Based on observation, interview, record review, and facility policy review, the facility failed to provide supervision and implement effective elopement prevention strategies for one (1) of four (4) sampled residents (Resident #1), who had a known cognitive impairment and elopement risk, resulting in an incident of elopement.The facility's failure to ensure supervision and implement interventions-including failure to detect the resident's absence promptly, and failure to secure exit doors-resulted in Resident #1 exiting the facility through the front entrance without staff knowledge and being unsupervised in the community for approximately one (1) hour and twenty-nine (29) minutes. The resident was found approximately two (2) miles away at a local business after receiving a ride from an unknown individual. This failure placed Resident #1 in a situation that was likely to cause serious injury, serious harm, serious impairment, or death, given the resident's severe cognitive impairment, multiple medical diagnoses, and the environmental risks encountered during elopement (e.g., traffic, extreme heat, lack of supervision).The facility's failure to ensure supervision and implement interventions for Resident #1, who was an elopement risk, put this resident and all other residents at risk for wandering and elopement, at risk for serious injury, serious harm, serious impairment, or death.This situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on 08/07/2025, when Resident #1 exited the facility unsupervised and without authorization. The State Agency (SA) notified the Administrator of the Immediate Jeopardy on 08/11/2025 at 4:15 PM and provided an IJ Template.The State Agency (SA) validated the Corrective Action Plan on 8/13/25 and determined that the IJ was removed on 8/9/25, prior to exit. Findings include:Record review of the facility policy titled, Missing Patient/Resident with Revision Date 8/01/2020 revealed, OVERVIEW: Staff will investigate cases of missing patient/resident and possible elopement. An elopement occurs when a patient/resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so, placing the patient/resident at risk for harm or injury. Record review of the facility policy Accident and incident Investigation with Effective Date 11/30/2014 revealed, Policy: Certain Accidents and Incidents.will be investigated to determine root cause and provide for opportunity to decrease future occurrences of the event. Record review of the facility policy Elopement/Wandering Risk Guideline with Revision Date 8/01/2020 revealed, Overview: To evaluate and identify patient/residents that are at risk for elopement and develop individualized interventions.Record review of the Incident Report dated 8/07/25 revealed documentation of the elopement and return without injury of Resident #1 on 8/07/25.Record review of the facility Verification of Investigation dated 8/07/25 revealed on 8/7/25 at 11:10 AM the nurse discovered Resident #1 was unable to be located. Facility staff called a Code Yellow and searched for the resident. The local police department and the Resident Representative (RR) were notified. At 11:53 AM the local police department notified the facility the resident had been found. At 12:05 PM, the Resident returned to the facility and was assessed by the Nurse Practitioner with no injury noted. On 8/11/25 at 10:10 AM, during a record review of the Facility Investigation and Incident Report both dated 8/7/25 and an interview with the Administrator and the Director of Nursing (DON), revealed the DON reported that the elopement of Resident #1 was discovered when Licensed Practical Nurse (LPN) #1 realized she no longer saw the resident sitting in the lobby where he had been last observed at or around 10:30 AM. The DON reported that she was on D Hall at approximately 10:45 AM when LPN #1 reported to her that she was unable to locate Resident #1. The DON immediately notified the Administrator at approximately 11:10 AM. At approximately 11:15 AM the DON notified the Administrator and called a CODE YELLOW using the overhead public announcement (PA) system. They reported that the resident was last seen seated in a chair in the lobby facing the reception desk and main entrance at approximately 10:30 AM in the lobby across from the front door. The DON and Administrator both said that in separate interviews with the resident upon return to the facility he had told them that he left the facility through the front door when visitors were coming in/going out. The Administrator and DON both confirmed that the resident was last observed in the facility at approximately 10:30 AM and was out of the facility unattended by staff for approximately one hour and twenty-nine minutes when he was observed at a local laundromat two (2) miles from the facility with no obvious injury. They explained that the system of how staff was made aware of a missing resident included word of mouth and Code Yellow announced over the overhead PA system. They explained that they call the alert anytime a resident couldn't be located and hadn't signed out using the alert, Code Yellow which was called at 11:20 AM on 8/07/25. The Administrator confirmed the report by the DON that the Administrator had been notified of a missing resident at 11:15 AM on 8/07/25 after the DON was notified at approximately 11:10 AM, and the Resident Representative for Resident #1 was called at 11:24 AM but the telephone number was out of service and the DON called the resident's daughter at 11:26 AM, and the NP for the resident's physician was notified at 11:20 AM. The DON said that she had conducted a body audit and found no injuries and the NP completed an assessment and noted no injuries and the resident was not transferred to the hospital. They said the immediate response of the facility was that the staff searched for resident, the resident was returned to the facility via Unit Manager, the NP was present at the facility upon the resident's return and assessed resident, which included a Body Audit, and finally one-on-one supervision was provided for Resident #1 for 48 hours and a wander guard anklet was applied to the resident's ankle immediately. The DON and Administrator said the police were notified, but during interview in the Administrator's office, The Unit Manager notified the resident had been located and was in route back to the facility at 11:46 AM, so they were not sure if a police report was written or not. The DON reported that elopement was reported to the State Agency on 8/07/25 at 1:28 PM. They reported that the Maintenance Supervisor checked the security of the doors at 1:00 PM on 8/07/25 as well as every day shift, Monday through Friday, and the residents' wander guard units were checked by the nurses as well as each night. The DON reported that she conducted Missing Resident/Elopement Drills every three months (quarterly) by DON in accordance with facility policy. The DON reported that In-Service Training for all staff was started on 8/07/25. The DON confirmed that the facility did routine audits to ensure elopement books and daily care guides were accurate. The Administrator and DON confirmed that a Census Audit was conducted, and the presence of all other residents not signed out was confirmed via direct observation by the nursing staff. The DON and record review of the Care Plan for Resident #1 revealed that Resident #1's care plan was revised/updated after the elopement on 8/7/25.On 8/11/25, the SA attempted multiple times to contact the RR and Contact #1 for Resident #1 without success and no mechanism to leave a message. On 8/13/25 during a telephone interview with Contact #1 for Resident #1, his family member confirmed that the facility had notified her on 8/07/25 that Resident #1 had eloped and that he had been returned to the facility.On 8/11/25 at 10:25 AM, observation and an interview with Resident #1 in his room revealed Resident #1 stated that he was from a nearby town where his family lived, approximately twenty-five miles away. He confirmed that he had eye surgery which had greatly improved his vision. He stated that he was able to get himself up and walk with his cane but used his wheelchair for longer distances. He said he remembered on 8/07/25 going out the front main entrance and getting a ride with a man in a truck to a nearby avenue. He stated that his ultimate goal was to get to his former residence. He said that the man in the truck dropped him off at the local business and that facility staff had shown up and given him a ride back to the facility. Observation revealed the resident had a wander guard safe wandering device on his left ankle. On 8/11/25 at 10:45 AM, during an interview LPN #1 stated she observed Resident #1 walking with a walker, and that he had taken a seat in the lobby across from the reception desk and main front entrance at approximately 10:00 AM wearing a black sock cap, a short-sleeved button up shirt, a pair of blue jeans and slide on shoes, holding his cane. She stated that at approximately 10:50 AM, she had begun to look for him and he was no longer sitting in the lobby, nor was he in the dining room or common areas and was not in his room. She said that after looking in those areas, at approximately 11:00 AM she notified the DON that she could not locate the resident, the DON called a Code Yellow over the PA system and staff continued to look inside and outside for the resident. She reported that notifications were made to the resident's primary healthcare provider (PHP), Contact #1 and local police department (PD). She stated that the PD sent out an officer but that shortly after the officer arrived, RN #1 (Unit Manager) notified the DON that she (RN #1) had located the resident and had him in her supervision and was returning to the facility with him. She stated that the PHP was present at the facility upon his return so Registered Nurse (RN) #1 and the PHP conducted assessment including body audit and identified no injuries and the resident's vital signs were all within normal limits. She stated she had not observed any change in physical or psychosocial condition since the elopement. She stated that the weather was clear and hot on 8/07/25. She stated that during the missing resident procedure, CNA #1 had reported to her that she (CNA #1) had last seen Resident #1 in the facility at approximately 10:45 AM in the lobby and noted no agitation or unusual behavior. LPN #1 reported that upon return to the facility at 11:59 AM the resident was immediately placed on one-on-one supervision for forty-eight (48) hours, and a safe wandering device was applied to his left ankle and tested for proper functioning. She confirmed that on 8/07/25 the facility provided in-service training regarding resident rights, abuse and neglect prevention and reporting, resident safety and facility protocol/procedures for safe wandering, missing residents and elopements on 8/07/25. LPN #1 stated that Resident #1 had never displayed exit seeking behavior prior to 8/07/25. On 8/11/25 at 11:00 AM, an interview with the facility Receptionist revealed she recalled that on 8/07/25 at approximately 11:10 AM, Resident #1 had approached the sliding glass window of her office walking with his cane and expressed that he needed to go home and see his family. She stated that he had developed a habit of visiting the Reception Desk and requesting cash and that he was usually in his wheelchair. She said she asked him to take a seat as she was busy with cash disbursements, answering telephone calls and granting entrance and exit for staff, contractors and visitors. She stated that she had not observed him get up or leave the lobby. She confirmed that the facility provided in-service training regarding resident rights, abuse and neglect prevention and reporting, resident safety and facility protocol/procedures for safe wandering, missing residents and elopements on 8/07/25. On 8/11/25 at 11:10 AM, observation revealed all parking spaces in the well-maintained facility parking lot surfaced with asphalt. Observation revealed the route to the location where Resident #1 was located lead through a well populated residential area, over a bridge that was over a railroad track and led to a four-lane avenue with a speed limit of thirty-five (35) miles per hour, with repaving in progress and several traffic lights and pedestrian walkways; the location was equal distance between two traffic lights. The location where the resident was located by RN # 1, was a local business with a deep parking lot surfaced with well-maintained concrete, four occupied parking spaces and five unoccupied and one main entrance. The SA observed one hundred fifty (150) cars traveling the avenue in front of the location in a five-minute period.Review of weather history for the locale for 8/07/25 per world wide web national weather service revealed that on 8/07/25 at 11:53 AM the temperature was eighty-nine (89) degrees Fahrenheit with six (6) mile per hour winds and zero (0) precipitation and conditions were partly cloudy. On 8/11/25 at 1:10 PM, an interview revealed RN #1 she observed Resident #1 sitting in the lobby at around 11:10 AM time when she left going to the hospital to take a sample to the laboratory. She stated that returning to the facility she was driving west on the boulevard and observed the resident wearing a black knitted hat, short-sleeved button-up shirt, slide on shoes and carrying a cane walking through the parking lot of a local business in a parking space near the business' door. She stated she had parked her car near the front door, got out and assisted the resident without resistance into the backseat of her car. She described the weather as partly cloudy and hot. She reported that during the drive back to the facility the resident told her that he exited the facility through the front door and got a ride with a man in a truck to the location where she located him. RN #1 confirmed that the facility provided in-service training regarding resident rights, abuse and neglect prevention and reporting, resident safety and facility protocol/procedures for safe wandering, missing residents and elopements on 8/07/25.On 8/11/25 at 4:05 PM interview with CNA #1 revealed she said was working dayshift on D Hall on 8/07/25 and was assigned to the care of Resident #1. She said she had observed him sitting in a chair holding his cane in the front lobby across from the front office and front entrance at approximately 8:45 AM. She reported that at approximately 11:15 AM she did not observe the resident anymore until he returned from elopement.Record review of the Ad Hoc Quality Assurance and Performance Improvement (QAPI) dated 8/08/25 with attached sign-in sheet revealed confirmed that the facility conducted a QAPI committee meeting attended by the Medical Director, DON, Infection Preventionist (IP) and other key personnel/department directors. The agenda included the elopement of Resident #1 on 8/07/25 with a plan for the prevention with corrective actions included. Record review of the Education In-Service Attendance Record dated 8/07/25 with attached sign in sheet confirmed the facility provided in-service training for all staff regarding the facility elopement policy and procedure for missing residents and missing resident procedure experience. Record review of the Education In-Service Attendance Record dated 8/07/25 with attached sign in sheet confirmed the facility provided in-service training for all staff regarding visualization of the door until it is clear and closed and locked when granting admission/egress and abuse and neglect prevention and reporting. Record review of the admission Record for Resident #1revealed the facility admitted the resident on 9/27/24 and the resident had diagnoses of osteoarthritis, hypertension, vision loss, and atherosclerotic heart disease. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 7/4/25 revealed Resident #1 had a Brief interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. Section B indicated the facility had assessed the resident having severely impaired vision and Section GG indicated that he relied on a wheelchair for mobility. Corrective Action Plan:Brief Summary of Events:On 8/11/25 at 4:15 PM the State Agency (SA) notified the Executive Director (ED) of an immediate jeopardy Past Noncompliance related to F 689 Free of Accident Hazards /Supervision /Devices.Resident #1 at approximately 10:30 am left out the front entrance door and exited facility without staff knowledge. Resident #1 was located at 11:56 am approximately 2.0 miles from facility by Licensed Nurse #1 who returned the resident to the facility where he was assessed by nursing staff and his primary healthcare provided with no injuries noted and he was fitted with a safe wandering device.Immediate Action was initiated on 8/7/25: At approximately 11:05 AM Licensed Practical Nurse (LPN) #1 and Certified Nurse's Aide (CNA) #1 performed cursory search for resident #1. At 11:10 AM LPN #1 notified Director of Nursing (DON) that Resident #1 could not be located and the DON notified the Executive Director (ED) at approximately 11:15 AM. At 11:15 AM DON announced Code Yellow using the overhead public announcement (PA) system, for missing resident was called, and staff were dispersed to search inside and outside for Resident #1. At 11: 14 100% audit completed by Unit Manager #1 and Wound Care to ensure all residents were in the facility and accounted for. At 11:20 AM Nurse Practitioner (NP) #1 and Resident's Physician were notified of elopement. At 11:26 AM Resident #1's Contact (daughter) was notified of elopement. At 11:46 AM the DON notified the local police department of the missing resident. At 11:48 AM neighboring police department was notified of Resident #1 home address for a well check. At 11:56 AM Registered Nurse (RN) 1 located Resident #1 approximately 2.5 miles from facility at 11:59 AM and transported Resident #1 back to the facility and arrived at 12:05 PM. At 12:05 PM NP #1 assessed Resident #1 with no injury noted. A body audit was completed. LPN #1 conducted a body audit with no noted injury. Resident #1 was interviewed by the DON and ED. Resident #1 stated he had exited the facility through the front door and an older man in a truck gave me a ride . The facility initiated one-on-one supervision for Resident #1 for forty-eight (48) hours. Social Services Director SSD) assessed Resident #1 for psychosocial distress and noted none and completed a new Brief Interview for Mental Status (BIMS) assessment. At 12:30 PM Director of Nursing obtained an order for Resident #1 to have a secure care bracelet placed and LPN #1 applied secure care bracelet to Resident #1's Left ankle. The Minimum Data Set (MDS) Nurse updated the Care Plan for Resident #1. At 1:00 PM the Maintenance Director checked all the exit doors and ensured they were closed and locked. At 1:28 PM the ED notified the State Ombudsman. At 1:28 PM DON called the State Agency (SA) hotline and reported the elopement. At 2:30PM the ED placed signage on door that reminded visitors and staff to ensure door was completely closed when entering and leaving. A sign was also placed on the front desk by the visitors' sign in book. At 2:45 PM SSD was notified of need to send out letter to families to re-educate them on the importance of out-on-pass and sign-out procedures, not escorting residents outside of the facility without a staff member present, and encourage them to notify a staff member immediately, if a resident was attempting to leave the facility unattended by staff. At 4:19 PM DON completed the complaint e-form for the Mississippi State Attorney General. At 5:00 PM Nurse Managers completed a 100% audit of all residents for elopement risk, checked orders for secure care bracelets, made sure care plans were in place, and assessed residents to ensure those who are elopement risk had secure care bracelets in place and working by testing with handheld Secure Care Tester 135. SSD created information cards that were placed in the front office with a picture of the residents who are at risk for elopement and updated elopement binders placed at the nurse's stations and front desk. On 8/7/25 DON initiated Quality Observation, Monitoring of visitor's entry and exits to ensure Resident's do not leave out of the facility without staff knowledge. This will be done 2 times a day, during receptionist hours, 5 days a week, times 3 months per ADON/Designee. Quality Assurance Performance Committee (QAPI) met on 8/7/25 at 2:00 PM to review the events of Resident #1's exit from facility and determine a Root Cause. Attendees were Executive Director (ED), Social Services Director (SSD), Business Office Manager (BOM), Director of Nursing (DON), Activities Director (AD), Therapy Manager (TM), Maintenance Supervisor (MS), Licensed Nurse (LPN) #1 and Medical Records Clerk (MRC) and IP. The Root Cause was determined to be that Resident #1 exited door when a visitor was entering.Education:On 8/7/25 and 8/8/25, In-Service education was conducted by the Director of Clinical Services on Elopement Policy, Procedure for Missing Resident , and emphasis on ensuring complete closure of door when letting visitors in/out. This was a 100% mandatory education, and all employees will receive training upon hire and prior to taking assignment.The Facility alleges all corrective actions were completed on 8/8/2025 and the immediate jeopardy was removed on 8/9/2025, prior to the State Agency entrance on 8/11/2025.On 8/13/25 the SA validated through observation, interview and record review that the facility had completed all corrective actions on 8/8/2025 and the Immediate Jeopardy was removed on 8/9/2025, prior to the State Agency entrance on 8/11/2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to develop or implement a comprehensive care plan for residents with a Supra-Pubic Catheter, diagnoses of Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure (CHF), Range-of-Motion (ROM) related to an Orthopedic Brace, Treatment related to a Vascular Implant, and Orthopedic, Wound and Vascular Appointments for five (5) of 24 care plans reviewed. Resident #31, Resident #34, Resident #75, Resident #87, and Resident #254. Serious harm occurred as a result of the facility's failure to develop or implement a Comprehensive Care Plan which resulted in decreased mobility for Resident #31, hospitalization for Resident #75, a wound infection for Resident #87, and sepsis for Resident #254. There was a likelihood of harm for Resident #34 due to a delay in changing a supra pubic catheter. The facility's failure to develop or implement care plan interventions placed these residents, and other residents who are at risk in a situation that was likely to cause serious harm, injury, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 11/21/22 when Resident #87 was referred to a vascular surgeon and the facility did not follow physician's orders. The Facility Administrator was notified of the IJ on 5/5/23 at 12:23 PM and provided an IJ Template. The facility provided an acceptable Removal Plan on 5/7/23, in which they alleged all corrective actions to remove the IJ were completed and the IJ was removed on 5/8/23. The State Agency (SA) validated the Removal Plan on 5/9/23 and determined the IJ was removed on 5/8/23, prior to exit. Therefore, the scope and severity for 42 CFR 483.21 (b)(1)(i) Comprehensive Care Plan, F656 was lowered from a J to a scope and severity of a D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: A review of the facility's Policy, Plans of Care revised 9/25/2017, revealed, Policy: An individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements .Procedure: Develop a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing .needs that are identified in the comprehensive assessment .Develop and implement an individualized Person-Centered comprehensive plan of care by the interdisciplinary team that includes .The Individualized Person Centered plan of care may include but is not limited to the following .Services to attain or maintain the resident's highest practicable physical, mental .well-being as required by state and federal regulatory requirements . Resident #75 Record review of the medical record revealed there was no Comprehensive Care Plan developed for Resident #75 that included measurable objectives and timetables to meet the resident's medical or nursing needs related to the resident's diagnoses of Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure (CHF). Review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date of 3/29/23, revealed Resident #75 had Active Diagnoses including Heart Failure and Respiratory Failure and had additional active diagnoses of Chronic Obstructive Pulmonary Disease. Record review of the admission Record revealed the facility admitted Resident #75 on 9/12/22 and she had diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Morbid Obesity, and Diastolic Congestive Heart Failure. Resident # 31 Record review of the medical record revealed there was no Comprehensive Care Plan developed for Resident #31 to meet the resident's medical or nursing needs to address his left lower leg related to Range of Motion, his [NAME] brace and Othropedic appointments. A record review of the admission Record revealed the facility admitted Resident #31 on 1/31/23 with diagnoses including Displaced Fracture of Right Femur and Encounter for Orthopedic aftercare following surgical amputation. Resident #34 Record review of the medical record revealed there was no Comprehensive Care Plan developed for Resident #34 that included measurable objectives and timetables to meet the resident's medical or nursing needs related to a newly placed suprapubic catheter. Record review of the Procedure Note, dated 3/24/23, revealed Resident #34 had a procedure for .placement of 16 french SPT (Suprapubic Tube) . Record review of the admission Record revealed the facility admitted Resident #34 on 06/22/2020 with a diagnosis of Spina Bifida. Resident #87 Record review of the Comprehensive Care Plan with a Focus of The resident has a surgical wound of the left thigh R/t (related to) infected graft wound revealed Resident #87 had an Intervention/Tasks of Administer treatments as ordered . Record review of the Order Summary Report dated 5/3/23, revealed Resident #87 had a Physician's Order, dated 11/21/22, for refer to (Proper Name of Physician) vascular surgeon at (Proper Name of Medical Clinic), a Physician's Order, dated 3/17/23, for Get appointment with physician at (Proper Name of Medical Clinic) .ASAP (as soon as possible) .related to Unspecified Open Wound, Left Thigh ., and a Physician's Order, dated 4/11/23, for Get appointment with (Proper Name of Physician) vascular surgeon .as soon as possible to have artificial implant removed from Left Groin/Thigh . A record review of the admission Record revealed the facility admitted Resident #87 on 07/06/2022, and he had diagnoses including Post-Traumatic Stress Disorder (PTSD) and Depression. Resident #254 Record review of the Comprehensive Care Plan with a Focus of The resident has a (stage 4) pressure injury (sacrum) r/t disease process . revealed Resident #254 had Intervention/Tasks of Administer treatments as ordered . Record review of the Progress Notes for Resident #254 revealed a Nursing Progress Note dated 4/14/23 at 13:53 (1:53 PM) for unable to take resident to wound care apt (appointment) today will contact family and wound care to reschedule. Record review of the admission Record revealed the facility admitted Resident 2354 on 4/14/22 with diagnoses including End Stage Heart Failure and Type 2 DM. During a phone interview on 05/05/23 at 02:50 PM, with RN, #2, who is the MDS/Care Plan nurse, she stated that she no longer worked for the facility as of 5/4/23. She explained there had always been three (3) nurses in the MDS/Care Plan office, but since the end of last year (2022), she had been in the office alone and had to complete all the care plans and the MDS assessments for the residents. RN #2 said that she was out in December and had not been able catch up with all the care plans. RN #2 said that at the end of March 2023, another nurse was hired for the MDS/Care Plan office, but both have had to work the floor and cart and have not been able to get caught up on all the care plans. RN #2 explained the purpose of the care plans was to provide a plan of care for the residents and she expected the staff to follow the care plans as indicated to provide residents with quality care and to meet their needs. RN #2 confirmed all residents should have individualized care plans to meet their needs. During an interview on 05/05/23 at 03:30 PM, with the Director of Nursing (DON), she said that due to staffing issues, both the MDS/Care Plan nurses have had to work the floor and cart lately. She explained she expected all staff members to develop and follow the care plans to meet the needs of all residents. The facility provided an acceptable Removal Plan which included: Immediate Action started on 05/05/2023 at 12:23 PM: Resident # 75 has a pulmonology scheduled for 06/19/2023 at 4:00 PM. Resident # 75 has a cardiology appointment scheduled for 05/23/2023 at 1:00 PM. Resident # 87 had a vascular stent removed on 05/04/2023 at 5:30 AM. On 05/05/2023 at 2:00 PM, Ad Hoc Quality Assurance Performance Improvement (QAPI) Committee met to ensure the residents receive needed medical services to prevent future occurrences of neglect, to ensure that Comprehensive Care Plans are developed and implemented to include needed medical services as physician ordered, to ensure that all residents residing in the facility receive the outside medical services needed to prevent complications, to prevent residents from experiencing avoidable loss of ROM, to ensure facility administration is administered in a manner that enables the use of its resources to effectively maintain the highest practicable physical well-being for residents receiving physician ordered services, and to ensure an effective QAPI program is maintained. A Root Cause Analysis (RCA) was conducted and reviewed policies and procedures for changes. RCA revealed the policy was not followed and one of two vans was out of commission. RCA revealed former ED only rented a van for two weeks during the timeframe one van was out of commission and did not continue to rent a van nor secure other means of transportation even though Company approval was given. Attendees were the Medical Director (MD), Executive Director (ED), Director of Nursing (DON), Infection Control Preventionist (ICP), Business Office Manager (BOM), Maintenance Director, Regional Director of Clinical Services 1 (RDCS 1), Regional [NAME] President of Operations (RVPO), Regional Director of Business Office Services (RDBOS), Regional Director of Clinical Services 2 (RDCS 2), Business Development Coordinator, Certified Nursing Assistant (CNA), Physical Therapist (PT), Registered Nurse Minimum Data Set Nurse (RN MDS Nurse), Activities Director, Housekeeping Manager, Social Services Director, Dietary Manager, Medical Records Nurse, and Human Resources Director (HRD). A review of policy and procedures were: Abuse, Neglect, Exploitation, and Misappropriation, Transportation, Skin and Wound, Plans of Care, and Quality Assurance Performance Improvement (QAPI) which required no changes. On 05/05/2023 at 3:30 PM, the RVPO initiated education to the Medical Director and Interdisciplinary Team (IDT) to ensure an effective QAPI program is maintained to address outside medical services of the residents. No new hired staff will work without the aforementioned education. On 05/05/2023 at 3:35 PM, the RVPO conducted a quality review to ensure the facility has a current non-emergent ambulance agreement in place. There is a current non-emergent ambulance agreement in place for the facility to ensure that residents with higher level of transfer care needs have non-emergent transportation provided by the facility. On 05/05/2023 at 3:45 PM, the RVPO initiated education to the ED and DON to ensure the administration in a manner that enables the use of its resources to effectively maintain the highest practicable physical well-being for residents to receive physician ordered services to prevent future non-compliance. No new hired staff will work without the aforementioned education. On 05/05/2023 at 4:00 PM, the DON initiated education to all staff to ensure the residents receive needed medical services and provide physician ordered services that are necessary. No current staff or new hired staff will work without the aforementioned education. On 05/05/2023 at 4:40 PM, RDCS 1 and LPN 1 (Licensed Practical Nurse 1) conducted a quality review of physician ordered appointments of current residents. A quality review of residents' physician ordered appointments were reviewed with the MD for medical urgency and transfer to a higher level of care. No residents were identified with medically urgent appointments. On 05/05/2023 at 4:45 PM, MD conducted a physician visit with Residents #75 and #87 to ensure medical stability and no new orders received. Resident #254 is no longer in the facility as of 04/19/2023 related to transferred to the hospital. On 05/07/2023 at 4:00 PM, MD conducted a physician's visit with Residents #75 and #87 and reviewed outstanding appointments for medical urgency and determined that no current appointments were medically urgent requiring a transfer to a higher level of care. MD gave new orders on Residents #75 and #87. On 05/07/2023 at 4:30 PM, the Regional Plant Operations Director delivered an additional wheelchair accessible van for the facility to maintain effectiveness transportation for physician ordered outside medical services. On 05/07/2023 at 4:45 PM, the RDCS 1 educated the ED, DON, MR Nurse, and Licensed Social Worker on the process to ensure physician ordered medical services are scheduled and transportation is provided. The MR Nurse will be the designated person to ensure all outside medical appointments are maintained and executed. On 05/07/2023 at 6:30 PM, Resident # 87 had an appointment scheduled with a wound specialist on 05/23/2023 at 9:15 AM. The facility alleges all corrective actions were completed to remove the immediacy on May 7, 2023, and the Immediate Jeopardy was removed May 8, 2023. The State Agency (SA) validated the facility's Corrective Actions: 1.) The State Agency (SA) validated through record review Resident # 75 has a pulmonology scheduled for 06/19/2023 at 4:00 PM. 2.) The State Agency (SA) validated through record review Resident # 75 has a cardiology appointment scheduled for 05/23/2023 at 1:00 PM. 3.) The State Agency (SA) validated through record review Resident # 87 had a vascular stent removed on 05/04/2023 at 5:30 AM. 4.) The State Agency (SA) validated through record review on 05/05/2023 at 2:00 PM, Ad Hoc Quality Assurance Performance Improvement (QAPI) Committee met and covered needed medical services to prevent future occurrences of neglect, Comprehensive Care Plans, residents residing in the facility receive the outside medical services needed to prevent complications, facility administration and review of an effective QAPI program is maintained. The SA determined a Root Cause Analysis (RCA) was conducted and policies and procedures were reviewed for changes. The SA determined attendees were the Medical Director (MD), Executive Director (ED), Director of Nursing (DON), Infection Control Preventionist (ICP), Business Office Manager (BOM), Maintenance Director, Regional Director of Clinical Services 1 (RDCS 1), Regional [NAME] President of Operations (RVPO), Regional Director of Business Office Services (RDBOS), Regional Director of Clinical Services 2 (RDCS 2), Business Development Coordinator, Certified Nursing Assistant (CNA), Physical Therapist (PT), Registered Nurse Minimum Data Set Nurse (RN MDS Nurse), Activities Director, Housekeeping Manager, Social Services Director, Dietary Manager, Medical Records Nurse, and Human Resources Director (HRD). The SA determined a review of policy and procedures were performed for: Abuse, Neglect, Exploitation, and Misappropriation, Transportation, Skin and Wound, Plans of Care, and Quality Assurance Performance Improvement (QAPI) which required no changes. 5.) The State Agency (SA) validated through interviews on 05/05/2023 at 3:30 PM, the RVPO initiated education to the Medical Director and Interdisciplinary Team (IDT) to ensure an effective QAPI program is maintained to address outside medical services of the residents. No new hired staff will work without the aforementioned education. 6.) The State Agency (SA) validated through record review on 05/05/2023 at 3:35 PM, the RVPO conducted a quality review to ensure the facility has a current non-emergent ambulance agreement in place. There is a current non-emergent ambulance agreement in place for the facility to ensure that residents with higher level of transfer care needs have non-emergent transportation provided by the facility. 7.) The State Agency (SA) validated through interviews on 05/05/2023 at 3:45 PM, the RVPO initiated education to the ED and DON to ensure the administration in a manner that enables the use of its resources to effectively maintain the highest practicable physical well-being for residents to receive physician ordered services to prevent future non-compliance. No new hired staff will work without the aforementioned education. 8.) The State Agency (SA) validated through interviews on 05/05/2023 at 4:00 PM, the DON initiated education to all staff to ensure the residents receive needed medical services and provide physician ordered services that are necessary. No current staff or new hired staff will work without the aforementioned education. 9.) The State Agency (SA) through interviews on 05/05/2023 at 4:20 PM, the RDCS initiated education with the RN MDS Nurses to ensure that Comprehensive Care Plans are developed and implemented to prevent further resident complications for residents' treatment related to a vascular implant and orthopedic and vascular appointments. No current staff or new hired staff will work without the aforementioned education. 10.) The State Agency (SA) through interviews on 05/05/2023 at 4:30 PM, the DON initiated education to licensed nurses to ensure that all residents residing in the facility receive the outside medical services needed to prevent complications. No current staff or new hired staff will work without the aforementioned education. 11.) The State Agency (SA) through interviews on 05/05/2023 at 4:40 PM, RDCS 1 and LPN 1 (Licensed Practical Nurse 1) conducted a quality review of physician ordered appointments of current residents. A quality review of residents' physician ordered appointments were reviewed with the MD for medical urgency and transfer to a higher level of care. No residents were identified with medically urgent appointments. 12. ) The State Agency (SA) validated through record review on 05/05/2023 at 4:45 PM, that the MD conducted a physician visit with Residents #75 and #87 to ensure medical stability and no new orders received. 13. The State Agency (SA) validated through interviews/record review on 05/07/2023 at 8:00 AM, RDCS 1, RDCS 2, RDCS 3 (Regional Director of Clinical Services 3), and RN Treatment Nurse completed assessments on current residents to ensure medical stability and not requiring a transfer to a higher level of care. The SA validated no residents at risk were identified. 14. The State Agency (SA) validated through record review on 05/07/2023 at 4:00 PM, MD conducted a physician's visit with Residents #75 and #87 and reviewed outstanding appointments for medical urgency and determined that no current appointments were medically urgent requiring a transfer to a higher level of care. MD gave new orders on Residents #75 and #87. 15. The State Agency (SA) validated through observation/interviews and record review on 05/07/2023 at 4:30 PM, the Regional Plant Operations Director delivered an additional wheelchair accessible van for the facility to maintain effectiveness transportation for physician ordered outside medical services. 16. The State Agency (SA) validated through interviews on 05/07/2023 at 4:45 PM, that the RDCS 1 educated the ED, DON, MR Nurse, and Licensed Social Worker on the process to ensure physician ordered medical services are scheduled and transportation is provided. The MR Nurse will be the designated person to ensure all outside medical appointments are maintained and executed. 17. The State Agency (SA) validated through record review on 05/07/2023 at 6:30 PM, Resident # 87 had an appointment scheduled with a wound specialist on 05/23/2023 at 9:15 AM.

Based on interviews and record review, the facility failed to ensure two (2) of 24 sampled residents received outside medical services as ordered to prevent complications and maintain the highest practicable physical, mental, and/or psychosocial wellbeing. Residents #75 and #87. The facility's failure to provide required outside medical services led to the hospitalization of Resident #75 due to Congested Heart Failure (CHF) and Pneumonia and was admitted to the Intensive Care Unit (ICU) and wound infection for Resident #87 caused serious injury, serious harm, and serious impairment to Resident #75 and Resident #87 and placed other residents in a situation that was likely to cause serious injury, harm, impairment or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 11/21/22 when Resident #87 missed scheduled appointments with the vascular surgeon and developed two separate infections awaiting rescheduled appointments. The Facility Administrator was notified of the IJ on 5/5/23 at 12:23 PM and provided an IJ Template. The facility provided an acceptable Removal Plan on 5/7/23, in which they alleged all corrective actions to remove the IJ were completed and the IJ was removed on 5/8/23. The State Agency (SA) validated the Removal Plan on 5/9/23 and determined the IJ was removed on 5/8/23 prior to exit. Therefore, the scope and severity for 42 CFR 483.25 Quality of Care, F684 was lowered from a J to a scope and severity of a D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Resident #75 On 05/01/23 at 03:20 PM, during an interview with Resident #75 she complained the facility has not made a follow-up appointment for the Cardiology and Pulmonary doctors and she ended up being in the hospital. Resident #75 voiced she was concerned over missing the doctor appointments because she had to be sent the hospital because she had difficulty breathing and was diagnosed with Pneumonia. She did not understand why she could not go to her doctors' appointments. On 5/3/23 at 01:00 PM, during an interview with Licensed Practical Nurse (LPN) #2, she reported Resident #75 did not go to see her Cardiologist and Pulmonologist because the facility van was not accessible to Resident #75 and the facility must pay in advance for non-medical transfers. LPN #2 stated for the same reason, Resident #75 was not sent to the hospital for a chest (CXR) x-ray. LPN #2 reported this information was provided to her by the previous Director of Nursing (DON) and the Administrator. On 5/3/23 at 3:30 PM, during an interview with the Nurse Practitioner (NP), the NP explained she wrote an order for Resident #75 to follow up with her Cardiologist and Pulmonologist in January 2023, which was not done. She had ordered a portable chest x-ray in January for the resident which was not done because her weight exceeded 300 pounds, so she ordered to schedule a chest x-ray at the hospital. The chest x-ray still was not completed. She explained she talked to the Administrator and previous DON about Resident #75 not getting scheduled for appointments. The Administrator told her Resident #75 was unable to fit in the company van and he would have to pay in advance to have residents transported for non-emergencies. The NP reported if the facility would have sent Resident #75 to the follow-up appointments with the Cardiologist and Pulmonologist and scheduled the chest x-ray that Resident #75 would not have been admitted to the hospital with diagnoses of Congested Heart Failure (CHF) and Pneumonia and admitted to the Intensive Care Unit (ICU). On 5/3/23 at 04:00 PM, during an interview with the current DON, she stated she was not the DON at the time the NP placed the order for Resident #75 to follow-up with Cardiologist and Pulmonologist or to get a chest x-ray at the hospital. She stated has been aware of the issue with transportation for residents and appointments because the facility must pay in advance for non-emergency visits. She confirmed that Resident #75 was not sent to her Cardiologist and Pulmonologist and was not sent to the hospital for a chest x-ray due to transportation problems with the facility. A record review of Resident #75's Order Summary Report with active orders as of 05/03/2023, revealed an order dated 01/03/2023, Schedule an appointment in (Proper name of city) with this resident's Cardiologist and Pulmonologist as she is c/o (complains) of Increased heart palpitations and Shortness of breath. She states she has not been seen in over a year. Review of Resident #75's Progress Notes *NEW* revealed a NP progress note dated 01/24/2023 revealed . The resident reports she is experiencing occasional heart palpations, states she just feels like her heart is running away from her and she feel short of breath when this happens . Will discuss the status of her orders to schedule a F/U (follow-up) appointment with her cardiologist and pulmonologist . POC (Plan of Care) 3. CXR (chest x-ray) c/o (complain) SOB (shortness of breath). Review of Resident #75's Progress Notes *NEW* nursing progress notes dated 1/26/23 by LPN #2 revealed . portable CXR, unable to perform r/t (related to) res (resident) weight exceeding 300 lbs (pounds) per policy. Resident aware, DON notified, NP notified then instructed for CXR to be scheduled and resident to be transferred to hospital to be obtained . A record review of Resident #75's Progress Notes *NEW* NP progress notes dated 03/01/2023 revealed . This resident request a couple of days of extra Lasix for increased fluid. She states she is having more shortness of breath even with her 02 (oxygen) NC (nasal cannula) . POC: . 1. Increase PM (evening) dose of Lasix to 80 milligrams (mgs) po (by mouth) Q (every) evening x 5 days . Review of Resident #75's Progress Notes *NEW* nursing progress notes dated 03/15/2023 at 01:38 PM revealed . Resident complained SOB with difficulty breathing . NP present in facility, made aware. N.O. (new order) to send resident to Proper Name for further evaluation . Review of #75's Progress Notes *NEW* nursing progress notes written by LPN #2, dated 03/15/2023 at 06:14 PM revealed . Placed call to Proper Name for follow up, spoke with charge nurse. admitted . with diagnoses Congested Heart Failure (CHF), pulmonary disease . A record review of the History and Physical Note from the local hospital, dated 3/15/23, for Resident #75, revealed, CT (Computed Tomography) of the chest showed evidence of pneumonitis and possible atypical pneumonia. She was admitted . A record review of Resident #75's admission Record revealed the facility admitted Resident #75 on 09/12/2022, per the admission Record with the diagnosis that included Chronic Obstructive Pulmonary Disease (COPD), Morbid Obesity, and Respiratory Failure. A record review of Resident #75's Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/29/23 revealed Resident #79 had a Brief Interview of Mental Status (BIMS) score of 11 that indicated Resident #75 has moderate cognitive impairment. Resident #87 On 05/03/23 at 03:30 PM, during an interview with the NP, she explained Resident #87 has an artificial implant that was place by the vascular surgeon prior to admission for poor circulation and Resident #87 has been constantly complaining of pain and has had recurrent infections in that area because the implant needs to be removed. She wrote orders last year for the facility to make an appointment to follow up with the vascular surgeon, but the facility kept changing Resident #87's appointments. Resident #87 has not seen the vascular surgeon as of today. She asked the DON why Resident #87 has not seen the surgeon and was told because the facility is down a van and dialysis residents have top priority. Record review of the Microbiology report for Wound Cultures collected 3/21/23 and reported 3/23/23 for Resident #87 revealed a specimen from the Thigh was collected and resulted in .Moderate Methicillin Resistant Staphylococcus aureus (MRSA) . Record review of the Microbiology report for Wound Cultures collected 4/11/23 and reported 4/15/23 for Resident #87 revealed a specimen was collected from the Thigh and resulted in Light .(MRSA) . On 05/03/23 at 04:00 PM, during an interview with Resident #87, he confirmed he has been having recurrent infections in his thigh and needed to have the implant removed. Resident #87 reported the NP said she would have the facility to set up appointment, but don't remember what month it was. He did remember it was last year. His appointments kept getting changed because the facility vans were not working. He stated he had an appointment scheduled for 05/04/2023 but he was afraid the appointment may be missed because the facility still only has one van. A record review of Resident #87's Order Summary Report dated 05/03/2023 revealed an order to refer to Vascular surgeon on 11/21/2022, 03/17/23 and 04/11/23. A record review of Resident #87's Progress Notes *NEW* dated 4/11/23 at 05:00 PM Physician Progress note revealed . This resident states he is having pain in his left groin/thigh. He just completed antibiotic therapy for MRSA to his left groin/thigh wound where he has an artificial implant placed by the vascular surgeon . for his PVD (Peripheral Vascular Disease) in the past. This implant has given him trouble since insertion, and he was trying to get it removed when he was first admitted to the facility last year . POC: . Get appointment with Vascular surgeon at (Proper Name) as soon as possible to have artificial implant removed from left groin/thigh . On 05/04/23 at 08:07 AM, during an interview with the Medical Director (MD) he explained he attended the Quality Assurance Performance Improvement/Quality Assurance (QAPI/QA) meeting quarterly and he was told at the last quarterly meeting that the facility had rescheduled some resident appointments because the facility was having problems with transportation, but the facility had addressed the problem and it was resolved. He did not know Resident #87 had not seen the surgeon and remembered telling staff in the meeting that residents need to follow up immediately with their surgeons. He stated that he told staff the transportation issue needed to be taken care of immediately. He thought the transportation problems were resolved. On 05/04/23 at 09:24 AM, during an interview with Certified Nurse Aide (CNA)#1, she explained she was the transportation driver. The facility had communication problems with appointments because the different nurses, residents, and DON were making appointments and the appointments were clashing with each other which caused confusion. Residents missed appointments because several appointments were scheduled at the same time. On 05/04/23 at 10:48 AM, during an interview with the current DON, she confirmed Resident #87's appointments with the vascular surgeon have been changed several times because the facility had problems with both vans. One van was damaged in an accident and the other van was in the shop being repaired. She said she had to try to rearrange several appointments but Resident #87's appointment got lost in the cracks. She stated that when she realized Resident #87's appointment was missed, she called the surgeon's office and asked the nurse to set up an appointment, however, this was several months later. The DON confirmed Resident #87 has had infections twice since he had the implant placed. On 05/04/23 at 11:58 AM, during an interview with the Administrator, he confirmed the facility failed to send Resident #87 out to follow up with his vascular surgeon. One van was disabled in February 2023 and the other van kept breaking down and was placed in the shop several times. He e-mailed his corporate office letting them know he did not have transportation for the residents to go out to their appointments. He rented a van to help with the dialysis appointments and some local appointments. He stated that the corporate office said they were working with the insurance company trying to get another van and the disabled van has not been replaced. A record review of Resident #87's admission Record revealed the facility admitted resident on 07/06/2022 with the diagnoses of Peripheral Vascular Disease (PVD), Post-Traumatic Stress Disorder (PTSD), and Depression. A record review of Resident #87's Quarterly MDS with an ARD of 04/05/2023 revealed Resident #87 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #87 was cognitively intact. The facility provided an acceptable Removal Plan which included: Immediate Action started on 05/05/2023 at 12:23 PM: * Resident # 75 has a pulmonology scheduled for 06/19/2023 at 4:00 PM. * Resident # 75 has a cardiology appointment scheduled for 05/23/2023 at 1:00 PM. * Resident # 87 had a vascular stent removed on 05/04/2023 at 5:30 AM. * On 05/05/2023 at 2:00 PM, Ad Hoc Quality Assurance Performance Improvement (QAPI) Committee met to ensure the residents receive needed medical services to prevent future occurrences of neglect, to ensure that Comprehensive Care Plans are developed and implemented to include needed medical services as physician ordered, to ensure that all residents residing in the facility receive the outside medical services needed to prevent complications, to prevent residents from experiencing avoidable loss of ROM, to ensure facility administration is administered in a manner that enables the use of its resources to effectively maintain the highest practicable physical well-being for residents receiving physician ordered services, and to ensure an effective QAPI program is maintained. A Root Cause Analysis (RCA) was conducted and reviewed policies and procedures for changes. RCA revealed the policy was not followed and one of two vans was out of commission. RCA revealed former ED only rented a van for two weeks during the timeframe one van was out of commission and did not continue to rent a van nor secure other means of transportation even though Company approval was given. Attendees were the Medical Director (MD), Executive Director (ED), Director of Nursing (DON), Infection Control Preventionist (ICP), Business Office Manager (BOM), Maintenance Director, Regional Director of Clinical Services 1 (RDCS 1), Regional [NAME] President of Operations (RVPO), Regional Director of Business Office Services (RDBOS), Regional Director of Clinical Services 2 (RDCS 2), Business Development Coordinator, Certified Nursing Assistant (CNA), Physical Therapist (PT), Registered Nurse Minimum Data Set Nurse (RN MDS Nurse), Activities Director, Housekeeping Manager, Social Services Director, Dietary Manager, Medical Records Nurse, and Human Resources Director (HRD). A review of policy and procedures were: Abuse, Neglect, Exploitation, and Misappropriation, Transportation, Skin and Wound, Plans of Care, and Quality Assurance Performance Improvement (QAPI) which required no changes. * On 05/05/2023 at 3:30 PM, the RVPO initiated education to the Medical Director and Interdisciplinary Team (IDT) to ensure an effective QAPI program is maintained to address outside medical services of the residents. No new hired staff will work without the aforementioned education. * On 05/05/2023 at 3:35 PM, the RVPO conducted a quality review to ensure the facility has a current non-emergent ambulance agreement in place. There is a current non-emergent ambulance agreement in place for the facility to ensure that residents with higher level of transfer care needs have non-emergent transportation provided by the facility. * On 05/05/2023 at 3:45 PM, the RVPO initiated education to the ED and DON to ensure the administration in a manner that enables the use of its resources to effectively maintain the highest practicable physical well-being for residents to receive physician ordered services to prevent future non-compliance. No new hired staff will work without the aforementioned education. * On 05/05/2023 at 4:00 PM, the DON initiated education to all staff to ensure the residents receive needed medical services and provide physician ordered services that are necessary. No current staff or new hired staff will work without the aforementioned education. * On 05/05/2023 at 4:40 PM, RDCS 1 and LPN 1 (Licensed Practical Nurse 1) conducted a quality review of physician ordered appointments of current residents. A quality review of residents' physician ordered appointments were reviewed with the MD for medical urgency and transfer to a higher level of care. No residents were identified with medically urgent appointments. * On 05/05/2023 at 4:45 PM, MD conducted a physician visit with Residents #75 and #87 to ensure medical stability and no new orders received. Resident #254 is no longer in the facility as of 04/19/2023 related to transferred to the hospital. * On 05/07/2023 at 4:00 PM, MD conducted a physician's visit with Residents #75 and #87 and reviewed outstanding appointments for medical urgency and determined that no current appointments were medically urgent requiring a transfer to a higher level of care. MD gave new orders on Residents #75 and #87. * On 05/07/2023 at 4:30 PM, the Regional Plant Operations Director delivered an additional wheelchair accessible van for the facility to maintain effectiveness transportation for physician ordered outside medical services. * On 05/07/2023 at 4:45 PM, the RDCS 1 educated the ED, DON, MR Nurse, and Licensed Social Worker on the process to ensure physician ordered medical services are scheduled and transportation is provided. The MR Nurse will be the designated person to ensure all outside medical appointments are maintained and executed. * On 05/07/2023 at 6:30 PM, Resident # 87 had an appointment scheduled with a wound specialist on 05/23/2023 at 9:15 AM. * The facility alleges all corrective actions were completed to remove the immediacy on May 7, 2023, and the Immediate Jeopardy was removed May 8, 2023. The State Agency (SA) validated the facility's Corrective Actions: 1.) The State Agency (SA) validated through record review Resident # 75 has a pulmonology scheduled for 06/19/2023 at 4:00 PM. 2.) The State Agency (SA) validated through record review Resident # 75 has a cardiology appointment scheduled for 05/23/2023 at 1:00 PM. 3.) The State Agency (SA) validated through record review Resident # 87 had a vascular stent removed on 05/04/2023 at 5:30 AM. 4.) The State Agency (SA) validated through record review on 05/05/2023 at 2:00 PM, Ad Hoc Quality Assurance Performance Improvement (QAPI) Committee met and covered needed medical services to prevent future occurrences of neglect, Comprehensive Care Plans, residents residing in the facility receive the outside medical services needed to prevent complications, facility administration and review of an effective QAPI program is maintained. The SA determined a Root Cause Analysis (RCA) was conducted and policies and procedures were reviewed for changes. The SA determined attendees were the Medical Director (MD), Executive Director (ED), Director of Nursing (DON), Infection Control Preventionist (ICP), Business Office Manager (BOM), Maintenance Director, Regional Director of Clinical Services 1 (RDCS 1), Regional [NAME] President of Operations (RVPO), Regional Director of Business Office Services (RDBOS), Regional Director of Clinical Services 2 (RDCS 2), Business Development Coordinator, Certified Nursing Assistant (CNA), Physical Therapist (PT), Registered Nurse Minimum Data Set Nurse (RN MDS Nurse), Activities Director, Housekeeping Manager, Social Services Director, Dietary Manager, Medical Records Nurse, and Human Resources Director (HRD). The SA determined a review of policy and procedures were performed for: Abuse, Neglect, Exploitation, and Misappropriation, Transportation, Skin and Wound, Plans of Care, and Quality Assurance Performance Improvement (QAPI) which required no changes. 5.) The State Agency (SA) validated through interviews on 05/05/2023 at 3:30 PM, the RVPO initiated education to the Medical Director and Interdisciplinary Team (IDT) to ensure an effective QAPI program is maintained to address outside medical services of the residents. No new hired staff will work without the aforementioned education. 6.) The State Agency (SA) validated through record review on 05/05/2023 at 3:35 PM, the RVPO conducted a quality review to ensure the facility has a current non-emergent ambulance agreement in place. There is a current non-emergent ambulance agreement in place for the facility to ensure that residents with higher level of transfer care needs have non-emergent transportation provided by the facility. 7.) The State Agency (SA) validated through interviews on 05/05/2023 at 3:45 PM, the RVPO initiated education to the ED and DON to ensure the administration in a manner that enables the use of its resources to effectively maintain the highest practicable physical well-being for residents to receive physician ordered services to prevent future non-compliance. No new hired staff will work without the aforementioned education. 8.) The State Agency (SA) validated through interviews on 05/05/2023 at 4:00 PM, the DON initiated education to all staff to ensure the residents receive needed medical services and provide physician ordered services that are necessary. No current staff or new hired staff will work without the aforementioned education. 9.) The State Agency (SA) through interviews on 05/05/2023 at 4:20 PM, the RDCS initiated education with the RN MDS Nurses to ensure that Comprehensive Care Plans are developed and implemented to prevent further resident complications for residents' treatment related to a vascular implant and orthopedic and vascular appointments. No current staff or new hired staff will work without the aforementioned education. 10.) The State Agency (SA) through interviews on 05/05/2023 at 4:30 PM, the DON initiated education to licensed nurses to ensure that all residents residing in the facility receive the outside medical services needed to prevent complications. No current staff or new hired staff will work without the aforementioned education. 11.) The State Agency (SA) through interviews on 05/05/2023 at 4:40 PM, RDCS 1 and LPN 1 (Licensed Practical Nurse 1) conducted a quality review of physician ordered appointments of current residents. A quality review of residents' physician ordered appointments were reviewed with the MD for medical urgency and transfer to a higher level of care. No residents were identified with medically urgent appointments. 12. The State Agency (SA) validated through record review on 05/05/2023 at 4:45 PM, that the MD conducted a physician visit with Residents #75 and #87 to ensure medical stability and no new orders received. 13. The State Agency (SA) validated through interviews/record review on 05/07/2023 at 8:00 AM, RDCS 1, RDCS 2, RDCS 3 (Regional Director of Clinical Services 3), and RN Treatment Nurse completed assessments on current residents to ensure medical stability and not requiring a transfer to a higher level of care. The SA validated no residents at risk were identified. 14. The State Agency (SA) validated through record review on 05/07/2023 at 4:00 PM, MD conducted a physician's visit with Residents #75 and #87 and reviewed outstanding appointments for medical urgency and determined that no current appointments were medically urgent requiring a transfer to a higher level of care. MD gave new orders on Residents #75 and #87. 15. The State Agency (SA) validated through observation/interviews and record review on 05/07/2023 at 4:30 PM, the Regional Plant Operations Director delivered an additional wheelchair accessible van for the facility to maintain effectiveness transportation for physician ordered outside medical services. 16. The State Agency (SA) validated through interviews on 05/07/2023 at 4:45 PM, that the RDCS 1 educated the ED, DON, MR Nurse, and Licensed Social Worker on the process to ensure physician ordered medical services are scheduled and transportation is provided. The MR Nurse will be the designated person to ensure all outside medical appointments are maintained and executed. 17. The State Agency (SA) validated through record review on 05/07/2023 at 6:30 PM, Resident # 87 had an appointment scheduled with a wound specialist on 05/23/2023 at 9:15 AM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to provide medical services to prevent an avoidable reduction in range-of-motion (ROM) and loss of mobility for one (1) of 24 sampled residents reviewed for ROM. Resident #31. The facility's failure to provide services to prevent the avoidable loss of ROM for Resident #31 resulted in serious injury, serious harm, and serious impairment and placed other residents in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be Immediate Jeopardy (IJ) that began on 2/14/23 when Resident #31 missed the first post operative appointment with an orthopedic surgeon. The Facility Administrator was notified of the IJ on 5/5/23 at 12:23 PM and provided an IJ Template. The facility provided an acceptable Removal Plan on 5/7/23, in which the facility alleged all corrective actions to remove the IJ were completed and the IJ was removed on 5/8/23. The State Agency (SA) validated the Removal Plan on 5/9/23 and determined the IJ was removed on 5/8/23 prior to exit. Therefore, the scope and severity for 42 CFR 483.25 (c)(1) Mobility, F688 was lowered from a J to a scope and severity of a D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: A record review of facility policy Contractures Prevention with a revision date of 8/22/2017, revealed Policy: To prevent contracture of extremities for those residents who no longer have full use of their extremities .Each resident must be evaluated for need of contracture prevention procedures . as needed . residents may have braces or splints to prevent or help release contractures . be sure to follow the physician's order . On 05/01/23 at 03:21 PM, in an interview, Resident #31 stated staff will not get him up out of the bed. He stated he has missed two physician appointments due to the facility's van not working. On 5/3/23 at 3:30 PM, in an interview with the Nurse Practitioner (NP) revealed Resident #31 had orders to follow up (F/U) with the Orthopedic surgeon in February. The NP explained the order was for follow-up before the resident could be seen by therapy. The resident was ordered non-weight bearing and could not get out of the bed until the Orthopedic surgeon follow-up appointment. The NP said the resident still had not seen the orthopedic surgeon as of today. The NP said the resident's left foot has turned to the side now. The NP said she has talked to the Administrator and the Director of Nurses (DON) several times explaining the resident's need for a follow up appointment. On 05/04/23 at 09:42 AM, an observation revealed Resident #31 had a right below the knee amputation (BKA). The resident's left leg was noted to be in a brace that was not secured to his leg and the resident's left foot was turned outward. Interview on 05/04/23 at 09:45 AM, revealed Resident #31 stated he wanted to get out of his room. The resident said he has not left his room since he was admitted on [DATE]. The resident said he wanted to go outside and enjoy the fresh air, and it is miserable staying in this room all the time watching television. The resident said he cannot go to therapy until he sees the surgeon. The resident also said he has lost one leg and he feel like he might lose another leg because it has been so long since he had a follow-up with the surgeon. Record review of the Order Recap Report revealed Resident #31 had a Physician's Order, dated 2/1/23 and discontinued on 3/8/23 for, Follow up appointment: Feb (February) 14, 2023 10:15 A . Post-Op visit . and a Physician's Order, dated 3/8/23 for, Schedule F/U appointment with Orthopedics (ortho) . Record review of the facility's Progress Notes revealed Resident #31 had a Physician Progress Note dated 2/14/23 at 15:44 (3:44 PM) for, .Wound care nurse requests evaluation of multiple areas with sutures, as he had a F/U appointment today with Orthopedics but did not go, will review the reason why with DON. Did document the following appointments on my last visit to be sure he did not miss them. Will again review all appointments with DON . revealed Resident #31 missed follow up appointment. NP will follow up with DON. Record review of the facility's Progress Notes revealed Resident #31 had a Physician Progress Note, dated 2/15/23 at 10:44 AM for, .Reviewed appointments with DON and information for each appointment documented in my note. Yesterday's appointment was rescheduled as the facility's transportation department already had a full calendar prior to his admission . Record review of the facility's Progress Notes revealed Resident #31 had a Physician Progress Note, dated 2/28/23 at 12:35 PM, for, NP/F/U stitch removal .Reassessed this resident's multiple surgical areas to see how they are doing after removing sutures last week to his Left leg and the Right AKA (Above Knee Amputation) stump .some sutures remain. On staff attempt to remove sutures some were too embedded to be able to remove. The staff nurse asked me if I could look at them and attempt to remove the remaining sutures. Removed remaining sutures from Right stump and Left thigh area .continues to wear a [NAME] brace to LLE (Left Lower Extremity) and remains NWB (non-weight bearing) LLE and s/p (status post) RLE (Right Lower Extremity) AKA . Record review of the Progress Notes revealed Resident #31 had a Physician Progress Note, dated 3/8/23 at 11:44 AM, for, .This resident asked if he could start receiving PT (Physical Therapy). I discussed this with the PT department, they are waiting for Weight bearing status update as he is NWB per his discharge paperwork .He had a F/U appointment scheduled for Feb. 14, 2023 that was missed and rescheduled for [DATE] according to the DON but when they called to confirm the 27th appointment prior to transport the DON states she was told they did not have any F/U appointment on the books with Ortho. (orthopedic) for this patient at all and no other appointment has been made as of today as I spoke with the scheduling department myself .this AM and she confirmed no F/U Ortho. appointment for this patient at this time. I discussed this with the DON, she is to schedule that F/U, after that visit we can get weight bearing status and be able to move forward with his PT/OT (Occupational Therapy) according to Ortho's recommendations . Record review of the Progress Notes revealed Resident #31 had a Nursing Progress Note dated 3/8/23 at 11:44 AM, for, Called (Proper Name of Orthopedic Facility) .in reference to f/u appt for resident .schedule is filled at the time and he does not have any openings . Record review of the Progress Notes revealed Resident #31 had a Physician Progress Note, dated 4/25/23 at 13:25 (1:25 PM) for, .He is asking when he remove his left leg brace. I explained to him he has to see Ortho and get the order to remove this brace from them. He voiced concern that he has missed several appointments to go back and see Ortho because of transportation, as he is being told. I spoke with DON and Administrator concerning this resident and his return appointments, they both state they are working on it as it has been a transportation issue. I expressed the importance of getting him back to the Orthopedic ASAP (As soon as possible) for F/U of his surgeries and hospital stay prior to admission on [DATE]. They both expressed understanding . Review of the medical record revealed there was no documentation indicating that Resident #31 was seen by the Orthopedic Surgeon as ordered. A record review of the admission Record revealed the facility admitted Resident #31 on 1/31/23 with diagnoses including Displaced Fracture of Right Femur and Encounter for Orthopedic aftercare following surgical amputation. Interview on 05/04/23 at 10:35 AM, with Physical Therapist Assistant (PTA) said the resident could not be seen by therapy until he was seen by his orthopedic surgeon. The therapist said they will need an order for the resident weight bearing status. On 05/05/23 at 9:50 AM, in an interview with Licensed Practical Nurse (LPN) #3 stated she was aware of the van breaking down several times in February and March and Resident #31 missing physician appointments. She stated he cannot get out of bed until he sees his orthopedic doctor. On 05/08/23 at 11:53 AM, in an interview with the current Director of Nursing (DON) revealed Resident #31 cannot put weight on his leg until after he sees the Orthopedic physician for a follow up appointment. She stated he has been in bed since admission on [DATE]. She confirmed the resident had missed appointments and stated the appointments he missed have been rescheduled. The DON stated the resident must go to his orthopedic appointment by non-emergency ambulance. She stated she informed the Administrator of the importance of the resident keeping his follow up appointment. A record review of Resident #31's admission Minimum Data Set (MDS)with an Assessment Reference Date of 2/7/23 revealed a Brief Interview of Mental Status score of 15, which indicates Resident #31 is cognitively intact. The facility provided an acceptable Removal Plan which included: Immediate Action started on 05/05/2023 at 12:23 PM: * Resident # 75 has a pulmonology scheduled for 06/19/2023 at 4:00 PM. * Resident # 75 has a cardiology appointment scheduled for 05/23/2023 at 1:00 PM. * Resident # 87 had a vascular stent removed on 05/04/2023 at 5:30 AM. * On 05/05/2023 at 2:00 PM, Ad Hoc Quality Assurance Performance Improvement (QAPI) Committee met to ensure the residents receive needed medical services to prevent future occurrences of neglect, to ensure that Comprehensive Care Plans are developed and implemented to include needed medical services as physician ordered, to ensure that all residents residing in the facility receive the outside medical services needed to prevent complications, to prevent residents from experiencing avoidable loss of ROM, to ensure facility administration is administered in a manner that enables the use of its resources to effectively maintain the highest practicable physical well-being for residents receiving physician ordered services, and to ensure an effective QAPI program is maintained. A Root Cause Analysis (RCA) was conducted and reviewed policies and procedures for changes. RCA revealed the policy was not followed and one of two vans was out of commission. RCA revealed former ED only rented a van for two weeks during the timeframe one van was out of commission and did not continue to rent a van nor secure other means of transportation even though Company approval was given.Attendees were the Medical Director (MD), Executive Director (ED), Director of Nursing (DON), Infection Control Preventionist (ICP), Business Office Manager (BOM), Maintenance Director, Regional Director of Clinical Services 1 (RDCS 1), Regional [NAME] President of Operations (RVPO), Regional Director of Business Office Services (RDBOS), Regional Director of Clinical Services 2 (RDCS 2), Business Development Coordinator, Certified Nursing Assistant (CNA), Physical Therapist (PT), Registered Nurse Minimum Data Set Nurse (RN MDS Nurse), Activities Director, Housekeeping Manager, Social Services Director, Dietary Manager, Medical Records Nurse, and Human Resources Director (HRD). A review of policy and procedures were: Abuse, Neglect, Exploitation, and Misappropriation, Transportation, Skin and Wound, Plans of Care, and Quality Assurance Performance Improvement (QAPI) which required no changes. * On 05/05/2023 at 3:30 PM, the RVPO initiated education to the Medical Director and Interdisciplinary Team (IDT) to ensure an effective QAPI program is maintained to address outside medical services of the residents. No new hired staff will work without the aforementioned education. * On 05/05/2023 at 3:35 PM, the RVPO conducted a quality review to ensure the facility has a current non-emergent ambulance agreement in place. There is a current non-emergent ambulance agreement in place for the facility to ensure that residents with higher level of transfer care needs have non-emergent transportation provided by the facility. * On 05/05/2023 at 3:45 PM, the RVPO initiated education to the ED and DON to ensure the administration in a manner that enables the use of its resources to effectively maintain the highest practicable physical well-being for residents to receive physician ordered services to prevent future non-compliance. No new hired staff will work without the aforementioned education. * On 05/05/2023 at 4:00 PM, the DON initiated education to all staff to ensure the residents receive needed medical services and provide physician ordered services that are necessary. No current staff or new hired staff will work without the aforementioned education. * On 05/05/2023 at 4:40 PM, RDCS 1 and LPN 1 (Licensed Practical Nurse 1) conducted a quality review of physician ordered appointments of current residents. A quality review of residents' physician ordered appointments were reviewed with the MD for medical urgency and transfer to a higher level of care. No residents were identified with medically urgent appointments. * On 05/05/2023 at 4:45 PM, MD conducted a physician visit with Residents #75 and #87 to ensure medical stability and no new orders received. Resident #254 is no longer in the facility as of 04/19/2023 related to transferred to the hospital. * On 05/07/2023 at 4:00 PM, MD conducted a physician's visit with Residents #75 and #87 and reviewed outstanding appointments for medical urgency and determined that no current appointments were medically urgent requiring a transfer to a higher level of care. MD gave new orders on Residents #75 and #87. * On 05/07/2023 at 4:30 PM, the Regional Plant Operations Director delivered an additional wheelchair accessible van for the facility to maintain effectiveness transportation for physician ordered outside medical services. * On 05/07/2023 at 4:45 PM, the RDCS 1 educated the ED, DON, MR Nurse, and Licensed Social Worker on the process to ensure physician ordered medical services are scheduled and transportation is provided. The MR Nurse will be the designated person to ensure all outside medical appointments are maintained and executed. * On 05/07/2023 at 6:30 PM, Resident # 87 had an appointment scheduled with a wound specialist on 05/23/2023 at 9:15 AM. * The facility alleges all corrective actions were completed to remove the immediacy on May 7, 2023, and the Immediate Jeopardy was removed May 8, 2023. The State Agency (SA) validated the facility's Corrective Actions: 1.) The State Agency (SA) validated through record review Resident # 75 has a pulmonology scheduled for 06/19/2023 at 4:00 PM. 2.) The State Agency (SA) validated through record review Resident # 75 has a cardiology appointment scheduled for 05/23/2023 at 1:00 PM. 3.) The State Agency (SA) validated through record review Resident # 87 had a vascular stent removed on 05/04/2023 at 5:30 AM. 4.) The State Agency (SA) validated through record review on 05/05/2023 at 2:00 PM, Ad Hoc Quality Assurance Performance Improvement (QAPI) Committee met and covered needed medical services to prevent future occurrences of neglect, Comprehensive Care Plans, residents residing in the facility receive the outside medical services needed to prevent complications, facility administration and review of an effective QAPI program is maintained. The SA determined a Root Cause Analysis (RCA) was conducted and policies and procedures were reviewed for changes. The SA determined attendees were the Medical Director (MD), Executive Director (ED), Director of Nursing (DON), Infection Control Preventionist (ICP), Business Office Manager (BOM), Maintenance Director, Regional Director of Clinical Services 1 (RDCS 1), Regional [NAME] President of Operations (RVPO), Regional Director of Business Office Services (RDBOS), Regional Director of Clinical Services 2 (RDCS 2), Business Development Coordinator, Certified Nursing Assistant (CNA), Physical Therapist (PT), Registered Nurse Minimum Data Set Nurse (RN MDS Nurse), Activities Director, Housekeeping Manager, Social Services Director, Dietary Manager, Medical Records Nurse, and Human Resources Director (HRD). The SA determined a review of policy and procedures were performed for: Abuse, Neglect, Exploitation, and Misappropriation, Transportation, Skin and Wound, Plans of Care, and Quality Assurance Performance Improvement (QAPI) which required no changes. 5.) The State Agency (SA) validated through interviews on 05/05/2023 at 3:30 PM, the RVPO initiated education to the Medical Director and Interdisciplinary Team (IDT) to ensure an effective QAPI program is maintained to address outside medical services of the residents. No new hired staff will work without the aforementioned education. 6.) The State Agency (SA) validated through record review on 05/05/2023 at 3:35 PM, the RVPO conducted a quality review to ensure the facility has a current non-emergent ambulance agreement in place. There is a current non-emergent ambulance agreement in place for the facility to ensure that residents with higher level of transfer care needs have non-emergent transportation provided by the facility. 7.) The State Agency (SA) validated through interviews on 05/05/2023 at 3:45 PM, the RVPO initiated education to the ED and DON to ensure the administration in a manner that enables the use of its resources to effectively maintain the highest practicable physical well-being for residents to receive physician ordered services to prevent future non-compliance. No new hired staff will work without the aforementioned education. 8.) The State Agency (SA) validated through interviews on 05/05/2023 at 4:00 PM, the DON initiated education to all staff to ensure the residents receive needed medical services and provide physician ordered services that are necessary. No current staff or new hired staff will work without the aforementioned education. 9.) The State Agency (SA) through interviews on 05/05/2023 at 4:20 PM, the RDCS initiated education with the RN MDS Nurses to ensure that Comprehensive Care Plans are developed and implemented to prevent further resident complications for residents' treatment related to a vascular implant and orthopedic and vascular appointments. No current staff or new hired staff will work without the aforementioned education. 10.) The State Agency (SA) through interviews on 05/05/2023 at 4:30 PM, the DON initiated education to licensed nurses to ensure that all residents residing in the facility receive the outside medical services needed to prevent complications. No current staff or new hired staff will work without the aforementioned education. 11.) The State Agency (SA) through interviews on 05/05/2023 at 4:40 PM, RDCS 1 and LPN 1 (Licensed Practical Nurse 1) conducted a quality review of physician ordered appointments of current residents. A quality review of residents' physician ordered appointments were reviewed with the MD for medical urgency and transfer to a higher level of care. No residents were identified with medically urgent appointments. 12. The State Agency (SA) validated through record review on 05/05/2023 at 4:45 PM, that the MD conducted a physician visit with Residents #75 and #87 to ensure medical stability and no new orders received. 13. The State Agency (SA) validated through interviews/record review on 05/07/2023 at 8:00 AM, RDCS 1, RDCS 2, RDCS 3 (Regional Director of Clinical Services 3), and RN Treatment Nurse completed assessments on current residents to ensure medical stability and not requiring a transfer to a higher level of care. The SA validated no residents at risk were identified. 14. The State Agency (SA) validated through record review on 05/07/2023 at 4:00 PM, MD conducted a physician's visit with Residents #75 and #87 and reviewed outstanding appointments for medical urgency and determined that no current appointments were medically urgent requiring a transfer to a higher level of care. MD gave new orders on Residents #75 and #87. 15. The State Agency (SA) validated through observation/interviews and record review on 05/07/2023 at 4:30 PM, the Regional Plant Operations Director delivered an additional wheelchair accessible van for the facility to maintain effectiveness transportation for physician ordered outside medical services. 16. The State Agency (SA) validated through interviews on 05/07/2023 at 4:45 PM, that the RDCS 1 educated the ED, DON, MR Nurse, and Licensed Social Worker on the process to ensure physician ordered medical services are scheduled and transportation is provided. The MR Nurse will be the designated person to ensure all outside medical appointments are maintained and executed. 17. The State Agency (SA) validated through record review on 05/07/2023 at 6:30 PM, Resident # 87 had an appointment scheduled with a wound specialist on 05/23/2023 at 9:15 AM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to ensure a functioning call light system was available for residents' bathrooms for 18 residents out of 107 residents that reside in the facility. (Residents #4, #5, #12, #21, #32, #37, #38, #44, #46, #49, #57, #60 #65, #69, #71, #81, #87, and #96) The facility's failure to ensure a functioning call light system was available for residents' bathrooms for 18 residents residing in the facility placed these residents, and other residents, in a situation that was likely to cause serious harm, injury, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 4/16/23 when a maintenance work order was completed for call light issues but was not acted upon. The facility Administrator was notified of the IJ on 5/2/23 at 5:38 PM and provided an IJ Template. The facility provided an acceptable Removal Plan on 5/2/23, in which they alleged all corrective actions to remove the IJ were completed and the IJ was removed on 5/3/23. The State Agency (SA) validated the Removal Plan on 5/9/23 and determined the IJ was removed on 5/3/23 prior to exit. Therefore, the scope and severity for 42 CFR 483.90 (g)(2) Resident Call System, F919 was lowered from a J to a scope and severity of a D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A record review of the facility's policy Call Bell System-Inoperable with revision date 08/22/2017, revealed, Policy: Resident must have, at all times, a system to notify staff when assistance is needed. The call bell system is to be inspected on a regular basis by Maintenance. If the Call Bell System is inoperable, in one room, one hall, or the entire unit, the following procedure must be followed: Procedure: Maintenance, the Executive Director, and the Director of Clinical Services must be notified immediately if any call bell or the system is inoperable . On 05/01/23 at 12:01 PM, during an interview with Resident #49, she reported the bathroom call light does not work in her current room, nor did it work in her previous bathroom when she was in room [ROOM NUMBER]. The resident explained when she tried to pull the call light cords in the bathrooms, nothing happened. Resident #49 revealed that she had reported the non-working call lights to a staff member but does not remember the name. On 05/02/23 at 08:05 AM, observed the metal frame and switch button of the bathroom call light located in the bathroom between 204 and 206 to be covered with a heavy corrosive material. It was very difficult to pull the cord but when the cord was pulled, the light did not work, and the call light switch could not be turned back to off position by pushing the button down. On 05/02/23 at 09:00 AM, during an interview with Resident #46, she reported she has never attempted to use the call light in her bathroom but had been told by staff members that the call light did not work. When the call light was tested, the light did not work. On 05/02/23 at 09:15 AM, during an interview with Resident #37, she reported thankfully she has never had to use her bathroom call light, because it does not work. On 05/02/23 at 09:25 AM, during an interview with Resident #5, she revealed she had never tried to use her bathroom call light, because a night shift employee had told her the light did not work. On 05/02/23 at 09:35 AM, during an observation of the call light button and metal base in the bathroom located between rooms [ROOM NUMBERS], revealed a heavy corrosive substance. When the call light was pulled, the call light did not work. On 05/02/23 at 10:13 AM, during an observation of the call lights in the bathrooms located between rooms [ROOM NUMBERS], 204 and 206, 209 and 211, 400 and 402, 401 and 403, 408 and 409, 414 and 415, and 516 and 518 revealed the call light strings were short and a heavy corrosive substance was noted on the metal base. On 05/02/23 at 10:20 AM, during an interview with Maintenance Director, he explained he has been at the facility for a month and a half. He revealed no one had reported anything to him about bathroom call lights. He explained he is not aware of a maintenance logbook, or a computer system for maintenance requests and that the requests that he had received for needed repairs, had been verbal requests. On 05/02/23 at 10:30 AM, during an interview with the Director of Nursing (DON), she explained she was not aware of bathroom call lights were not working. The DON revealed the nurses and Certified Nurse Aides (CNAs) are responsible for making sure the call lights are within a resident's reach and functioning properly, as it is important for residents to get assistance as quickly as possible to ensure that their needs are met. On 05/02/23 at 10:35 AM, during an interview with Certified Nurse Aide (CNA) #11, she revealed that none of her residents had reported their bathroom call lights not working. In an observation with CNA #11, it was confirmed that the call lights did not work in the bathrooms in room [ROOM NUMBER], 101, and in the joining bathroom for rooms [ROOM NUMBERS]. On 05/02/23 at 10:42 AM, during an interview with the Administrator, he reported he was not aware of bathroom call lights not working. He revealed he expects maintenance to check all call lights weekly, during weekly rounds and make repairs as needed or reported. The Administrator revealed the facility does have a work order system for maintenance. He confirmed that each nurse's station has a work order book for staff to record needed repairs and that maintenance should check the book daily and perform the requested repairs. On 05/02/23 at 10:45 AM, during an interview with CNA #12, she confirmed the bathroom call light for rooms [ROOM NUMBERS] had not worked for a long time and remembered notifying the nurses. On 05/02/23 at 10:46 AM, during an interview with CNA #5 for 400 hall, she explained the call lights in the bathrooms haven't worked for several months and the problem was reported to the last Maintenance Director. Record review on 11:10 AM on 05/02/23, revealed a Maintenance Book was noted at the nurse's station with a record for work order dated 04/16/2023, completed by LPN #13 on night shift. A record review of the Maintenance Work Order with date 04/16/2023 revealed, . rooms listed 203, 206, 209 call lights not showing up on call system or outside door . The work order was blank on the completed part of the form. On 05/02/23 at 11:45 AM , during an interview with Licensed Practical Nurse (LPN) #6, she explained she mostly works the 200 hall and reported some of the call lights have not worked for a long period of time. She revealed she reported the problem to the Administrator and Maintenance Director and has even put the information in the maintenance log. She confirmed she had written a maintenance work order in the maintenance book dated 04/16/2023. On 05/02/23 at 12:20 PM, during an interview with Resident #49, she explained when she was in room [ROOM NUMBER] and tried to use the bathroom call light, it didn't work. She reported her roommate used the call light in the room to call for help. She told the nurse and the CNA that the bathroom call light did not work. A record review of Resident #49's admission Record revealed the facility admitted resident on 12/13/2022 with the diagnoses of Acute Myocardial Infarction, Unspecified and Chronic Obstructive Pulmonary Disease, Unspecified. A record review of Resident # 49's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/18/2023 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated cognitively intact, and Section H revealed Resident #49 was occasionally incontinent of bowel and bladder. A record review of Resident #4's admission Record revealed the facility admitted resident on 02/24/2023 with the diagnoses of Type 2 Diabetes Mellitus with Diabetic Nephropathy and Muscle Weakness (Generalized). A record review of Resident #4's admission MDS with an ARD of 03/03/2023 revealed a BIMS score of 15, which indicated cognitively intact, and Resident #4 was occasionally incontinent of urine. A record review of Resident #5's admission Record revealed the facility admitted the resident on 05/05/2014 with the diagnoses of Poly osteoarthritis and Intervertebral Disc Disorders with Radiculopathy, Lumbar Region. A record review of Resident #5's Quarterly MDS with an ARD of 03/10/2023 revealed a BIMS score of 15, which indicated cognitively intact, and Resident #5 was occasionally incontinent of urine and always continent of bowel. A record review of Resident 12's admission Record revealed the facility admitted the resident on 04/09/2018 with the diagnoses of Heart Failure, Unspecified and Flaccid Hemiplegia affecting Right Dominant Side. A record review of Resident #12's Quarterly MDS with an ARD of 02/16/2023 revealed a BIMS score of 14, which indicated cognitively intact, and Resident #12 was occasionally incontinent of urine and always continent of bowel. A record review of Resident #21's admission Record revealed the facility admitted the resident on 10/19/2018 with the diagnoses of [NAME] Fascial Fibromatosis (Dupuytren) and Muscle Weakness. A record review of Resident #21's Quarterly MDS with an ARD of 03/10/2023 revealed a BIMS score of 12, which indicated cognitively intact, and Resident #21 was always continent of bowel and bladder. A record review of Resident #32's admission Record revealed the facility admitted the resident on 02/22/2022 with the diagnoses of Type 2 Diabetes Mellitus Without Complications and Primary Osteoarthritis, Unspecified Site. A record review of Resident #32's Quarterly MDS with an ARD of 02/16/2023 revealed a BIMS score of 15, which indicated cognitively intact, and Resident #32 was always continent of bowel and bladder. A record review of Resident #37's admission Record revealed the facility admitted the resident on 05/06/2022 with the diagnoses of Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbances and Psychotic Disturbance. A record review of Resident #37's Quarterly MDS with an ARD of 03/10/2023 revealed a BIMS score of 15, which indicated cognitively intact, and Resident #37 was always continent of bowel and bladder. A record review of Resident #38's admission Record revealed the facility admitted resident on 09/09/2016 with the diagnoses Major Depressive Disorder, Recurrent, Unspecified and Anemia, Unspecified. A record review of Resident #38's Annual MDS with an ARD of 03/08/2023 revealed a BIMS score of 09, which indicated moderately cognitively impaired, and Resident #38 was occasionally incontinent of urine and bowel. A record review of Resident #44's admission Record revealed the facility admitted Resident #44 on 07/29/2019 with the diagnoses of Arthropathy and Chronic Pain Syndrome. A record review of Resident #44's Quarterly MDS with an ARD of 04/10/2023 revealed a BIMS score of 06, which indicated server cognitively impaired, and Resident #44 was always continent of bowel and bladder. A record review of Resident #46's admission Record revealed the facility admitted the resident on 02/02/2023 with the diagnoses of Unspecified Dementia, Moderate, With Mood Disturbance and Muscles Weakness (Generalized). A record review of Resident #46's Annual MDS with an ARD of 02/14/2023 revealed a BIMS score of 13, which indicated cognitively intact, and Resident #46 was frequently incontinent of urine and bowel. A record review of Resident #57's admission Record revealed the facility admitted Resident #57 on 021/15/2020 with the diagnoses of Difficulty in Walking, Not Elsewhere Classified and Dementia. A record review of Resident #57's Quarterly MDS with an ARD of 11/16/2022 revealed a BIMS score of 03, which indicated severely cognitively impaired, and Resident #57 was frequently incontinent of urine and bowel. A record review of Resident #60's admission Record revealed the facility admitted resident on 09/15/2021 with the diagnoses of Contracture of Right Wrist and Anemia, Unspecified. A record review of Resident #60's Quarterly MDS with an ARD of 03/10/2023 revealed a BIMS score of 09, which indicated moderately cognitively impaired, and Resident #60 was always continent of bowel and bladder. A record review of Resident #65's admission Record revealed the facility admitted the resident on 06/29/2023 with the diagnoses of Stiffness of Unspecified Joint, Not Elsewhere Classified and Contracture of Right Elbow. A record review of Resident #65's Quarterly MDS with an ARD of 04/01/2023 revealed a BIMS score of 07, which indicated moderately cognitively impaired, and Resident #65 is occasionally incontinent of urine and frequently incontinent of bowel. A record review of Resident #69's admission Record revealed the facility admitted the resident on 08/24/2022 with the diagnoses of COVID-19 and Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side. A record review of Resident #69's Quarterly MDS with an ARD of 02/20/2023 revealed a BIMS score of 15, which indicated cognitively intact, and Resident #69 was occasionally incontinent of urine and always continent of bowel. A record review of Resident #71's admission Record revealed the facility admitted the resident on 04/30/2021 with the diagnoses of Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side and Muscle Weakness. A record review of Resident #71's Annual MDS with an ARD of 04/17/2023 revealed a BIMS score of 14, which indicated cognitively intact, and Resident #71 was always continent of bowel and bladder. A record review of Resident #81's admission Record revealed the facility admitted the resident on 01/28/2022 with the diagnoses Myalgia, Unspecified Site and Essential (Primary) Hypertension. A record review of Resident #81's Quarterly MDS with an ARD of 04/11/2023 revealed a BIMS score of 15, which indicated cognitively intact, and Resident #81 was occasionally always continent of bowel and bladder. A record review of Resident #87's admission Record revealed the facility admitted resident on 07/06/2022 with the diagnoses of Post-Traumatic Stress Disorder, Chronic and Major Depressive Disorder, Recurrent, Moderate. A record review of Resident #87's Quarterly MDS with an ARD of 04/05/2023 revealed a BIMS score of 15, which indicated cognitively intact, and Resident # 87 was always continent of bowel and bladder. A record review of Resident #96's admission Record revealed the facility admitted the resident on 02/03/2023 with the diagnoses of Leukemia, Unspecified Not Having Achieved Remission and Muscle Weakness (Generalized). A record review of Resident #96's admission MDS with an ARD of 02/13/2023 revealed a BIMS score of 13, which indicated cognitively intact, and Resident #96 was incontinent of bowel and bladder. The facility provided an acceptable Removal Plan which included: Immediate Action started on 05/02/2023 at 5:45 PM On 05/02/2023 at 6:00pm, Ad Hoc Quality Assurance Performance Improvement (QAPI) Committee met to ensure a functioning call light system was available for resident bathrooms. A Root Cause Analysis (RCA) was conducted and reviewed policies and procedures for changes. RCA determined the facility hired a new Maintenance Director who was not aware of the maintenance repair request forms located at the nurses' stations and will be educated. Attendees were the Executive Director (ED), Director of Nursing (DON), Maintenance Director, Infection Control Preventionist (ICP), Business Office Manager (BOM), Regional Plant Operations (RPO), Regional Director of Clinical Services (RDCS), Regional [NAME] President of Operations (RVPO), and Human Resources Director (HRD). The Medical Director (MD) attended by phone. A review of policy and procedures were: Call Bell System-Inoperable and Communication Failure Nurse Call System which required no changes. On 05/02/2023 at 6:05pm, RVPO educated the Maintenance Director on the location of the maintenance repair request forms located at each nurse's stations for staff to use when notifying maintenance department of any issue related to ensure a functioning call light system. On 05/02/2023 at 6:10pm, RDCS initiated education on Call Bell System-Inoperable and Communication Failure Nurse Call System to ensure a functioning call light system. No current staff or new hire will work without the aforementioned education. On 05/02/2023 at 6:15pm, the emergency call light system for resident bathrooms was audited by observation for 107 residents on census to ensure proper functioning of call system by the Regional Plant Operations (RPO), RVPO, and ED. There were 16 resident bathrooms affecting 26 residents in the facility. Resident bathrooms #101, #103, #109, #203, #204, #206, #209, #409, #414, and #415 were repaired on 5/2/23 by the RPO. Resident bathrooms #211, #308, #310, #400, #402, and #403 had a bell installed by the RPO and ED on 5/2/23 related to the annunciator board light functioning but not sounding at the nurses' station. The residents residing in #211, #308, #310, #400, #402, and #403 were shown a demonstration by the RDCS on 05/02/2023 on how to use the bell in the bathroom. On 05/02/2023 at 7:00pm, an outside contracted vendor was called and scheduled to come to inspect our nurse call light system to ensure additional verification of proper functioning, on May 3, 2023. The facility alleges all corrective actions were completed to remove the immediacy on May 2, 2023, and the Immediate Jeopardy was removed May 3, 2023. The State Agency (SA) validated the facility's Corrective Actions: 1. The State Agency (SA) validated through record review on 05/02/2023 at 6:00 PM, Ad Hoc Quality Assurance Performance Improvement (QAPI) Committee met to ensure a functioning call light system was available for resident bathrooms. A Root Cause Analysis (RCA) was conducted and reviewed policies and procedures for changes. RCA determined the facility hired a new Maintenance Director who was not aware of the maintenance repair request forms located at the nurses' stations and will be educated. Attendees were the Executive Director (ED), Director of Nursing (DON), Maintenance Director, Infection Control Preventionist (ICP), Business Office Manager (BOM), Regional Plant Operations (RPO), Regional Director of Clinical Services (RDCS), Regional [NAME] President of Operations (RVPO), and Human Resources Director (HRD). The Medical Director (MD) attended by phone. A review of policy and procedures were: Call Bell System-Inoperable and Communication Failure Nurse Call System which required no changes. 2. On 05/8/2023 at 11:35 AM, in an interview with Maintenance Director stated that stated he attended the in-service on 5/2/2023 in reference to call lights function. in service on call lights. He stated he will keep a daily log of checking call lights daily. He stated they have a quote on getting a whole new system. 3. A record review on 05/09/2023 at 12:00 PM, of the Education in-service record for Maintenance Director. 4. On 05/09/2023 at 12:10 PM, an interview with RVPO stated all parties attended the QAPI meeting. She stated the medical director attended the meeting by phone and came into the facility and signed the sign in sheet. 5. At 12:30 PM on 05/09/2023, during an interview with the Administrator, she confirmed she was in-serviced on call light system and the procedure if the call light system is inoperable. 6. A record review on 05/09/23, of the bathroom call light audit revealed it was done on 05/02/2023. 7. A record review of the Senior Maintenance Director outside contractors came in the building in related to call lights. 8. A recorded review of the call light audit schedule revealed no concerns. All rooms were checked. 9. A record review of the staff in-service on call lights were signed by all staff. 10. On 50/09/2023 at 1:00 PM, SA validated with all staff about call light in-service on call lights and use of alternative bells. The staff validated the steps to take if call lights are not working.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and facility policy review, the facility neglected to provide physician ordered services that were necessary for five (5) of 24 sampled residents. This resulted in actual harm for Residents #31, #75, #87, and #254 and had the likelihood of serious harm for Resident # 34. The facility's failure to provide services necessary to avoid physical harm caused serious harm as Resident #31 experienced decreased range of motion and mobility, Resident #75 was hospitalized for Congestive Heart Failure (CHF), Resident #87 developed a infection of a vascular stent placement, and Resident #254 was hospitalized due to sepsis. There was likelihood of harm for Resident #34 due to a delay in follow-up appointment for a supra pubic catheter placement. This non-compliance put these residents and other residents in a situation that was likely to cause serious harm, injury, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 11/21/22 when Resident #87 was referred to a vascular surgeon and the facility did not follow physician's orders for follow-up appointment. The SA notified the facility Administrator of the IJ and provided an IJ template on 5/5/23 at 12:23 PM. The facility submitted an acceptable Removal Plan on 5/7/23, in which they alleged all corrective actions to remove the IJ were completed and the IJ was removed on 5/8/23. The State Agency (SA) validated the Removal Plan on 5/9/23 and determined the IJ was removed on 5/8/23 prior to exit. Therefore, the scope and severity for 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F600 was lowered from a K to a scope and severity of an E, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Review of the facility's policy, Abuse, Neglect, Exploitation & Misappropriation policy, revised on 11/16/2022, revealed , Employees of the center are charged with a continuing obligation to treat residents so they are free from .neglect .No employee may at any time commit an act of .neglect .Definitions .Neglect is the failure of the center, its employees or service provides to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Resident #31 During an interview on 5/3/23 at 3:30 PM, with the Nurse Practitioner (NP), she revealed Resident #31 had orders to follow up with an orthopedic surgeon in February 2023, but the resident still had not been seen by the surgeon. The NP said Resident #31 could not receive therapy services until he was assessed by the Orthopedic Surgeon and cleared for weight bearing status. She explained that Resident #31 currently had a non-weight bearing status and could not get out the bed until he was seen by surgeon. The NP stated that because he did not go to the post operative appointment, the resident's surgical staples were embedded in his surgical wound, and she had to call the orthopedic surgeon to obtain an order to remove the staples. She also commented that his left foot was turned outward to the left side now and she thought his foot would have to be broken again before anything could be done for him. She said she had talked to the Administrator and the DON several times explaining that Resident #31 needed to go to his post operative appointments. During an observation and interview with Resident #31, on 05/04/23 at 09:42 AM, revealed he was lying in bed wearing a left leg brace that was not secured to his leg, a boot on his left foot with the foot turned outward, and had a right lower extremity amputation. He explained that he was hit by a car prior to entering the facility. Resident #31 said he wanted to get out of his room because he had not left the room since he was admitted on [DATE]. He confirmed that the facility failed to send him to a follow up visit with his orthopedic doctor. He said he was miserable staying in this room all the time watching television and he commented that he had lost one leg and he might lose another leg because it had been so long since he saw the orthopedic doctor. During an interview on 5/04/23 at 10:35 AM, the facility's Physical Therapy Assistant (PTA) confirmed Resident #31 could not participate in therapy services until he was assessed by his orthopedic surgeon to obtain a weight bearing status. The PTA said he had ordered the resident a prosthesis for the newly amputated extremity, but it could not be used because the resident did not have a weight bearing status. The PTA said until the resident was assessed by the orthopedic surgeon, their hands are tied. Record review of the Order Recap Report revealed Resident #31 had a Physician's Order, dated 2/1/23 and discontinued on 3/8/23 for, Follow up appointment: Feb (February) 14, 2023 10:15 A . Post-Op visit . and a Physician's Order, dated 3/8/23 for, Schedule F/U appointment with Orthopedics . Record review of the facility's Progress Notes revealed Resident #31 had a Physician Progress Note dated 2/14/23 at 15:44 (3:44 PM) for, .Wound care nurse requests evaluation of multiple areas with sutures, as he had a F/U appointment today with Orthopedics but did not go, will review the reason why with DON. Did document the following appointments on my last visit to be sure he did not miss them. Will again review all appointments with DON . revealed Resident #31 missed follow up appointment. NP will follow up with DON. Record review of the facility's Progress Notes revealed Resident #31 had a Physician Progress Note, dated 2/15/23 at 10:44 AM for, .Reviewed appointments with DON and information for each appointment documented in my note. Yesterday's appointment was rescheduled as the facility's transportation department already had a full calendar prior to his admission . Record review of the facility's Progress Notes revealed Resident #31 had a Physician Progress Note, dated 2/28/23 at 12:35 PM, for, NP/F/U stitch removal .Reassessed this resident's multiple surgical areas to see how they are doing after removing sutures last week to his Left leg and the Right AKA (Above Knee Amputation) stump .some sutures remain. On staff attempt to remove sutures some were too embedded to be able to remove. The staff nurse asked me if I could look at them and attempt to remove the remaining sutures. Removed remaining sutures from Right stump and Left thigh area .continues to wear a [NAME] brace to LLE (Left Lower Extremity) and remains NWB (non-weight bearing) LLE and s/p (status post) RLE (Right Lower Extremity) AKA . Record review of the Progress Notes revealed Resident #31 had a Physician Progress Note, dated 3/8/23 at 11:44 AM, for, .This resident asked if he could start receiving PT (Physical Therapy). I discussed this with the PT department, they are waiting for Weight bearing status update as he is NWB per his discharge paperwork .He had a F/U appointment scheduled for Feb. 14, 2023 that was missed and rescheduled for [DATE] according to the DON but when they called to confirm the 27th appointment prior to transport the DON states she was told they did not have any F/U appointment on the books with Ortho. for this patient at all and no other appointment has been made as of today as I spoke with the scheduling department myself .this AM and she confirmed no F/U Ortho. Appointment for this patient at this time. I discussed this with the DON, she is to schedule that F/U, after that visit we can get weight bearing status and be able to move forward with his PT/OT according to Ortho's recommendations . Record review of the Progress Notes revealed Resident #31 had a Nursing Progress Note dated 3/8/23 at 11:44 AM, for, Called (Proper Name of Orthopedic Facility) .in reference to f/u appt for resident .schedule is filled at the time and he does not have any openings . Record review of the Progress Notes revealed Resident #31 had a Physician Progress Note, dated 4/25/23 at 13:25 (1:25 PM) for, .He is asking when he remove his left leg brace. I explained to him he has to see Ortho and get the order to remove this brace from them. He voiced concern that he has missed several appointments to go back and see Ortho because of transportation, as he is being told. I spoke with DON and Administrator concerning this resident and his return appointments, they both state they are working on it as it has been a transportation issue. I expressed the importance of getting him back to the Orthopedic ASAP (As soon as possible) for F/U of his surgeries and hospital stay prior to admission on [DATE]. They both expressed understanding . Review of the medical record revealed there was no documentation indicating that Resident #31 was seen by the Orthopedic Surgeon as ordered. A record review of the admission Record revealed the facility admitted Resident #31 on 1/31/23 with diagnoses including Displaced Fracture of Right Femur and Encounter for Orthopedic aftercare following surgical amputation. A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/07/23, revealed Resident #31 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact. Resident #75 During an interview on 05/01/23 at 03:20 PM, with Resident #75, she stated the facility had failed to schedule and keep follow up appointments for her to see her cardiologist or pulmonologist. The resident said she was concerned because she had been hospitalized for pneumonia and had difficulty breathing. She did not understand why she could not go to her doctor's appointments. During an interview on 5/3/23 at 1:00 PM, with License Practical Nurse (LPN) #2, she confirmed the resident did not go to see her Cardiologist and Pulmonologist because the facility van was inaccessible for the resident and the facility must pay the local Ambulance service in advance for non-emergent transporting of residents. LPN #2 also confirmed the resident was not sent to the hospital for a chest x-ray (CXR). LPN #2 revealed she was given this information by the previous Director of Nursing (DON) and the Administrator. During an interview on 5/3/23 at 4:00 PM, with the current DON, she revealed she was not the DON at the time the Nurse Practitioner (NP) placed the order for the resident to have follow up appointments with the Cardiologist and Pulmonologist. The DON also said she was not the DON when the NP wrote an order for the resident to get a CXR at the hospital. The DON stated she was aware that the local ambulance company required payment in advance for non-emergency transport services and that Resident #75 was not sent to see her Cardiologist and Pulmonologist. The DON also confirmed the resident was not sent to the hospital for a CXR due to transportation problems with the facility. During an interview on 5/3/23 at 3:30 PM, with the NP, she said she wrote an order for the resident to follow up with her Cardiologist and Pulmonologist in January of 2023, and the facility failed to follow her orders. The NP also said she ordered a portable CXR in January 2023 for the resident, but she exceeded 300 pounds, and the technician could not get a good picture. The NP then wrote an order to schedule the resident to have a CXR at the hospital, which was not carried out. The NP stated that she talked to the Administrator and the previous DON about residents not going to ordered appointments. The Administrator told her that the Resident was too large to fit in the company van and that he had to pay the local ambulance in advance before they would transfer any of the residents for non-emergency appointments. The NP reported that she told the Administrator, You admitted the residents now you must take care of their needs. The NP stated that had the facility sent the resident to the follow up visit with the Cardiologist, Pulmonologist, and CXR, the resident would not have had to be hospitalized with Congestive Heart Failure (CHF) and pneumonia. Record review of the Order Summary Report with Active Orders as of 05/03/2023, revealed Resident #75 had a Physician's Order, dated 1/3/23 to Schedule appointment in [NAME], MS with this resident's Cardiologist and Pulmonologist as she is c/o (complaining of) increased heart palpitations and Shortness of breath. She states she has not been seen in over a year. Record review of the Progress Notes for Resident #75 revealed a Physician Progress Note dated 1/24/23 at 18:19 (6:19 PM) for, .The resident reports she is experiencing occasional heart palpitations, states she just feels like her heart is running away from her and she feel short of breath when this happens. Reviewed V/S (vital signs) and noted her BP (blood pressure) is running higher than it should be .Will discuss the status of her order to schedule a F/U (follow up) appointment with her cardiologist and pulmonologist in [NAME], MS that is known to her for a checkup . POC (Plan of Care) .3. CXR c/o SOB (Shortness of Breath). Record review of the Progress Notes for Resident #75 revealed a Nursing Progress Note dated 1/26/23 at 18:20 (6:20 PM) for, (Proper Name of Portable X-ray Company) present at this time to do portable CXR, unable to perform r/t (related to) res (resident) weight exceeding 300 pounds per policy .DON notified .NP notified then instructed for CXR to be scheduled and res to be transferred to hosp (hospital) to be obtained . Record review of the Progress Notes for Resident #75 revealed a Nursing Progress Note, dated 3/1/23 at 10:10 (AM) for, .She states she is having more shortness of breath .her thighs and lower abdomen feel tight .POC .2. Place a Foley (indwelling) catheter today . Record review of the Progress Notes for Resident #75 revealed a Nursing Progress Note, dated 3/15/23 at 13:38 (1:38 PM), for, Res c/o SOB with difficulty breathing to this nurse .NP present in facility, made aware. N.O. (New Order) to send res to (Proper Name of Local Hospital) . Record review of the Progress Notes for Resident #75 revealed a Nursing Progress Note, dated 3/15/23 at 18:14 (6:14 PM), for, .admitted .with dx-CHF, pulmonary disease, stable condition noted. Review of the medical record revealed there was no documentation indicating that Resident #75 was seen by the Cardiologist or Pulmonologist, and there was no documentation that she received the diagnostic CXR as ordered. Record review of a hospital History and Physical Note, dated 3/15/2023 at 17:02 (5:02 PM), revealed, .CT (Computed Tomography) of the chest showed evidence of pneumonitis and possible atypical pneumonia. She was admitted . Record review of the admission Record revealed the facility admitted Resident #75 on 9/12/22 and she had diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Morbid Obesity, and Diastolic Congestive Heart Failure. Record review of the Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/29/23 revealed Resident #79 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated her cognition was moderately impaired. Resident #87 During an interview on 05/03/23 at 03:30 PM, the NP stated that Resident #87 had an artificial implant because of poor circulation that was placed by the vascular surgeon prior to his admission to the facility on 7/6/22. The NP said the resident has had complaints of pain and has had recurrent infections with Methicillin-Resistant Staphylococcus (MRSA) in that area because the implant needed to be removed. The NP said she wrote orders last year for the facility to make an appointment to follow up with the vascular surgeon, but the facility kept changing the appointment, and he still has not seen the surgeon. The NP stated that she had asked the DON why the resident had not seen the surgeon and was told it was because the facility's van was being repaired and the dialysis residents have top priority related to transportation. The NP said she told the DON that the resident should not have to continue to be in pain or suffer from infections because the facility had transportation problems. During an interview on 05/03/23 at 04:00 PM, with Resident #87, he confirmed he had pain and recurrent infections in his thigh. The resident said he talked to the NP and explained that his thigh was hurting and that he needed to have the implant removed and the NP said she would have the facility to set up an appointment. The resident was unable to recall the exact month that the NP said she was going to get him appointment, but he knew it was last year. The resident said that his appointments kept getting changed because the facility vans were not working, but he had an appointment scheduled for tomorrow (5/4/23). Record review of the Order Summary Report dated 5/3/23, revealed Resident #87 had a Physician's Order, dated 11/21/22, for refer to (Proper Name of Physician) vascular surgeon at (Proper Name of Medical Clinic), a Physician's Order, dated 3/17/23, for Get appointment with physician at (Proper Name of Medical Clinic) .ASAP (as soon as possible) .related to Unspecified Open Wound, Left Thigh ., and a Physician's Order, dated 4/11/23, for Get appointment with (Proper Name of Physician) vascular surgeon .as soon as possible to have artificial implant removed from Left Groin/Thigh . Record review of the Progress Notes for Resident #87, revealed a Physician Progress Note, dated 4/11/23 at 15:00 (3:00 PM) for .The resident states he is having pain to his left groin/thigh. He just completed antibiotic therapy for MRSA to his left groin/thigh wound where he has an artificial implant placed by the vascular surgeon .The implant has given him trouble since insertion, and he was trying to get it removed when he was first admitted here last year. He had infection at that time and keep getting recurrent infection usually MRSA to this same area. Order placed to get him an appointment with (Proper Name of Physician) ASAP now that he has just completed another round of antibiotics on the 31st of March for MRSA. He is c/o pain to this area and leg .Getting him to the surgeon for possible removal of this implant will be what will help him the most to get rid of his pain .POC .Get appointment with .vascular surgeon .as soon as possible to have artificial implant removed from Left Groin/Thigh. During an interview on 05/04/23 at 10:48 AM, with the DON, she confirmed the residents' appointments with the vascular surgeon were changed several times because there were problems with both facility vans. The DON explained that one van was out of commision and the other van was in the shop being repaired. The DON said that she tried to rearrange several appointments and that Resident # 87's appointments got lost in the cracks because of all the appointments that had to be canceled. The DON said when she realized the resident's appointment was not made, she called the surgeon's office and asked the nurse to set up an appointment. She confirmed that the resident had complaints of pain and that he had been treated for infections twice since the implant was placed. A record review of the admission Record revealed the facility admitted Resident #87 on 07/06/2022, and he had diagnoses including Post-Traumatic Stress Disorder (PTSD) and Depression. Record review of the Quarterly MDS with an ARD of 04/05/23 revealed Resident #87 had a BIMS score of 15, which indicated he was cognitively intact. Record review of the Microbiology report for Wound Cultures collected 3/21/23 and reported 3/23/23 for Resident #87 revealed a specimen from the Thigh was collected and resulted in .Moderate Methicillin Resistant Staphylococcus aureus (MRSA) . Record review of the Microbiology report for Wound Cultures collected 4/11/23 and reported 4/15/23 for Resident #87 revealed a specimen was collected from the Thigh and resulted in Light .(MRSA) . Resident #254 On 05/03/23 at 10:10 AM, during an interview with Registered Nurse (RN) #1, she explained Resident #254 was transferred to the hospital from a wound care appointment and has not returned to the facility. RN #1 stated that she scheduled Resident #254 for a wound care appointment on the 4/14/23, but the facility was unable to transport her because of transportation problems. On 05/04/23 at 09:10 AM, during a phone interview with Resident #254's niece, she said she was not aware that Resident #254 had missed the wound care appointment scheduled on 4/14/23, but she was informed that the resident had an appointment scheduled for 04/18/23. On 05/08/23 at 11:10 AM, during a phone interview with the local would care clinic, the staff revealed Resident #254 arrived for the wound appointment. Upon arrival, her vital signs were abnormal, she had a fever, and was lethargic, so the clinic sent her to the Emergency Room, and she was diagnosed with Sepsis. Record review of the Progress Notes for Resident #254 revealed a Nursing Progress Note dated 4/14/23 at 13:53 (1:53 PM) for unable to take resident to wound care apt (appointment) today will contact family and wound care to reschedule. Resident #34 During an interview on 5/3/23 at 3:30 PM, with the NP, she revealed Resident #34 had a suprapubic catheter placed on 3/24/23 and had orders to return to the Urology for a follow up on 4/19/23. The facility changed the appointment to 5/9/23 because of transportation issues and then changed it again to 5/11/23 due to continued transportation problems. The NP said that she called the Urologists' office on 4/25/23 to ask if she could change the suprapubic catheter since his appointment had been postponed due to transportation problems. The doctor replied, Absolutely not. The doctor then said the resident needed to be in her office by tomorrow because she was concerned about the resident developing an infection. The NP said she took her phone to the Administrator and let him talk to the doctor. She said the Administrator called the facility's transportation staff and rearranged dialysis residents so the resident could be at the Urologists' office the following day. The NP said that if she had not called the doctor herself, the resident would not have had his newly placed suprapubic catheter changed timely. During an interview on 05/14/23 at 08:16 AM, with Resident #34, he confirmed his follow up appointment was scheduled for 4/19/23 and the facility changed the appointment due to transportation issues. Resident #34 said he was told the facility van was in the shop and the facility had to reschedule his appointment to 5/9/23. He explained that later the staff came to him and said they had to change his appointment again to 5/11/23 because they were not sure when the van would be ready. Resident #34 said he was concerned because the doctor told him it was especially important for him to return for his follow up visit in a month. Record review of the Progress Notes revealed Resident #34 had a Physician Progress Note, dated 4/25/23 at 13:56 (1:56 PM), .He is concerned with his newly placed Suprapubic catheter needing changed as it was placed 3/24/23. He was told by (Proper Name of Physician) she would change it for the first time on his return visit for F/U, the appointment was made for 4/19/23, then changed by the facility because of transportation to 5/9/23 and then again because of transportation to 5/11/23. I called the nurse of (Proper Name of Physician) to question whether we, the staff of (Proper Name of Facility) or myself (NP) could change the catheter for the first time since his appointments had been postponed. The nurse states No, the Dr. has to change it for the first time and he cannot wait until 5/11/23 for this to be done, as a matter of fact he needs to be in the office by tomorrow to get it done, as they are worried of an infection developing should he wait that long after surgery to have it changed or even see the Dr. for F/U after surgery. Spoke with Administrator .he contacted the van driver and rearranged some dialysis transports and stated they can have the resident in [NAME] .at 2pm, the nurse put him on the book for 2pm tomorrow . Record review of the admission Record revealed the facility admitted Resident #34 on 06/22/2020 with a diagnosis of Spina Bifida. Record review of the Significant Change in Status MDS with an ARD of 02/20/23 revealed Resident #34 had a BIMS score of 15 which indicated he was cognitively intact. During an interview on 5/3/23 at 2:00 PM, with the Chief Executive Officer (CEO) of the local ambulance company, he confirmed they required the facility to pay in advance for non-emergency transportation services. During an interview on 05/04/23 at 08:07 AM, with the Medical Director (MD), he stated that he was told at the last Quality Assurance (QA) meeting that the facility had rescheduled some resident appointments because of transportation problems. The MD said he was told the facility had addressed the problem and it was resolved. The MD said he did not know that Resident #37 and Resident #81 had not been able to see their surgeons and recalled stating at that meeting that those residents needed to follow up immediately with their surgeons. The MD also stated that the residents not having transportation to appointments is unacceptable and must be taken care of immediately. The doctor said he thought the transportation problems were resolved. During an interview on 05/04/23 at 09:24 AM, with CNA #1, she said she had been the van transportation driver and took residents to dialysis. CNA #1 confirmed the facility had communication problems with appointments because different nurses and the DON were making appointments. The resident appointments were clashing with each other which caused a lot of confusion and some residents missed appointments because they were scheduled at the same time. During an interview on 05/04/23 at 09:58 AM, with CNA #2, he said he drives the facility's transportation van, but he does not schedule the appointments. CNA #2 stated the facility van was placed in the shop for repairs three (3) times since he started driving the van in February 2023. CNA #2 confirmed the facility rented a van, and dialysis residents were the top priority for transports. CNA #2 said this facility is too big for one van and needs two vans to meet the residents' needs. On 05/04/23 at 11:58 AM, during an interview with the Administrator, revealed one van was disabled in February and the other van kept breaking down and was placed in the shop several times. The Administrator said he emailed his corporate office to let them know that he did not have transportation for the residents to go out to their appointments. He stated that he rented a van to help with dialysis appointments and some local appointments. The corporate office said they were working with the insurance company to try to get another van because the disabled van had not been replaced. The Administrator confirmed that one van could not take all the residents to dialysis and to local and out of town appointments. The facility provided an acceptable Removal Plan which included: Immediate Action started on 05/05/2023 at 12:23 PM: Resident # 75 has a pulmonology scheduled for 06/19/2023 at 4:00 PM. Resident # 75 has a cardiology appointment scheduled for 05/23/2023 at 1:00 PM. Resident # 87 had a vascular stent removed on 05/04/2023 at 5:30 AM. On 05/05/2023 at 2:00 PM, Ad Hoc Quality Assurance Performance Improvement (QAPI) Committee met to ensure the residents receive needed medical services to prevent future occurrences of neglect, to ensure that Comprehensive Care Plans are developed and implemented to include needed medical services as physician ordered, to ensure that all residents residing in the facility receive the outside medical services needed to prevent complications, to prevent residents from experiencing avoidable loss of ROM, to ensure facility administration is administered in a manner that enables the use of its resources to effectively maintain the highest practicable physical well-being for residents receiving physician ordered services, and to ensure an effective QAPI program is maintained. A Root Cause Analysis (RCA) was conducted and reviewed policies and procedures for changes. RCA revealed the policy was not followed and one of two vans was out of commission. RCA revealed former ED only rented a van for two weeks during the timeframe one van was out of commission and did not continue to rent a van nor secure other means of transportation even though Company approval was given. Attendees were the Medical Director (MD), Executive Director (ED), Director of Nursing (DON), Infection Control Preventionist (ICP), Business Office Manager (BOM), Maintenance Director, Regional Director of Clinical Services 1 (RDCS 1), Regional [NAME] President of Operations (RVPO), Regional Director of Business Office Services (RDBOS), Regional Director of Clinical Services 2 (RDCS 2), Business Development Coordinator, Certified Nursing Assistant (CNA), Physical Therapist (PT), Registered Nurse Minimum Data Set Nurse (RN MDS Nurse), Activities Director, Housekeeping Manager, Social Services Director, Dietary Manager, Medical Records Nurse, and Human Resources Director (HRD). A review of policy and procedures were: Abuse, Neglect, Exploitation, and Misappropriation, Transportation, Skin and Wound, Plans of Care, and Quality Assurance Performance Improvement (QAPI) which required no changes. On 05/05/2023 at 3:30 PM, the RVPO initiated education to the Medical Director and Interdisciplinary Team (IDT) to ensure an effective QAPI program is maintained to address outside medical services of the residents. No new hired staff will work without the aforementioned education. On 05/05/2023 at 3:35 PM, the RVPO conducted a quality review to ensure the facility has a current non-emergent ambulance agreement in place. There is a current non-emergent ambulance agreement in place for the facility to ensure that residents with higher level of transfer care needs have non-emergent transportation provided by the facility. On 05/05/2023 at 3:45 PM, the RVPO initiated education to the ED and DON to ensure the administration in a manner that enables the use of its resources to effectively maintain the highest practicable physical well-being for residents to receive physician ordered services to prevent future non-compliance. No new hired staff will work without the aforementioned education. On 05/05/2023 at 4:00 PM, the DON initiated education to all staff to ensure the residents receive needed medical services and provide physician ordered services that are necessary. No current staff or new hired staff will work without the aforementioned education. On 05/05/2023 at 4:40 PM, RDCS 1 and LPN 1 (Licensed Practical Nurse 1) [TRUNCATED]

Based on interviews, record review, and job description review, the facility's administration failed to use its resources effectively to ensure residents received physician-ordered services for five (5) of 24 residents reviewed, with the likelihood to affected any resident who needed outside transportation. Resident #31, Resident #34, Resident #75, Resident #87, and Resident #254. Serious harm occurred as a result of the facility's Administration's failure to ensure residents received physician-ordered services which caused Resident #31 to have decreased mobility, Resident #75 to be hospitalized , Resident #87 to have a wound infection, and Resident #254 to have sepsis. There was a likelihood of harm for Resident #34 due to a delay in changing a newly placed supra pubic catheter. The failure placed these residents, and other residents who are at risk in a situation that was likely to cause serious harm, injury, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 11/21/22 when Resident #87 was referred to a vascular surgeon and the facility did not follow physician's orders. The Facility Administrator was notified of the IJ on 5/5/23 at 12:23 PM and provided an IJ Template. The facility provided an acceptable Removal Plan on 5/7/23, in which they alleged all corrective actions to remove the IJ were completed and the IJ was removed on 5/8/23. The State Agency (SA) validated the Removal Plan on 5/9/23 and determined the IJ was removed on 5/8/23 prior to exit. Therefore, the scope and severity for 42 CFR 483.70 Administration, F835 was lowered from a K to a scope and severity of a E, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A review of the job description entitled Executive Director I documented, .The primary purpose of the Executive Director is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines and regulations that govern nursing facilities to ensure that the highest degree of quality care can be always provided to our residents at all times .you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties . Responsible for day-to-day clinical and administrative activities of the facility .Duties and Responsibilities . Schedule regular meeting with direct report staff to provide supervision, ensure communication and to monitor facility operations .Support and guide the facility's quality improvement process .Attend to overall operation of the facility . On 05/04/23 at 03:40 PM, in an interview with the Administrator regarding transportation issues and residents missing outside medical appointments, he revealed that the local ambulance service had stopped all non-emergency transportation in June of 2022, when he first started working at the facility. He also revealed one of the facility's vans broke down in February 2023, due to an automobile accident and the facility's second van kept breaking down and needing repairs. He explained the facility had to move outside appointments around during this time, due to the lack of transportation. The Administrator confirmed that he had notified the Corporate office of the facility's issues with transportation and was told that they were working with the insurance company to purchase a replacement van. He explained that the corporate office had rented a van, but only for a few weeks and there were several times that he had no other option than to use the local ambulance company for non-emergent transportation for dialysis residents and had to pay between $400-800 out of his pocket and wait for the corporate office to reimburse him. The Administrator noted when the physicians wrote orders for appointments, the Director of Nurses (DON) would set up the appointments. However, due to lack of transportation, many times the scheduled appointments had to be canceled and re-scheduled. The Administrator confirmed he informed the Regional [NAME] President of Operations (RVPO) of every issue. However, he could not afford to continue to pay for transportation out of his pocket and the corporate office had not directed him to rent a van. On 05/04/23 at 4:40 PM, in an interview with the Director of Nurses (DON), she confirmed she set up all the physician appointments. She stated that many times the re-scheduled appointments had to be canceled due to lack of transportation. The DON revealed she informed the Administrator of all missed appointments. On 05/08/23 at 5:00 PM, in an interview with the RVPO, she confirmed she was informed when the van was disabled on 2/10/23. She stated she told the Administrator to schedule appointments as needed and use petty cash or pay for the non-emergent transportation with the local ambulance company and fill out expense report. She stated the expense report takes one week to one and half weeks to reimburse. She stated she was not aware of residents missing appointments. She stated the Administrator did not follow company policy. The facility provided an acceptable Removal Plan which included: Immediate Action started on 05/05/2023 at 12:23 PM: * Resident # 75 has a pulmonology scheduled for 06/19/2023 at 4:00 PM. * Resident # 75 has a cardiology appointment scheduled for 05/23/2023 at 1:00 PM. * Resident # 87 had a vascular stent removed on 05/04/2023 at 5:30 AM. * On 05/05/2023 at 2:00 PM, Ad Hoc Quality Assurance Performance Improvement (QAPI) Committee met to ensure the residents receive needed medical services to prevent future occurrences of neglect, to ensure that Comprehensive Care Plans are developed and implemented to include needed medical services as physician ordered, to ensure that all residents residing in the facility receive the outside medical services needed to prevent complications, to prevent residents from experiencing avoidable loss of ROM, to ensure facility administration is administered in a manner that enables the use of its resources to effectively maintain the highest practicable physical well-being for residents receiving physician ordered services, and to ensure an effective QAPI program is maintained. A Root Cause Analysis (RCA) was conducted and reviewed policies and procedures for changes. RCA revealed the policy was not followed and one of two vans was out of commission. RCA revealed former ED only rented a van for two weeks during the timeframe one van was out of commission and did not continue to rent a van nor secure other means of transportation even though Company approval was given. * Attendees were the Medical Director (MD), Executive Director (ED), Director of Nursing (DON), Infection Control Preventionist (ICP), Business Office Manager (BOM), Maintenance Director, Regional Director of Clinical Services 1 (RDCS 1), Regional [NAME] President of Operations (RVPO), Regional Director of Business Office Services (RDBOS), Regional Director of Clinical Services 2 (RDCS 2), Business Development Coordinator, Certified Nursing Assistant (CNA), Physical Therapist (PT), Registered Nurse Minimum Data Set Nurse (RN MDS Nurse), Activities Director, Housekeeping Manager, Social Services Director, Dietary Manager, Medical Records Nurse, and Human Resources Director (HRD). A review of policy and procedures were: Abuse, Neglect, Exploitation, and Misappropriation, Transportation, Skin and Wound, Plans of Care, and Quality Assurance Performance Improvement (QAPI) which required no changes. * On 05/05/2023 at 3:30 PM, the RVPO initiated education to the Medical Director and Interdisciplinary Team (IDT) to ensure an effective QAPI program is maintained to address outside medical services of the residents. No new hired staff will work without the aforementioned education. * On 05/05/2023 at 3:35 PM, the RVPO conducted a quality review to ensure the facility has a current non-emergent ambulance agreement in place. There is a current non-emergent ambulance agreement in place for the facility to ensure that residents with higher level of transfer care needs have non-emergent transportation provided by the facility. * On 05/05/2023 at 3:45 PM, the RVPO initiated education to the ED and DON to ensure the administration in a manner that enables the use of its resources to effectively maintain the highest practicable physical well-being for residents to receive physician ordered services to prevent future non-compliance. No new hired staff will work without the aforementioned education. * On 05/05/2023 at 4:00 PM, the DON initiated education to all staff to ensure the residents receive needed medical services and provide physician ordered services that are necessary. No current staff or new hired staff will work without the aforementioned education. * On 05/05/2023 at 4:40 PM, RDCS 1 and LPN 1 (Licensed Practical Nurse 1) conducted a quality review of physician ordered appointments of current residents. A quality review of residents' physician ordered appointments were reviewed with the MD for medical urgency and transfer to a higher level of care. No residents were identified with medically urgent appointments. * On 05/05/2023 at 4:45 PM, MD conducted a physician visit with Residents #75 and #87 to ensure medical stability and no new orders received. Resident #254 is no longer in the facility as of 04/19/2023 related to transferred to the hospital. * On 05/07/2023 at 4:00 PM, MD conducted a physician's visit with Residents #75 and #87 and reviewed outstanding appointments for medical urgency and determined that no current appointments were medically urgent requiring a transfer to a higher level of care. MD gave new orders on Residents #75 and #87. * On 05/07/2023 at 4:30 PM, the Regional Plant Operations Director delivered an additional wheelchair accessible van for the facility to maintain effectiveness transportation for physician ordered outside medical services. * On 05/07/2023 at 4:45 PM, the RDCS 1 educated the ED, DON, MR Nurse, and Licensed Social Worker on the process to ensure physician ordered medical services are scheduled and transportation is provided. The MR Nurse will be the designated person to ensure all outside medical appointments are maintained and executed. * On 05/07/2023 at 6:30 PM, Resident # 87 had an appointment scheduled with a wound specialist on 05/23/2023 at 9:15 AM. * The facility alleges all corrective actions were completed to remove the immediacy on May 7, 2023, and the Immediate Jeopardy was removed May 8, 2023. The State Agency (SA) validated the facility's Corrective Actions: 1.) The State Agency (SA) validated through record review Resident # 75 has a pulmonology scheduled for 06/19/2023 at 4:00 PM. 2.) The State Agency (SA) validated through record review Resident # 75 has a cardiology appointment scheduled for 05/23/2023 at 1:00 PM. 3.) The State Agency (SA) validated through record review Resident # 87 had a vascular stent removed on 05/04/2023 at 5:30 AM. 4.) The State Agency (SA) validated through record review on 05/05/2023 at 2:00 PM, Ad Hoc Quality Assurance Performance Improvement (QAPI) Committee met and covered needed medical services to prevent future occurrences of neglect, Comprehensive Care Plans, residents residing in the facility receive the outside medical services needed to prevent complications, facility administration and review of an effective QAPI program is maintained. The SA determined a Root Cause Analysis (RCA) was conducted and policies and procedures were reviewed for changes. The SA determined attendees were the Medical Director (MD), Executive Director (ED), Director of Nursing (DON), Infection Control Preventionist (ICP), Business Office Manager (BOM), Maintenance Director, Regional Director of Clinical Services 1 (RDCS 1), Regional [NAME] President of Operations (RVPO), Regional Director of Business Office Services (RDBOS), Regional Director of Clinical Services 2 (RDCS 2), Business Development Coordinator, Certified Nursing Assistant (CNA), Physical Therapist (PT), Registered Nurse Minimum Data Set Nurse (RN MDS Nurse), Activities Director, Housekeeping Manager, Social Services Director, Dietary Manager, Medical Records Nurse, and Human Resources Director (HRD). The SA determined a review of policy and procedures were performed for: Abuse, Neglect, Exploitation, and Misappropriation, Transportation, Skin and Wound, Plans of Care, and Quality Assurance Performance Improvement (QAPI) which required no changes. 5.) The State Agency (SA) validated through interviews on 05/05/2023 at 3:30 PM, the RVPO initiated education to the Medical Director and Interdisciplinary Team (IDT) to ensure an effective QAPI program is maintained to address outside medical services of the residents. No new hired staff will work without the aforementioned education. 6.) The State Agency (SA) validated through record review on 05/05/2023 at 3:35 PM, the RVPO conducted a quality review to ensure the facility has a current non-emergent ambulance agreement in place. There is a current non-emergent ambulance agreement in place for the facility to ensure that residents with higher level of transfer care needs have non-emergent transportation provided by the facility. 7.) The State Agency (SA) validated through interviews on 05/05/2023 at 3:45 PM, the RVPO initiated education to the ED and DON to ensure the administration in a manner that enables the use of its resources to effectively maintain the highest practicable physical well-being for residents to receive physician ordered services to prevent future non-compliance. No new hired staff will work without the aforementioned education. 8.) The State Agency (SA) validated through interviews on 05/05/2023 at 4:00 PM, the DON initiated education to all staff to ensure the residents receive needed medical services and provide physician ordered services that are necessary. No current staff or new hired staff will work without the aforementioned education. 9.) The State Agency (SA) through interviews on 05/05/2023 at 4:20 PM, the RDCS initiated education with the RN MDS Nurses to ensure that Comprehensive Care Plans are developed and implemented to prevent further resident complications for residents' treatment related to a vascular implant and orthopedic and vascular appointments. No current staff or new hired staff will work without the aforementioned education. 10.) The State Agency (SA) through interviews on 05/05/2023 at 4:30 PM, the DON initiated education to licensed nurses to ensure that all residents residing in the facility receive the outside medical services needed to prevent complications. No current staff or new hired staff will work without the aforementioned education. 11.) The State Agency (SA) through interviews on 05/05/2023 at 4:40 PM, RDCS 1 and LPN 1 (Licensed Practical Nurse 1) conducted a quality review of physician ordered appointments of current residents. A quality review of residents' physician ordered appointments were reviewed with the MD for medical urgency and transfer to a higher level of care. No residents were identified with medically urgent appointments. 12. ) The State Agency (SA) validated through record review on 05/05/2023 at 4:45 PM, that the MD conducted a physician visit with Residents #75 and #87 to ensure medical stability and no new orders received. 13. The State Agency (SA) validated through interviews/record review on 05/07/2023 at 8:00 AM, RDCS 1, RDCS 2, RDCS 3 (Regional Director of Clinical Services 3), and RN Treatment Nurse completed assessments on current residents to ensure medical stability and not requiring a transfer to a higher level of care. The SA validated no residents at risk were identified. 14. The State Agency (SA) validated through record review on 05/07/2023 at 4:00 PM, MD conducted a physician's visit with Residents #75 and #87 and reviewed outstanding appointments for medical urgency and determined that no current appointments were medically urgent requiring a transfer to a higher level of care. MD gave new orders on Residents #75 and #87. 15. The State Agency (SA) validated through observation/interviews and record review on 05/07/2023 at 4:30 PM, the Regional Plant Operations Director delivered an additional wheelchair accessible van for the facility to maintain effectiveness transportation for physician ordered outside medical services. 16. The State Agency (SA) validated through interviews on 05/07/2023 at 4:45 PM, that the RDCS 1 educated the ED, DON, MR Nurse, and Licensed Social Worker on the process to ensure physician ordered medical services are scheduled and transportation is provided. The MR Nurse will be the designated person to ensure all outside medical appointments are maintained and executed. 17. The State Agency (SA) validated through record review on 05/07/2023 at 6:30 PM, Resident # 87 had an appointment scheduled with a wound specialist on 05/23/2023 at 9:15 AM.

Based on interviews, record review, and facility policy review, the facility failed to maintain an effective Quality Assurance Performance Improvement (QAPI) program to ensure transportation was provided for outside medical services for five (5) of 24 sampled residents, with the likelihood to affect any resident who required outside transportation. The facility's failure to maintain an effective QAPI program placed residents who require outside transportation at risk for serious injury, serious harm, serious impairment, or death. This caused Resident #31 to experience decreased mobility, Resident #75 to be hospitalized , Resident #87 to develop a wound infection, and Resident #254 to become septic. There was a likelihood of harm for Resident #34 due to the delay in changing a newly placed supra pubic catheter. The situation was determined to be an Immediate Jeopardy (IJ) that began on 11/21/22 when Resident #87 was referred to a vascular surgeon and the facility did not follow physician's orders. The Facility Administrator was notified of the IJ on 5/5/23 at 12:23 PM and provided an IJ Template. The facility provided an acceptable Removal Plan on 5/7/23, in which they alleged all corrective actions to remove the IJ were completed and the IJ was removed on 5/8/23. The State Agency (SA) validated the Removal Plan on 5/9/23 and determined the IJ was removed on 5/8/23 prior to exit. Therefore, the scope and severity for 42 CFR 483.75 (a)(1) Quality Assurance and Performance Improvement (QAPI) Program, F865 was lowered from a K to a scope and severity of an E, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Review of the facility policy, Quality Assurance Performance Improvement Program (QAPI) revised 10/24/2022, revealed, Policy: The center and organization has a comprehensive, data-driven Quality Assurance Performance Improvement Program that focuses on indicators of the outcomes of care and quality of life .Program Design and Scope 1. The center's QAPI program is on-going comprehensive review of care and services provided to residents. Including but not limited to: a. Medical b. Clinical care .Important functional areas may include but are not limited to .Quality of care .g. Continuity of care .Review of activities may include but not limited to .d. Interdisciplinary care planning .Leadership: The Central Executive Director is accountable for the overall implementation and functioning of the QAPI program. This includes but is not limited to .b) Identify priorities c) Ensures adequate resources .e) Ensures corrective actions are implemented to address identified problems in systems f) Evaluates the effectiveness of actions .4. The program is a coordinated effort among departments and services within the organization that involves leadership working with input from Center staff, residents and families Identifying Quality Deficiencies and Corrective Actions: The center will monitor department performance systems to identify issues or adverse events .15. If a quality deficiency is identified, the committee will oversee the development of corrective action(s) . Record review of the facility's QAPI sign-in sheet for a meeting held 4/27/23 revealed the Administrator, Medical Director, and the Director of Nursing (DON) were in attendance. During an interview on 5/3/23 at 4:00 PM, the DON confirmed she was aware that the facility had to change residents' physician appointments due to transportation issues and that the facility had to pay in advance for non-emergency transportation with the local ambulance company. She said that it was discussed in the QAPI meeting, and the team decided to rent a van until the facility van was repaired. They also decided to wait until the insurance company finished the negotiations regarding the purchase of a new facility van. During an interview on 05/04/23 at 08:07 AM, with the Medical Director (MD) confirmed he attended QAPI meetings quarterly. The MD said he was told at the last quarterly meeting that the facility had rescheduled some resident appointments because the facility was having problems with transportation, but the facility was addressing the problem and it was resolved. The MD also said he did not know that residents had missed follow up appointments with surgeons. The MD said he remembered stating at the QAPI meeting that residents needed to follow up immediately with their appointments. During an interview on 05/04/23 at 10:32 AM, with the Administrator, he confirmed the Quality Assurance Performance Improvement Program (QAPI) Interdisciplinary Team met quarterly to discuss high risk issues. The Administrator stated the facility met in April in which they discussed the transportation van issues and that the corporate office was working with the insurance company to purchase another van. The Administrator confirmed the interventions put in place were not effective. The facility provided an acceptable Removal Plan which included: Immediate Action started on 05/05/2023 at 12:23 PM: Resident # 75 has a pulmonology scheduled for 06/19/2023 at 4:00 PM. Resident # 75 has a cardiology appointment scheduled for 05/23/2023 at 1:00 PM. Resident # 87 had a vascular stent removed on 05/04/2023 at 5:30 AM. On 05/05/2023 at 2:00 PM, Ad Hoc Quality Assurance Performance Improvement (QAPI) Committee met to ensure the residents receive needed medical services to prevent future occurrences of neglect, to ensure that Comprehensive Care Plans are developed and implemented to include needed medical services as physician ordered, to ensure that all residents residing in the facility receive the outside medical services needed to prevent complications, to prevent residents from experiencing avoidable loss of ROM, to ensure facility administration is administered in a manner that enables the use of its resources to effectively maintain the highest practicable physical well-being for residents receiving physician ordered services, and to ensure an effective QAPI program is maintained. A Root Cause Analysis (RCA) was conducted and reviewed policies and procedures for changes. RCA revealed the policy was not followed and one of two vans was out of commission. RCA revealed former ED only rented a van for two weeks during the timeframe one van was out of commission and did not continue to rent a van nor secure other means of transportation even though Company approval was given. Attendees were the Medical Director (MD), Executive Director (ED), Director of Nursing (DON), Infection Control Preventionist (ICP), Business Office Manager (BOM), Maintenance Director, Regional Director of Clinical Services 1 (RDCS 1), Regional [NAME] President of Operations (RVPO), Regional Director of Business Office Services (RDBOS), Regional Director of Clinical Services 2 (RDCS 2), Business Development Coordinator, Certified Nursing Assistant (CNA), Physical Therapist (PT), Registered Nurse Minimum Data Set Nurse (RN MDS Nurse), Activities Director, Housekeeping Manager, Social Services Director, Dietary Manager, Medical Records Nurse, and Human Resources Director (HRD). A review of policy and procedures were: Abuse, Neglect, Exploitation, and Misappropriation, Transportation, Skin and Wound, Plans of Care, and Quality Assurance Performance Improvement (QAPI) which required no changes. On 05/05/2023 at 3:30 PM, the RVPO initiated education to the Medical Director and Interdisciplinary Team (IDT) to ensure an effective QAPI program is maintained to address outside medical services of the residents. No new hired staff will work without the aforementioned education. On 05/05/2023 at 3:35 PM, the RVPO conducted a quality review to ensure the facility has a current non-emergent ambulance agreement in place. There is a current non-emergent ambulance agreement in place for the facility to ensure that residents with higher level of transfer care needs have non-emergent transportation provided by the facility. On 05/05/2023 at 3:45 PM, the RVPO initiated education to the ED and DON to ensure the administration in a manner that enables the use of its resources to effectively maintain the highest practicable physical well-being for residents to receive physician ordered services to prevent future non-compliance. No new hired staff will work without the aforementioned education. On 05/05/2023 at 4:00 PM, the DON initiated education to all staff to ensure the residents receive needed medical services and provide physician ordered services that are necessary. No current staff or new hired staff will work without the aforementioned education. On 05/05/2023 at 4:40 PM, RDCS 1 and LPN 1 (Licensed Practical Nurse 1) conducted a quality review of physician ordered appointments of current residents. A quality review of residents' physician ordered appointments were reviewed with the MD for medical urgency and transfer to a higher level of care. No residents were identified with medically urgent appointments. On 05/05/2023 at 4:45 PM, MD conducted a physician visit with Residents #75 and #87 to ensure medical stability and no new orders received. Resident #254 is no longer in the facility as of 04/19/2023 related to transferred to the hospital. On 05/07/2023 at 4:00 PM, MD conducted a physician's visit with Residents #75 and #87 and reviewed outstanding appointments for medical urgency and determined that no current appointments were medically urgent requiring a transfer to a higher level of care. MD gave new orders on Residents #75 and #87. On 05/07/2023 at 4:30 PM, the Regional Plant Operations Director delivered an additional wheelchair accessible van for the facility to maintain effectiveness transportation for physician ordered outside medical services. On 05/07/2023 at 4:45 PM, the RDCS 1 educated the ED, DON, MR Nurse, and Licensed Social Worker on the process to ensure physician ordered medical services are scheduled and transportation is provided. The MR Nurse will be the designated person to ensure all outside medical appointments are maintained and executed. On 05/07/2023 at 6:30 PM, Resident # 87 had an appointment scheduled with a wound specialist on 05/23/2023 at 9:15 AM. The facility alleges all corrective actions were completed to remove the immediacy on May 7, 2023, and the Immediate Jeopardy was removed May 8, 2023. The State Agency (SA) validated the facility's Corrective Actions: 1. The State Agency (SA) validated through record review Resident # 75 has a pulmonology scheduled for 06/19/2023 at 4:00 PM. 2. The State Agency (SA) validated through record review Resident # 75 has a cardiology appointment scheduled for 05/23/2023 at 1:00 PM. 3. The State Agency (SA) validated through record review Resident # 87 had a vascular stent removed on 05/04/2023 at 5:30 AM. 4. The State Agency (SA) validated through record review on 05/05/2023 at 2:00 PM, Ad Hoc Quality Assurance Performance Improvement (QAPI) Committee met and covered needed medical services to prevent future occurrences of neglect, Comprehensive Care Plans, residents residing in the facility receive the outside medical services needed to prevent complications, facility administration and review of an effective QAPI program is maintained. The SA determined a Root Cause Analysis (RCA) was conducted and policies and procedures were reviewed for changes. The SA determined attendees were the Medical Director (MD), Executive Director (ED), Director of Nursing (DON), Infection Control Preventionist (ICP), Business Office Manager (BOM), Maintenance Director, Regional Director of Clinical Services 1 (RDCS 1), Regional [NAME] President of Operations (RVPO), Regional Director of Business Office Services (RDBOS), Regional Director of Clinical Services 2 (RDCS 2), Business Development Coordinator, Certified Nursing Assistant (CNA), Physical Therapist (PT), Registered Nurse Minimum Data Set Nurse (RN MDS Nurse), Activities Director, Housekeeping Manager, Social Services Director, Dietary Manager, Medical Records Nurse, and Human Resources Director (HRD). The SA determined a review of policy and procedures were performed for: Abuse, Neglect, Exploitation, and Misappropriation, Transportation, Skin and Wound, Plans of Care, and Quality Assurance Performance Improvement (QAPI) which required no changes. 5. The State Agency (SA) validated through interviews on 05/05/2023 at 3:30 PM, the RVPO initiated education to the Medical Director and Interdisciplinary Team (IDT) to ensure an effective QAPI program is maintained to address outside medical services of the residents. No new hired staff will work without the aforementioned education. 6. The State Agency (SA) validated through record review on 05/05/2023 at 3:35 PM, the RVPO conducted a quality review to ensure the facility has a current non-emergent ambulance agreement in place. There is a current non-emergent ambulance agreement in place for the facility to ensure that residents with higher level of transfer care needs have non-emergent transportation provided by the facility. 7. The State Agency (SA) validated through interviews on 05/05/2023 at 3:45 PM, the RVPO initiated education to the ED and DON to ensure the administration in a manner that enables the use of its resources to effectively maintain the highest practicable physical well-being for residents to receive physician ordered services to prevent future non-compliance. No new hired staff will work without the aforementioned education. 8. The State Agency (SA) validated through interviews on 05/05/2023 at 4:00 PM, the DON initiated education to all staff to ensure the residents receive needed medical services and provide physician ordered services that are necessary. No current staff or new hired staff will work without the aforementioned education. 9. The State Agency (SA) through interviews on 05/05/2023 at 4:20 PM,the RDCS initiated education with the RN MDS Nurses to ensure that Comprehensive Care Plans are developed and implemented to prevent further resident complications for residents' treatment related to a vascular implant and orthopedic and vascular appointments. No current staff or new hired staff will work without the aforementioned education. 10. The State Agency (SA) through interviews on 05/05/2023 at 4:30 PM, the DON initiated education to licensed nurses to ensure that all residents residing in the facility receive the outside medical services needed to prevent complications. No current staff or new hired staff will work without the aforementioned education. 11. The State Agency (SA) through interviews on 05/05/2023 at 4:40 PM, RDCS 1 and LPN 1 (Licensed Practical Nurse 1) conducted a quality review of physician ordered appointments of current residents. A quality review of residents' physician ordered appointments were reviewed with the MD for medical urgency and transfer to a higher level of care. No residents were identified with medically urgent appointments. 12. The State Agency (SA) validated through record review on 05/05/2023 at 4:45 PM, that the MD conducted a physician visit with Residents #75 and #87 to ensure medical stability and no new orders received. 13. The State Agency (SA) validated through interviews/record review on 05/07/2023 at 8:00 AM, RDCS 1, RDCS 2, RDCS 3 (Regional Director of Clinical Services 3), and RN Treatment Nurse completed assessments. on current residents to ensure medical stability and not requiring a transfer to a higher level of care. The SA validated no residents at risk were identified. 14. The State Agency (SA) validated through record review on 05/07/2023 at 4:00 PM, MD conducted a physician's visit with Residents #75 and #87 and reviewed outstanding appointments for medical urgency and determined that no current appointments were medically urgent, requiring a transfer to a higher level of care. MD gave new orders on Residents #75 and #87. 15. The State Agency (SA) validated through observation/interviews and record review on 05/07/2023 at 4:30 PM, the Regional Plant Operations Director delivered an additional wheelchair accessible van for the facility to maintain effectiveness transportation for physician ordered outside medical services. 16. The State Agency (SA) validated through interviews on 05/07/2023 at 4:45 PM, that the RDCS 1 educated the ED, DON, MR Nurse, and Licensed Social Worker on the process to ensure physician ordered medical services are scheduled and transportation is provided. The MR Nurse will be the designated person to ensure all outside medical appointments are maintained and executed. 17. The State Agency (SA) validated through record review on 05/07/2023 at 6:30 PM, Resident # 87 had an appointment scheduled with a wound specialist on 05/23/2023 at 9:15 AM.