Inservice included calling the physician as well as notify the Director of Nursing or Designee if staff including nurses are unable to carry out a physician's order. d) Inservice included how it led to neglect and the facility's Abuse Policy titled Abuse Policy. The in-service was completed on March 26th, 2025 for 21 of 21 nurses, 9/9 PT staff, 16/16 of administrative staff. On 3/26/2025, 21 of 21 of the nursing staff were all educated by the Director of Nursing or Assistant Director of Nursing and 1:1 in-service to LPN #14, RN #15, LPN #11, RN #20, and RN #16. The in-service included that a printed MAR will be ready for the 1st of each month. A copy of the paper MAR will be kept at each nurses' station for use during downtime. Education included that RNs and LPNs who receives an order or confirms a new order for any medication changes including all new orders for new admits will update the paper medication administration records at the time the order is received or confirmed for all current resident and new admits. The Administrator educated the Director of Nursing and the Assistant Director of Nursing on 03/26/2025 that both of them are responsible to print the paper MAR to be ready for the 1st of each month and will be placed by each of the nurse's station. A monthly MAR print out schedule was created for clarity. The education included that the DON and the ADON will confirm that an accurate MAR for all residents is printed and available for use in the event of a forecasted severe storm such as tropical depression, tropical storm, hurricane, or winter snow storm or other reason to expect downtime. A mock drill was conducted on 3/21/25 for the nursing personnel on shift. 2) Assessment Due to the failure of functionality of the router which caused the internet outage in the facility, the facility replaced the router on January 30th, 2025 through its internet provider. On 3/26/25 The entire Medical Record Administration was reprinted in the event of outage and nurses were all educated that any medication changes or new admissions will need to be updated in the paper medical administration records. All residents that had the potential of being affected by this deficient practice from January 21st 2025 to January 22nd 2025. A report was generated from the electronic medical records to see which residents could have been affected during 1/21/25 - 1/22/25. There was a total of 56 of 56 residents were assessed by the medical director and completed on March 26th, 2025. No adverse effects were identified by the physician due to this deficient practice and no recommendations were made. 2) Quality Assurance An ad-hoc Quality Assurance meeting which included the entire IDT team ( Director of Nursing, Administrator, Rehab Director, Business Office Manager, Social Worker Director, Governing Body, Medical Director, Business Office Manager, Assistant Director of Nursing, Staffing Coordinator, Unit Manager, Dietary Director, Admissions Director) was conducted on March 25, 2025 in response to F600, F658, F580, and F760 to discuss the deficient practice and plan of correction. The nurses that were responsible were immediately educated about the in-proper practice that led to F600, F658, F580, and F760 and on the Policy on Computer or Internet Downtime and EHR access. The QA team discussed the needed in services/education for LPN #14, RN #15, LPN #11, RN #20, and RN #16. This plan was completed on March 26th, 2025. ******************************************************* After review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team determined the facility implemented the immediate corrective actions as of 03/26/2025. ******************************************************** 2.) Cross reference F609, F610, F745, F867, and F943. On 01/30/2025 at 3:04 PM, the State Agency (SA) received an Online Incident Report (FRI) from the facility alleging RI #15 was verbally abused by CNA #10 after RI #15 reported to Licensed Physical Therapy Assistant (LPTA) #7 that a CNA had been mean to him/her (RI #15) and called him/her (RI #15) a Stupid Motherfucker. The FRI documented the LPTA became aware of the incident at 10:50 AM and the ADM was made aware of the incident at 11:20 AM, more than three hours before the SA was informed. The FRI report further documented the CNA had been rough with RI #15's legs, RI #15 was not hurt, but was scared of that CNA. The FRI documented actions taken included suspending CNA #10 pending the investigation, calling the mental health nurse to review, and initiating abuse and customer service in-services. The FRI also included that RI #15 was no longer scared since the CNA was gone. Further review of the facility's Abuse Policy, revealed the following: Our residents have the right to be free from abuse . To help with recognition of incidents of abuse, the following definitions of abuse are provided: 1. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. 2. Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents . within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability. RI #15 was readmitted to the facility on [DATE] and had diagnoses to include: Cellulitis of Left and Right Lower Limb, Need for Assistance with Personal Care, Abnormalities of Gait and Mobility, Hemiplegia and Hemiparesis following Cerebral Infarction. RI #15's Significant Change in Status Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 12/24/2024 revealed a Brief Interview for Mental Status (BIMS) score of 12 of 15 which indicated moderately impaired cognition. The facility investigative file contained a summary of the incident involving RI #15 and CNA #10, dated 02/06/2025, signed by the Administrator (ADM) that documented: . (RI #15) alleged that . (CNA #10), cursed (him/her) out and was rough with (his/her) legs . After discussing the allegation . we suspended the C.N.A. pending investigation. Based on the statements and interviews with staff . we have concluded (CNA #10) did curse (RI #15) . going to substantiate the allegation of verbal abuse in this instance. We have initiated abuse in-services for all staff. We are going to terminate the C.N.A. The facility investigative file contained a form titled DIVERSICARE PERSONNEL CHANGE/TERMINATION FORM dated 02/07/2025 for CNA #10 with a reason for termination of abuse. CNA #10's facility time sheet indicated CNA #10 had not worked at the facility since she was clocked out at 12:48 PM on 01/30/2025. On 03/18/2025 at 10:25 AM, an interview was conducted with RI #15. RI #15 told the surveyor CNA #10 came into his/her room on 01/30/2025 to get him/her dressed told him/her to get up and stand up you stupid mother fucker, get up you are going to stand today. RI #15 said, he/she fell back in the bed and CNA #10 called him/her a stupid mother fucker again. RI #15 said, he/she did not care for the CNA to be in his/her room. RI #15 said, CNA #10 told him/her during the incident that she had a bad day the day before. During a follow up interview on 03/22/2025 at 12:24 PM, the surveyor asked RI #15 how it made him/her feel when CNA #10 called him/her a stupid motherfucker. RI #15 stated, stunned and shocked. Contained within the facility's investigative file was a handwritten statement signed by CNA #10 dated 01/30/2025, which documented she was tired and frustrated at the time RI #15 was verbally abused, as follows: I (CNA #10's name) went to (RI #15's) room to change (him/her) to get (him/her) up for activities . I said a few words like I was tired from . doing a double on the previous shift from the day before and I wasn't directly saying it to (RI#15) just whisper it under my breath due to the frustration . Unsuccessful attempts were made to contact CNA #10 during the survey. Contained within the facility's investigative file was a handwritten statement given by the LPTA dated 01/30/2025 at 10:50 AM, which documented the following: Entered (RI #15's room number) and asked (RI #15) how (he/she) was feeling today. (He/She) responded, I'm being abused. That lady called me a 'stupid mother fucker.' When asked who called (him/her) that, (he/she) stated that it was a CNA. On 03/19/2025 at 3:49 PM, in an interview with the LPTA she stated, on 01/30/2025 RI #15 told her that a CNA called him/her a mother fucker. The LPTA stated, RI #15 appeared to be mad. The LPTA stated, she reported to her supervisor the Therapy Director (TD) and the ADM. When asked what type of abuse this would be considered, she stated it would be verbal and emotional. During an interview on 03/19/2025 at 3:31 PM with the TD she stated, she was notified of the allegation on 01/30/2025 by the LPTA who stated RI #15 told her that a CNA used aggressive language toward him/her. The TD stated she had the LPTA to write out a statement and notified the ADM. When asked what type of abuse this would be considered the TD stated verbal. Contained within the facility's investigative file was a handwritten statement given by CNA #8 dated 12/30/25, which documented the following: Today (RI #15) said to me after I walked into (his/her) room because (CNA #10) stormed out heated that she was getting a attitude with (him/her) and calling (him/her) names because (he/she) didn't stand up . An interview was conducted on 03/19/2025 at 4:16 PM, with CNA #8. CNA #8 stated that she went into RI #15's room and he/she told her that CNA #10 called him/her a stupid mother fucker. Contained within the facility's investigative file was a written statement given by CNA #9 dated 01/30/2025, which documented the following: I walked (room number of RI #15) to help (him/her) get up and (he/she) said (CNA #10) left (him/her) and was mean to (him/her) and called (him/her) a dumb mother fucker. A telephone interview was conducted on 03/19/2025 at 04:32 PM, with CNA #9. CNA #9 stated that on 01/30/2025 that she and CNA #8 were in RI #15's room providing personal care and that he/she told her a CNA was rude, nasty and called him/her a mother fucker. CNA #9 stated this was verbal abuse. Contained within the facility's investigative file was a handwritten statement signed by the ADM dated 01/30/2025 when he interviewed RI #15, which documented the following: . I asked (RI #15) who was treating (him/her) bad and (he/she) replied (CNA #10). I asked what was said and (CNA #10) called me a stupid motherfucker . I asked (him/her) if (he/she) was scared (he/she) stated yes of her (CNA #10) . During an interview on 03/20/2025 at 11:32 AM the ADM stated he became aware of the allegation of abuse involving RI #15 on 01/30/2025 at about 11:20 AM by the TD. The ADM stated, the TD was told by the LPTA that CNA #10 called RI #15 a stupid mother fucker. The ADM stated, he initiated an investigation. The ADM stated RI #15 told him that CNA #10 called him/her a stupid mother fucker. The ADM said this allegation was substantiated and it would be considered verbal abuse.

Based on interviews, record review, review of facility policies titled Administering Medications, and Policy on Computer or Internet Downtime and EHR (Electronic Health Record) Access, the facility failed to ensure Licensed Practical Nurse (LPN) #14, Registered Nurse (RN) #15, RN #16, RN #20, and LPN #18 followed standards of practice and facility's policies. Specifically, LPN #14 and RN #15 failed to follow standards of practice to administer medications and perform Capillary Blood Glucose (CBG) monitoring as ordered by the physician on 01/21/2025 during the 2 PM to 10 PM shift on the Second Floor. The nurses did not notify the residents' physician, DON, or the Administrator that medications were not being administered and CBG checks were not being performed. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death. The Immediate Jeopardy (IJ) was cited in reference to 483.21 Comprehensive Resident Centered Care Plan. On 03/25/2025 at 4:15 PM, the Administrator (ADM), the DON, the Assistant Director of Nursing (ADON), and Executive Director of Operations were provided a copy of the IJ template and notified of the finding of immediate jeopardy in the area Comprehensive Resident Centered Care Plan at F658-Services Provided Meet Professional Standards. The IJ began on 01/21/2025 and continued until 03/26/2025 when the facility implemented corrective action to remove the immediacy. On 03/27/2025 the immediate jeopardy was removed, F658 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. In addition, RN #20 and RN #16 failed to follow standards of practice when they administered medications using the pre-packaged medications without following the rights of medication administration to verify the physician's order. RN #20 and RN #16 did not document that they administered the residents' medications at the time of administration or when the EHR system was restored. Further LPN #18 failed to administer and document medication administration per standards of practice and facility's policy. This affected residents on the Second and Third Floors who were received medications at the facility, 48 of 52 residents who resided at the facility on 01/21/2025 and 01/22/2025. This deficiency was cited as the result of the investigation of complaint/report number AL00050173. Findings Include: Cross-Reference F580, F600 and F760. Review of an undated facility policy titled, Policy on Computer or Internet Downtime and EHR (Electronic Health Record) Access, revealed the following: Purpose To establish procedures for maintaining continuity of care and operations when the facility experiences a computer or internet outage that prevents access to the Electronic Health Record (EHR) system . Procedures 1. Notification Process . If the outage is expected to last more the 30 minutes, staff will initiate downtime procedures. 2. Documentation During Downtime Paper documentation will be used for all resident care activities, including but not limited to: Medication Administration Records (MARs) . 3. Medication Administration Nurses will refer to printed MARs/TARs (Treatment Administration Records) or previously printed backup records if available . 4. Restoring EHR Data Once systems are restored, all paper documentation must be entered into the EHR system as soon as possible . Nursing and administrative staff will verify that all data has been accurately transferred before discounting paper documentation . The facility policy titled, Administering Medications, with a revised date of 04/2019, revealed the following: Policy Statement Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation . 4. Medications are administered in accordance with prescriber orders, including any required time frames . 7. Medications are administered within (1) hour of their prescribed time . 10. The individual administering the medication check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication . 23. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. The date and time the medication was administered; b. The dosage; c. The route of administration . g. The signature and title of the person administering the drug . A review of the facility's Midnight Census Report documented a facility census of 52 residents on 01/21/2025 with 27 residents on the Second Floor and 25 residents on the Third Floor. Second Floor The DAILY ASSIGNMENT SHEET indicated that LPN #14 was assigned the Second Floor back hall medication cart 01/21/2025 on the 2 PM to 10 PM shift. On 03/22/2025 at 1:43 PM, a telephone interview was conducted with LPN #14, who said on 01/21/2025 she could not pass medications because the internet was down, and she did not have the MARs to see what needed to be done. LPN #14 said she did not check residents CBG either during that time. LPN #14's assigned residents' MARs and physician orders were reviewed. The review revealed that 12 residents including RI #4, 35, 12, 38, 7, 21, 2, 52, 158, 6, 308, and 30 had scheduled medications that were not administered during the 01/21/2025 2 PM to 10 PM shift. A total of 85 doses of residents' medications were not administered, and 2 residents missed CBG checks as ordered during her shift on 01/21/2025. Medications not administered included, but not limited to, Metformin, Symbiotic Inhalation, Novolin Insulin, and Memantine Tablet. The DAILY ASSIGNMENT SHEET indicated that RN #15 was assigned the Second Floor front hall medication cart 01/21/2025 on the 2 PM to 10 PM shift. On 03/22/2025 at 2:40 PM during an interview with RN #15, she indicated she worked the Second Floor on 01/21/2025 from 6 AM to 10 PM. RN #15 said she could not administer medications during the 2 PM to 10 PM shift as ordered because the computers were not working. RN #15 said she reported that she was unable to administer medications to the Supervisor at the facility, LPN #11. RN #15 said she was unable to administer any medications except controlled pain medications upon resident's request. RN #15 said she did not check anyone's CBG because the computer was down. RN #15's assigned resident MARs and physician orders were reviewed. The review revealed 13 residents including RI #3, 56, 31, 27, 32, 17, 51, 20, 34, 46, 24, 159, and 15 had scheduled medications that were not administered during the 01/21/2025 2 PM to 10 PM shift. A total of 77 doses of residents' medications were not administered as ordered, and 2 residents missed CBG checks during RN #15's shift on 01/21/2025. Medications not administered included, but not limited to, Tamiflu Capsule, Carvedilol, Valproic Acid, Remeron, Hydralazine, Metoprolol Tartrate, Insulin Lispro, and Dilantin Capsule. On 03/19/2025 at 3:53 PM, during a telephone with LPN #11, she said on 01/21/2025 the computer system went down and there were new nurses working. LPN #11 continued to say the facility did not print MARs for the new nurses to use to administer residents' medications. LPN #11 said the physician orders were not being followed if the residents do not get their medications. The DAILY ASSIGNMENT SHEET indicated that RN #20 was assigned both medication carts on the Second Floor on 01/22/2025 on the 6 AM to 2 PM shift. On 03/22/2025 at 5:14 PM an interview was conducted with RN #20. Regarding medication administration on 01/22/2025, RN #20 said she administered medications using the prepacked medications that were labeled with resident's name, medication, dose, and time it was due. RN #20 said residents who had orders for over-the-counter (OTC) or stock medication would not have received those medications without the printed MARs because those medications were not prepackaged. RN #20 said she was able to check residents' CBG because she had a report sheet. RN #20 said she was unable to document anything in the residents' medical records. The DAILY ASSIGNMENT SHEET indicated that RN #16 was assigned to both medication carts on the Second Floor on 01/22/2025 on the 2 PM to 10 PM shift and 10 PM to 6 AM shift. On 03/22/2025 at 5:47 PM an interview was conducted with RN #16 who worked on the Third Floor on 01/21/2025 and Second Floor on 01/22/2025. RN #16 said she also used the prepackaged medications to administer medications during her shifts and was unable to document medication administration because she did not have paper MARs. RN #16 said if anyone required CBG monitoring such as a sliding scale, she could not have administered it, because the facility did not have the paper MAR or eMAR. RN #16 said she could administer residents with scheduled doses of insulin because she knew which residents were routine. Residents' who resided on the Second Floor MARs and physician's orders were reviewed. The reviews revealed 4 residents with orders for CBG monitoring and 25 residents had medications that were not documented as administered on 01/22/2025. A total 410 doses of residents' medication were not documented as administered on 01/22/2025 between all shifts. Medications not administered included, but not limited to, sliding scale insulin and OTC medications such as Aspirin, Multivitamins, Colace, and Miralax. Third Floor The DAILY ASSIGNMENT SHEET indicated that RN #16 was assigned to administer medications on the Third Floor on 01/21/2025 on the 2 PM to 10 PM shift and 10 PM to 6 AM shift. RN #16's assigned residents' MARs and physician's orders were reviewed and revealed that 21 residents including RI #36, 37, 45, 25, 39, 29, 44, 161, 48, 47, 23, 22, 19, 43, 162, 50, 33, 9, 42, 14, and 40 had scheduled medications that had not been documented as administered on 01/22/2025 during the 2 PM to 10 PM shift. A total of 68 doses of residents' medications were not documented as administered and 3 residents CBG checks were not documented as completed during RN #16's shift on 01/21/2025. Medications not documented as administered included Eliquis, Insulin Detemir, Metoprolol Succinate Extended Release, Multivitamin tablets, Docusate Sodium, and Miralax. Further review of Third Floor residents MARs and physician's orders revealed 5 residents including RI #36, 19, 2, 59, and 33 had scheduled medications that were not documented as administered on 01/22/2025 at 6:00 AM. A total of a total of 36 doses of residents' medications were not documented as administered on 01/22/2025 at 6:00 AM. Medications that were not documented as administered included, but not limited to, Amlodipine Besylate, Cymbalta, Ferrous Sulfate, Tamsulosine, and Telmisartan. The DAILY ASSIGNMENT SHEET indicated that LPN #18 was assigned to administer medications on the Third Floor on 01/22/2025 on the 6 AM to 2 PM shift and 2 PM to 10 PM shift. On 03/20/2025 at 4:49 PM, an interview was conducted with LPN #18 who said she used her cellular hotspot to connect to the internet so she could administer residents' medications and document on their eMAR (Electronic Medication Administration Record). LPN #18 said the evidence that the resident had received their medications as ordered by the physician would be the initials on eMAR. LPN #18 said the physician orders were not followed if the residents did not receive their medications. When asked why it would be important for residents to receive their medications as ordered by the physician, LPN #18 said because residents need to get their medications. LPN #18 said if residents do not get their seizure medications, they might have a seizure, if they did not get their blood pressure medication their blood pressure might go up or down. LPN #18's assigned residents' MARs and physician's orders were reviewed. The review revealed 10 residents including RI #25, 47, 22, 19, 50, 33, 9, 42, 14, and 40 had medications that were not documented as administered and 1 resident had CBG ordered, but not documented on 01/22/2025 during LPN #18's shift. Medications not documented as administered included, but not limited to, Insulin Detemir, Docusate Sodium, Lisinopril, Memantine, and Metoprolol Succinate Oral Capsule Extended Release (ER). On 03/22/2025 at 9:42 AM the DON was interviewed. The DON said she was not notified that residents' medications were not administered on 01/21/2025. The DON said she had not been able to locate the January 2025 paper MARS. The DON said the possibility of things that could have occurred when residents did not receive their medications as ordered by the physician depended on the medication. The DON said if it was a blood pressure (BP) medication not given, the BP may go up or down, if insulin was not administered hypo- or hyperglycemia may occur. On 03/25/2025 at 12:00 PM a follow-up interview was conducted with the DON who was asked, when should a nurse not administer medication as ordered and not notify the facility's DON or the person in charge that they were not able to administer medications. The DON responded never. The DON was asked, when should a nurse administer the pre-packaged medications and not document medications as administered. The DON responded, never. On 03/21/2025 at 10:23 AM an interview was conducted with the Administrator (ADM) who said he was notified the internet was not working, but not notified that staff were not administering medications as ordered. The ADM said he instructed staff to use the paper MARs. The ADM said he was not aware residents' medications had not been administered as ordered until the current survey. ********************************************************* On 03/26/2025, the facility submitted an acceptable removal plan, which documented: ********************************************************** 1) Process: To ensure that in the event of a power/internet outage the most updated Medical Record Administration (MAR) will be available for nurses that provide care to the residents: The medication administration Record (MAR) will be printed monthly by the Director of Nursing Assistant Director of Nursing or Unit Manager, by the 1st of each month. The paper MAR will be updated at the time the order is received or confirmed for all current resident and new admits by the RN/LPN who receives the order or confirms the new order for any medication changes including all new orders for new admits. The updated MAR will be located by the nursing stations. All, 100% of LPNs and RNs were in-serviced and completed on March 26th, 2025. Inservice was to ensure nurses know where the paper MAR is located and to update it as soon as a new admission or whenever the physician changes an order in the MAR. 2) In services On 3/20/2025 - 03/26/2025 the Director of Nursing and Assistant Director of Nursing began to educate all nurses, all physical therapy staff and administrative staff (receptionist, Admissions Coordinator, Staffing Coordinator and Human Resources) and provided the education with 1:1 in-service to LPN #14, RN #15, LPN #11, RN #20, and RN #16. The in-services included: a) the policy titled Policy on Computer or Internet Downtime and EHR, b) the standard of practice to: i) administer medication, ii) monitor blood glucose, iii) the implementation of the prescribing physicians' orders iv) the importance of documenting medication administration at the time of administration. c) Inservice included calling the physician as well as notify the Director of Nursing or Designee if staff including nurses are unable to carry out a physician's order. d) Inservice included how it led to neglect and the facility's Abuse Policy titled Abuse Policy. The in-service was completed on March 26th, 2025 for 21 of 21 nurses, 9/9 PT staff, 16/16 of administrative staff. On 3/26/2025, 21 of 21 of the nursing staff were all educated by the Director of Nursing or Assistant Director of Nursing and 1:1 in-service to LPN #14, RN #15, LPN #11, RN #20, and RN #16. The in-service included that a printed MAR will be ready for the 1st of each month. A copy of the paper MAR will be kept at each nurses' station for use during downtime. Education included that RNs and LPNs who receives an order or confirms a new order for any medication changes including all new orders for new admits will update the paper medication administration records at the time the order is received or confirmed for all current resident and new admits. The Administrator educated the Director of Nursing and the Assistant Director of Nursing on 03/26/2025 that both of them are responsible to print the paper MAR to be ready for the 1st of each month and will be placed by each of the nurse's station. A monthly MAR print out schedule was created for clarity. The education included that the DON and the ADON will confirm that an accurate MAR for all residents is printed and available for use in the event of a forecasted severe storm such as tropical depression, tropical storm, hurricane, or winter snow storm or other reason to expect downtime. A mock drill was conducted on 3/21/25 for the nursing personnel on shift. 2) Assessment Due to the failure of functionality of the router which caused the internet outage in the facility, the facility replaced the router on January 30th, 2025 through its internet provider. On 3/26/25 The entire Medical Record Administration was reprinted in the event of outage and nurses were all educated that any medication changes or new admissions will need to be updated in the paper medical administration records. All residents that had the potential of being affected by this deficient practice from January 21st 2025 to January 22nd 2025. A report was generated from the electronic medical records to see which residents could have been affected during 1/21/25 - 1/22/25. There was a total of 56 of 56 residents were assessed by the medical director and completed on March 26th, 2025. No adverse effects were identified by the physician due to this deficient practice and no recommendations were made. 2) Quality Assurance An ad-hoc Quality Assurance meeting which included the entire IDT team ( Director of Nursing, Administrator, Rehab Director, Business Office Manager, Social Worker Director, Governing Body, Medical Director, Business Office Manager, Assistant Director of Nursing, Staffing Coordinator, Unit Manager, Dietary Director, Admissions Director) was conducted on March 25, 2025 in response to F600, F658, F580, and F760 to discuss the deficient practice and plan of correction. The nurses that were responsible were immediately educated about the in-proper practice that led to F600, F658, F580, and F760 and on the Policy on Computer or Internet Downtime and EHR access. The QA team discussed the needed in services/education for LPN #14, RN #15, LPN #11, RN #20, and RN #16. This plan was completed on March 26th, 2025. ******************************************************** After review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team determined the facility implemented the immediate corrective actions as of 03/26/2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of a facility policy titled Administering Medications the facility failed to ensure residents were free of significant medication errors when licensed nursing staff failed to administer medications including insulin and other significant medications. Specifically, on 01/21/2025 during a forecasted snowstorm the facility lost internet connection sometime after lunch which resulted in inability to access residents Electronic Health Record (EHR)/Electronic Medication Administration Record (eMAR) until the evening of 01/22/2025. Resident Identifier (RI) #12, RI #15, RI #30, and RI #308 were not administered significant medications from 01/21/2025 at 5:00 PM until 01/22/2025 at 9:00 PM. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death. The Immediate Jeopardy (IJ) was cited in reference to 483.45 Pharmacy Services. On 03/25/2025 at 4:15 PM, the Administrator (ADM), the DON, the Assistant Director of Nursing (ADON), and Executive Director of Operations were provided a copy of the IJ template and notified of the finding of immediate jeopardy substandard quality of care in the area of Pharmacy Services at F 760-Residents are Free of Significant Med Errors. The IJ began on 01/21/2025 and continued until 03/26/2025 when the facility implemented corrective action to remove the immediacy. On 03/27/2025 the immediate jeopardy was removed, F760 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficient practice affected RI #12, 15, 30 and 308, four of four residents reviewed for significant medication errors. This deficiency was cited as the result of the investigation of complaint/report number AL00050173. Findings Include: Cross-Reference F580, F600, and F658. Review of the facility's policy titled, Administering Medications, with a revised date of 04/2019, revealed the following: Policy Statement Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation . 4. Medications are administered in accordance with prescriber orders, including any required time frame . 7. Medications are administered within one (1) hour of their prescribed time . 22. The individual administering the medication initials the resident's MAR . after giving each medication . RI #12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis to include Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease and Hyperglycemia. RI #12 resided on the Third Flood of the facility. RI #12's January 2025 Order Summary Report (Physicians Orders) revealed RI #12 had orders for: sliding scale Insulin Aspart Injection Solution subcutaneous four times a for hyperglycemia related to Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease; and 6 units of Novolin N FlexPen Subcutaneous Suspension Pen-Injection subcutaneously at bedtime related to Type 2 Diabetes Mellitus with Other Specific Complication. A review of RI #12's January 2025 eMAR revealed RI #12's Insulin Aspart injection per sliding scale was not administered on 01/21/2025 at 5:00 PM, 01/21/2025 at 9:00 PM, 01/22/2025 at 7:30 AM, 01/22/2025 at 11:30 AM, 01/22/2025 at 5:00 PM, and 01/22/2025 at 9:00 PM. The eMAR further revealed Novolin N 6 units was not administered to RI #12 on 01/21/2025 at 9:00 PM and 01/22/2025 at 9:00 PM. On 03/22/2025 at 5:47 PM an interview was conducted with RN #16. During the interview RN #16 said she worked on the Third Floor on the 2 PM to 10 PM and 10 PM to 6 AM shift on 01/21/2025. RN #16 said if anyone required blood glucose monitoring such as a sliding scale, she could not have administered it, because the facility did not have the paper MAR or eMAR while the internet was down. RN #16 said she could administer residents with scheduled doses of insulin because she knew which residents were routine. On 03/20/2025 at 4:49 PM an interview was conducted with Licensed Practical Nurse (LPN) #18 who reported she worked on the Third Floor on the 6 AM to 2 PM and 2 PM to 10 PM shifts on 01/22/2025. She reported when the facility lost internet that she connected to a hotspot and passed medications as ordered. RI #15 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include Type 2 Diabetes Mellitus, Localization-Related (Focal) (Partial) Symptomatic Epilepsy, and Essential (Primary) Hypertension. RI #15 resided on the Second Floor of the facility. RI #15's January 2025 Physicians Orders revealed RI #15 had orders for Carvedilol 25 mg two times a day related to Hypertension, Hydralazine 50 mg two times a day related to Hypertension, Insulin Glargine 30 units subcutaneous in the evening related to Diabetes, Lacosamide 50 mg two times a day related to Seizures, and Insulin Lispro per sliding scale before meals related to Diabetes. A review of RI #15's January 2025 eMAR revealed RI #15's was not administered: Hydralazine 50 milligram (mg) 01/21/2025 at 5:00 PM, 01/22/2025 at 8:00 AM, and 01/22/2025 at 5:00 PM; Lacosamide 50 mg on 01/21/2025 at 5:00 PM, 01/22/2025 at 8:00 AM, and 01/22/2025 at 5:00 PM; Carvedilol 25 mg on 01/21/2025 at 8:00 PM, 01/22/2025 at 8:00, and 01/22/2025 at 8:00 PM; Glargine Insulin 30 units on 01/21/2025 at 5:00 PM and 01/22/2205 at 5:00 PM; and Insulin Lispro sliding scale on 01/21/2025 at 4:00 PM, 01/22/2025 at 7:30 AM, 01/22/2025 at 11:00 AM and 01/22/2025 at 4:00 PM. RI #30 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include Type 2 Diabetes Mellitus with Diabetic Neuropathy, Chronic Diastolic (Congestive) Heart Failure, Essential Hypertension, Atherosclerotic Heart Disease of Native Coronary Artery, and Long Term (Current) Use of Insulin. RI #30 resided on the Second Floor. RI #30's January 2025 Physicians Orders revealed RI #30 had orders for blood glucose monitoring twice a day related to Type 2 Diabetes, Carvedilol 12.5 mg every morning and at bedtime for Beta Blockers, Furosemide 40 mg two times a day for Diuretics, Novolog 8 units before meals related to Type 2 Diabetes, and Rivaroxaban 2.5 mg two times a day for Anticoagulants. A review of RI #30's January 2025 eMAR revealed RI #30 was not administered: Lasix 40 mg 01/21/2025 at 5:00 PM, 01/22/2025 at 8:00 AM, 01/22/2025 at 5:00 PM; Rivaroxaban 2.5 mg 01/21/2025 at 5:00 PM, 01/22/2025 at 8:00 AM, 01/22/2025 at 5:00 PM; Coreg 12.5 mg 01/21/2025 at 8:00 PM, 01/22/2025 at 8:00 AM, 01/22/2025 at 8:00 PM; Novolog 8 units on 01/21/2025 at 4:00 PM, 01/21/2025 at 9:00 PM, 01/22/2025 at 7:30 AM, 01/22/2025 at 11:00 AM, 01/22/2025 at 4:00 PM, and 01/22/2025 at 9:00 PM. RI #30's January 2025 eMAR also indicated his/her blood glucose was not monitored on 01/21/2025 at 5:00 PM, 01/22/2025 at 8:00 AM, or on 01/22/2025 at 5:00 PM. RI #308 was admitted to the facility on [DATE] and discharged on 01/29/2025. RI #308 had diagnoses that included Epilepsy, Unspecified, Conversion Disorder with Seizures or Convulsions and Localization-Related (Focal) (Partial) Symptomatic Epilepsy and Epileptic Syndrome with Complex Partial Seizures. RI #308 resided on the Second Floor. RI #308's January 2025 Physicians Orders revealed RI #308 had orders for Clobazam 10 mg two times a day for Anticonvulsants, Lacosamide 50 mg two times a day for Anticonvulsants, Lamotrigine 100 mg two times a day for Anticonvulsants, Oxcarbazepine 300 mg two times a day for Anticonvulsant, and Topiramate 300 mg two times a day for Anticonvulsant. A review of RI #308's January 2025 eMAR revealed RI #308 was not administered his/her: Clobazam 10 mg on 01/21/2025 at 5:00 PM, 01/22/2025 at 8:00 AM, and 01/22/2025 at 5:00 PM; Lacosamide 50 mg on 01/21/2025 at 5:00 PM, 01/22/2025 at 8:00 AM, and 01/22/2025 at 5:00 PM; Lamotrigine 100 mg on 01/21/2025 at 5:00 PM, 01/22/2025 at 8:00 AM, and 01/22/2025 at 5:00 PM; Oxcarbazepine 300 mg on 01/21/2025 at 5:00 PM, 01/22/2025 at 8:00 AM, and 01/22/2025 at 5:00 PM; Topiramate 300 mg on 01/21/2025 at 5:00 PM, 01/22/2025 at 8:00 AM, and 01/22/2025 at 5:00 PM. On 03/25/2025 at 11:05 AM an interview was conducted with RI #308 who said he/she was scheduled to receive medications for seizures twice a day. RI #308 said there was a few shifts that he/she did not receive any of his/her medications. On 03/21/2025 at 11:58 AM an interview was conducted with Registered Nurse (RN) #15. RN #15 reported she worked a double shift from 6 AM to 10 PM on 01/21/2025 on the Second Floor. RN #15 said something happened during the evening shift on 01/21/2025 and she was unable to pass any medications because she did not have access to residents' eMAR. On 03/22/2025 at 1:43 PM an interview was conducted with LPN #14 who reported she worked a double shift from 6 AM to 10 PM on 01/21/2025 on the Second Floor and was assigned to RI #15's rooms for medication passes. LPN #14 reported that RN #15 was assigned to RI #30 and RI #308's medication passes. LPN #14 said the facility's internet stopped functioning around 2 PM on 01/21/2025. LPN #14 said she was unable to access residents' eMAR. RN #15 said she did not administer medications or monitor resident blood glucose because the internet was down. LPN #14 said she did not know who needed their blood glucose checked off the top of her head, so she did not check. On 03/25/2025 at 1:32 PM, a telephone interview was conducted with the Medical Director (MD) and RI #12, 308, 40 and 15's physician. Regarding RI #12's missed medications the MD said, the likelihood of harm was that resident's blood sugars could go up if a resident did not receive their scheduled insulin and their blood sugars were not monitored as ordered. The MD said other things that could result from a person not receiving their insulin and not having their blood sugars checked as ordered would be short term DKA (Diabetic Ketoacidosis) and being placed on an insulin drip if blood sugars were too high. Regarding RI #308's missed medications, the MD said there was a likelihood of reoccurrence of seizures if a resident did not receive their seizure medications as ordered. Regarding RI #40's missed medications, the MD said a person with a history of diabetes, hypertension and stroke, and congestive heart failure not receiving their scheduled medications as ordered could cause their blood sugars to go up, fluid retention, and reoccurrence of heart failure. Regarding RI #15's missed medications the MD was asked, what was likely to occur if a resident did not receive their insulin, blood pressure, and seizure medications as ordered. The MD said there could be a reoccurrence of seizures, elevated blood pressures, and a person's blood sugars could go up. ******************************************************* On 03/26/2025, the facility submitted an acceptable removal plan, which documented: ****************************************************** 1) Process: To ensure that in the event of a power/internet outage the most updated Medical Record Administration (MAR) will be available for nurses that provide care to the residents: The medication administration Record (MAR) will be printed monthly by the Director of Nursing Assistant Director of Nursing or Unit Manager, by the 1st of each month. The paper MAR will be updated at the time the order is received or confirmed for all current resident and new admits by the RN/LPN who receives the order or confirms the new order for any medication changes including all new orders for new admits. The updated MAR will be located by the nursing stations. All, 100% of LPNs and RNs were in-serviced and completed on March 26th, 2025. Inservice was to ensure nurses know where the paper MAR is located and to update it as soon as a new admission or whenever the physician changes an order in the MAR. 2) In services On 3/20/2025 - 03/26/2025 the Director of Nursing and Assistant Director of Nursing began to educate all nurses, all physical therapy staff and administrative staff (receptionist, Admissions Coordinator, Staffing Coordinator and Human Resources) and provided the education with 1:1 in-service to LPN #14, RN #15, LPN #11, RN #20, and RN #16. The in-services included: a) the policy titled Policy on Computer or Internet Downtime and EHR, b) the standard of practice to: i) administer medication, ii) monitor blood glucose, iii) the implementation of the prescribing physicians' orders iv) the importance of documenting medication administration at the time of administration. c) Inservice included calling the physician as well as notify the Director of Nursing or Designee if staff including nurses are unable to carry out a physician's order. d) Inservice included how it led to neglect and the facility's Abuse Policy titled Abuse Policy. The in-service was completed on March 26th, 2025 for 21 of 21 nurses, 9/9 PT staff, 16/16 of administrative staff. On 3/26/2025, 21 of 21 of the nursing staff were all educated by the Director of Nursing or Assistant Director of Nursing and 1:1 in-service to LPN #14, RN #15, LPN #11, RN #20, and RN #16. The in-service included that a printed MAR will be ready for the 1st of each month. A copy of the paper MAR will be kept at each nurses' station for use during downtime. Education included that RNs and LPNs who receives an order or confirms a new order for any medication changes including all new orders for new admits will update the paper medication administration records at the time the order is received or confirmed for all current resident and new admits. The Administrator educated the Director of Nursing and the Assistant Director of Nursing on 03/26/2025 that both of them are responsible to print the paper MAR to be ready for the 1st of each month and will be placed by each of the nurse's station. A monthly MAR print out schedule was created for clarity. The education included that the DON and the ADON will confirm that an accurate MAR for all residents is printed and available for use in the event of a forecasted severe storm such as tropical depression, tropical storm, hurricane, or winter snow storm or other reason to expect downtime. A mock drill was conducted on 3/21/25 for the nursing personnel on shift. 2) Assessment Due to the failure of functionality of the router which caused the internet outage in the facility, the facility replaced the router on January 30th, 2025 through its internet provider. On 3/26/25 The entire Medical Record Administration was reprinted in the event of outage and nurses were all educated that any medication changes or new admissions will need to be updated in the paper medical administration records. All residents that had the potential of being affected by this deficient practice from January 21st 2025 to January 22nd 2025. A report was generated from the electronic medical records to see which residents could have been affected during 1/21/25 - 1/22/25. There was a total of 56 of 56 residents were assessed by the medical director and completed on March 26th, 2025. No adverse effects were identified by the physician due to this deficient practice and no recommendations were made. 2) Quality Assurance An ad-hoc Quality Assurance meeting which included the entire IDT team ( Director of Nursing, Administrator, Rehab Director, Business Office Manager, Social Worker Director, Governing Body, Medical Director, Business Office Manager, Assistant Director of Nursing, Staffing Coordinator, Unit Manager, Dietary Director, Admissions Director) was conducted on March 25, 2025 in response to F600, F658, F580, and F760 to discuss the deficient practice and plan of correction. The nurses that were responsible were immediately educated about the in-proper practice that led to F600, F658, F580, and F760 and on the Policy on Computer or Internet Downtime and EHR access. The QA team discussed the needed in services/education for LPN #14, RN #15, LPN #11, RN #20, and RN #16. This plan was completed on March 26th, 2025. ******************************************************** After review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team determined the facility implemented the immediate corrective actions as of 03/26/2025.

Based on interviews and review of the Administrator job description, the facility's Administrator, responsible for the day-to-day operation of the facility failed to ensure the QAPI (Quality Assurance and Performance Improvement) committee met to identify all concerns using root cause analysis to ensure corrective actions needed with plans to prevent further occurrence including ongoing monitoring after Resident Identifier (RI) #1 eloped from the facility on 02/05/2023. This failure placed all 53 residents residing in the facility at risk for immediate jeopardy, as it was likely to result in serious injury, serious harm, serious impairment, or death, due to the ongoing risk of elopement. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, §483.70 Administration at a scope and severity of L. On 04/06/2024 at 12:44 PM, the Director of Nursing (DON), Owner, and Regional Consultant (via phone) were provided a copy of the Immediate Jeopardy Template and notified of the findings at the immediate jeopardy level in the area of F 835 - Administration. The IJ began on 02/05/2023 and continued until 04/09/2024. On 04/09/2024 the immediate jeopardy was removed, F835 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL00043280 and AL00046465. Findings include: Cross-Reference F689, F867, and F837. A review of the Administrator job description documented: . Lead and direct the overall operation of the facility in accordance with resident needs, government regulations and Company policies so as to maintain care for the residents while achieving the facility's business objectives . The facility policy titled Quality Assurance and Performance Improvement (QAPI) Program - Governance and Leadership revised date of March 2020 documented: Policy Statement The quality assurance and performance improvement program is overseen and implemented by the QAPI committee, which reports its findings, actions and results to the administrator and governing body. Policy Interpretation and Implementation 1. The administrator, whether a member of the QAPI committee of not, is ultimately responsible for the QAPI program, and for interpreting its results and findings to the governing body. 4. The responsibilities of the QAPI committee are to: . c. identify and help resolve negative outcomes . d. utilize root cause analysis to help identify where identified problems point to underlying systematic problems; . An interview was conducted on 04/03/2024 at 7:36 PM with the Former Administrator #1, who said that she started as the administrator in January of 2022, and held the position for over a year. She said that she served as the Abuse Coordinator and was available round the clock to address any allegations, which were reported to Alabama Department of Public Health (ADPH) and the ombudsman. When asked about RI #1 leaving the premises on 02/05/2023, she stated that she did not recall the specific incident but remembered that he/she was discovered on a nearby street and brought back to the facility. Regarding the protocol for staff encountering a resident off-site, she stated that they should remain with the resident and contact the facility for assistance. When asked if the staff member followed the protocol when RI #1 was found off-site, she said that the CNA received one on one re-education. After RI #1 arrived back to the facility a body audit was conducted, and he/she was sent to the hospital. Additionally, the incident was reported to ADPH. In response to the question about how far RI #1 had gotten off-site, she replied approximately 0.5 miles. The Former Administrator said RI #1 had exited the building through a side door that had a closing issue. When asked about the measures taken to prevent RI #1 or other residents from leaving the building, she stated that the door had been changed out. She explained that when RI #1 managed to leave the building, the door became stuck when a staff member took the trash to the dumpster. Finally, when asked if this incident was taken to Quality Assurance (QA), she said that typically all reportable incidents are presented to QAPI. She was uncertain if an emergency QAPI was conducted after the incident. On 04/05/2024 at 3:02 PM, a follow-up interview was conducted with the Former Administrator #1. During the interview, she was asked about the education provided to the staff after RI #1 eloped. She said that one on one training was conducted with CNA #11, and typically elopement training would have been conducted as well, although she was uncertain if it had taken place. According to her, the training records were usually stored in the staff members' personnel files. The FA #1 was also asked about the concern regarding leaving doors unsecured when a resident expressed a desire to leave the building. She stated that it posed a general safety risk. When questioned about why QAPI did not create an action plan after RI #1 eloped from the facility, she explained that all QAPI records were maintained on the medical records computer and no formal plan was implemented. An interview was conducted with the Director of Nursing (DON) on 04/06/2024 at 11:41 AM. During the interview, the DON was questioned regarding the documentation of the incident when RI #1 eloped from the facility. She stated that there was no documentation available. The DON said that the QAPI program was overseen by the Administrator, with monthly meetings scheduled. When asked about evidence of a QAPI meeting following RI #1's elopement, she said there was no evidence. Finally, when questioned about the facility's compliance with effective administration, the DON said they were not in compliance. ******************************************************************** On 04/08/2024 at 4:44 PM, the facility submitted an acceptable Removal Plan for F835 which documented: ************************************************************************* 1. After RI #1 eloped from the facility on February 5th, 2023, the Administrator failed to ensure the QAPI committee met to identify all concerns using root cause analysis to ensure corrective actions needed with plans to prevent further occurrence including ongoing monitoring. 2. Removal plan written on April 6th, 2024, by Regional Consultant 3. The new Administrator started on April 8th, 2024, and was trained by the Regional Consultant on the QAPI Policy, Quality Assurance and Performance Improvement (QAPI) Program-Governance Leadership and their responsibility of ensuring QAPI compliance and resident safety. The NHA was also trained on the new Door Safety Assessment and Review Policy, Elopement Prevention and Response, the Elopement Response Policy. The new administrator was trained on the Administrator's job responsibilities. 4. The facility has a policy and procedure on QAPI as well as the NHA's responsibility to ensure QAPI. Policy is from med pass and is titled Quality Assurance and Performance Improvement (QAPI) Program-Governance Leadership. Administrator Training completed on April 8th, 2024. *********************************************************************** The Immediate Jeopardy was removed as of 04/09/2024 and the scope and severity was lowered to no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to further address and monitor the deficient practice in order to achieve compliance.

Based on record review, interviews and the facility policy Governing Body Duties and Responsibilities, the governing body failed to provide oversight to the QAPI committee. The Governing Body failed to provide guidance to the QAPI committee to use root cause analysis to determine all concerns and to make a determination of corrective actions needed with plans to prevent further occurrence after Resident Identifier (RI) #1 eloped from the facility on 02/05/2023. On 02/05/2023, RI #1 told the staff he/she wanted to leave the facility around 1:10 PM. RI #1 was given a psychotropic medication at 2:21 PM, then was not supervised. RI #1 left the facility through an unsecured door. RI #1 was seen by an off-duty staff member at approximately 3:30 PM on a busy two-lane road near the facility, but the staff member did not stay with the resident to provide supervision, and left RI #1 in unsafe environment. RI #1 was not returned to the facility until another off-duty staff member returned him/her to the facility at approximately 4:10 PM. This failure affected all 53 residents residing in the facility. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, §483.70 Administration at a scope and severity of L. On 04/06/2024 at 12:44 PM, The Owner of the company, the Corporate Consultant, and the Director of Nursing, were provided a copy of the immediate jeopardy template and notified of the immediate jeopardy finding in the area of Governing Body, F837. The IJ began on 02/05/2023 and continued until 04/09/2024. On 04/09/2024 the immediate jeopardy was removed, F837 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. Further the Governing Body failed to ensure the facility had an acting Administrator from 03/29/2024 through 04/09/2024. This deficiency was cited as a result of the investigation of complaint/report number AL00043280. Cross-Reference F689, F835, and F867. Findings Include: Review of an undated facility policy titled Governing Body Duties and Responsibilities documented: Policy Statement/Purpose: The Company must have a Governing Body that assumes full legal responsibility for establishing and implementing policies regarding the management and operation of the facility. Policy Interpretation and Implementation: 1. GOVERNING BODY DUTIES AND RESPONSIBILITIES A. Policies and Procedures: The Governing Body is legally responsible for establishing and implementing policies regarding the management and operation of the facility. The Governing Body, in conjunction with regular reporting by the Administrator, should assess on a regular basis that services are being provided in accordance with facility policies, that policies are current and reflect an acceptable standard of care, that care is coordinated among professional staff, and that there is effective use of resources. C. Appointment of Administrator: The Governing Body is responsible for appointing an Administrator who shall: . c. Report to and be accountable to the Governing Body. i. Facility will determine a means and schedule for regular reporting to the Governing Body and how the Governing Body will respond to the Administrator. The facility policy titled Quality Assurance and Performance Improvement (QAPI) Program - Governance and Leadership revised date of March 2020 documented: Policy Statement The quality assurance and performance improvement program is overseen and implemented by the QAPI committee, which reports its findings, actions and results to the administrator and governing body. Policy Interpretation and Implementation 1. The administrator, whether a member of the QAPI committee of not, is ultimately responsible for the QAPI program, and for interpreting its results and findings to the governing body. 2. The governing body is responsible for ensuring the QAPI program: a. is implemented . b. is sustained through transitions of leadership and staffing . On 04/05/2024 an interview was conducted with the Facility Owner #2. FO #2 said he only remembered that RI #1 had left the building either through the front or side door. FO #2 said when the staff were taking out the garbage or taking a break, they were leaving the door ajar. FO #2 said the staff were putting on top of the door so the door would not close when they left because they did not want to walk around to the front door. FO #2 did not recall if the incident was reviewed by the Quality Assurance, also called QAPI, team. FO #2 did not know how often the QAPI committee meet and said the Director of Nursing was currently responsible for the QAPI program. On 04/05/2024 at 5:33 PM an interview was conducted with the Facility Owner (FO) #1. He said that Facility Owner #2 and himself were the Governing Body. FO #1 said he did not remember the oversight he gave to Former Administrator #1 during the incident involving RI #1. He said he would have instructed to do a full investigation of what occurred, how it occurred, at the time, interview any staff and resident, that might have been around the area around that time. The facility would have reported it to the authorities. FO #1 said he did not remember all the details of the incident. He directed them to check all exit doors, do a head count, they evaluated any other concerns, changed the codes of doors, educated all staff on proper protocol and the necessity for ensuring all doors are properly closed and secured at all times. When he was asked where this information was documented he said that was a good question. He said he could not answer if there was a formal plan done; he said the facility had a nurse consultant that would have done one and there should have been a sign-in sheet. When asked what oversight was the governing body providing now since the facility did not have an Administrator. FO #1 said the duties of the governing body were to oversee the facility and the Administrator and to be involved in QAPI and administration. On 04/24/2024 at 4:22 PM an interview was conducted with the Regional Nurse Consultant (RNC). The RNC said it was important for the facility to have an Administrator so that they could oversee what was going on in the facility, oversee regulatory issues, develop monitor any care approaches with the deptartment heads, and to supervise the home and department heads. The RNC said from 03/29/2024 to 04/08/2024 the facility did not have an acting Administrator. ********************************************************** On 04/08/2024 at 4:44 PM, the facility submitted an acceptable Removal Plan for F 837 which documented: 1. RI #1 eloped from the facility on 2/5/2023, the Governing Body failed to provide oversight to the Administrator and QAPI committee and guide the committee to identify all concerns using root cause analysis to ensure corrective actions needed were in place with plans to prevent further occurrence including ongoing monitoring. 2. On April 6th, 2024, the F867 Removal Plan was written by Regional Consultant. 3. On April 7th, 2024, the Regional Consultant completed education with The Governing Body (Owner, Regional Director via phone, and Regional Consultant via phone) on their responsibility to provide oversight over the Administrator and ensuring the QAPI Program meets to identify all concerns using root cause analysis and developing corrective actions needed with plans to prevent further occurrence including ongoing monitoring. 4. On April 7th, 2024, the Governing Body met with the Director of Nursing to discuss ensuring an effective QAPI committee (Director of Nursing, Medical Director via phone, Facility Owner, Dietary Manager, Social Services, Activities Director, Environmental Services/Maintenance Director, Rehabilitation Director, MDS Coordinator, Staff Development/Infection Control via phone, Unit Manager 2nd Floor, Unit Manager, 3rd Floor, Business Office Manager, Staffing Coordinator, Human Resources Director, Wound Care Coordinator, Housekeeping Supervisor) takes place in the facility, that can function to identify all concerns with incidents, perform root cause analysis and determine corrective actions needed to prevent further incidents. 5. On April 7th, 2024, an emergency QAPI meeting was then held by the Governing Body. The Governing Body guided the QAPI committee in identifying root causes and corrective actions needing to take place for elopement prevention. 6. Root causes identified, on April 7th, 2024, were lack of staff education regarding elopement, staff failure to supervise the resident at risk, staff not ensuring all doors and exits were secure, and further, staff not ensuring resident safety if observed in an unsafe environment. 7. On April 7th, 2024, at 0900, The Governing Body met with the QAPI committee to review the new and updated policies and procedures Door Safety Assessment and Review Policy, Elopement Prevention and Response, and the Elopement Response Policy that will ensure staff is able to respond appropriately to residents at risk for elopement as well as to residents observed in an unsafe environment. 8. The facility has a policy and procedure on QAPI as well as the NHA's responsibility to ensure QAPI. Policy is from med pass and is titled Quality Assurance and Performance Improvement (QAPI) Program-Governance Leadership. Governing Body meetings are scheduled weekly every Thursday via Teams. 9. On April 8th, 2024, the Governing Body met with the new Administrator to ensure an effective QAPI committee takes place in the facility, that can function to identify all concerns with incidents, perform root cause analysis and determine corrective actions needed to prevent further incidents. The Governing Body also provided training to the new administrator on Quality Assurance and Performance Improvement (QAPI) Program-Governance Leadership and that the Governing Body meetings are scheduled weekly every Thursday via Teams. *********************************************************************** After review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team determined the facility implemented the immediate corrective actions as of 04/08/2024 and the scope and severity was lowered to an F level, to allow the facility time to further address and monitor the deficient practice in order to achieve compliance.

An interview was conducted on 04-24-2024 at 11:15 AM with former adminstrator. She was asked how often QAPI meetings were held and she stated monthly. When asked who attended the QAPI meetings she stated most department heads, the Administrator, Director of Nursing and maintenance. She stated the Medical Director came periodically but was updated every other week by phone or email .She was asked what was the most recent PIP (program improvement plan) the QAPI committee implemented. She stated she did not remember. She was asked if QAPI Plan included adverse event monitoring; she stated yes and that she was recording anything that was reported to the state including reportables, FRI's and emergency plans that were put in place to prevent episodes from happening and abuse plans. She was asked what direction was provided by the Governing Body regarding the QAPI Program and she stated she did not remember; only had two during the time she she was employed. The facility was unable to locate the records. During an interview conducted on 04-24-2024 at 3:00 PM with former administrator. she was asked how were results of the QAPI meeting communicated to the Governing Body. She stated usually by phone or in person and the local owner was usually present. When asked how the Governing Body provided oversight to the QAPI Program she stated meetings were held quarterly.When asked what actions were taken by the Governing Body to ensure QAPI Program was sustained during changes of leadership/administrators she stated she could not account for the other governing bodies. She was asked why it was important for QAPI to meet at least quarterly she stated so we can look at any trending areas that need addressing and find the root cause such as falls and other incidents. On 04-24-2024 at 4:22 PM an interview was conducted with the Regional Consultant who stated she has been a consultant since October 2023 and she does all the recruiting and oversees any regulatory issues. She further stated some situations can be taken care of via phone. When asked what her role was as Governing Body of the facility she stated she handles governing calls and any issues that may come up. When asked what actions were taken by the Governing Body to ensure QAPI Program was sustained during changes of leadership/administrators she stated previously they were doing QAPI but they were not scanning the data to shared drive. Going forward during our weekly governing body calls will be shared what is to be discussed in our QAPI meetings. She stated governing body calls are held weekly on Thursdays. During an interview with the adminstator on 04-25-2024 at 12:15 PM she was asked to provide QAPI meeting records for October, November and December 2023 and she replied there is no QAPI papers at all for October 2023, November sign in was blank and the material to be discussed for November 2023 was blank. She furthe stated the December QAPI document and the signature page was blank. When asked where the QAPI documentation that addressed the 10/11/2023 incident involving RI#3 was she stated she could not answer that. Based on record review, the facility policy Quality Assurance and Performance Improvement (QAPI) Program, and the facility's policy Quality Assurance and Performance Improvement (QAPI) Program - Analysis and Action the facility's QAPI committee failed to thoroughly review all factors related to Resident Identifier (RI) #1's elopement on 02/05/2023. The facility further failed to develop and implement effective plans and interventions to prevent recurrence and ensure the facility was secured. On 02/05/2023 RI #1 exited the facility through an unsecured side door without staff's knowledge. RI #1 was further left by staff unsupervised in an unsafe area 2,640 feet from the facility. The failure of the QAPI committee to thoroughly review all factors and implement effective interventions following an adverse event had the potential to affect all 53 residents. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, §483.75 Quality Assurance and Performance Improvement at a scope and severity of L. On 04/06/2024 at 12:44 PM, The Facility's Owner, the Corporate Consultant, and the Director of Nursing, were provided a copy of the immediate jeopardy template and notified of the immediate jeopardy finding in the area of Quality Assurance and Performance Improvement (QAPI), F867-QAPI/Quality Assessment and Assurance (QAA). The IJ began on 02/05/2023 and continued until 04/09/2024. On 04/09/2024 the immediate jeopardy was removed, F 867 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL00043280. Findings Include: Cross-Reference F689, F835, and F837. A review of a facility policy Quality Assurance and Performance Improvement (QAPI) Program, with a revised date of February 2020 documented Policy Statement This facility shall develop, implement, and maintain an ongoing, facility wide data driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents. Authority 1. The owner and/or governing board (body) of our facility is ultimately responsible for the QAPI program A review of the facility policy titled Quality Assurance and Performance Improvement (QAPI) Program - Analysis and Action dated March 2020 documented: .Policy Interpretation and Implementation 1. The QAPI Program, overseen by the QAPI Committee is designed to identify and address quality deficiencies through analysis of the underlying cause and actions targeted at correcting systems at a comprehensive level. 2. The methodology for analysis and action is guided by a written QAPI plan that includes: a. definition of the problem, based on information obtained through data, self-assessments, and feedback systems. b. an analysis of the root cause of the problem from a systems perspective. c. establishing measurable goals and benchmarks for improvement. d. specific interventions aimed at correcting the problem and achieving the stated goals or benchmarks. e. methods and frequency of monitoring performance improvement objectives. 3. The QAPI committee is responsible for analyzing identified problems, establishing corrective actions, measuring progress against the established goals and benchmarks, communicating information to staff, residents, and reporting findings to the administrator and governing board . On 04/06/2024 at 11:41 the Director of Nursing said she could not find QAPI minutes from the incident of elopement that occurred on 02/05/2023. On 04/03/2024 at 7:36 PM during a phone interview with the Former Administrator, she said she did not recall much about the incident of RI #1 leaving the facility he/she was found and returned. She said staff should stay with the resident and call the facility for help if they will not come back with them. She said RI #1 left the building through a side door that had an issue with closing. She said she was not sure what was done when RI #1 expressed wanting to leave the building. The former Administrator said she did not know if there was an emergency QAPI meeting. On 04/06/2024 at 11:41 AM, during an interview with the Director of Nursing, she said there was no evidence of what was done after RI #1 eloped from the facility. She said she had been employed at that facility since January 2024. The DON said the concern of not having evidence of what was done after RI #1 eloped from the facility was the facility could not justify what was done or that staff were provided training and education. The DON said that after RI #1 eloped from the facility, the facility should have conducted proper notification, investigation, in-services, monitoring of the resident, identified the root cause of the incident, and ensured safety measures were implemented after the incident. The DON said the Administrator was over the QA/QAPI program and meetings were supposed to be held monthly. She said the QAPI team was the Administrator, DON, Social Services, MDS, Activities, basically key personal and the Medical Director. ********************************************************************************************************** On 04/08/2024 at 4:44 PM, the facility submitted an acceptable Removal Plan for F867 which documented: 1. The QAPI committee failed to develop and implement effective interventions including ongoing monitoring to prevent recurrence after the facility failed to prevent RI #1 from leaving the facility on 02/05/2023 unsupervised, through an unsecure side door exiting to the outside of the building. RI #1 was further left by staff unsupervised in an unsafe area 2640 feet from the facility crossing a two-lane road with oncoming traffic. 2. On April 6th, 2024, the F867 Removal plan was written by Regional Consultant. 3. On April 7th, 2024, the Governing Body (Owner, Regional Director, and Regional Consultant) met with the Director of Nursing to discuss ensuring an effective QAPI committee takes place in the facility, that can function to identify all concerns with incidents, perform root cause analysis and determine corrective actions needed to prevent further incidents. An emergency QAPI meeting was then held by the Governing Body. The Governing Body guided the QAPI committee in identifying root causes and corrective actions needing to take place for elopement prevention. 4. On April 7th, 2024, the Regional Consultant provided training to the QAPI committee (Director of Nursing, Medical Director via phone, Facility Owner, Dietary Manager, Social Services, Activities Director, Environmental Services/Maintenance Director, Rehabilitation Director, MDS Coordinator, Staff Development/Infection Control via phone, Unit Manager 2nd Floor, Unit Manager, 3rd Floor, Business Office Manager, Staffing Coordinator, Human Resources Director, Wound Care Coordinator, Housekeeping Supervisor) during an emergency QAPI meeting to ensure an effective QAPI committee takes place in the facility, that can function to identify all concerns with incidents, perform root cause analysis and determine corrective actions needed to prevent further incidents. The QAPI Committee was trained on the facility's QAPI Policy Quality Assurance and Performance Improvement (QAPI) Program-Governance Leadership. 5. On April 7th, 2024, root causes identified were lack of staff education regarding elopement, staff failure to supervise the resident at risk, staff not ensuring all doors and exits were secure, and further, staff not ensuring resident safety if observed in an unsafe environment. 6. On April 7th, 2024, the QAPI committee reviewed the new and updated policies and procedures The Door Safety Assessment and Review, Elopement Prevention and Response, and Elopement Response policies to ensure staff are able to respond appropriately to residents at risk for elopement as well as to residents observed in an unsafe environment. 7. On April 7th, 2024, the Door Safety Assessment and Review, Elopement Prevention and Response, and Elopement Response policies were developed and implemented to ensure staff respond appropriately to residents at risk for elopement as well as residents observed in an unsafe environment. ********************************************************************** The Immediate Jeopardy was removed as of 04/09/2024 and the scope and severity was lowered to an F level, to allow the facility time to further address and monitor the deficient practice in order to achieve compliance.