Every finding on record at Access Mental Health

Based on observation, interview, and record review, the facility failed to report allegations of abuse from Resident (R) 17 to the State Agency as required and further failed to ensure all contracted vendors or providers reported allegations of staff to resident abuse to the Administrator immediately. Findings included: - R17's Electronic Medical Record (EMR) included diagnoses of schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), major depressive disorder (major mood disorder that causes persistent feelings of sadness), adverse effect of methamphetamines (an illegal stimulant with high addiction potential), and adjustment disorder with anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R17's Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. R17 had verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others), other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds), and wandered occurred daily. R17 was independent with activities of daily living. R17's Behavioral Symptoms Care Area Assessment (CAA), dated 04/02/2026, documented R17 has refused care, including taking medications. The resident rarely participated in activities. R17's behavior interfered with others and their well-being. Some behavior is provoked, but most are unprovoked. R17 had been mentally ill for several years. R17's Care Plan, dated 12/08/2025, documented R17 had a potential for aggressive behavior, both physical and verbal, related to schizoaffective and bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods). The plan directed staff that when R17 exhibited aggressive behavior, attempt to de-escalate, keep the situation calm, validate the complaint, give the resident time to vent, and do not argue. The Progress Note dated 03/25/2026 at 10:18 AM documented the staff met with R17 to follow up regarding a reported incident from 02/20/2026. Staff asked R17 to clarify a prior statement in which he had reported that a charge nurse had placed her hands on his neck. Staff offered R17 the opportunity to complete a written witness statement so the allegation could be formally submitted to the appropriate state agency for investigation. R17 asked if it was required that a witness statement be filled out. Staff told R17 that it would help do an investigation and proper review of the incident and explained it would be sent to the state as well. R17 replied never mind and declined to complete a written statement to pursue the allegation further at that time. The note further stated that R17 had not provided additional details regarding the allegation when prompted. No immediate signs or symptoms of distress or injury were observed at the time of assessment. Staff informed R17 that he may report concerns at any time, and the facility staff remained available to assist. A Therapy Progress Note by the mental health consultant, dated 05/28/2026, documented that R17 had reported that the facility nurse had put her hands around his neck and another facility staff member had shown him a bag of marijuana and inappropriate pictures during a smoke break. On 06/03/2026 at 08:40 AM, Consultant Staff GG expressed concern related to R17, who had reported on 05/28/2026 that a nurse had placed her hands around his neck and staff had shown a bag of marijuana and inappropriate pictures to him. Consultant Staff GG reported that the documentation of concerns had not been shared with the facility and would be brought to the survey team. Consultant GG verified that the consultant company staff were also mandated reporters. On 06/03/2026 at 12:30 PM, Administrative Staff AA reported that the staff member named by R17 had not been employed at the facility. Administrative Staff AA stated she should have reported that the state agency should have been notified. On 06/03/2026 at 01:55 PM, Administrative Staff AB reported she had not received notes from the contracted company reporting R17 comments related to staff placing their hands on R17's neck. Administrative Staff AB stated the incident should have been reported to the state agency. The facility's undated Reporting Abuse, Neglect, or Misappropriation of a Resident policy documented that all employees are expected to report all actual or potential incidents of abuse, neglect, or misappropriation of a resident's property immediately to their team leader, the Administrator, or the State Agency Complaint Hotline. The facility reviews all actual or potential incidents involving residents that live in the facility through a multi-disciplinary team.

Based on observations, interviews and record review, the facility failed to maintain and/or dispose of kitchen garbage and refuse properly. Findings included:- During a tour of the kitchen on 06/01/2026 at 07:51 AM, observation revealed the outside garbage receptacle had three of the eight lids open. During an interview on 06/01/2026 at 08:04 AM, Dietary Staff E reported that all the lids were to be closed. During an interview on 06/02/2026 at 12:52 PM, Maintenance Staff B stated all the lids on the outside trash dumpster should always be closed. During an interview on 06/02/2026 at 12:56, Administrative Staff A stated she expected all trash dumpster lids to be closed when not being used. The facility's 2020 policy Garbage and Rubbish Disposal documented outdoor trash receptacles will be kept covered.

The facility identified a census of 42 residents. The sample included 12 residents, with one reviewed for behavioral services. Based on observation, record review, and interviews, the facility failed to provide adequate behavioral health services, including resident-centered interventions to address Resident (R)15's auditory hallucinations related to his schizophrenia and bipolar disorder. On 09/23/35, R15 had exit-seeking behaviors as he heard voices telling him he was supposed to discharge from the facility. The facility staff did not report the incident, and the facility did not assess and identify possible triggers or implement interventions to address the auditory hallucinations. R15's mental provider assessed the resident on 10/07/25 but did not address this resident's recent auditory hallucinations or the associated behaviors. On 11/02/25, R15 again had auditory hallucinations telling him to go outside, so R15 entered the door code and exited the facility without staff knowledge or supervision. R15 was outside alone for 1.5 hours, and was located two blocks from the facility, walking towards the highway in 39-degree Fahrenheit temperatures. Rl5's behavioral manifestations were not assessed by the mental health provider until 11/05/25. The failure to identify and implement behavioral health interventions placed R15 in immediate jeopardy.Findings included: - The Medical Diagnosis section within R15's Electronic Medical Records (EMR) included diagnoses of schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought) with bipolar type (a major mental illness that causes people to have episodes of severe high and low moods). R15's 02/15/25 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS documented R15 hallucinated (sensing things while awake that appear to be real, but the mind created) and had delusions (untrue, persistent belief or perception held by a person although evidence shows it was untrue), but no other behaviors. The MDS documented R15 required setup assistance with dressing, hygiene, and bathing, and was independent with other activities of daily living (ADL). The MDS documented R15 took an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication. R15's Psychotropic Drug Use Care Area Assessment (CAA) completed 02/07/25 indicated he used psychotropic medications. R15's CAA did not trigger for mood or behaviors. R15's 12/01/25 Quarterly MDS documented a BIMS score of 14. The MDS documented R15 did not hallucinate or have delusions, but did have other behaviors. R15 had behaviors directed toward others for one to three days during the lookback period. R15 wandered on four to six days during the lookback period. The MDS documented R15 required setup assistance with dressing, hygiene, and bathing, and was independent with other ADL. The MDS documented he received antipsychotic and antianxiety medication (a class of medications that calm and relax people). R15's Care Plan, revised on 08/17/23, documented he had a psychosocial well-being problem related to lack of motivation and distractions from auditory hallucinations. The intervention initiated on 12/08/20 and revised on 03/25/21 directed staff to allow R15 time to answer questions and verbalize his feelings, encourage participation with decisions though the resident depends on other people to make decisions, and encourage the resident to set realistic goals. An intervention dated 07/07/23 documented the resident needed to identify the causative and contributing factors to clarify what the voices told him, such as his family did not die in a plane crash. R15's Care Plan, revised on 11/19/24, documented he used psychotropic medications related to behavior management for a diagnosis of schizoaffective bipolar type. The plan noted on 10/21/24, Abilify (an antipsychotic medication) was added for hallucinations and delusions. Staff monitored behaviors. R15's Care Plan recorded a focus, initiated on 11/27/20 and revised on 11/07/25, that noted R15 had an elopement risk score of eight and had a history of attempts to leave the facility unattended. The focus noted R15 left the facility unattended on 11/02/25 and made an additional attempt on 11/04/25. An intervention dated 11/02/25 and revised on 11/07/25 recorded R15 eloped from the facility. He was looking for someone to take him to church, and voices told him he needed to go to church that day. The resident was screened by a psychiatric provider for potential admission to a state hospital. R15's Care Plan listed a focus, initiated on 10/05/24 and resolved on 09/03/25, which indicated the resident had a behavior problem and sprayed his roommate with a fire extinguisher due to being commanded to do so by voices. The Alert Note on 09/07/25 at 05:45 PM documented the nurse received a report that R15 was observed at the back door by the laundry area early in the morning before the nurse arrived. The note documented R15 made no attempts or said anything about leaving the rest of the day. The Behavior Note on 09/23/25 at 03:16 PM recorded R15 reported he received messages telepathically that he was leaving that day and was trying to go out the front door. The nurse advised R15 the voices were confused and assured him he was not leaving that day. R15 tried to leave twice and then went to the room. R15 frequently complained of communicating with others telepathically. R15's Psychiatric Visit note dated 10/07/25 by Consultant GG documented the reason for the visit was psychiatric medication review. The provider started R15 on a new medication for abnormal movements related to the antipsychotic medications he received. The note lacked mention of the incident on 09/23/25 or auditory hallucinations. The Behavior Note dated 11/02/25 at 09:49 AM documented staff were looking for R15 and located him walking out of the tree line down the road from the facility. Upon return to the facility R15 stated he was not hurt, just cold. R15 told staff he had been looking for someone so they could go to church. The Behavior Note on 11/02/25 at 10:37 AM documented another resident notified the nurse at 07:45 AM that R15 was out of the facility. The nurse immediately sent a staff member to look for R15 and followed the procedure until R15 was located. The Health Status Note on 11/02/25 at 02:17 PM documented R15 arrived back at the facility at 09:59 AM with the Director of Nursing. He reported he was cold and not injured. The Health Status Note on 11/02/25 at 03:29 PM documented at approximately 01:00 PM R15 was screened by a mental health assessment company and was awaiting a response. The Alert Note on 11/02/25 at 03:31 PM documented the nurse received a call from the mental health screening company, and they were not admitting R15 to another facility for psychiatric needs. The Health Status Note dated 11/02/25 at 02:17 PM noted R15 returned to the facility with Administrative Nurse D at approximately 09:50 AM. Staff assessed R15's vital signs and his temperature registered as low and would not read at first. Staff wrapped R15 in a blanket, upon recheck his temperature was 96 degrees Fahrenheit (normal temperature is 97.8 degrees F. R15's pulse was 110 beats per minute (normal pulse is 60-100 beats per minute). R15 had a small scratch to forearm. R15 reported he was still cold and declined breakfast but said he would get a snack. R15's EMR lacked any behavioral intervention related to voices telling him to elope after the 09/23/25 and 11/02/25 incidents until 11/05/25. The Psych Visit note on 11/05/25 at 05:39 PM revealed the psychiatric provider, Consultant GG, saw R15 for follow-up psychiatric medication evaluation. R15 exhibited an increase in delusional thinking and believed he was telecommunicating with others. He believed he was being discharged and was exit seeking, going to the front door and pushing on the keypad. Consultant GG requested a screen for an inpatient hospitalization and ordered to increase the resident's Abilify to 20 mg daily. On 12/08/25 at 10:12 AM, R15 lay in bed with the covers over him. He appeared clean, but his hair was disheveled. He agreed to answer questions. R15 responded to every question first with a whisper of Yes, No, or It's okay, go ahead and tell her. He reported he left the facility because he was going across the street to his house. R15 reported he bought the house telepathically about a year ago. R15 stated he put in the door code and left. When asked what the code was, he said, 756, 757, 758, 759. When asked how he got the code, R15 responded with, I guess the Holy Spirit gave it to me. On 12/10/25 at 11:23 AM, R15 lay in bed. R15 answered questions without whispering before responding. R15 stated the voices come and go, and that day, the voices were not there. He reported he does not want to go to activities because he is afraid of a psychotic episode where the voices flood his head with negative voices. A review of the area where R15 was hiding revealed a line of trees with barbed wire present. The area was approximately 1300 feet from a highway with varying posted speeds of at least 55 miles per hour. According to Wunderground.com, the temperature on 11/02/25 at 07:56 AM was 39 degrees F. The temperature was 44 degrees F. at 08:56 AM and 48 degrees F. at 09:56 AM. During an interview on 12/10/25 at 11:01 AM, Certified Nurse Aide (CNA) O stated staff did elopement training for R15, and they do behavior training all the time. CNA O reported R15 does not have any behaviors, but R15 did have voices that tell him he is going to another place. CNA O said when R15 did that, staff reminded him the facility was working on discharge plans, and the Director of Nursing (DON) would let him know when he was ready for discharge. CNA O stated R15 was very redirectable and returned to his room. She said if any resident had a behavior, staff reported it to the DON. During an interview on 12/09/25 at 02:28 PM, Licensed Nurse (LN) G stated R15 was hiding in the bushes down the street from the facility while staff searched for him. She said R15 frequently approached the nurse's station saying he was there for his discharge, but he could be easily redirected. During an interview on 12/10/25 at 11:17 AM, LN H stated the staff received ongoing behavior training and received extra elopement training following R15's elopement. She said R15 did not go to the door when she worked, but did ask her if he had been discharged and if he was leaving that day. She told him no, and he went back to his room. LN H stated R15 did hear voices, sometimes the voices were more than other times. LN H said R15 was easily redirected, and if there was a change in a resident's behavior, LN H would immediately tell the DON, then the owner/psychiatric provider (Consultant GG). During an interview on 12/09/25 at 02:31 PM, Administrative Nurse D stated R15 was not actually physically trying to get out on 09/23/25; he was telepathically communicating with someone, then said he was going to leave and went to stand by the door; he did not try to leave. Administrative Nurse D stated R15 did that sometimes and would say he was discharging that day. Administrative Nurse D said staff told R15 no, and he went back to his room and did not try to get out. Administrative Nurse D stated she did not tell any other staff because it was not a change, and R15 did not actually attempt to get out. On 12/09/25 at 05:38 PM, Consultant GG stated she saw residents quarterly and as needed. Consultant GG confirmed the last visit with R15, before the 11/02/25 incident, was on 10/07/25 and verified the visit did not address the auditory hallucinations, stating it was not a new issue. On 12/10/25 at 11:43 AM, Consultant GG stated she was aware of the events of 09/23/25, but did not address it because it was not a change, and R15 did not attempt to get out. R15 was redirected when he was by the door, and his baseline included delusions. On 12/10/25 at 12:04 PM, Administrative Staff A reported R15 received a WanderGuard (a bracelet that helps monitor residents who are at risk of wandering) and frequent checks after the 11/02/25 incident. The facility changed the door codes immediately, and all staff were called in to receive training. The facility's Behavioral Health Services policy dated 02/03/25, documented each resident will receive and the facility will provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. On 12/10/25 at 06:10 PM, Administrative Staff A received a copy of the Immediate Jeopardy [IJ] Template and was informed of the IJ. The facility identified, implemented, and completed corrective measures on 11/05/25, which included the following:1. R15 received increased monitoring and a WanderGuard to address the wandering and exit-seeking behavior.2. Consultant HH assessed the resident's changes in behaviors and implemented changes to the plan of care to address the auditory hallucinations on 11/05/25.3. An emergency QAPI meeting was held to review interventions. The onsite surveyor verified the above completed corrective action. Due to all corrections completed prior to the onsite survey, the deficient practice was cited as past noncompliance at a scope and severity of J (isolated, immediate jeopardy).

The facility reported a census of 42 residents. Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for nine residents, Resident (R) 33, R2, R31, R49, R17, R42, R10, R15, and R16, related to uncomfortable, torn, and/or damaged mattresses with exposed filling on nine mattresses rendering them unsanitizable. Findings included:- Observations on 12/10/2025 at 09:00 AM, during an environmental tour with Maintenance Staff V and Maintenance Staff W, revealed the following concerns for nine residentsR33's mattress was worn.R2's mattress had a tear at the bottom.R31's mattress had multiple tears on the bottom side.R49's mattress had multiple tears on both the bottom and top.R17's mattress had tears along the side, exposing the bed cover, which was worn and ripped.R42's mattress had a tear along the side. R10's mattress had multiple tears/rip areas in the cover at the top of the bed.R15's mattress had multiple tears/rips on the side.R16's mattress had multiple tears.All nine mattresses with visible tears had unsanitizable surfaces noted. On 12/10/2025 at 09:00 AM, R33 reported his mattress was uncomfortable. On 12/10/2025 at 10:33 AM, Housekeeping Staff U reported she would notify nursing staff and/or Consultant Staff HH of mattresses in disrepair, which would need to be replaced in order to provide a sanitizable, comfortable sleep surface for the residents. On 12/10/2025 at 10:35 AM, Certified Medication Aide (CMA) R reported the facility's maintenance room had a sign on the door directing staff to report environmental concerns. On 12/10/2025 at 10:37 AM, Consultant Staff HH, Maintenance V, and Maintenance W verified the above findings and the need to replace the mattresses to ensure a comfortable and sanitizable sleep surface for the residents. Consultant Staff HH reported the staff should report damaged mattresses to the maintenance staff or the administrator. She reported she was not made aware of the need to replace mattresses. The undated facility policy titled Westview [NAME] General Cleaning and Maintenance of Resident Environment documentation included that Management staff and Environmental Service staff will establish and maintain a safe and functional environment. Environmental Service and Custodial staff will keep furnishings and equipment safe and in good repair.

The facility had a census of 42 residents. The sample included 12 residents. Based on interview and record review, the facility failed to provide services to meet professional standards of care when staff failed to ensure Resident (R) 47's Electronic Medical Record (EMR) contained appropriate documentation to include physician notifications and R47's refusals to be transferred to the local hospital. Findings included:- R47 's EMR revealed diagnoses of bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and sleep apnea (a disorder of sleep characterized by periods without respirations). R47's [DATE] admission Minimum Data Set (MDS) documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R47 rejected evaluation or care daily. The MDS documented R47 required oxygen and a non-invasive mechanical ventilator, such as a continuous positive airway pressure (CPAP- a ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep). R47's [DATE] Cognitive Loss/Dementia Care Area Assessment (CAA) documented R47 rejected care frequently, which was in part due to hypoxia (inadequate supply of oxygen) due to low oxygen saturation (percentage of oxygen in the blood) below 80 percent. R47 used a CPAP due to sleep apnea and had increased hypoxia at night, which could increase confusion. R47 would be confused with low oxygen saturation and was resistant to wearing oxygen. R47's [DATE] Care Plan lacked documentation regarding oxygen and CPAP use. Furthermore, the care plan lacked R47's behaviors of refusal of care. R47's Physician Orders ordered to obtain oxygen saturation twice a day, ordered [DATE]. R47's Physician Orders ordered continuous oxygen 3 to 4 liters; oxygen saturation must stay above 80 percent, ordered [DATE]. R47's Medication Administration Record (MAR), reviewed from [DATE] through [DATE], lacked an area for documentation of continuous oxygen applied or refused. R47's Progress Note dated 10/1325 at 05:22 AM documented R47's eyes were closed. Staff educated R47 they were going to readminister his oxygen as his oxygen saturation was 52 percent on room air. Staff applied oxygen at 3 liters, and R47's oxygen saturation increased to 84 percent. His lower extremities were warm to the touch, but his bilateral legs were dark purple. The note lacked documentation that the provider was called about the discoloration. R47's Progress Note dated [DATE] at 00:07 AM documented R47 did not wake up when vital signs were assessed; his oxygen saturation was 82 percent at 3 liters. R47's lips continued to be dark purple, and he had mottling (blotchy, red-purplish marbling of the skin near the end of life caused by slow blood circulation) noted all over areas of his body. R47 had increased confusion and asked where he was, and reported he had never seen that room before. The note lacked documentation the provider was called with a change in condition. R47's Progress Note dated [DATE] at 04:54 AM documented R47 had continuous oxygen on throughout the night. R47 would remove his oxygen, and his oxygen saturation on room air ranged from 57 to 73 percent. Staff encouraged R47 to keep his oxygen on and let staff help put it back on. R47 had a cough. Staff repositioned him during the night, and he rested comfortably. His lung sounds were audibly gurly'[sic]. His respirations increased to 26 with a rise and fall of his chest. At 04:10 AM, R47's respirations were shallow and slow, and within a few minutes, the resident passed peacefully. He had no audible heart rate, radial heart rate, or jugular heart rate noted, and no respirations. R47 expired at 04:21 AM. Staff contacted the provider and received orders. During an interview on [DATE] at 06:10 AM, Licensed Nurse (LN) I reported that if a resident had a change in condition, she would notify Physician HH and then notify Administrative Nurse D. LN I reported that she did not document in R47's EMR when he had changes in condition and reported that Administrative Nurse D knew about the changes and Administrative Nurse D had contacted Physician HH. During an interview on [DATE] at 02:28 PM, Administrative Nurse D reported she expected staff to document in the residents' EMR when a provider was contacted for a change in condition. Additionally, Administrative Nurse D reported that R47's EMR should have had documentation when he refused to go to the hospital for evaluation. Administrative Nurse D reported she updated the provider with R47's changes. During an interview on [DATE] at 08:35 AM, Physician HH reported the staff had contacted her when R47 had a change in condition, and she expected the staff to document in the resident's EMR when staff contacted a physician and the physician's response. The facility did not provide a policy for professional standards related to the documentation of care provided.

The facility identified a census of 42 residents. The sample included 12 residents, with one resident reviewed for catheters (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid). Based on observation, record review, and interviews, the facility failed to ensure adequate catheter care within the standards of practice was provided for Resident (R) 1 when staff failed to secure the catheter tubing to R1's leg to prevent pulling and/or dislodgement and also failed to provide catheter care using adequate infection control practices to prevent catheter related urinary tract infections (UTI).Findings included:- R1's Electronic Health Record (EHR) for R1 included diagnoses of schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), diabetes mellitus type 2 (DM2 - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) and neuropathic bladder (a condition where bladder control is impaired due to damage or dysfunction in the nervous system).R1's Annual Minimum Data Set (MDS), dated 10/09/25, documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The assessment documented R1 had hallucinations (sensing things while awake that appear to be real, but the mind created), delusions (untrue, persistent belief or perception held by a person although evidence shows it was untrue), and an indwelling catheter. The assessment documented R1 did not display behaviors that qualified as rejection of care.R1's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 10/09/25, documented R1 had a catheter in place due to neurogenic (neuropathic) bladder.R1's Quarterly MDS, completed on 07/28/25, documented a BIMS score of 15, which indicated intact cognition. The assessment documented R1 had hallucinations, delusions, and an indwelling catheter. The assessment documented R1 rejected care for four to six days during the look-back period.R1's Care Plan, initiated 09/14/25 and revised on 12/09/25, documented R1 had a catheter for the management of a neurogenic bladder, initiated on 10/05/25 and revised on 02/29/24. The plan documented that he had a catheter that was 14 or 16 French with an undocumented balloon size bulb, and a leg bag (a small urine collection bag that is attached to a catheter and worn on the leg), and staff provided the following interventions:Staff would change monthly and as needed, and staff would drain the bag every two to three hours and as needed, initiated on 10/05/23 and revised on 12/09/25.Staff would monitor and document intake and output in accordance with facility policy; R1 did attempt to empty the leg bag without staff assistance, initiated on 10/05/23 and revised on 11/06/23.Staff would monitor and document any pain/discomfort associated with the catheter, initiated on 10/05/23Staff would monitor, record, and report to the physician any signs or symptoms of a UTI, such as pain, burning, blood-tinged urine, cloudiness, lack of urine output, deepening of urine color, foul-smelling urine, fever, altered mental status, or behavioral changes, initiated on 10/05/23.Nursing staff would assess R1's catheter for tubing kinks each shift and as needed; R1 did have behaviors of fidgeting with the tubing and/or collection bag. If R1's clothing was wet, the nurse would assess the catheter, initiated on 10/05/23, revised on 11/20/24.R1 was resistant to catheter care and staff assistance to empty his leg bag. Behaviors included emptying it himself, not completely closing the valve, or utilizing clean procedures. Staff would encourage R1 to allow staff to assist him in relation to infection control and proper techniques, initiated on 02/08/24 and revised on 11/20/24.Staff would use Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms, which employ targeted gown and glove use during high contact care) when draining or emptying the catheter leg bag, initiated on 01/14/25 and revised on 12/09/25.R1 Care Plan did not include any evidence of failed or resolved interventions regarding the use of a securement device for catheter tubing.R1's EHR Orders tab revealed the following physician orders:Foley (a brand of catheter) catheter (14-16 French) in place to leg bag, change every 28 days related to neuropathic bladder, dated 01/10/25 at 09:00 AM.Empty the leg bag four times every day and as needed, every two hours related to neuropathic bladder, initiated 11/21/23 at 08:00 PM.R1's EHR under the Progress Notes tab, reviewed from 08/01/25 to 12/09/25, lacked documentation related to the application of a leg securement device/safety anchor on the catheter or catheter tubing. The record lacked entries of any failed attempts to utilize a leg securement device/safety anchor.During an observation on 12/08/25 at 09:25 AM, R1 was in his room with a catheter leg bag concealed under his left pant leg. The bag appeared full and bulging. R1 stated he would alert staff to allow them to assist in emptying the leg bag.During an observation on 12/08/25 at 11:27 AM, no change from the previous observation of R1's leg bag.During an observation on 12/09/25 at 09:34 AM, R1 ambulated in the hallway and had appropriate interactions with peers and staff.During an observation on 12/09/25 at 01:17 PM, Certified Nurse Aide (CNA) M emptied R1's leg bag into an empty urinal. CNA M entered the room, performed hand hygiene, and applied appropriate EBP. CNA M then emptied the urine collection bag and allowed the drain port of R1's leg bag to come in contact with the side of the urinal. CNA M did not clean or sanitize the drain port pad after emptying the contents of the drain bag. CNA M did not place a cap or other barrier device over the end of the drain port on the leg bag. R1 complained that the catheter was pulling. CNA M removed the EBP and performed hand hygiene, then consulted with Licensed Nurse (LN) G. CNA M re-entered R1's room and readjusted R1's leg bag without reapplying the appropriate EBP or performing hand hygiene.During an interview on 12/09/25 at 11:27 AM, CNA M said R1 had a catheter, and CNA staff should empty the catheter drain bag every two hours and clean the catheter tubing every two hours when the drain bag is emptied. CNA M said the CNA staff documented the output on a piece of paper, then gave it to the nurse to chart on the Medication Administration Record (MAR) or Treatment Administration Record (TAR). During an interview on 12/09/25 at 12:52 PM, LN G stated R1 had a catheter, and CNA staff were responsible for cleaning the catheter and emptying the drainage bag; the tasks should be performed every two hours. LN G said R1 was able to clean and empty the drainage bag, although it was the responsibility of the staff. LN G said training has been attempted with R1 for the correct procedure to clean and empty the drainage bag, although it is not certain if R1 retained the training. R1 sometimes allowed the staff to assist in the draining and cleaning of his leg bag. LN G stated the CNA staff would document R1's urine output on a piece of paper and give it to the nurse, who then documented it in the EHR on the MAR/TAR. During an interview on 12/09/25 at 01:41 PM, CNA M denied any knowledge of any type of securement device for R1's catheter tubing. CNA M confirmed she did not sanitize or clean the drainage port on R1's catheter bag. CNA M stated she did not utilize the appropriate EBP when adjusting R1's leg bag. CNA M stated that nurses performed catheter care on shower days.During an interview on 12/19/25 at 01:45 PM, Administrative Nurse D revealed the facility did not utilize or order securement devices for catheters because R1 was the only resident in the facility with a catheter and stated R1 would not allow the devices or anchors to be utilized.During an interview on 12/10/25 at 09:45 AM, Administrative Nurse D revealed that nurses were responsible for the insertion and changing of catheters, and CNA staff were responsible for emptying and cleaning the catheters. Administrative Nurse D revealed that catheter cleaning was performed with showers and should be performed with soap and water only. Administrative Nurse D reported that the facility does not utilize catheter securement devices since R1 would not allow them to be used. Administrative Nurse D verified she had no documentation of R1's refusal of a securement device for the tubing or of any failed attempts to secure the tubing. Administrative Nurse D reported that when a leg bag was being emptied, the drain spout should not come into contact with the urinal and should have been cleaned with an isopropyl alcohol wipe before the spout was placed in the stowed position.The facility's undated Westview Manor of [NAME] Foley Catheter Care policy documented that catheter care would be provided at least twice daily and more often as needed. The policy documented that the catheter should be taped or anchored to the upper thigh to avoid tension on the catheter. The drainage bag would be emptied at the end of each shift, or more often if needed, into a measured container with the total documented in the EHR.

The facility identified a census of 42 residents. Based on observation, record review, and interviews, the facility failed to implement and maintain an effective infection control program when staff failed to provide catheter care using adequate infection control practices and failed to implement Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) during high contact care for Resident (R)1.Findings Included:- During an observation on 12/09/25 at 01:17 PM, Certified Nurse Aide (CNA) M emptied R1's leg bag into an empty urinal. CNA M entered the room, performed hand hygiene, and applied appropriate EBP. CNA M then emptied the urine collection bag and allowed the drain port of R1's leg bag to come in contact with the side of the urinal. CNA M did not clean or sanitize the drain port pad after emptying the contents of the drain bag. CNA M did not place a cap or other barrier device over the end of the drain port on the leg bag. R1 complained that the catheter was pulling. CNA M removed the EBP and performed hand hygiene, then consulted with Licensed Nurse (LN) G. CNA M re-entered R1's room and readjusted R1's leg bag without reapplying the appropriate EBP or performing hand hygiene.During an interview on 12/09/25 at 01:41 PM, CNA M confirmed she did not sanitize or clean the drainage port on R1's catheter bag. CNA M stated she did not utilize the appropriate EBP when adjusting R1's leg bag. CNA M stated that nurses performed catheter care on shower days.During an interview on 12/10/25 at 09:45 AM, Administrative Nurse D said catheter cleaning was performed with showers and should be performed with soap and water only. Administrative Nurse D reported that when a leg bag was being emptied, the drain spout should not come into contact with the urinal and should have been cleaned with an isopropyl alcohol wipe before the spout was placed in the stowed position. Administrative Nurse D outlined the use of appropriate EBP while staff were emptying or manipulating the urine drainage system or any of its components. The facility did not provide a policy related to Enhanced Barrier Precautions.The facility's undated Westview Manor of [NAME] Infection Surveillance policy documented that surveillance in the facility was accomplished by reviewing and implementing systems for infection control and prevention that complied with facility policies and procedures and evidence-based best practices. The facility would measure outcomes or systems that included compliance with infection control practices, including catheter care.

The facility had a census of 42 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to accurately complete the Minimum Data Set (MDS) for three residents: Resident (R) 5, related to restraint; R1 related to catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid); and R2 related to dental. Findings included:1. R5's Electronic Medical Record (EMR) recorded a Annual Minimum Data Set (MDS) dated [DATE] that documented R5 had a bed rail used daily under the physical restraints (are any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body) section. During an observation and interview on 12/08/2025 at 09:04 AM. R5 ambulated in the hallway near his room. He opened the door to his room to complete an interview. Further observation of the room revealed a half side-rail secured to the right side of R5's bed. R5 reported he used the side rail to transfer in and out of his bed. During an interview on 12/10/2025 at 07:00 AM, Certified Medication Aide (CMA) R reported that R5 used the side-rail on his bed to help him be independent with his transfers. During an interview on 12/10/2025 at 10:40 AM, Administrative Nurse D reported that she had been instructed to code any bed rail as a restraint on the MDS. Administrative Nurse D reported that R5 used the bed positioning rail to assist him in being more independent with transfers and bed mobility, and reported that the bed positioning rail was not a restraint for R5. 2. R1's EMR recorded an Annual MDS dated [DATE], which recorded R5 was always continent of urine. R1's Care Plan dated 04/22/2025 documented staff instructed to provide R1 reminders to allow staff to assist him in emptying his leg bag. R1's EMR recorded a Physician Order that directed to empty the leg bag four times a day, and as needed every two hours related to neuropathic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system), dated 11/21/2023. During an observation and interview on 12/08/2025 at 09:25 AM, R1's catheter leg bag was full of urine. R1 stated he would alert staff for assistance. During an interview on 12/10/2025 at 10:40 AM, Administrative Nurse D reported she coded the MDS inaccurately, and the correct code she should have documented was Not Rated. 3. R2's EMR recorded an admission MDS dated [DATE], which recorded R2 had no dental issues in the dental section R2's EMR recorded an Admit Screener dated 01/11/2025, which recorded R2 had broken or carious (tooth decay or cavities) teeth. During an observation and interview on 12/08/2025 at 10:11 AM, R2 reported he had asked to see a dentist and was told insurance would not pay for a partial denture. R2 opened his mouth, and observation revealed missing and broken teeth on the bottom gumline. During an interview on 12/09/2025 at 03:45 PM, Licensed Nurse (LN) G reported that R2 had teeth missing and cavities. LN D reported that R2 had recently completed an antibiotic for tooth pain and infection. LN G reported R2 had a pending dental appointment. During an interview on 12/10/2025 at 10:40 AM, Administrative Nurse D reported that the MDS was coded inaccurately and reported that the dental issues were not captured. Administrative Nurse D reported she expected the MDS to be documented accurately. The facility's undated policy Westview Manor of [NAME] Minimum Data Set Accuracy Audits documented the facility was committed to ensuring the accuracy, timeliness, and completeness of all MDS assessments.

The facility identified a census of 42 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for Resident (R) 2's left shoulder limited mobility and shoulder pain and R47s oxygen, refusal of cares, and continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) use. Findings included:1.R2's Electronic Medical Record (EMR) revealed diagnoses of osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk) and chronic pain. R2's 10/27/25 Quarterly Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 15, which indicated intact cognition. R2's MDS recorded that he had impairment of the upper extremity on one side. R2's was independent for dressing and mobility. R2's 01/24/25 admission MDS documented a BIMS of 15. R2's MDS recorded he had no impairment of his upper extremities. R2 was independent for dressing and mobility. R2's 01/24/25 Activities of daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA) documented he was a new admission and was monitored for the ability to complete tasks. R2 would maintain his current level of functioning. R2's Care Plan lacked documentation for left shoulder pain and therapy. R2's Physician's Orders documented Physical and Occupational therapy evaluation dated 10/22/25.R2's Physician's Orders documented meloxicam (a prescription nonsteroidal anti-inflammatory drug used primarily to relieve pain) 7.5 milligrams (mg), by mouth twice a day for pain dated 10/29/25. R2's Physician Visit Note on 10/22/25 documented R2 reported shoulder pain without any history of injury or trauma. The pain was described as mild on one side and more pronounced on the other, particularly with certain movements such as pushing against resistance. R2 denied running into anything or sustaining any injuries. The note documented a new order for physical therapy, and if no improvement, refer to orthopedics for further evaluation and possible magnetic resonance imaging (MRI-medical imaging used to view soft tissue). R2's Progress Note on 10/29/25 at 02:02 PM documented R2 was out of the facility at the local hospital for left shoulder pain evaluation. R2's Hospital Note on 10/29/25 at 03:58 PM documented left shoulder pain follow-up with an orthopedic consult and a new order for meloxicam 7.5 mg by mouth twice a day. R2's Progress Note on 11/03/25 at 05:27 PM documented he had an appointment with orthopedics on 11/20/25 at 07:30 AM for treatment of the left shoulder. R2's Progress Note on 11/20/25 at 09:05 AM documented R2 returned from the orthopedic consult with orders for physical therapy two to three times per week for left shoulder pain, and he needed an MRI of the painful area. R2's Progress Note on 12/03/25 at 12:42 PM documented an MRI without contrast was scheduled at the hospital on [DATE] at 02:45 PM. During an observation on 12/09/25 at 12:40 PM, R2 sat in the dining room and ate lunch with no obvious issues. During an interview on 12/08/25 at 10:13 AM, R2 reported he had been waiting for therapy because he had limited motion in his left shoulder and a rotator cuff tear, which caused pain. R2 reported that the pain medication he received worked for the pain. During an interview on 12/09/25 at 09:20 AM, Certified Medication Aide (CMA) R reported R2 recently started to complain of left shoulder pain and R2 received medications for the pain. During an interview on 12/09/25 at 03:45 PM, Licensed Nurse (LN) G reported that R2 was scheduled for an MRI this month. LN G said Administrative Nurse D completed the care plans. During an interview on 12/10/25 at 10:30 AM, Administrative Nurse D confirmed R2's Care Plan lacked documentation and interventions for his left shoulder pain and reported she expected the care plan to be current with residents' concerns, goals, and interventions. 2. R47 's EMR revealed diagnoses of bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and sleep apnea (a disorder of sleep characterized by periods without respirations). R47's 10/01/25 admission Minimum Data Set (MDS) documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R47 rejected evaluation or care daily. The MDS documented R47 required oxygen and a non-invasive mechanical ventilator, such as a continuous positive airway pressure (CPAP). R47's 10/06/25 Cognitive Loss/Dementia Care Area Assessment (CAA) documented R47 rejected care frequently, which was in part due to hypoxia (inadequate supply of oxygen) due to low oxygen saturation (percentage of oxygen in the blood) below 80 percent. R47 used a CPAP due to sleep apnea and had increased hypoxia at night, which could increase confusion. R47 would be confused with low oxygen saturation and was resistant to wearing oxygen. R47's 10/15/25 Care Plan lacked documentation regarding oxygen and CPAP use. R47's Physician Orders ordered to obtain oxygen saturation twice a day, date ordered 09/18/25. R47's Physician Orders ordered continuous oxygen 3 to 4 liters; oxygen saturation must stay above 80 percent, date ordered 09/24/25. R47's Progress Note dated 09/18/2025 05:12 PM documented R47 arrived via ambulance. R47 was alert and oriented. R47 required a wheelchair, walker, oxygen, and CPAP. R47's Progress Note dated 09/24/2025 at 05:20 AM documented R47 agreed to try his CPAP machine this evening at bedtime around 10:00 pm. R47's Progress Note dated 10/13/25 at 05:22 AM documented R47's eyes were closed. Staff educated R47 that they were going to readminister his oxygen as his oxygen saturation was 52 percent on room air. Staff applied oxygen at 3 liters, and R47's oxygen saturation increased to 84 percent. His lower extremities were warm to the touch, but his bilateral legs were dark purple. During an interview on 12/11/25 at 09:44 AM, Licensed Nurse H reported that Administrative Nurse D completed all the care plans. During an interview on 12/11/2025 at 11:05 AM, Administrative Nurse D reported that she realized R47's Care Plan was not completed by the MDS nurse, who no longer worked at the facility, as she had not completed her assigned work, which included care plans. Administrative Nurse D stated she expected the care plan to be completed in a timely manner and include person-centered care goals and interventions. The facility's policy Care Plan Revisions undated documented the care planning process, which included resident assessment, goal setting, intervention, referrals to other health care professionals, evaluation of resident responses to treatment, and revision of care and treatment in order to meet the resident's needs. Changes in a resident's condition always require changes to be made in the plan of care, either by a change in individual approaches or by the addition of new problems to the plan of care.

The facility reported a census of 42 residents. Based on observation, record review, and interview the facility failed to maintain an effective infection control program related to a sanitary environment to help prevent cross-contamination and the spread of infections in the laundry, and to ensure appropriate handling, storage, processing, and transportation of linen for the residents of the facility. This placed the residents at risk for infectious disease. Findings included: - Observation on 06/18/25 at 09:33 AM revealed Certified Nurse Aide (CNA) N pushed an uncovered soiled/dirty laundry bin down the hallway with soiled laundry overflowing the container. On 06/18/25 at 09:43 AM CNA N pushed a closed dirty laundry bin with an open laundry basket overflowing with soiled laundry on top of the lid of the closed bin. Observation on 06/23/25 at 02:29 PM, with Laundry Staff U, revealed a wood table in the laundry used for folding resident's clean laundry and processing linen. The table had chipped laminate on the surface and bare wood around the edge of the table resulting in an unsanitizable surface that was in direct contact with resident personal laundry and linen. Laundry staff U confirmed the above findings and agreed the table needed repair to provide a sanitizable surface to handle, process, and prevent infection and cross-contamination of facility laundry and residents' clothing. On 06/18/25 at 09:45 AM, CNA N confirmed the above findings. She stated she was unaware the laundry was supposed to be covered while transporting soiled laundry down the hallway from the resident's room to the laundry area. On 06/18/25 at 09:50 AM, Administrative Nurse D confirmed that all laundry being transported in the facility should be in a covered container during transport through the hallways to prevent cross-contamination and prevent the spread of infection. The facility policy .Infection Surveillance, dated 02/19/25, documented cleansing and disinfection of products, equipment, or environmental surfaces for storage, handling, processing, and transporting linens according to facility procedures is a part of the surveillance program for prevention of infections.

The facility reported a census of 42 residents, one central kitchen, and one dining area. Based on observation, interview, and record review, the facility failed to follow sanitary dietary standards related to the storage of food. This deficient practice placed the residents at risk for food-borne illnesses. Findings included: - During an initial tour of the facility on 06/17/25 at 09:30 AM with Dietary BB revealed the following areas of concern: In the standing freezer, a package of shredded potatoes was open to air. In a chest freezer, a box of pork sausage patties was open to air. Observation in the dry storage area revealed the following: A package of lemon pudding mix was open to air. A large package of butterscotch chocolate chips was open to air. A large package of Italian dressing mix was open to air. A large can of sliced apples and a small can of sliced mushrooms were dented. In the standing refrigerator, a large package of yellow/white shredded cheese mixture was open to air. During an interview 06/17/25 at 09:45 AM, Dietary BB revealed he was not aware that food containers should be closed and not open to air. During an interview on 06/17/25 at 09:50 AM, Administrative Staff A reported that all food items stored in the kitchen area should be closed and dented cans should be returned to the supplier or discarded. The facility's undated Dietary Purchases, Receipt, and Storage policy documented that food and non-food supplies would be received and stored under sanitary and safe conditions as required by law. All cans with dents would be returned or destroyed.

The facility reported a census of 42 residents. The sample included 12 residents. Based on record review and staff interviews, the facility failed to complete Care Area Assessments (CAA) that addressed the individual underlying causes, contributing factors and risk factors for five residents. Resident (R)1, R8, R 9, R245, and R195. This placed the residents at risk for inadequate care due to unidentified care needs. Findings included: - R1's Electronic Health Record (EHR) recorded an Annual Minimum Data Set (MDS), dated [DATE] which triggered the Psychotropic Drug Use CAA documented R1 took psychotropic (alters mood or thought) medications to manage schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), depression, and anxiety. The CAA lacked an analysis of the findings. R8's EHR recorded an annual MDS dated 05/18/25 which triggered the Dental Care CAA. The CAA documented R8 had potential for cavities related to the types of food the resident consumed but lacked an analysis of the findings. R9's EHR recorded an Annual MDS, dated 02/18/25 that triggered the Psychotropic Drug Use CAA. The CAA documented R9 took psychotropic medications for behavior management related to schizoaffective disorder and anxiety. The Behavioral Symptoms CAA documented R9 had a behavioral problem, used foul language, and urinated on the floor related to schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thoughts). Both CAAs lacked an analysis of the findings. R245's EHR recorded an admission MDS, dated 06/17/25 that triggered the Psychotropic Drug Use CAA The CAA documented R245 took psychotropic medications for schizoaffective disorder, and bipolar type (a major mental illness that causes people to have episodes of severe high and low moods) but lacked an analysis of findings. R195's EHR recorded an admission MDS, dated 06/17/25 that triggered the Psychotropic Drug Use CAA. The CAA documented R195 took psychotropic medications for schizoaffective disorder and bipolar type. The Behavioral Symptoms CAA documented the resident was a new admit struggling to adjust. The Cognitive Loss/Dementia CAA documented the resident was a new admit struggling with adjusting to the facility. All the listed CAAs lacked an analysis of findings. On 06/23/25 at 12:06 PM, Administrative Nurse E identified as the MDS Nurse and confirmed the CAA notes were not completed as they should have been and lacked analysis and risk findings. Administrative Nurse E revealed she was unsure on what to write for CAA notes as she really had not been educated on how to complete a CAA note. On 06/23/25 at 02:36 PM, Administrative Nurse D reported she expected the MDS to be completely accurate. Administrative Nurse D reported that she would review and sign off on MDS completed by Administrative Nurse F; she said she would review them carefully for any errors and communicate any concerns to Administrative Nurse F. The facility's undated policy Comprehensive Assessment including MDS and CAAs documented the resident assessment instrument system developed by the federal government and would be used as the basis for assessment, care planning, and documentation system. Each CAA area triggered is noted on the MDS Resident Assessment Protocol Summary and requirements are further assessed. After appropriate documentation on the MDS CAA summaries, the Registered Nurse would date and sign to verify all triggered CAAs had been applied to complete a detailed, comprehensive, individualized care plan.

The facility had a census of 42 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to accurately complete the Minimum Data Set (MDS) for seven residents: Resident (R) 1 and R30 related to insulin (a hormone that lowers the level of glucose in the blood); R5 related to physical restraints; R9, R8, R245, and R195 related to Wander Guard alarm (a bracelet that helps monitor residents who are at risk of wandering). This deficient practice placed the affected residents at risk for impaired care due to unidentified care needs. Findings included: - R1's Electronic Health Record (EHR) recorded a Physician Order for metformin (a medication used to lower blood sugar levels) 500 milligram (mg) tablet dated 02/27/24 and an order for Ozempic (a hormone that plays a crucial role in regulating blood sugar levels by stimulating insulin secretion in response to elevated blood sugar) weekly dated 04/15/25. R1's Annual MDS, dated 04/22/25 inaccurately recorded R1 received one insulin injection, one time during the week of look back, and one order change during the week of look back. R1's MDS lacked documentation in Section N of R1's hypoglycemic (medications used to lower blood glucose levels in individuals with diabetes) medications including Ozempic and Metformin. R30's EHR recorded a Physician Orders for Trulicity (a hormone that plays a crucial role in regulating blood sugar levels by stimulating insulin secretion in response to elevated blood sugar) dated 05/03/24. R30's EHR recorded an Annual MDS, dated 05/26/25 that inaccurately recorded R30 received one insulin injection, one time the week of look back. During an interview on 06/23/25 at 12:06 PM, Administrative Nurse F (MDS Nurse) reported that she had made an error when she coded the Trulicity and Ozempic as insulin on R1's and R30's annual MDSs. Administrative Nurse F reported that R1 should have hypoglycemic medications checked off as a yes on the annual MDS. - R5's Electronic Health Record (EHR) recorded a Quarterly MDS, dated 05/05/25 that documented R5 had a bed rail used daily under the physical restraints (are any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body) section. During an observation on 06/17/25 at 12:00 PM, R5 had a bed positioning device located on the right side of his bed, secured to the bed frame. On 06/17/25 at 12:10 PM, R5 reported he used that bed positioning device to help his bed mobility and to assist with getting out of bed. On 06/23/25 at 12:06 PM, Administrative Nurse F reported that she had been instructed to code any bed rail as a restraint on the MDS. Administrative Nurse F reported that R5 used the bed positioning rail to assist him in being more independent with transfers and bed mobility and reported the bed positioning rail was not a restraint for R5. - R9's Electronic Health Record (EHR) recorded a Physician Order to check R9's WanderGuard function every shift, two times a day, dated 08/26/24. R9's Annual MDS, dated [DATE], and Quarterly MDS, dated 05/18/25 inaccurately documented R9 had no WanderGuard alarm. R8's EHR recorded a Physician Order to check placement of R8's WanderGuard every shift, two times a day, dated 08/17/24. R8's EHR recorded an Annual MDS, dated 05/18/25 that inaccurately documented R8 had no Wander Guard alarm. R245's EHR recorded a Physician Order to check placement of R245's WanderGuard every shift, two times a day, dated 06/04/25. R245's EHR recorded an admission MDS, dated 06/17/25 that inaccurately documented R245 had no WanderGuard alarm. R195's EHR recorded a Physician Order to check placement of R195's WanderGuard every shift, two times a day, dated 06/04/25. R195's EHR recorded an admission MDS, dated 06/17/25 that inaccurately documented R195 had no WanderGuard alarm. On 06/23/25 at 12:06 PM, Administrative Nurse F reported that she had made an error when she did not check off yes for Wander/Elopement Alarm in Section P of the MDS for all the above residents. Administrative Nurse F reported that she worked part-time and came into the facility once a month. Additionally, she reported she may not always have enough time to complete them and that is how an error could occur. During an interview on 06/23/25 at 02:36 PM, Administrative Nurse D reported she expected the MDS to be completely accurate. Administrative Nurse D reported that she would review and sign off on MDS completed by Administrative Nurse F; she said she would review them carefully for any errors and communicate any concerns to Administrative Nurse F. The facility's policy Comprehensive Assessment including MDS and CAAs documented that the resident assessment instrument system developed by the federal government would be used as the basis for assessment, care planning, and documentation system. The assessment would accurately reflect the resident's status at the time of the assessment.

The facility had a census of 42 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to ensure a medication error rate of less than five percent when 25 medication administration opportunities were observed with two insulin (a hormone that lowers the level of glucose in the blood) medication errors identified. This placed the residents who received insulin at risk for adverse medication reactions and ineffective medication regimens and resulted in a medication error rate of eight percent. Findings included: - Resident(R)38's Physician Orders recorded an order for insulin lispro (fast-acting insulin) subcutaneous (beneath the skin) solution pen-injector 100 unit/ milliliter (ml), administer six units subcutaneously two times a day for diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), date ordered 03/27/25. R38's Physician Orders recorded an order for insulin glargine (long-acting insulin) subcutaneous solution pen-injector 300 unit/ml, administer 32 units subcutaneously, one time a day for diabetes mellitus, date ordered 03/31/25. During an observation on 06/18/25 at 11:48 AM, Licensed Nurse (LN) G dialed the insulin glargine pen 32 units on the insulin pen. LN G then dialed the insulin lispro six units on the insulin pen. Neither insulin pen was primed. LN G did not verify the insulin order to a medication administration record when she prepared the insulin pens. Both insulin pens were labeled with the type of insulin, a date open of 06/10/25, and the resident's name on the pen insulin pens that she pulled from a bag from the top drawer of the treatment cart parked outside R38's room. LN G administered the insulin to R38. Additionally, LN G kept the insulin pen button pressed for only two seconds before removing the needle from the skin. Review of the manufacturer instructions for insulin lispro revealed the button should remain depressed for a count of approximately five seconds to ensure the full dose was administered. Review of manufacturer instructions for insulin glargine revealed the button should remain depressed for 10 seconds to ensure full dose was administered. During an interview on 06/18/25 at 11:52 AM, LN G reported that she always would have looked at the medication administration record on the computer screen in her office when she prepared the insulin pens, but she used the treatment cart today to administer the insulin. LN G reported she was unsure how long to keep an insulin needle from a pen inserted into the skin when insulin was administered. During an interview on 06/18/25 at 11:58 AM, Administrative Nurse D reported she expected the nurses to verify all medications orders with a medication administration record prior to administering medications. Administrative Nurse D reported that it depended on the dose of insulin that was administered as to how long the insulin needle from an insulin pen was kept in the skin when insulin was administered. The facility's undated policy Pen Devices for Insulin Administration documented that the facility will ensure that each elder received proper appropriate treatment and care for insulin administration per pen device as ordered by a physician. Prior to administration, the authorized clinical staff would verify that the medication selected matches the medication order and product label. Additionally, authorized clinical staff would verify that the medication is being administered at the proper time, in the prescribed dose, by the correct route. Inject the insulin by pushing the button on the insulin pen completely keep the button pressed and count to five before removing the needle from the skin.

The facility reported a census of 42 residents. Based on observation, interview, and record review, the facility failed to ensure that meals were prepared in a way to preserve and/or promote palatability. This placed the residents at risk for decreased enjoyment of meals and related complications. Findings included: - A review of the facility's June 2025 menu revealed the 06/18/25 noon meal consisted of turkey, stuffing, mixed vegetables and a dinner roll. During an observation on 06/18/25 at approximately 11:45 AM, Dietary CC prepared the noon meal. Dietary CC stated that turkey needed to be served with gravy and combined one ounce of chicken base with approximately three quarts of water and an unknown quantity of corn starch. Dietary CC brought the mixture to a boil then transferred the water-thin liquid to a serving pan and placed the mixture on the steam table for serving. Dietary CC was unable to produce a recipe for the gravy and instead, pointed to her head and stated that she had been cooking for so long, she had memorized the recipe and did not need to look at it. On 06/18/25 12:30 PM, Administrative Staff B and Administrative Staff A were in the kitchen and observed the meal service in progress which included the water-thin mixture being placed over the turkey and dressing and then served to the residents. Administrative Staff A confirmed that gravy was not on the menu for the noon meal service. Administrative Staff A was unable to produce a gravy recipe and instructed Dietary CC to ask for approved recipes before preparing items to serve to the residents. On 06/18/25 at 04:00 PM, Administrative Staff B reported the mixture served to the residents for the noon service appeared to be a broth, not a gravy. Administrative Staff B stated the ingredients of the mixture were not appealing and would not make what is commonly known or identified as gravy. The facility did not provide a policy related to food palatability as requested on 06/18/25 and 06/23/25.

The facility reported a census of 42 residents. The sample included 12 residents with five residents reviewed for psychotropic (alters mood or thoughts) medications. Based on interview, observation, and record review, the facility failed to inform Resident (R) 30 and R9 and/or their representatives regarding the risks related to psychotropic medications. These practices had the potential to lead to negative and unwarranted physical side effects. Findings included: - On 06/23/25 at approximately 10:00 AM, a review of the Psychoactive Medication Therapy Informed Consent Form logbook provided by Social Services X revealed the following: A consent form for Invega (paliperidone - a psychotropic medication) lacked a signature from R30. The document contained a signature of Administrative Nurse D as the person who obtained R30's consent, dated 08/01/24 at 02:15 PM. A consent form for Haldol (haloperidol - a psychotropic medication) lacked a signature from R30. The document contained a signature of Administrative Nurse D as the person who obtained R30's consent, dated 06/09/25 at 02:10 PM. A consent form for Abilify (aripiprazole - a psychotropic medication) lacked a signature from R9's guardian and was dated 10/09/24. A consent form for lithium (a psychotropic medication) lacked a signature from R9's guardian and was dated 10/08/24. A consent form for Ativan (lorazepam - a psychotropic medication) lacked a signature from R9's guardian and was dated 10/08/24. A consent form for trazodone (a psychotropic medication) lacked a signature from R9's guardian and was dated 12/19/24. A consent form for Zyprexa (olanzapine - a psychotropic medication) lacked a signature from R9's guardian and was dated 01/02/25. R30's Electronic Medical Record (EMR) lacked documentation of informed consent for the Invega or Haldol. R9's EMR lacked documentation of informed consent for Abilify, lithium, Ativan, trazodone, or Zyprexa. During an interview on 06/23/25 at 10:15 AM, Social Services X revealed she was recently notified by the facility's administration that she was responsible for obtaining and maintaining consent for psychotropic medication use. During an interview on 06/23/25 at 11:45 AM, Social Services X revealed she was assigned the task of obtaining consent and signatures from the applicable residents on 06/16/25 and organizing the older consent forms. Social Services X said she was unaware that residents with a guardian could not sign consent forms without written permission from the guardian. During an interview on 06/23/25 at 12:34 PM, Administrative Nurse B confirmed the lack of signatures on the consent forms and revealed that she signed some of the consent forms and delegated the task of obtaining the consent signatures to another staff member. Administrative Nurse B stated the facility expected Social Services X to obtain consent signatures and sign as the person who obtained the signatures, but Social Services X refused to sign as a witness so Administrative Nurse B would sign the documents ahead of time. The facility's undated Psychotropic Medication Monitoring policy documented a discussion with the resident and/or responsible party regarding the risk versus benefit related to the use of medications.

The facility reported a census of 42 residents. The sample included 12 residents, and three residents were reviewed for a baseline care plan. Based on interviews, observations, and record review, the facility failed to develop a person-centered baseline care plan within the required timeframe for Resident (R) 245. This deficient practice had the potential to lead to impaired care due to uncommunicated needs. Findings included: - R245's Electronic Health Record (EHR) revealed R245 was admitted to the facility on [DATE]. R245's Baseline Care Plan had one of five components, Functional Status completed on 06/04/25, one component, BCP [baseline care plan] Summary and Signatures was completed on 06/10/25 and one component, Dietary, Therapy and Social Services completed on 06/13/25. As of 06/17/25, two components, General Information and Initial Goals and Health Conditions remained incomplete. On 06/18/25 at 09:10 AM, R245 rested in bed under a blanket. On 06/23/25 at 01:30 PM, Administrative Nurse D revealed the nurse who admitted a resident to the facility was responsible for the immediate completion of the baseline care plan. Administrative Nurse D said if the nurse was unable to complete the baseline care plan, the task could be delegated to an administrative nurse for completion within the first 72 hours the resident was in the building. Administrative Nurse D verbalized she was unaware baseline care plans were required to be completed in the first 48 hours. Administrative Nurse D confirmed that R245's Baseline Care Plan was initiated but was not completed. The facility's undated Baseline Care Plan policy documented the facility would develop an initial person-centered care plan within the first 48 hours of a resident's admission to the facility for every resident.

The facility reported a census of 42 with five residents selected for review of vaccines. Based on record review and interview, the facility failed to offer the pneumococcal (type of bacterial infection) vaccine to three residents, Resident (R) 1, R11, and R9. This deficient practice placed the residents at increased risk for pneumococcal infections. Findings included: - R1's Electronic Medical Record (EMR) lacked evidence the facility offered and provided or obtained informed declination for a pneumococcal vaccine. R11's EMR lacked evidence the facility offered and provided or obtained informed declination for a pneumococcal vaccine. R9's EMR lacked evidence the facility offered and provided or obtained informed declination for a pneumococcal vaccine. On 06/23/25 at 03:45 PM, Administrative Nurse D verified the above findings. She reported the facility attempted to get the residents that qualify for the Pneumovax but sometimes the insurance company did not cover the cost. The facility policy, .Immunization Policy, dated 02/19/25, documentation included before offering influenza and pneumovax each resident and or representative will receive education current education regarding the benefits and potential side effects of the immunization.

The facility identified a census of 45 residents. The sample included 12 residents with two reviewed for nutrition. Based on observation, record review, and interviews the facility failed to identify and implement nutritional interventions related to Resident (R) 27's significant weight loss between 01/01/24 to 06/07/24. The facility additionally failed to implement alternative nutritional interventions for R27's ongoing significant weight loss between 08/01/24 and 01/01/25. As a result of the deficient practice, R27 had a significant unplanned weight loss of 19.52 percent (%) and 16.84 % within two three-month periods. This also placed R27 at risk for malnourishment-related complications. Findings included: - The Medical Diagnosis section within R27's Electronic Medical Records (EMR) documented diagnoses of schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), asthma (a disorder of narrowed airways that causes wheezing and shortness of breath), abnormal weight loss, and history of fractures (broken bones). R27's Quarterly Minimum Data Set (MDS) completed 03/16/24 revealed she weighed 191 pounds (lbs.) and had no significant weight loss or physician-prescribed weight loss program. The MDS noted she required partial to moderate assistance with dressing, personal hygiene, bathing, and toileting. The MDS noted she required supervision during meals. R27's Quarterly MDS dated [DATE] indicated she weighed 170 lbs. The MDS noted no significant weight loss or physician-prescribed weight loss program. The MDS noted she required partial to moderate assistance with dressing, personal hygiene, bathing, and toileting. The MDS noted she required supervision during meals. R27's Significant Change MDS completed 08/21/24 indicated she weighed 169 lbs. The MDS indicated she had no significant weight loss or was on a physician-prescribed weight loss regimen. The MDS noted she required partial to moderate assistance with dressing, personal hygiene, bathing, and toileting. The MDS noted she required supervision during meals. R27's Quarterly MDS dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero indicating severe cognitive impairment. The MDS noted she required partial to moderate assistance with dressing, personal hygiene, bathing, and toileting. The MDS noted she required supervision during meals. The MDS indicated she weighed 145 lbs. The MDS noted she had weight loss without a physician-prescribed regimen. R27's Nutritional Status Care Area Assessment (CAA) completed 09/12/24 indicated she desired weight loss but had unintended weight loss noted. The CAA noted she ate less than 50 percent (%) of her meals and sometimes displayed psychotic symptoms that affected her ability to feel hungry and eat. The CAA noted weight improvement or stabilization was desired. R27's Functional Abilities CAA completed 09/15/24 indicated she required frequent assistance with her activities of daily living (ADLs). The CAA noted she required cueing and supervision for her ADLs. The CAA noted she required staff to cut her meals up and provide assistance during meals. R27's Care Plan initiated on 04/22/22 indicated she was at risk for an ADLs deficit related to her medical diagnoses. The plan instructed staff to provide her diet as ordered. The plan indicated she required assistance and encouragement during meals (04/24/22). The plan instructed staff to monitor for fatigue and weight loss (04/24/22). On 11/20/24 R27's plan was updated to reflect she had significant weight loss related to impaired thought processes. The updated plan indicated she required one-to-one staff assistance during meals (11/20/24). The plan instructed staff to provide supplemental shakes when the resident refuses or eats less than 50 % of her meal (11/20/24). The plan lacked indication she was on a weight loss program. The plan lacked preventative weight loss intervention prior to 11/20/24. R27's EMR under Orders revealed an active order, started 03/11/22. The order indicated she was on a regular diet with regular consistency and texture. R27's EMR lacked documentation she was on a prescribed weight loss program. R27's EMR revealed no orders for dietary supplementation between 03/11/22 through 11/20/24. R27's EMR lacked dietician-related documentation from 12/01/23 to 08/01/24. A review of R27's EMR under Weights revealed she weighed 209.4 lbs. on 01/01/24. The EMR revealed she had repeated weight losses of 201.6 lbs. on 02/01/24, 191.0 lbs. on 03/01/24, 180.6 lbs. on 04/01/24, 174 lbs. on 05/01/24, and 168.2 lbs. on 06/17/24. The EMR indicated R27 had a significant weight decline of 19.52% from 01/01/24 to 06/17/24 (within six months). R27's EMR under Assessments revealed that Dietary Profiles were completed on 12/26/23, 03/29/24, 06/22/24, 09/24/24, and 12/17/24. The dietary profiles lacked documentation showing that R27 had a weight loss program. R27's EMR under the Progress note revealed a Nutrition / Dietary note completed on 08/29/24 by the Registered Dietician (RD). The note indicated the RD was notified of the significant weight loss. The RD documented R27 had varied appetites and consumed 25 to 75 % of her meal. The note indicated R27 was independent and could make her own meal choices. The note instructed staff to offer alternative meals or snacks if her meal intake was less than 50%. A review of R27's EMR under Weights revealed she weighed 169.4 lbs. on 08/01/24. The EMR noted she had repeated weight losses of 162 lbs. on 09/01/24, 157.8 lbs. on 10/01/24, 147.6 lbs. on 11/01/24, 145.2 lbs. on 12/01/24, and 140.2 lbs. on 01/01/24. The EMR indicated R27 had a significant weight decline of 16.84% from 08/01/24 to 01/01/25 (within six months). R27's EMR under Orders noted an order (added 11/18/24) for staff to offer protein shakes when R27 ate less than 50% of her meals. The order noted she could have the protein shake up to three times daily as needed for abnormal weight loss. R27's EMR under Progress Notes revealed a Weight Change note completed on 11/03/24 indicating she had a weight loss of 5.1 % within 30 days. The note indicated she had a poor appetite and often refused meals or spit out her food. The note indicated she was on medication that decreased her appetite. The note recommended supplemental shakes twice daily for added calories. R27's EMR under Progress Notes revealed a Weight Change note completed on 12/16/24 indicating she had a weight loss of six percent within 30 days. The note recommended her supplemental shakes be increased to three times daily. On 01/13/25 at 08:00 AM an inspection of the facility's dietary department revealed the facility had no certified dietary manager. On 01/14/24 at 08:12 AM R27 sat in the dining room with staff. R27 was confused but able to communicate her needs as staff assisted her with breakfast. R 27 ate 75% of her meal with staff assistance. On 01/15/24 at 12:42 PM Certified Medication Aide (CMA) R stated R27 struggled with meal intake and often needed staff cueing and assistance for her meals. She stated R27 would often eat about 50% of her meals but also had behaviors that prevented her from finishing her meals. CMA R stated she should offer alternatives, be patient, offer snacks, and eliminate distractions during mealtimes. She stated R27 had significant weight loss due to behaviors during meals and refusal to eat. She stated she was not sure if R27 had been on a weight loss program. She stated staff would notify the dietician related to weight loss. She stated the RD came to the facility monthly to meet with the residents. On 01/15/24 at 01:33 PM Licensed Nurse G stated R27 needed constant supervision and assistance during mealtime. She stated R27 struggled with behaviors and needed staff to assist in feeding her. She stated she was recently put on one-to-one assistance for meals and provided supplementation in November. She stated R27 also refused to come out for meals and would sleep through breakfast. She stated staff were expected to provide supplement shakes if she consumed less than 50% of her meals. On 01/15/24 at 02:32 PM Administrative Nurse D stated R27's ability to eat meals varied from day to day due to her cognitive changes. She stated each resident's weight was revealed monthly by the RD. She stated R27 had a significant weight decline. She stated the facility placed her on supplemental shakes if her mal intake fell below 50%. She stated staff could also offer ice cream, pudding, and other snacks to supplement her calories. She stated staff often had to feed her due to her cognitive impairment. She stated the care plan should identify her risks for weight loss and provide fortified food alternatives to help prevent further loss. On 01/16/2025 at 11:30 AM the facility's Registered Dietician reported the facility did not communicate changes related to weights, intake, or status to her. She stated she had to go into the facility and look up the information herself. He stated she made recommendations but was not informed about R27's significant decline. She stated the facility did not include her in care plan meetings. She stated the facility currently did not have a fortified food program and only would provide shakes. She stated she had only been with the facility since 08/01/24 and was not able to find dietary notes for R27 from the previous dietician. The facility's Nutritional Services policy (undated) indicated all residents will be screened for potential weight loss and nutritional impairments. The policy indicated residents at risk for significant weight loss will be care plan based on nutritional impairments to include special dietary requirements, medication review, health, and preferences. The policy noted interventions will be implemented to prevent further weight loss. The policy indicated all residents will be monitored by the registered dietician, pharmacist, and medical provider. The policy indicated the facility will provide appropriate dietary nutrition and supplementation. The facility failed to identify and implement nutritional interventions related to R27's significant weight loss between 01/01/24 to 06/07/24. The facility additionally failed to implement alternative nutritional interventions for R27's ongoing significant weight loss between 08/01/24 and 01/01/25. As a result of the deficient practice, R27 had a significant unplanned weight loss of 19.52 and 16.84 % within two three-month periods. This also placed R27 at risk for malnourishment-related complications.

The facility identified a census of 45 residents. The facility had one main kitchen and one main dining area. Based on observation, record review, and interview the facility failed to ensure the director of food and nutrition services had the required qualifications of a certified dietary manager (CDM). This placed residents at risk for unmet dietary and nutritional needs. Findings included: - On 01/13/25 at 07:17 AM, Dietary BB stated she did not have her CDM certification. Dietary BB stated she had completed her Safe Serv courses and had not been told she needed to get her CDM. Dietary BB stated the registered dietician was only at the facility once a month. On 01/15/25 at 03:42 PM, Administrative Staff A stated it was her understanding that as long as the facility had a registered dietician the dietary manager did not have to be certified. The facility did not provide a policy regarding the CDM as requested. The facility failed to ensure the director of food and nutrition services had the required qualifications of a CDM. This placed residents at risk for unmet dietary and nutritional needs.

The facility reported a census of 43 residents, with six residents sampled and one resident reviewed for treatment and services for mental/psychosocial concerns. Based on interview and record review, the facility failed to acknowledge and respond appropriately to Resident (R) 3's behaviors which aligned to treatment and services related to his psychosocial disorder and physical aggression related to his diagnoses. The resident made statements such as I will kill my guardian and comments regarding killing himself on 09/18/24 at 05:07 PM. The resident became loud, insisted he had nothing to live for and wanted to kill himself. R3 became very belligerent and combative. R3 stated he just wanted to die and then started to hit his head with his fist, banged his head on the wall, hit himself in his own face with his knee, and five staff assisted in restraining the resident from hurting himself. Resident was crying, yelling, and was relentless to hurt himself. R3 attempted to stab himself with a paperclip. On 09/19/24 at 06:15 PM, R3 became agitated stating he was going to kill his aunt, himself, and other people. His agitation increased and he started to throw objects at staff, stabbed at a nurse's leg with a pen, tried to punch staff, pinch, kick, spit in staff's face, and tried to head butt staff. The staff placed the resident in a sheet restraint to protect him and others and restrained his hands. R3 was very wild, was not listening to anyone, and broke free of a sheet restraint and slid himself to the floor. R3 required several people to sit on his legs and arms to control him from hurting himself and others. The police came and assisted in restraining R3. R3 banged his head with his knee several times, stating he wanted to kill himself. On 09/20/24 at 06:30 PM, R3 made further statements he was going to kill everyone here and was hitting, kicking, spitting, pinching, and biting staff and himself. The facility chemically and physically restrained R3 on 09/18/24, 09/19/24, and 09/20/24. With this deficient practice, the likelihood of harm could occur due to the aggressive behaviors related to the restraining of R3 placing him in immediate jeopardy. Findings included: - The Medical Diagnosis tab for R3 included diagnoses of bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods) with psychotic features, major depressive disorder (major mood disorder which causes persistent feelings of sadness), attention deficit hyperactivity disorder (ADHD- a chronic condition including attention difficulty, hyperactivity, and impulsiveness), post-traumatic stress disorder (PTSD- mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), and autistic disorder (a developmental disorder that impairs the ability to communicate and interact). The Admission Minimum Data Set(MDS) dated [DATE] revealed the facility did not assess R3's Brief Interview for Mental Status and did not complete the staff assessment for mental status. R3 did not have any hallucinations (sensing things while awake that appear to be real, but the mind created) or delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue) during the assessment period, and no behavioral symptoms or rejection of care. The MDS indicated R3 did not require restraints. The Psychotropic Drug Use Care Area Assessment (CAA) dated 09/11/24, revealed R3 had a baseline for delusions and hallucinations. R3 required psychiatric medications on a daily basis. R3 did not trigger for further development of the following CAAs: Cognitive Loss/Dementia, Psychosocial Well-Being, Mood State, Behavioral Symptoms, or Physical Restraints. The Care Plan dated 09/18/24, revealed R3 had behavior problems related to impulsivity and poor judgement. The staff were to monitor behavior episodes and attempt to determine underlying causes, provide a program of activities that was of interest, accommodate his status, and assist R3 to develop more appropriate methods of coping, and interacting. R3's preferred activities included watching television, going on outings, and playing video games. He had the potential to be verbally aggressive and threatening others on social media related to ineffective coping skills, poor impulse control, and severe and persistent mental illness (SPMI - a group of mental health disorders that cause significant functional impairment). When R3 became agitated the staff were to intervene before agitation escalated, guide him away from source of distress, engage calmly in conversation, and if response was aggressive, the staff were to walk calmly away and approach later. On 09/23/24, the facility added R3 was physically aggressive related to anger and poor impulse control and the trigger identified was anxiety related to legal issues and R3's behaviors were de-escalated by medication/sedation and physical restraint by personnel. On 09/18/24, R3 was upset about violating a PFA (protection from abuse) order and wanted to go to jail and turn himself in. The staff advised R3 it was still in the investigation stage, and he did not need to worry about it. R3 threw desk tools, a hole punch, and a water bottle that was in Administrative Nurse's D's office. R3 tried to stab himself and staff with a pen and made several threats he was going to harm himself and others. The event lasted three hours. The facility called the Sheriff to assist and had the resident screened for placement at a hospital, which treats adults diagnosed with psychiatric disorders. R3 calmed down with medications and placement was deferred as he did not meet current criteria for admission. The facility placed R3 on one-to-one monitoring and his medications were reviewed and adjusted by the psychiatric provider. On 09/19/24, R3 called 911 and stated he was going to blow up the (specified name) county courthouse. The facility advised R3 it was illegal to make threats like that and that it would not help his court case. R3 became aggressive stating he was going to hurt everybody. R3 threw items from the desk and five staff members restrained R3, sedated him, and four hours later he ceased trying to hurt other and himself. The facility called the Sheriff, had him screened for hospital placement and accepted, however, on a waiting list. After several hours the facility received information that another local mental health facility would take R3 until he could be placed and required medical clearance. The facility took R3 to a local hospital where R3 was medically cleared, however the local mental health facility rejected the admission and R3 returned to the facility where he was placed on one-to-one and medicated with Haldol (antipsychotic- class of medications used to treat major mental conditions which cause a break from reality) and Ativan (antianxiety- class of medications that calm and relax people). On 09/20/24, R3 was medicated all day but was able to function, walk in the hall, go to meals, and watch television. R3 became angry and violent as he was upset another resident was on the phone he wanted to use and R3 stated he was going to hurt all the (explicit language) and called everyone a (explicit language). The care plan revealed the staff placed R3 in a chair and took him to Administrative Nurse D's office where he had to be physically restrained as he was biting, spitting in staff's face, head butting, and trying to punch, kick, and pinch. The facility called the Sheriff to assist, utilized intramuscular injection of Haldol and Ativan, and R3 was taken to the local hospital where he was admitted . The Electronic Medical Record (EMR) lacked a physician order for the facility to physically restrain R3. The Progress Notes dated 09/17/24 at 07:33 PM by Administrative Staff A revealed the staff removed R3's PlayStation per the request of his Guardian since R3 violated the no contact order. R3 had emailed the person who had the no contact order against him over five times on 09/16/24 and 09/17/24, threatening that person and saying hateful things, and caused the facility she was at to be placed on lock down, due to R3's threats. The facility staff and the Guardian spoke with R3 regarding complying with the no contact order and why the PlayStation was removed. The Progress Notes dated 09/18/24 at 01:49 AM by Administrative Nurse D revealed R3 was up in the hall pacing with repetitive motion of hands. R3 stated he did not want to go to jail. R3 was advised he needed to stop worrying about things in the world he cannot change. R3 stated he was stupid and did not know what to do. R3 continued to say over and over he did not know what to do, while pacing the floor. Administrative Nurse D called Administrative Staff A, then administered lorazepam (Ativan) for agitation. The Progress Notes dated 09/18/24 at 01:59 AM, by Administrative Nurse D revealed R 3 was in bed sleeping and talking in his sleep. The Progress Notes dated 09/18/24 at 04:27 PM by Licensed Nurse (LN) G revealed R3 paced a lot today and when he started talking to Administrative Nurse D, he became very anxious, started twisting his hands fast, crying, and picking at his arms. R3 became more agitated so Administrative Nurse D called Administrative Staff A who ordered clonazepam (benzodiazepine class of medication - depressant medication that produces sedation and can be used to treat anxiety), every evening at 04:00 PM, for seven days. The staff administered the medication. The Progress Notes dated 09/18/24 at 05:07 PM by Administrative Nurse D revealed R3 was upset and believed there was a warrant out for his arrest, could not wait for them to come get him, could not go to prison, and stated he knew he did wrong. Administrative Nurse D asked the resident not to worry about what he cannot change and R3 stated he was so screwed. R3 then switched to being bored, needed his PlayStation stating his Guardian did not have the right to take his stuff, and stated he could not live without his gaming system. R3 stated he needed someone to give back the PlayStation, then said he was killing his Guardian and hated everyone. R3 was scratching his arm, making rapid movements back and forth and staff administered clonazepam, one milligram. After 15 minutes, R3 started to settle down, talking quietly, and stated he was hungry. Then R3 became loud, insisted he had nothing to live for, wanted to kill himself, became belligerent and combative, then started to hit his head with fist, bang his head on the wall, and hit his face with his knee. Five staff assisted to restrain R3 from hurting himself. R3 was crying, yelling, relentless to hurt self, and tried to staff himself with a paperclip. The staff administered Haldol, five milligrams (mg), intramuscular (IM), for agitation to R3. The resident slowed down after 15 minutes remaining awake and alert, continued to need someone to hang onto him, and screened for aggressive behavior, with request it be rushed. The Progress Notes dated 09/18/24 at 05:12 PM by LN G revealed R3 had been in Administrative Nurse D's office much of the afternoon talking about the consequences of his behaviors, worked up, and sobbing. He then started hitting himself and tried to injure himself and the staff tried to hold him. R3 required clonazepam, orally, and Haldol, IM this afternoon and was a little calmer now. Call made (specified name) for a screen (lacked what type) for him. The Progress Notes dated 09/18/24 at 07:03 PM by Administrative Nurse D revealed a call back received from (specified organization) to advise because of R3's diagnosis of intellectual and developmental disability- (IDD- a significantly below-average score on a test of mental ability or intelligence and by limitations in the ability to function in areas of daily life), he did not qualify to go to the state hospital. The Progress Notes dated 09/18/24 at 10:33 PM by LN I revealed R3 was one-on-one for behaviors, was in his bed, he was being monitored every 15 minutes sitting outside his door, and he was sleeping. The Progress Notes dated 09/19/24 at 07:09 PM by LN G revealed a call received from Administrative Staff A on how R3 was doing now and told he was still sleeping. Administrative Staff A ordered haloperidol (Haldol), five mg, by mouth, every day, for seven days, for psychotic behaviors. The Progress Notes dated 09/19/24 at 04:19 PM by LN G revealed R3 was calm today and had good insight on how things worked and could calmly discuss his situation with staff. R3 was currently resting in bed. The Progress Notes dated 09/19/24 at 06:01 PM, by LN H revealed R3 continued yelling out I am going to kill you [explicit language, I will find you and I will kill you. R3 stated he wanted to be like all the men in his family, they were in jail or the penitentiary and we were all going to pay. The Progress Notes dated 09/19/24 at 06:15 PM by Administrative Nurse D revealed R3 called 911 and reported he was going to bomb the (specified place). R3 was confronted with calling in a terroristic threat, he became agitated, stated he was going to kill his (specified family member), myself, and other people. R3 stated he was in a gang and wanted to go to prison and he violated the PFA, so he deserved the death penalty. R3 became increasingly agitated and started to throw objects at staff such as water bottles and clipboards, then grabbed a pen and stabbed Administrative Nurse D in the leg. Other staff members (lacked names) responded while R3 was throwing things from the shelves and the desk, he tried to punch staff, pinch, kick, spit in staff's face, and tried to head butt. R3 was placed in a sheet restraint to protect self and others, hands restrained, resident very wild and not listening to anyone. Resident broke free of sheet restraint and slid to floor. Resident required several people to sit on his legs and arms to control resident from hurting himself and others. R3 was given Haldol, five mg, and Ativan, one mg, to decrease agitation. R3 continued to fight and threaten to kill people. Sheriff officers arrived and assisted to keep R3 from hurting himself and others. After given Haldol, 15 mg, and Ativan, four mg, and three hours later R3 was calmer. After helped to a chair R3 complained of being thirsty, provided water and when water was gone, he threw ice and glass at Administrative Nurse D and tried to stab her with a pen. R3 was given another mg of Ativan and then began to calm down. R3 was screened by (specified organization), was awake and alert, answered questions, and tried again to stab a nurse (lacked name) with a pen. Police were still here assisting with restraining R3, who began to hit himself and police officers while calling them names. R3 banged head with knee several times stating he wanted to kill himself. R3 given Ativan, two mg at 10:30 PM, and then he asked to go to bed as he was very sleepy. R3 assisted to bed and was dozing with a one-to-one staff member. The Progress Notes dated 09/19/24 at 11:00 PM by Administrative Nurse D revealed (specified organization) screener called to do screening and since R3 escalated to harming others as well as himself he was to be sent to the state hospital. The Progress Notes dated 09/20/24 at 01:19 AM by LN H revealed R3 left the facility and was transported (lacked by who) to the local hospital. The Progress Notes dated 09/20/24 at 05:20 AM by LN G revealed R3 was out of control and was physically and verbally aggressive. Administrative Nurse D spent five hours in the screening process. R3 was taken to the local hospital as instructed, and once made aware R3 was too acute, and they denied admitting him. The Progress Notes dated 09/20/24 at 01:06 PM by LN J revealed R3 rested in bed most of the day, continued to be a one-on-one at this time, and new orders were noted for Ativan, two mg, by mouth, every two hours. The Progress Notes dated 09/20/24 at 04:31 PM by LN J revealed the order for Ativan changed to one mg tablet or 1 mg/0.5 milliliters (ml) IM, every three hours. The Progress Notes dated 09/20/24 at 06:30 PM by Administrative Nurse D, a late entry on 10/07/24 at 09:55 PM, revealed R3 was waiting for the phone and upset that another resident was using the phone. R3 yelled to the resident to get off the phone [explicit language] that he needed to use it. R3 was directed to Administrative Nurse D's office to use the phone and advised not to call names, the phone was a community phone, and needed to be shared. R3 picked up a hole punch and tried to hit Administrative Nurse D, and it was taken away by Certified Nurse Aide (CNA) O. R3 turned to hit CNA O and Administrative Nurse D pushed (lacked name) an office chair underneath R3 to try and calm him. R3 stated he was going to kill everyone here, torture other (explicit language), stated he wanted to be a criminal like his biological family, and began to hit and bite staff. The staff used a speakerphone to call 911 as R3 was hitting, kicking, spitting, pinching, biting staff and himself. R3 tried to raise his knee to his head to headbutt himself and continued to threaten to hurt staff and others. R3 caused injuries to all six staff members. The staff placed a sheet over R3's arms and chest to prevent him from hurting himself and others. R3 continued to spit, and staff placed a small corner of the sheet over his face. The Sheriff arrived and assisted to keep R3 safe as R3 continued to try and hurt himself and staff and called out racist names. Administrative Staff A came to assess the situation as we had been trying to find placement elsewhere all day. The Sheriff was unable to arrest or press charges and R3 stated they could not do anything and continued to try and injure the officer and the staff. Another state hospital was unable to take R3 because he was not in a catchment area and advised to have R3 arrested. The Sheriff suggested to take R3 to the local hospital as they can call another county Sheriff to arrest. Administrative Staff A took R3 to the local hospital. During an interview on 10/17/24 at 04:06 PM, CMA R stated R3 was suicidal and very combative (could not recall date), spitting at staff, kicking, and at one point he grabbed a pen and tried to stab Administrative Nurse D. CMA R stated R3 had a PFA order on him and R3 contacted the person the PFA was related to. CMA R said the staff told R3 he could not do that, and staff took the game system away so he could not contact that person. The next night, R3 would be okay one minute and the next minute he was going off the charts cussing (explicit language). CMA R stated R3 was in Administrative Nurse D's office, and he was trying to destroy the whole room. CMA R stated CNA M, Administrative Nurse D, and herself were in the office with R3, holding his hands down so he could not hit us when two members from law enforcement came. CMA R stated R3 was sweaty from all the commotion, and the staff put a sheet across his arms, noting it was never tied, while R3 sat in a chair with his arms to his sides. CMA R stated the sheet went across his stomach and lower arms and was kept in place for 15 to 20 minutes while Administrative Nurse D held it. CMA R stated at one point, R3 calmed down and they removed the sheet, he was calm and just sat there, and all of a sudden, he would start throwing things. CMA R stated she was sitting on R3 in the chair, R3 was trying to get up, and the staff did not want R3 to get up and go where everybody else was. CMA R stated R3 tried to get up and scooted himself out of the chair and R3 and her both went to the floor. CMA R said, during that time he was kicking trying to destroy a monitor or television on a shelf and law enforcement held his feet down. CMA R stated she usually took her break at 06:00 PM and when she returned that night, she had heard the commotion and R7 stated they needed our help, and at that time R3 and Administrative Nurse D were in Administrative Nurse D's office. After R3 was in the office for a while, he asked to go to his room and go to bed and law enforcement walked R3 to his room, and one officer stayed and talked to R3 for a bit, then he fell asleep, and the staff did one-on-one with him. During an interview on 10/07/24 at 04:35 PM, CNA N recalled a night when R3 was upset in Administrative Nurse D office, he would calm down for a little bit, then get agitated again. CNA N stated R3 started throwing things and Administrative Nurse D held a sheet in place so R3 would not hit while CNA N got him to calm down then the sheet was not used again. CNA N stated R3 sat in a chair and LN H and Administrative Nurse D tried to keep R3 from getting up by using their hands. During an interview on 10/07/24 at 04:48 PM, Administrative Nurse D stated on 09/19/24, every staff member she had on 09/19/24 and 09/20/24, held R3's hands, as it took 45 minutes for law enforcement to show up. Administrative Nurse D said both days R3 came into her office could see in his eyes this kid go from Dr. Jekyll to Mr. [NAME] and when asked if he was alright, he picked up a [NAME] cup and threw it, hitting Administrative Nurse D's head and then started to tear everything off of her desk. Administrative Nurse D stated she thought the staff, CNA M, doing one-on-one was with him, and R3 went ballistic tearing things off her desk, throwing things after being told to settle down, tried to stab at her, and bit her finger. Administrative Nurse D stated the sheet I put across him. I held on to it, never tied. Basically, a band to keep his arms down. Administrative Nurse D stated R3 would try to hit them, and they did hold him with their hand on top of his and used the least amount of force we could then R3 struggled, for I don't know how long and we were having a terrible time trying to get R3 to calm down. She stated the staff administered Ativan and Haldol to R3. Administrative Nurse D stated she did not want R3 to hurt himself or her staff and he tried to bite himself, hit himself in the head, head butts against the staff, and on 09/20/24 he brought in an electric razor and was going to stab her, but law enforcement took it. She said R3 had cleared off the counter and grabbed different objects, throwing a stapler that hit her shoulder, and threw ice at her, and called staff names. Administrative Nurse D stated at one point on 09/19/24 R3 was on the floor, law enforcement showed up, staff let loose of the sheet, and R3 popped up and hit the officer and back down he went, where he was on the floor for about 15 minutes, hitting, scratching, kicking, clearing things off the desks in the room and basically the officer pinned him down. R3 tried to bite the officer, which did not work to well, and he tried to spit in Administrative Nurse D's face. Administrative Nurse D stated on 09/20/24, she put sheets around R3's legs while he sat, so he would not kick us. Administrative Nurse D stated she did not have an order to use a sheet on R3. On 10/07/24 at 06:24 PM, Administrative Staff B stated the facility did not have a policy for use of restraints. The facility failed to acknowledge and respond appropriately to Resident (R) 3's behaviors which aligned to treatment and services related to his psychosocial disorder and physical aggression related to his diagnoses, who had a history of self-harm and physically and verbally aggressive behaviors, remained free of physical or chemical restraints when on 09/18/24, 09/19/24, and 09/20/24 the resident attempted to injure himself and became combative with staff and the facility staff chemically and physically restrained the resident. On 10/07/24 at 06:45 PM, Administrative Staff B was provided a copy of the Immediate Jeopardy template and notified of the facility's failure to ensure R3 remained free of physical or chemical restraints, placed R3 in immediate jeopardy. The facility provided an acceptable plan for removal of the immediacy on 10/08/24 at 09:40 PM which included the following: 1. The facility completed a violence risk screening on all current residents by 10/09/24 at 12:30 AM. 2. The facility revised care plan for residents identified at high risk for assault identified in the screening tool. 3. The facility began educating staff on the Federal Guidelines on the use of restraints on 10/09/24. 4. The facility assigned online training on 10/07/24 and staff began training on 10/08/24 for Handling Aggressive Behaviors, Overview of Abuse and Neglect of Individuals with IDD, Understanding Wandering and Elopement, and the Meaning Behind Behaviors. The onsite surveyor verified the implementation of the above corrective actions on 10/10/24 at 09:45 AM and the deficient practice remained at a G scope and severity.

The facility reported a census of 43 residents, with six residents sampled and one resident reviewed for the right to be free from physical restraints. Based on interview and record review, the facility failed to ensure Resident (R) 3, who had a history of self-harm and physically and verbally aggressive behaviors, remained free of physical or chemical restraints when on 09/18/24, 09/19/24, and 09/20/24 the resident attempted to injure himself and became combative with staff and the facility staff chemically and physically restrained the resident. The facility failed to identify the resident's medical/behavioral symptoms that warranted the use of chemical restraint, physical restraint of five to six staff, and the use of a bedsheet to further restrain the resident. The resident's record lacked any physician orders related to the use of the restraints, any specific documentation related to assessment of the resident for restraint use and/or person-centered care planning, which included the use of a physical restraints or the least amount of restriction/time possible and/or ongoing evaluation. This deficient practice placed R3 in immediate jeopardy. Findings included: - The Medical Diagnosis tab for R3 included diagnoses of bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods) with psychotic features, major depressive disorder (major mood disorder which causes persistent feelings of sadness), attention deficit hyperactivity disorder (ADHD - a chronic condition including attention difficulty, hyperactivity, and impulsiveness), post-traumatic stress disorder (PTSD- mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), and autistic disorder (a developmental disorder that impairs the ability to communicate and interact). The Admission Minimum Data Set, dated dated dated [DATE], revealed the facility did not assess R3's Brief Interview for Mental Status and did not complete the staff assessment for mental status. R3 did not have any hallucinations (sensing things while awake that appear to be real, but the mind created) or delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue) during the assessment period, and no behavioral symptoms or rejection of care. R3 did not require restraints. The Psychotropic Drug Use Care Area Assessment (CAA) dated 09/11/24, revealed R3 had a baseline for delusions and hallucinations. R3 required psychiatric medications on a daily basis. R3 did not trigger for further development of the following CAA's: Cognitive loss/Dementia, Psychosocial Well-being, Mood, Behavioral symptoms, or Physical Restraints. The Care Plan dated 09/18/24, revealed R3 had behavior problems related to impulsivity and poor judgement. The staff were to monitor behavior episodes and attempt to determine underlying causes, provide a program of activities that was of interest, accommodate his status, and assist R3 to develop more appropriate methods of coping and interacting. R3's preferred activities were watching television, going on outings, and playing video games. He had the potential to be verbally aggressive and threatening others on social media related to ineffective coping skills, poor impulse control, and severe and persistent mental illness (SPMI - a group of mental health disorders that cause significant functional impairment). When R3 became agitated the staff were to intervene before agitation escalated, guide him away from source of distress, engage calmly in conversation, and if response was aggressive the staff were to walk calmly away and approach later. On 09/23/24, the facility added R3 was physically aggressive related to anger and poor impulse control and the trigger identified was anxiety related to legal issues and R3's behaviors were de-escalated by medication/sedation and physical restraint by personnel. On 09/18/24, R3 was upset about violating a PFA (protection from abuse) order and wanted to go to jail and turn himself in. The staff advised R3 it was still in the investigation stage, and he did not need to worry about it. R3 threw desk tools, a hole punch, and a water bottle that was in Administrative Nurse's D's office. R3 tried to stab himself and staff with a pen and made several threats he was going to harm himself and others. The event lasted three hours. The facility called the Sheriff to assist and had the resident screened for placement at a hospital, which treats adults diagnosed with psychiatric disorders. R3 calmed down with medications and placement was deferred as he did not meet current criteria for admission. The facility placed R3 on one-to-one monitoring and his medications were reviewed and adjusted by the psychiatric provider. On 09/19/24, R3 called 911 and stated he was going to blow up the (specified name) county courthouse. The facility advised R3 it was illegal to make threats like that and that it would not help his court case. R3 became aggressive stating he was going to hurt everybody. R3 threw items from the desk and five staff members restrained R3, sedated him, and four hours later he ceased trying to hurt other and himself. The facility called the Sheriff, had him screened for hospital placement and accepted, however, on a waiting list. After several hours the facility receive information that another local mental health facility would take R3 until he could be placed and required medical clearance. The facility took R3 to a local hospital where R3 was medically cleared, however the local mental health facility rejected the admission and R3 returned to the facility where he was placed on one-to-one and medicated with Haldol (antipsychotic - class of medications used to treat major mental conditions which cause a break from reality) and Ativan (antianxiety - class of medications that calm and relax people). On 09/20/24, R3 was medicated all day but was able to function, walk in the hall, go to meals, and watch television. R3 became angry and violent as he was upset another resident was on the phone he wanted to use and R3 stated he was going to hurt all the (explicit language) and called everyone a (explicit language). The care plan revealed the staff placed R3 in a chair and took him to Administrative Nurse D's office where he had to be physically restrained as he was biting, spitting in staff's face, head butting, and trying to punch, kick, and pinch. The facility called the Sheriff to assist, utilized intramuscular injection of Haldol and Ativan, and R3 was taken to the local hospital where he was admitted . Record review of R3's Electronic Medical Record (EMR) lacked a physician order to the facility to physically restrain R3. The Progress Notes dated 09/17/24 at 07:33 PM, by Administrative Staff A revealed the staff removed R3's PlayStation per the request of his Guardian since R3 violated the no contact order and emailed the person who had the no contact order against him over five times on 09/16/24 and 09/17/24, threatening that person and saying hateful things, and caused the facility she was at to be placed on lock down due to R3's threats. The facility staff and the Guardian spoke with R3 regarding complying with the no contact order and why the PlayStation had been removed. The Progress Notes dated 09/18/24 at 01:49 AM, by Administrative Nurse D revealed R3 was up in the hall pacing with repetitive motion of hands. R3 stated he did not want to go to jail. R3 was advised he needed to stop worrying about things in the world he cannot change. R3 stated he was stupid and did not know what to do. R3 continued to say over and over he did not know what to do while pacing the floor. Administrative Nurse D called Administrative Staff A, then administered lorazepam (Ativan) for agitation. The Progress Notes dated 09/18/24 at 01:59 AM, by Administrative Nurse D revealed resident was in bed sleeping and talking in his sleep. The Progress Notes dated 09/18/24 at 04:27 PM, by Licensed Nurse (LN) G revealed R3 paced a lot today and when he started talking to Administrative Nurse D, he became very anxious, started twisting his hands fast, crying, and picking at his arms. R3 became more agitated so Administrative Nurse D called Administrative Staff A who ordered clonazepam (benzodiazepine class of medication - depressant medication that produces sedation and can be used to treat anxiety), every evening at 04:00 PM, for seven days. The staff administered the medication. The Progress Notes dated 09/18/24 at 05:07 PM, by Administrative Nurse D revealed R3 was upset and believed there was a warrant out for his arrest, could not wait for them to come get him, could not go to prison, and stated he knew he did wrong. Administrative Nurse D asked the resident not to worry about what he cannot change and R3 stated he was so screwed. R3 then switched to being bored, needed his PlayStation stating his Guardian did not have the right to take his stuff, and stated he could not live without his gaming system. R3 stated he needed someone to give back the PlayStation, then said he was killing his Guardian and hated everyone. R3 was scratching his arm, making rapid movements back and forth and was given clonazepam, one milligram. After 15 minutes, R3 started to settle down, talking quietly, and stated he was hungry. Then R3 became loud, insisted he had nothing to live for, wanted to kill himself, became belligerent and combative, then started to hit his head with fist, bang his head on the wall, and hit his face with his knee. Five staff assisted to restrain R3 from hurting himself. R3 was crying, yelling, relentless to hurt self, and tried to staff himself with a paperclip. R3 was given Haldol, five milligrams (mg), intramuscular, for agitation. R3 slowed down after 15 minutes remaining awake and alert, continued to need someone to hang onto him, screened for aggressive behavior, with request it be rushed. The Progress Notes dated 09/18/24 at 05:12 PM, by LN G revealed R3 had been in Administrative Nurse D's office much of the afternoon talking about the consequences of his behaviors, worked up, and sobbing. He then started hitting himself and tried to injure himself and the staff tried to hold him. R3 required clonazepam, orally, and Haldol, IM this afternoon and was a little calmer now. Call made (specified name) for a screen (lacked what type) for him. The Progress Notes dated 09/18/24 at 07:03 PM, by Administrative Nurse D revealed a call back received from (specified organization) to advise because of R3's diagnosis of intellectual and developmental disability- (IDD- a significantly below-average score on a test of mental ability or intelligence and by limitations in the ability to function in areas of daily life), he did not qualify to go to the state hospital. The Progress Notes dated 09/18/24 at 10:33 PM, by LN I revealed R3 was one-on-one for behaviors, was in his bed, he was being monitored every 15 minutes sitting outside his door, and he was sleeping. The Progress Notes dated 09/19/24 at 07:09 PM, by LN G revealed a call received from Administrative Staff A on how R3 was doing now and told he was still sleeping. Administrative Staff A ordered haloperidol (Haldol), five mg, by mouth, every day, for seven days, for psychotic behaviors. The Progress Notes dated 09/19/24 at 04:19 PM, by LN G reveled R3 was calm today and had good insight on how things worked and could calmly discuss his situation with staff. R3 was currently resting in bed. The Progress Notes dated 09/19/24 at 06:01 PM, by LN H revealed R3 continued yelling out I am going to kill you (explicit language), I will find you and I will kill you. R3 stated he wanted to be like all the men in his family, they were in jail or the penitentiary and we were all going to pay. The Progress Notes dated 09/19/24 at 06:15 PM, by Administrative Nurse D revealed R3 called 911 and reported he was going to bomb the (specified place). R3 was confronted with calling in a terroristic threat, he became agitated, stated he was going to kill his (specified family member), myself, and other people. R3 stated he was in a gang and wanted to go to prison and he violated the PFA, so he deserved the death penalty. R3 became increasingly agitated and started to throw objects at staff such as water bottles and clipboards, then grabbed a pen and stabbed Administrative Nurse D in the leg. Other staff members (lacked names) responded while R3 was throwing things from the shelves and the desk, he tried to punch staff, pinch, kick, spit in staff's face, and tried to head butt. R3 was placed in a sheet restraint to protect self and others, hands restrained, resident very wild and not listening to anyone. Resident broke free of sheet restraint and slid to floor. Resident required several people to sit on his legs and arms to control resident from hurting himself and others. R3 was given Haldol, five mg, and Ativan, one mg, to decrease agitation. R3 continued to fight and threaten to kill people. Sheriff officers arrived and assisted to keep R3 from hurting himself and others. After given Haldol, 15 mg, and Ativan, four mg, and three hours later R3 was calmer. After helped to a chair R3 complained of being thirsty, provided water and when water was gone, he threw ice and glass at Administrative Nurse D and tried to stab her with a pen. R3 was given another mg of Ativan and then began to calm down. R3 was screened by (specified organization), was awake and alert, answered questions, and tried again to stab a nurse (lacked name) with a pen. Police were still here assisting with restraining R3, who began to hit himself and police officers while calling them names. R3 banged head with knee several times stating he wanted to kill himself. R3 given Ativan, two mg at 10:30 PM, and then he asked to go to bed as he was very sleepy. R3 assisted to bed and was dozing with a one-to-one staff member. The Progress Notes dated 09/19/24 at 11:00 PM, by Administrative Nurse D revealed (specified organization) screener called to do screening and since R3 escalated to harming others as well as himself he was to be sent to the state hospital. The Progress Notes dated 09/20/24 at 01:19 AM by LN H revealed R3 left the facility and was being transported (lacked by who) to the local hospital. The Progress Notes dated 09/20/24 at 05:20 AM by LN G revealed R3 was out of control and was physically and verbally aggressive. Administrative Nurse D spent five hours in the screening process. R3 was taken to local hospital as instructed once made aware R3 was too acute, and they denied him. The Progress Notes dated 09/20/24 at 01:06 PM, by LN J revealed R3 rested in bed most of the day, continued to be a one-on-one at this time, and new orders were noted for Ativan, two mg, by mouth, every two hours. The Progress Notes dated 09/20/24 at 04:31 PM, by LN J revealed the order for Ativan changed to one mg tablet or 1 mg/0.5 milliliters (ml) IM, every three hours. The Progress Notes dated 09/20/24 at 06:30 PM, by Administrative Nurse D on 10/07/24 at 09:55 PM, revealed R3 was waiting for the phone and upset that another resident was using the phone. R3 yelled to the resident to get off the phone (explicit language) that he needed to use it. R3 was directed to Administrative Nurse D's office to use the phone and advised not to call names, the phone was a community phone, and needed to be shared. R3 picked up a hole punch and tried to hit Administrative Nurse D, and it was taken away by Certified Nurse Aide (CNA) O. R3 turned to hit CNA O and Administrative Nurse D, pushed (lacked name) an office chair underneath R3 to try and calm him. R3 stated he was going to kill everyone here, torture other (explicit language), stated he wanted to be a criminal like his biological family, and began to hit and bite staff. A speakerphone used to call 911 as R3 was hitting, kicking, spitting, pinching, biting staff and himself. R3 tried to raise his knee to his head to headbutt himself and continued to threaten to hurt staff and others. R3 made several connections that caused injuries to all six staff members. The staff placed a sheet over R3's arms and chest to prevent him from hurting himself and others. R3 continued to spit, a small corner of the shift placed over his face, and a Sheriff arrived and assisted to try and keep R3 safe as he was still trying to hurt himself and staff and call racist names. Administrative Staff A came to assess situation as we had been trying to find placement elsewhere all day. The Sheriff was unable to arrest or press charges and R3 stated they could not do anything and continued to try and injure the officer and the staff. Another state hospital was unable to take R3 because he was not in a catchment area and advised to have R3 arrested. The Sheriff suggested to take R3 to the local hospital as they can call another county Sheriff to arrest. Administrative Staff A took R3 to the local hospital. On 10/17/24 at 04:06 PM CMA R stated R3 was suicidal and very combative (could not recall date), spitting at us, kicking, and at one point he grabbed a pen and tried to stab Administrative Nurse D. CMA R stated R3 had a PFA order on him and R3 contacted the person the PFA was related to, we told R3 he could not do that, and we took the game system away so he could not contact that person. The next night, R3 would be okay one minute and the next minute he was going off the charts cussing (explicit language). CMA R stated R3 was in Administrative Nurse D's office .and he was trying to destroy the whole room. CMA R stated CNA M, Administrative Nurse D, and herself were in the office with R3 holding his hands down with ours so he could not hit us when two members from law enforcement came. CMA R stated R3 was sweaty from all the commotion, and we put a sheet across his arms, it was never tied, while sitting in a chair with his arms to his sides. CMA R stated the sheet went across his stomach and lower arms and kept in place for 15 to 20 minutes while Administrative Nurse D held it. CMA R stated at one point, R3 calmed down and they removed the sheet, he was calm and just sit there then all of a sudden, he would start throwing things. CMA R stated she was sitting on R3 in the chair, R3 was trying to get up, and we did not want him to get up and go where everybody else was. CMA R stated R3 tried to get up and scooted himself out of the chair and R3 and her both went to the floor and during that time he was kicking trying to destroy a monitor or television on a shelf and law enforcement held his feet down. CMA R stated she usually take her break at 06:00 PM and when she returned that night, she had heard the commotion and R7 stated they needed our help and at that time R3 and Administrative Nurse D was in Administrative Nurse D's office. After R3 was in the office for a while, he asked to go to his room and go to bed and law enforcement walked R3 to his room, one stayed and talked to R3 for a bit then he fell asleep, and we did one-on-one with him. On 10/07/24 at 04:35 PM, CNA N recalled a night when R3 was upset in Administrative Nurse D office, he would calm down for a little bit, then get agitated again. CNA N stated R3 started throwing things and Administrative Nurse D held a sheet in place so R3 would not hit while CNA N got him to calm down then the sheet was not used again. CNA N stated R3 was sitting in a chair and LN H and Administrative Nurse D tried to keep R3 from getting up by using their hands. On 10/07/24 at 04:48 PM, Administrative Nurse D stated on 09/19/24, every staff member she had on 09/19/24 and 09/20/24, held R3's hands, as it took 45 minutes for law enforcement to show up. Administrative Nurse D both days R3 came in my office, and you could see in his eyes, this kid go from Dr. Jekyll to Mr. [NAME] and when asked if he was alright, he picked up a [NAME] cup and threw it hitting my head and then started to tear everything off of my desk. Administrative Nurse D stated she thought the staff, CNA M, doing one-on-one was with him, and R3 went ballistic tearing things off my desk, throwing things after told to settle down, tried to stab at me, bit my finger. Administrative Nurse D stated the sheet I put across him. I held on to it, never tied. Basically, a band to keep his arms down. Administrative Nurse D stated R3 would try to hit them, and they did hold him with their hand on top of his and used the least amount of force we could then R3 struggled, for I don't know how long and we were having a terrible time trying to get R3 to calm down, he was given Ativan and Haldol. Administrative Nurse D stated she did not want R3 to hurt himself or her staff and he tried to bite himself, hit himself in the head, head butts against us, and on 09/20/24 he brought in an electric razor and was going to stab me, but law enforcement took it. R3 had cleared off the counter and grabbed different objects, throwing a stapler that hit my shoulder, and threw ice at me, calling us names. Administrative Nurse D stated at one point on 09/19/24 R3 was on the floor, law enforcement showed up, we let loose of the sheet, and R3 popped up and hit the officer and back down he went, where he was on the floor for about 15 minutes, hitting, scratching, kicking, clearing things off the desks in the room and basically the officer pinned him down. R3 tried to bite the officer, which did not work to well, and he tried to spit in my face. Administrative Nurse D stated on 09/20/24, she put sheets around R3's legs while he was sitting, so he would not kick us. Administrative Nurse D stated she did not have an order to use a sheet on R3. On 10/07/24 at 06:24 PM Administrative Staff B stated the facility did not have a policy for use of restraints. The facility failed to ensure Resident (R)3, who had a history of self-harm and physically and verbally aggressive behaviors, remained free of physical or chemical restraints when on 09/18/24, 09/19/24, and 09/20/24 the resident attempted to injure himself and became combative with staff and the facility staff chemically and physically restrained the resident. On 10/07/24 at 06:45 PM, Administrative Staff B was provided a copy of the Immediate Jeopardy template and notified of the facility's failure to ensure R3 remained free of physical or chemical restraints. The facility provided an acceptable plan for removal of the immediacy on 10/08/24 at 09:40 PM which included the following: 1. The facility completed a violence risk screening on all current residents by 10/09/24 at 12:30 AM. 2. The facility revised care plan for residents identified at high risk for assault identified in the screening tool. 3. The facility began educating staff on the Federal Guidelines on the use of restraints on 10/09/24. 4. The facility assigned online training on 10/07/24 and staff began training on 10/08/24 for Handling Aggressive Behaviors, Overview of Abuse and Neglect of Individuals with IDD, Understanding Wandering and Elopement, and the Meaning Behind Behaviors. The onsite surveyor verified the implementation of the above corrective actions on 10/10/24 at 09:45 AM and the deficient practice remained at a G scope and severity.

The facility reported a census of 45 residents. The six sampled residents included three reviewed for elopement (when a cognitively impaired resident leaves the facility without the knowledge or supervision of staff). The facility identified six residents at risk for elopement. Based on observation, interview, and record review the facility failed to provide appropriate supervision, implement interventions, and identify elopement behaviors to prevent the elopement of Resident (R)1, who remained on 30-minutes checks from a prior elopement, eloped again from the facility on 01/28/24 at 04:36 PM, with staff present. The facility staff did not realize R1 was missing until another staff member saw R1 walk past a window outside the building, on 01/28/24 at 05:30 PM. almost an hour after the resident eloped. Review of the 30-minute check log revealed the facility staff failed to check and log on the resident's whereabouts since 01/28/24 at 04:30 PM. This deficient practice placed the resident in immediate jeopardy. Findings included: - The Electronic Health Record (EHR) documented R1 had diagnoses, which included unspecified schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), cannabis (marijuana) abuse, and insomnia (inability to sleep). The 03/01/23 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R1 hallucinated (sensing things while awake that appear to be real, but the mind created). R1 had no behaviors directed towards self or others during the seven-day look-back period and was independent for all cares. The resident took an antipsychotic (a class of medications used to treat major mental conditions which cause a break from reality) daily during the seven-day look-back period. The 12/02/23 Quarterly MDS documented a BIMS score of 13, which indicated intact cognition. The resident hallucinated and had delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue). The resident had other behavioral symptoms not directed at others one-to-three days and wandered four-to-six days in the look back period. R1 received antipsychotic medication during the assessment look-back period. The Care Plan documented that the resident was a high elopement risk and documented the following: On 10/14/20, staff were to assess the resident for fall risk. On 10/14/20, staff were to identify patterns of wandering and to intervene as appropriate. On 10/14/20, staff were to place a Wander Guard (a bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) on R1's right ankle. On 03/04/21, staff were to monitor the resident's location several times a day and document wandering behavior. On 01/05/24, staff placed a Wander Guard on R1's right wrist after assessment and elopement, where R1 broke out a bedroom window. The Wandering Risk Scale assessments revealed a low risk on 08/24/22, 11/24/22, 02/24/23, 05/25/23, 05/25/23 and 11/27/23. Further documented a high risk to wander on 01/15/24 and 01/28/24. The Progress Notes documented the following: From 12/19/23 to 01/28/24, R1 displayed 19 episodes where he had wandering behaviors and/or paced near the main entrance with and without talking to himself. On 01/05/24, R1 eloped from the facility where he sustained injuries that required sutures (a medical device used to hold wound edges together to promote healing after an injury). On 01/12/24, the facility discontinued 1:1 staff supervision and initiated staff observations of the resident's whereabouts every 15 minutes. On 01/20/24, the facility discontinued every 15-minute checks and initiated 1:1 staff supervision due to the resident calling 911 and requesting to be taken to a county jail. On 01/21/24, the facility discontinued 1:1 staff supervision and initiated staff observations every 15 minutes. On 01/23/24, the facility discontinued every 15-minute checks and initiated staff observations every 30 minutes as ordered by Physician Extender F. On 01/28/24 at 07:38 PM, Certified Nurse Aide (CNA) C and Certified Medication Aide (CMA) D observed R1 outside the facility at 05:30 PM, when R1 attempted to enter the building through the main doors. CMA D let R1 into the building and took him to the nurses' station where she notified Licensed Nurse (LN) E. LN E assessed R1 for injuries, then notified administration (Administrative Staff A, Administrative Nurse B, Physician Extender F) and R1's guardian. It further documented Law Enforcement notified by Physician Extender F at an unknown time. Review of the undated facility investigation revealed the following: On 01/28/24 at 04:30 PM, R1 went out the back patio door with CNA C and other residents to smoke. On 01/28/24 at 04:36 PM, R1 went over a six-foot wooden privacy fence surrounding the courtyard. On 01/28/24 at 05:00 PM, the Wandering Resident Monitor log lacked documentation of the staff 30-minute required check. On 01/28/24 at 05:30 PM, (one hour after staff last seen R1, and 54 minutes after R1 left the facility), documented R1 returned to the facility and R1's Wander Guard was intact on the resident's right wrist. R1 stated that he walked to the store (approximately 4000 feet or three-quarters of a mile from the facility and approximately 200 feet from a heavily traveled highway which includes semi-trucks and a speed limit of 55 miles per hour [mph]) to ask someone to light his previously lit cigarette, then he walked back to the facility. Review of weather data for the facility area from Weather Underground (www.wunderground.com), on 01/28/24 at 04:56 PM (20 minutes after the elopement and 34 minutes before R1 returned to the facility), the temperature was 52 degrees Fahrenheit ( F) with south winds at 8 mph, and the sunset was at 05:49 PM (19 minutes after R1 returned to the facility). Observation of the area around the facility revealed a highway approximately one-third of a mile north with heavy traffic that included semi-trucks and a speed limit of 55 mph. On 01/31/24 at 09:30 AM, Administrative Staff A was unable to provide an explanation as to why the 05:00 PM entry on the Wandering Resident Monitor log was blank and incomplete. Administrative Staff A had no further information to provide as her investigation of the elopement was ongoing. On 01/31/24 at 10:08 AM, CNA C stated that at the time R1 eloped, she had taken several residents out to smoke and another unidentified resident started an unknown disturbance that occupied her attention. When the residents and CNA C returned inside the building, she failed to recognize that R1 was not among the group of residents. Additionally, she stated that after the smoking period, residents would congregate in the dining area for the evening meal and neither her nor CMA D noticed R1 was not present. On 01/28/24 at 05:30 PM, CNA C and CMA D observed R1 through the dining room windows, walking up the sidewalk to the main entrance. He wore jeans, a shirt, a medium-weight coat, and shoes. CMA D let R1 in though the main entrance. On 01/31/24 at 10:14 AM, CMA D was unavailable for comment in the investigation. Review of facility investigation witness statements revealed that the investigation lacked a witness statement from CMA D. On 01/31/24 at 10:21 AM, LN E revealed that R1 had gone out to the patio with CNA C to smoke and sometime during that time, eloped over the fence in the courtyard. LN E revealed R1 had been pacing in the front lobby near the main doors earlier. LN E stated that she failed to perform the 05:00 PM observation of the resident because she thought that R1 had come in with CNA C and was in the dining area with the rest of the residents, so she had gone to the kitchen for a refreshment, utilized the bathroom, and then chatted with Physician Extender F in her office and lost track of the time. LN E realized that she failed to perform the 05:00 PM observation. LN E was advised at 05:30 PM when CMA D brought R1 to the nursing station and was informed R1 eloped. LN E stated that she notified Physician Extender F who then notified the remaining members of the administrative team (Administrative Nurse B and Administrative Staff A) and Law Enforcement. On 01/31/24 at 10:54 AM, Administrative Nurse B stated that CNA C failed to perform adequate supervision during the smoking period due to another resident had caused a disturbance. Administrative Nurse B stated that LN E failed to recognize that R1 had eloped from the building when she failed to perform the 05:00 PM observation of R1 and that her investigation was incomplete and ongoing. Administrative Nurse B stated that corrective actions that had been implemented since R1 eloped on 01/28/24 included: suspension of LN E pending an investigation, staff education that had been initiated but had not been completed, implementation of a sign out/in log for residents who smoke, implementation of 1:1 observation of R1 and that R1 had been screened for placement at a more appropriate facility. Administrative Nurse B stated that LN E failed to perform the appropriate notifications after R1's elopement and that Physician Extender F notified her. Administrative Nurse B stated that she feared that LN E would not have notified the administrative team if Physician Extender F had not been physically present in the building at the time of the elopement. On 01/31/24 at 11:48 AM, Law Enforcement G revealed that 911 dispatch received a call regarding R1's elopement on 01/31/24 at 06:49 PM (two hours and 13 minutes after the resident left the facility and one hour and 19 minutes after the resident returned to the facility) and that an officer responded to the facility at 06:54 PM and contacted Physician Extender F filed a report. The facility's undated Accident Prevention policy documented that all staff members of the facility will ensure that the environment remains as free from accident hazards as possible and will receive adequate supervision to prevent accidents. The facility's undated Elopement Policy documented that the facility wishes to ensure the safety of residents identified as being a risk for elopement and to take precautions to ensure safety and well-being. Upon discovering an unaccountable absence of a resident by a staff member, they will inform the nurse, record the time that the resident was discovered missing and where the resident was last seen. The nurse will contact law enforcement, perform a resident roll call, and direct other staff to search the facility and grounds. The facility failed to provide appropriate supervision, implement interventions, and identify elopement behaviors to prevent the elopement of R1, who eloped from the facility on 01/28/24 at 04:36 PM, with staff present, but without staff knowledge. The facility staff did not realize R1 was missing until another staff member saw R1 outside through a window, on 01/28/24 at 05:30 PM. The facility was notified of the IJ for F689 for R1 on the prior 2567 dated 01/16/24. Upon investigation into the second elopement of R1 on 01/28/24 at 04:36 PM, revealed the facility remained out of compliance and the failure to prevent the additional elopement of R1, and placed R1 back in immediate jeopardy. On 01/31/24 at 02:50 PM, Administrative Staff A was provided the Immediate Jeopardy (IJ) Template for failure to provide adequate supervision to prevent elopement. The facility provided an acceptable plan for removal of the IJ on 02/01/24 at 09:15 AM and the following corrective measures were verified by the surveyor on-site during the investigation on 02/01/24 at 10:00 AM. 1. On 01/29/24 at 06:00 AM, R1's care plan was updated with interventions to protect R1 and other residents to monitor outside while smoking and ensure that R1 signs in and out during scheduled smoking periods. 2. On 01/28/24 at 05:47 PM, Administrative staff B placed R1 on 1:1 observation at all times, even during scheduled smoking periods. 3. On 01/31/24 at 09:00 AM, all staff were required to participate in a tabletop scenario and write out the process for what to do in the event of an elopement prior to returning to work. 4. On 01/28/24 at 09:00 PM, the facility created sign out and sign in sheets for residents who go outside to smoke. 5. On 02/01/24 at 09:15 AM, the daily staffing sheet was modified to include an assignment for 1:1 observation of R1. 6. On 01/29/24 at 06:00 AM, the charge nurse would document every two hours to reflect the 1:1 observation of R1. The surveyor verified the facility implemented the corrective actions to remove the immediacy, while onsite on 02/01/24 at 10:00 AM. The deficient practice remained at a scope and severity of G after removal of the jeopardy.

The facility reported a census of 45 residents and identified six residents at risk for elopement (an incident in which a cognitively impaired resident with poor or impaired decision-making ability/safety awareness leaves the facility without the knowledge of staff). Based on observation, interview, and record review, the facility failed to provide sufficient staff with the appropriate competencies and skills sets to meet the behavioral health needs one Resident (R)1, who had known elopement behaviors and a history of an elopement, to prevent an additional elopement from the facility. Findings included: - The Electronic Health Record (EHR) documented R1 had diagnoses which included unspecified schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), cannabis (marijuana) abuse, and insomnia (inability to sleep). The 03/01/23 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R1 hallucinated (sensing things while awake that appear to be real, but the mind created). R1 had no behaviors directed towards self or others during the seven-day look-back period and was independent for all cares. The resident took an antipsychotic (a class of medications used to treat major mental conditions which cause a break from reality) daily during the seven-day look-back period. The 12/02/23 Quarterly MDS documented a BIMS score of 13, which indicated intact cognition. The resident hallucinated and had delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue). The resident had other behavioral symptoms not directed at others one-to-three days and wandered four-to-six days in the look back period. R1 received antipsychotic medication during the assessment look-back period. The Care Plan documented that the resident was a high elopement risk and documented the following: On 10/14/20, staff were to assess the resident for fall risk. On 10/14/20, staff were to identify patterns of wandering and to intervene as appropriate. On 10/14/20, staff were to place a Wander Guard (a bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) on R1's right ankle. On 03/04/21, staff were to monitor the resident's location several times a day and document wandering behavior. On 01/05/24, staff placed a Wander Guard on R1's right wrist after assessment and elopement, where R1 broke out a bedroom window, and exited the facility without staff knowledge. (The staff member assigned to monitor R1 at that time, was currently dealing with another resident having behaviors at the same time that R1 returned to his room and went out the broken window). The Wandering Risk Scale assessments revealed a low risk on 08/24/22, 11/24/22, 02/24/23, 05/25/23, 05/25/23 and 11/27/23. Further documented a high risk to wander on 01/15/24 and 01/28/24. The Progress Notes documented the following: From 12/19/23 to 01/28/24, R1 displayed 19 episodes where he had wandering behaviors and/or paced near the main entrance with and without talking to himself. On 01/05/24, R1 eloped from the facility where he sustained injuries that required sutures (a medical device used to hold wound edges together to promote healing after an injury). On 01/12/24, the facility discontinued 1:1 staff supervision and initiated staff observations of the resident's whereabouts every 15 minutes. On 01/20/24, the facility discontinued every 15-minute checks and initiated 1:1 staff supervision due to the resident calling 911 and requesting to be taken to a county jail. On 01/21/24, the facility discontinued 1:1 staff supervision and initiated staff observations every 15 minutes. On 01/23/24, the facility discontinued every 15-minute checks and initiated staff observations every 30 minutes as ordered by Physician Extender F. On 01/28/24 at 07:38 PM, Certified Nurse Aide (CNA) C and Certified Medication Aide (CMA) D observed R1 outside the facility at 05:30 PM, when R1 attempted to enter back into the building through the main doors. CMA D let R1 into the building and took him to the nurses' station where she notified Licensed Nurse (LN) E. LN E assessed R1 for injuries, then notified administration (Administrative Staff A, Administrative Nurse B, Physician Extender F) and R1's guardian. It further documented Law Enforcement notified by Physician Extender F at an unknown time. Review of the undated facility investigation revealed the following: On 01/28/24 at 04:30 PM, R1 went out the back patio door with CNA C and other residents to smoke. On 01/28/24 at 04:36 PM, R1 went over a six-foot wooden privacy fence surrounding the courtyard. On 01/28/24 at 05:00 PM, the Wandering Resident Monitor log lacked documentation of the staff 30-minute required check. On 01/28/24 at 05:30 PM, (one hour after staff last seen R1, and 54 minutes after R1 left the facility), documented R1 returned to the facility and R1's Wander Guard was intact on the resident's right wrist. R1 stated that he walked to the store (approximately 4000 feet or three-quarters of a mile from the facility and approximately 200 feet from a heavily traveled highway which includes semi-trucks and a speed limit of 55 miles per hour [mph]) to ask someone to light his previously lit cigarette, then he walked back to the facility. Review of weather data for the facility area from Weather Underground (www.wunderground.com), on 01/28/24 at 04:56 PM (20 minutes after the elopement and 34 minutes before R1 returned to the facility), the temperature was 52 degrees Fahrenheit ( F) with south winds at 8 mph, and the sunset was at 05:49 PM (19 minutes after R1 returned to the facility). The facility's Facility Assessment Tool, dated 03/01/23, documented that the facility would have a sufficient number of qualified staff to meet the needs the residents at any given time and documented that this would include one licensed nurse providing direct care, two nurse aides (CNAs) and two other nursing personnel for a total of five staff members. On 01/31/24 at 10:08 AM, CNA C stated that at the time R1 eloped, she had taken several residents out to smoke and another unidentified resident started an unknown disturbance that occupied her attention. When the residents and CNA C returned inside the building, she failed to recognize that R1 was not among the group of residents. Additionally, she stated that after the smoking period, residents would congregate in the dining area for the evening meal and neither her nor CMA D noticed R1 was not present. On 01/28/24 at 05:30 PM, CNA C and CMA D observed R1 through the dining room windows, walking up the sidewalk to the main entrance. He wore jeans, a shirt, a medium-weight coat, and shoes. CMA D let R1 in though the main entrance. On 01/31/24 at 10:21 AM, LN E revealed that R1 had gone out to the patio with CNA C to smoke and sometime during that time, eloped over the fence in the courtyard. LN E revealed R1 had been pacing in the front lobby near the main doors earlier. LN E stated that she failed to perform the 05:00 PM observation of the resident because she thought that R1 had come in with CNA C and was in the dining area with the rest of the residents, so she had gone to the kitchen for a refreshment, utilized the bathroom, and then chatted with Physician Extender F in her office and lost track of the time. LN E realized that she failed to perform the 05:00 PM observation. LN E was advised at 05:30 PM when CMA D brought R1 to the nursing station and was informed R1 eloped. LN E stated that she notified Physician Extender F who then notified the remaining members of the administrative team (Administrative Nurse B and Administrative Staff A) and Law Enforcement. On 01/31/24 at 10:54 AM, Administrative Nurse B stated that CNA C failed to perform adequate supervision during the smoking period due to another resident had caused a disturbance. Administrative Nurse B stated that LN E failed to recognize that R1 had eloped from the building when she failed to perform the 05:00 PM observation of R1. Administrative Nurse B stated that corrective actions that had been implemented since R1 eloped on 01/28/24 included: suspension of LN E pending an investigation, staff education that had been initiated but had not been completed, implementation of a sign out/in log for residents who smoke, implementation of 1:1 observation of R1 and that R1 had been screened for placement at a more appropriate facility. Administrative Nurse B stated that LN E failed to perform the appropriate notifications after R1's elopement and that Physician Extender F notified her. Administrative Nurse B stated that she feared that LN E would not have notified the administrative team if Physician Extender F had not been physically present in the building at the time of the elopement. On 01/31/24 at 11:48 AM, Law Enforcement G revealed that 911 dispatch received a call regarding R1's elopement on 01/31/24 at 06:49 PM (two hours and 13 minutes after the resident left the facility and one hour and 19 minutes after the resident returned to the facility) and that an officer responded to the facility at 06:54 PM and contacted Physician Extender F filed a report. On 02/01/24 at 11:35 AM, Administrative Staff A stated that per the facility assessment, the normal nurse staffing required for a weekend afternoon shift, was one licensed nurse, one CMA and two CNAs and that all four staff members were present on that date. Additionally, that the number of required staff had not been increased to compensate for the increased observations of R1, up to and including the implemented continuous 1:1 observation) following the elopement on 01/05/24 or on 01/28/24, when the same resident eloped twice from the facility without staff knowledge. The facility's undated Accident Prevention policy documented that all staff members of the facility will ensure that the environment remains as free from accident hazards as possible and will receive adequate supervision to prevent accidents. The facility's undated Elopement Policy documented that the facility wishes to ensure the safety of residents identified as being a risk for elopement and to take precautions to ensure safety and well-being. Upon discovering an unaccountable absence of a resident by a staff member, they will inform the nurse, record the time that the resident was discovered missing and where the resident was last seen. The nurse will contact law enforcement, perform a resident roll call, and direct other staff to search the facility and grounds. The facility failed to provide training records related to behavior monitoring for CNA C, CNA H, CMA D or LN E as requested on 02/01/24 at 11:04 AM and 02/01/24 at 11:45 AM. The facility failed to provide sufficient staff with the appropriate competencies and skills sets to meet the behavioral health needs of R1, who had known elopement behaviors and a history of elopement, to prevent an additional elopement from the facility.

The facility reported a census of 45 residents with two residents reviewed for behaviors/resident-to-resident abuse. Based on observation, interview, and record review, the facility failed to protect residents from incidents of sexual assault and harassment the failure to provide adequate supervision and care planned interventions to prevent Resident (R)2, with a history of sexual behaviors since admission (August 2023), from sexually assaulting and harassing female residents in the facility. On 12/25/23, R2 grabbed R3's breast and masturbated in a public area, and the facility failed to place any interventions to protect R3 and other residents from R2's unwanted sexual advances/touching. R2 again on 12/25/23 masturbated in a public area. On 01/02/24, R2 attempted to grab R3's breast with no interventions in place. This deficient practice placed R3 and all other residents in immediate jeopardy, and at risk for negative psychosocial impact of female residents' safety and well-being. Findings included: - R2's Electronic Health Record (EHR) revealed a diagnosis of unspecified schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought). The Admission Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 15, which indicated intact cognition. R2 had delusions (untrue persistent beliefs or perception held by a person although evidence shows it was untrue) and physical and verbal behaviors directed towards others, rejection of care and wandering behaviors one-to-three days in the seven-day look-back period that were disruptive of the living environment and/or social interactions. R2 took antipsychotic (a class of medications used to treat major mental conditions which cause a break from reality) medications daily in the seven-day look back period. The Quarterly MDS dated [DATE] documented a BIMS of 14, which indicated intact cognition. R2 had delusions and displayed physical behaviors towards others, other behaviors not directed at others, and rejection of care one-to-three days in the seven-day look-back period. R2 had wandering behaviors four-to-six days in the seven-day look-back period and took antipsychotic medication. The 08/27/23 Delirium Care Area Assessment (CAA) documented R2 exhibited several episodes of disorganized thinking. The 08/27/23 Psychosocial Well-Being CAA documented R2 did not attend activities or socialize with other residents and could be physically aggressive. The 08/27/23 Behavioral CAA documented the resident displayed several behaviors daily. The 01/11/24 Care Plan documented on 09/13/23, the resident displayed behavior problems of not following directions, inappropriate conversation, and screaming at staff. The care plan included the following: On 09/13/23, staff were to administer medications as ordered and monitor for effectiveness. On 09/13/23, caregivers were to provide an opportunity for positive interaction and attention. On 09/13/23, caregivers were to discuss the resident's behavior and explain/reinforce why behaviors were inappropriate or unacceptable. On 09/13/23, caregivers were to intervene as necessary to protect the rights and safety of others by diverting attention and removing from situation to alternate location as needed. On 09/13/23, caregivers were to praise indications of progress or improvement in R2's behavior. On 09/13/23, caregivers were to provide a program of activities of interest to R1. The care plan lacked interventions specific to R1's sexual behaviors to prevent further inappropriate sexual advances toward other residents, statements, and/or behaviors. The Progress Notes documented the following: 1. On 08/30/23 at 10:00 AM, R2 made inappropriate sexual advances and statements to staff when R2 wanted a female staff member to kiss him and touch his penis. 2. On 08/31/23 at 09:05 AM, R2 made inappropriate sexual advances and statements to staff when R2 asked a female staff member to undress and engage in sexual intercourse with him. 3. On 09/02/23 at 01:20 PM, R2 made inappropriate sexual advances to an unidentified female resident who had fallen asleep in a chair in the common area. R2 kissed the (unidentified) female resident on the lips without consent. 4. On 10/27/23 at 12:33 AM, R2 made inappropriate sexual statements to staff that he could have sex with children or any woman he wanted to because Santa [NAME] had told him to. 5. On 10/28/23 at 12:39 AM, R2 made inappropriate sexual statements to staff about having sexual relations with children. 6. On 11/08/23 at 06:08 PM, R2 made inappropriate statements to (unidentified) female residents. 7. On 11/25/23 at 06:35 PM, an unknown Certified Nurse Aide (CNA) reported to Licensed Nurse (LN) C that R2 purposefully urinated in the shower of the men's shower room and when confronted by staff, R2 claimed he had masturbated in the men's shower room. 8. On 12/12/23 at 11:57 PM, R2 made inappropriate sexual statements to (unidentified) female residents. R2 told the (unidentified) female residents that he was waiting for sex. 9. On 12/25/23 at 04:15 AM, R2 masturbated in a public area. LN J redirected R2 to his room. 10. On 12/25/23 at 04:40 AM, R3 reported to LN J that R2 grabbed her breast. When questioned about the incident by LN J, R2 admitted to grabbing R3's breast and stated that he did not know why he grabbed her breast. 11. On 12/25/23 at 05:01 AM, LN J observed R2 masturbating in a public area. LN J attempted to redirect R2 to the privacy of his room when R2 stated he could not help it and he got so horny around her (R3). 12. On 01/02/24 at 06:22 PM, R2 attempted to grab R3's breasts, but was redirected by staff. 13. On 01/04/24 at 02:33 PM, R2 made inappropriate sexual statements to an (unidentified) female resident. R2 asked the female resident if she wanted to be raped. Review of the facility's investigation and witness statements revealed no additional information. However, the investigation did have date stamp, by Administrative Staff A, on 12/25/23 that she had notified local law enforcement. On 01/11/24 at 10:41 AM, R3 reported she did not feel safe in her current environment, however, would not elaborate on why she felt unsafe. She reported she was uncomfortable with R2's sexual actions and did not want to further discuss any details. On 01/11/24 at 03:00 PM, Law Enforcement E revealed that no reports were on file related to the resident-to-resident sexual abuse that occurred on 12/25/23. Additionally, Law Enforcement E stated local law enforcement should be notified anytime there is an incident of unwanted sexual contact. On 01/11/24 at 03:39 PM, CNA D, CNA M, and CMA L revealed that if two or more residents were involved in an altercation of any type, they had been trained to physically separate the residents in question and to tell the licensed nurse on duty, then to follow the instructions given by the nurse. They further revealed if R2 and R3 got too close to each other, staff were to redirect one or both residents. On 01/11/24 at 03:45 PM, LN K revealed that if two or more residents were involved in an altercation of any type staff should separate the residents then investigate what happened, then relay the information to administration (Administrative Staff A, Administrative Nurse B and Physician Extender G). Administrative Nurse B was responsible to develop care plan interventions and instructions for staff to follow. Further stated that R2 has not made any unwanted sexual advances towards any peers other than R3. On 01/11/24 at 03:47 PM, Administrative Nurse B revealed staff were expected to keep R2 and R3 always separated per the communication notice in the EHR. Administrative Nurse B confirmed no interventions on the resident's care plan specific to inappropriate sexual contact/speech, sexual aggression, or sexual touching and stated that the staff have walking rounds after an incident and were to relay information from shift to shift with new interventions or that the new interventions placed on the communication notice in the EHR. Administrative Nurse B revealed that in the event of two or more residents being involved in an altercation of any type, staff were to separate the residents involved. The residents should be assessed by the LN on duty and investigate what happened. The LN was to notify all members of administration (Administrative Staff A, Administrative Nurse B, and Physician Extender G) who would then handle the remainder of the investigation and make the appropriate notifications of family/guardians, and if warranted, local law enforcement. On 01/11/24 at 03:58 PM, Physician Extender G stated the care plan entry dated 09/13/23 related to inappropriate speech addresses inappropriate sexual advances/speak/groping made towards peers or staff. R3 had attempted to go into R2's room since the incident on 12/25/23 but noted no documentation in R2 or R3's EHR to support this claim. Stated that law enforcement was not notified because R2 had the ability to call 911 herself and would have if she felt it necessary. On 01/11/24 at 04:00 PM, Administrative Staff A confirmed that she did not inform law enforcement on 12/25/23 as documented in the facility report. Stated that she did not notify local law enforcement because the resident and the resident's guardian did not want law enforcement involved. The undated facility policy Right to Consensual Sexual Activities documented that each resident has the right to a dignified existence, self-determination, and communication with persons/services inside and outside the facility and have all the rights provided to all citizens and residents of the United States of America, which includes affording all residents with privacy to engage in safe, consensual sexual expression. The policy defined sexual expression to include, but not limited to, hugs, kisses, masturbation, intimate touch, and intercourse. Further documented that sexual abuse was a non-consensual sexual contact of any type with a resident including but not limited to unwanted intimate touching of any kind especially of breasts or genitals, all types of sexual assault or battery, forced observation of masturbation and/or pornography. Further defined nonconsensual sexual contact as any resident who appears to want to contact to occur but lacks the cognitive ability to consent, or a resident who does not want the contact to occur. The undated facility Abuse, Neglect and Exploitation Policy documented that facility would prohibit and prevent abuse and that residents of the facility would remain free from abuse which may include verbal, mental, sexual, or physical abuse while residing at the facility. Documented that any staff that becomes aware of abuse should immediately report to the administrator who would report the abuse per state and federal requirements. Further, defined sexual abuse as non-consensual sexual contact of any type with a resident that included, but not limited to, unwanted intimate touching of any kind especially of the breasts or genitals and forced observation of masturbation. Additionally documented that willful abuse is defined that the individual must have acted deliberately, whether or not harm or injury was inflicted. Additionally documented that the administrator will file a report with the State Regulatory Agency immediately within 24 hours of the incident and any suspicion of abuse resulting in injury will be reported to the State Regulatory Agency within two hours and local law enforcement. Further documented that residents' sexual rights to not extend to acts which are non-consensual, acts with minors, or acts that impact negatively on the resident community as a whole through public display. Additionally documented that if there is any evidence of an incident that meets the definition of assault, battery, or other crime against a person that local law enforcement would be notified by the administrator or designee immediately. Additionally documented that if the alleged perpetrator of abuse is a facility resident, that a staff member will stay with the alleged perpetrator and wait for further instruction from administration. Further documented that all sexual assaults of a resident will be reported to local law enforcement immediately. The facility failed to protect residents from incidents of sexual assault and harassment through the failure to provide adequate supervision and care planned interventions to prevent R2, with a history of sexual behaviors since admission (August 2023), from sexually assaulting and harassing female residents in the facility. On 12/25/23, R2 grabbed R3's breast and masturbated in a public area, and the facility failed to place any interventions to protect R3 and other residents from R2's unwanted sexual advances/touching. R2 again on 12/25/23 masturbated in a public area. On 01/02/24, R2 attempted to grab R3's breast with no interventions in place. This deficient practice placed R3 and all other residents in immediate jeopardy and at risk for negative psychosocial impact of resident' safety and well-being. On 01/11/24 at 05:30 PM, Administrative Staff A was provided the Immediate Jeopardy (IJ) template for failure to ensure the protection of residents from sexual assault placing them in immediate jeopardy. The facility submitted an acceptable plan for removal of the immediate jeopardy on 01/12/24 at 06:09 PM which included the following: 1. On 01/12/24 at 08:00 PM, the facility updated care plans for residents with sexually inappropriate behaviors by 01/16/24 completed for the four identified residents. 2. On 01/11/24 at 08:00 PM the facility educated staff on the policy Abuse, Neglect and Exploitation and completed 01/12/24 at 04:40 PM. 3. On 01/11/24 at 08:00 PM, the facility educated staff on the policy Sexual Consent and completed 01/12/24 at 04:40 PM 4. On 01/11/24 at 08:00 PM, the facility initiated an online training module for staff to complete on Relias with the topic of Preventing, Recognizing and Reporting Abuse and completed 01/13/24 at 03:08 AM 5. On 01/11/24 at 08:00 PM, the facility initiated an online training module for staff to complete on Relias with the topic of Abuse, Neglect and exploitation and completed 01/13/24 at 03:08 AM 6. On 01/11/24 at 08:00 PM, the facility initiated an online training module for staff to complete on Relias with the topic of Ethical Issues of Sexuality and the Older Adult and completed 01/13/24 at 03:08 AM 7. On 01/16/24 at 10:00 AM the facility initiated a process through which the Social Services Designee (SSD) would conduct resident interview questions related to abuse, neglect and exploitation 45 residents in the first week and had completed three of the 45 resident interviews on 01/16/24 at 12:05 PM with the remaining resident interviews ongoing. 8. On 01/11/24 at 08:00 PM the facility placed R2, with concerns of unwanted sexual advances under 1:1 observation until LEO investigated and resident would been assessed by Physician Extender G and/or Administrative Nurse B. Policy/procedure reviewed on 01/16/24 at 11:56 AM with Administrative Staff A. 9. On 12/22/23 at 05:00 AM the facility instructed staff to redirect/intervene/distract/encourage self-soothing activities in the privacy of R1's room and is an ongoing intervention. 10. On 01/12/24 at 08:00 PM, the facility instructed all staff instructed to maintain visual contact with R2 when out of his room and updated on care plan with this intervention. 11. On 01/12/24 at 05:51 PM, the facility placed a door alarm on R2's door to alert staff when R2 left his room and will be maintained for minimum of 30 days and reviewed at next QAPI meeting. 12. On 01/02/24 (at unknown time) R2 was seen by psychological provider for medication follow up and will be seen on an as needed basis until the 30 day review period, this included medication changes with Lithium (an antipsychotic medication) increased to 600 milligrams (mg) orally (PO) twice daily related to schizophrenia and started on trazodone (an antidepressant medication that is sometimes used to help with sleep) 100 mg po every night at bedtime related to insomnia. The surveyor verified the facility implemented the above corrective measures on-site during on 01/16/24 at 12:05 PM. The deficient practice remained at a scope and severity level of an F, following the implementation of the removal plan.

The facility reported a census of 45 residents with two residents reviewed for behaviors/resident-to-resident abuse. Based on observation, interview, and record review, the facility failed to ensure the reporting of incidents of sexual assault and harassment to local law enforcement, as required. The facility failed to provide adequate supervision and care planned interventions to prevent R2, with a history of sexual behaviors since admission (August 2023), from sexually assaulting and harassing female residents in the facility. On 12/25/23, R2 grabbed R3's breast and masturbated in a public area, and the facility failed to place any interventions to protect R3 and other residents from R2's unwanted sexual advances/touching. R2 again on 12/25/23 masturbated in a public. On 01/02/24 R2 attempted to grab another resident's breast with no interventions in place. This deficient practice placed R3 and all other residents in immediate jeopardy. Findings included: - R2's Electronic Health Record (EHR) revealed a diagnosis of unspecified schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought). The Admission Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 15, which indicated intact cognition. R2 had delusions (untrue persistent beliefs or perception held by a person although evidence shows it was untrue) and physical and verbal behaviors directed towards others, rejection of care and wandering behaviors one-to-three days in the seven-day look-back period that were disruptive of the living environment and/or social interactions. R2 took antipsychotic (a class of medications used to treat major mental conditions which cause a break from reality) medications daily in the seven-day look back period. The Quarterly MDS dated [DATE] documented a BIMS of 14, which indicated intact cognition. R2 had delusions and displayed physical behaviors towards others, other behaviors not directed at others, and rejection of care one-to-three days in the seven-day look-back period. R2 had wandering behaviors four-to-six days in the seven-day look-back period and took antipsychotic medication. The 08/27/23 Delirium Care Area Assessment (CAA) documented R2 exhibited several episodes of disorganized thinking. The 08/27/23 Psychosocial Well-Being CAA documented R2 did not attend activities or socialize with other residents and could be physically aggressive. The 08/27/23 Behavioral CAA documented the resident displayed several behaviors daily. The 01/11/24 Care Plan documented on 09/13/23, the resident displayed behavior problems of not following directions, inappropriate conversation, and screaming at staff. The care plan included the following: On 09/13/23, staff were to administer medications as ordered and monitor for effectiveness. On 09/13/23, caregivers were to provide an opportunity for positive interaction and attention. On 09/13/23, caregivers were to discuss the resident's behavior and explain/reinforce why behaviors were inappropriate or unacceptable. On 09/13/23, caregivers were to intervene as necessary to protect the rights and safety of others by diverting attention and removing from situation to alternate location as needed. On 09/13/23, caregivers were to praise indications of progress or improvement in R2's behavior. On 09/13/23, caregivers were to provide a program of activities of interest to R1. The care plan lacked interventions specific to R1's sexual behaviors to prevent further inappropriate sexual advances toward other residents, statements, and/or behaviors. The Progress Notes documented the following: 1. On 08/30/23 at 10:00 AM, R2 made inappropriate sexual advances and statements to staff when R2 wanted a female staff member to kiss him and touch his penis. 2. On 08/31/23 at 09:05 AM, R2 made inappropriate sexual advances and statements to staff when R2 asked a female staff member to undress and engage in sexual intercourse with him. 3. On 09/02/23 at 01:20 PM, R2 made inappropriate sexual advances to an unidentified female resident who had fallen asleep in a chair in the common area. R2 kissed the (unidentified) female resident on the lips without consent. 4. On 10/27/23 at 12:33 AM, R2 made inappropriate sexual statements to staff that he could have sex with children or any woman he wanted to because Santa [NAME] had told him to. 5. On 10/28/23 at 12:39 AM, R2 made inappropriate sexual statements to staff about having sexual relations with children. 6. On 11/08/23 at 06:08 PM, R2 made inappropriate statements to (unidentified) female residents. 7. On 11/25/23 at 06:35 PM, an unknown Certified Nurse Aide (CNA) reported to Licensed Nurse (LN) C that R2 purposefully urinated in the shower of the men's shower room and when confronted by staff, R2 claimed he had masturbated in the men's shower room. 8. On 12/12/23 at 11:57 PM, R2 made inappropriate sexual statements to (unidentified) female residents. R2 told the (unidentified) female residents that he was waiting for sex. 9. On 12/25/23 at 04:15 AM, R2 masturbated in a public area. LN J redirected R2 to his room. 10. On 12/25/23 at 04:40 AM, R3 reported to LN J that R2 grabbed her breast. When questioned about the incident by LN J, R2 admitted to grabbing R3's breast and stated that he did not know why he grabbed her breast. 11. On 12/25/23 at 05:01 AM, LN J observed R2 masturbating in a public area. LN J attempted to redirect R2 to the privacy of his room when R2 stated he could not help it and he got so horny around her (R3). 12. On 01/02/24 at 06:22 PM, R2 attempted to grab R3's breasts, but was redirected by staff. 13. On 01/04/24 at 02:33 PM, R2 made inappropriate sexual statements to an (unidentified) female resident. R2 asked the female resident if she wanted to be raped. Review of the facility's investigation and witness statements revealed no additional information. However, the investigation did have date stamp, by Administrative Staff A, on 12/25/23 that she had notified local law enforcement. On 01/11/24 at 10:41 AM, R3 reported she did not feel safe in her current environment, however, would not elaborate on why she felt unsafe. She reported she was uncomfortable with R2's sexual actions and did not want to further discuss any details. On 01/11/24 at 03:00 PM, Law Enforcement E revealed that no reports were on file related to the resident-to-resident sexual abuse that occurred on 12/25/23. Additionally, Law Enforcement E stated local law enforcement should be notified anytime there is an incident of unwanted sexual contact. On 01/11/24 at 03:39 PM, CNA D, CNA M, and CMA L revealed that if two or more residents were involved in an altercation of any type, they were trained to physically separate the residents in question and to tell the licensed nurse on duty, then to follow the instructions given by the nurse. They further revealed if R2 and R3 got too close to each other, staff were to redirect one or both residents. On 01/11/24 at 03:45 PM, LN K revealed that if two or more residents were involved in an altercation of any type staff should separate the residents then investigate what happened, then relay the information to administration (Administrative Staff A, Administrative Nurse B and Physician Extender G). Administrative Nurse B was responsible to develop care plan interventions and instructions for staff to follow. Further stated that R2 has not made any unwanted sexual advances towards any peers other than R3. On 01/11/24 at 03:47 PM, Administrative Nurse B revealed staff were expected to keep R2 and R3 always separated per the communication notice in the EHR. Administrative Nurse B confirmed no interventions on the resident's care plan specific to inappropriate sexual contact/speech, sexual aggression, or sexual touching and stated that the staff have walking rounds after an incident and were to relay information from shift to shift with new interventions or that the new interventions placed on the communication notice in the EHR. Administrative Nurse B revealed that in the event of two or more residents being involved in an altercation of any type, staff were to separate the residents involved. The residents should be assessed by the LN on duty and investigate what happened. The LN was to notify all members of administration (Administrative Staff A, Administrative Nurse B, and Physician Extender G) who would then handle the remainder of the investigation and make the appropriate notifications of family/guardians, and if warranted, local law enforcement. On 01/11/24 at 03:58 PM, Physician Extender G stated the care plan entry dated 09/13/23 related to inappropriate speech addresses inappropriate sexual advances/speak/groping made towards peers or staff. R3 had attempted to go into R2's room since the incident on 12/25/23 but noted no documentation in R2 or R3's EHR to support this claim. Stated that law enforcement was not notified because R2 had the ability to call 911 herself and would have if she felt it necessary. On 01/11/24 at 04:00 PM, Administrative Staff A confirmed that she did not inform law enforcement on 12/25/23 as documented in the facility report. Stated that she did not notify local law enforcement because the resident and the resident's guardian did not want law enforcement involved. The undated facility policy Right to Consensual Sexual Activities documented that each resident has the right to a dignified existence, self-determination, and communication with persons/services inside and outside the facility and have all the rights provided to all citizens and residents of the United States of America, which includes affording all residents with privacy to engage in safe, consensual sexual expression. The policy defined sexual expression to include, but not limited to, hugs, kisses, masturbation, intimate touch, and intercourse. Further documented that sexual abuse was a non-consensual sexual contact of any type with a resident including but not limited to unwanted intimate touching of any kind especially of breasts or genitals, all types of sexual assault or battery, forced observation of masturbation and/or pornography. Further defined nonconsensual sexual contact as any resident who appears to want to contact to occur but lacks the cognitive ability to consent, or a resident who does not want the contact to occur. The facility failed to report an allegation of sexual abuse to local law enforcement, as required. The undated facility Abuse, Neglect and Exploitation Policy documented that facility would prohibit and prevent abuse and that residents of the facility would remain free from abuse which may include verbal, mental, sexual, or physical abuse while residing at the facility. Documented that any staff that becomes aware of abuse should immediately report to the administrator who would report the abuse per state and federal requirements. Further, defined sexual abuse as non-consensual sexual contact of any type with a resident that included, but not limited to, unwanted intimate touching of any kind especially of the breasts or genitals and forced observation of masturbation. Additionally documented that willful abuse is defined that the individual must have acted deliberately, whether or not harm or injury was inflicted. Additionally documented that the administrator will file a report with the State Regulatory Agency immediately within 24 hours of the incident and any suspicion of abuse resulting in injury will be reported to the State Regulatory Agency within two hours and local law enforcement. Further documented that residents' sexual rights to not extend to acts which are non-consensual, acts with minors, or acts that impact negatively on the resident community as a whole through public display. Additionally documented that if there is any evidence of an incident that meets the definition of assault, battery, or other crime against a person that local law enforcement would be notified by the administrator or designee immediately. Additionally documented that if the alleged perpetrator of abuse is a facility resident, that a staff member will stay with the alleged perpetrator and wait for further instruction from administration. Further documented that all sexual assaults of a resident will be reported to local law enforcement immediately. The facility failed to ensure the reporting of incidents of sexual assault and harassment to local law enforcement, as required. The facility failed to provide adequate supervision and care planned interventions to prevent R2, with a history of sexual behaviors since admission (August 2023), from sexually assaulting and harassing female residents in the facility. On 12/25/23, R2 grabbed R3's breast and masturbated in a public area, and the facility failed to place any interventions to protect R3 and other residents from R2's unwanted sexual advances/touching. R2 again on 12/25/23 masturbated in a public. On 01/02/24 R2 attempted to grab another resident's breast with no interventions in place. On 01/11/24 at 05:30 PM, Administrative Staff A was provided the Immediate Jeopardy (IJ) template for failure to ensure the reporting of incidents of sexual assault and harassment to local law enforcement, as required, placing them in immediate jeopardy. The facility submitted an acceptable plan for removal of the immediate jeopardy on 01/12/24 at 06:09 PM which included the following: 1. On 01/12/24 at 08:00 PM, the facility updated care plans for residents with sexually inappropriate behaviors by 01/16/24 completed for the four identified residents. 2. On 01/11/24 at 08:00 PM the facility educated staff on the policy Abuse, Neglect and Exploitation and completed 01/12/24 at 04:40 PM. 3. On 01/11/24 at 08:00 PM, the facility educated staff on the policy Sexual Consent and completed 01/12/24 at 04:40 PM 4. On 01/11/24 at 08:00 PM, the facility initiated an online training module for staff to complete on Relias with the topic of Preventing, Recognizing and Reporting Abuse and completed 01/13/24 at 03:08 AM 5. On 01/11/24 at 08:00 PM, the facility initiated an online training module for staff to complete on Relias with the topic of Abuse, Neglect and exploitation and completed 01/13/24 at 03:08 AM 6. On 01/11/24 at 08:00 PM, the facility initiated an online training module for staff to complete on Relias with the topic of Ethical Issues of Sexuality and the Older Adult and completed 01/13/24 at 03:08 AM 7. On 01/16/24 at 10:00 AM the facility initiated a process through which the Social Services Designee (SSD) would conduct resident interview questions related to abuse, neglect and exploitation 45 residents in the first week and had completed three of the 45 resident interviews on 01/16/24 at 12:05 PM with the remaining resident interviews ongoing. 8. On 01/11/24 at 08:00 PM the facility placed R2, with concerns of unwanted sexual advances under 1:1 observation until LEO investigated and resident would been assessed by Physician Extender G and/or Administrative Nurse B. Policy/procedure reviewed on 01/16/24 at 11:56 AM with Administrative Staff A. 9. On 12/22/23 at 05:00 AM the facility instructed staff to redirect/intervene/distract/encourage self-soothing activities in the privacy of R1's room and is an ongoing intervention. 10. On 01/12/24 at 08:00 PM, the facility instructed all staff instructed to maintain visual contact with R2 when out of his room and updated on care plan with this intervention. 11. On 01/12/24 at 05:51 PM, the facility placed a door alarm on R2's door to alert staff when R2 left his room and will be maintained for minimum of 30 days and reviewed at next QAPI meeting. 12. On 01/02/24 (at unknown time) R2 was seen by psychological provider for medication follow up and will be seen on an as needed basis until the 30 day review period, this included medication changes with Lithium (an antipsychotic medication) increased to 600 milligrams (mg) orally (PO) twice daily related to schizophrenia and started on trazodone (an antidepressant medication that is sometimes used to help with sleep) 100 mg po every night at bedtime related to insomnia. The surveyor verified the facility implemented the above corrective measures on-site during on 01/16/24 at 12:05 PM. The deficient practice remained at a scope and severity level of a F, following the implementation of the removal plan.

The facility reported a census of 45 residents with two residents reviewed for behaviors/resident-to-resident abuse. Based on observation, interview, and record review, the facility failed to provide adequate supervision and care planned interventions to prevent Resident (R)2, with a history of sexual behaviors since admission (August 2023), from sexually assaulting and harassing female residents in the facility. On 12/25/23, R2 grabbed R3's breast and masturbated in a public area, and the facility failed to place any interventions to protect R3 and other residents from R2's unwanted sexual advances/touching. R2 again on 12/25/23 masturbated in a public area. On 01/02/24, R2 attempted to grab R3's breast with no interventions in place. This deficient practice placed R3 and all other residents in immediate jeopardy. Findings included: - R2's Electronic Health Record (EHR) revealed a diagnosis of unspecified schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought). The Admission Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 15, which indicated intact cognition. R2 had delusions (untrue persistent beliefs or perception held by a person although evidence shows it was untrue) and physical and verbal behaviors directed towards others, rejection of care and wandering behaviors one-to-three days in the seven-day look-back period that were disruptive of the living environment and/or social interactions. R2 took antipsychotic (a class of medications used to treat major mental conditions which cause a break from reality) medications daily in the seven-day look back period. The Quarterly MDS dated [DATE] documented a BIMS of 14, which indicated intact cognition. R2 had delusions and displayed physical behaviors towards others, other behaviors not directed at others, and rejection of care one-to-three days in the seven-day look-back period. R2 had wandering behaviors four-to-six days in the seven-day look-back period and took antipsychotic medication. The 08/27/23 Delirium Care Area Assessment (CAA) documented R2 exhibited several episodes of disorganized thinking. The 08/27/23 Psychosocial Well-Being CAA documented R2 did not attend activities or socialize with other residents and could be physically aggressive. The 08/27/23 Behavioral CAA documented the resident displayed several behaviors daily. The 01/11/24 Care Plan documented on 09/13/23, the resident displayed behavior problems of not following directions, inappropriate conversation, and screaming at staff. The care plan included the following: On 09/13/23, staff were to administer medications as ordered and monitor for effectiveness. On 09/13/23, caregivers were to provide an opportunity for positive interaction and attention. On 09/13/23, caregivers were to discuss the resident's behavior and explain/reinforce why behaviors were inappropriate or unacceptable. On 09/13/23, caregivers were to intervene as necessary to protect the rights and safety of others by diverting attention and removing from situation to alternate location as needed. On 09/13/23, caregivers were to praise indications of progress or improvement in R2's behavior. On 09/13/23, caregivers were to provide a program of activities of interest to R1. The care plan lacked interventions specific to R1's sexual behaviors to prevent further inappropriate sexual advances toward other residents, statements, and/or behaviors. The Progress Notes documented the following: 1. On 08/30/23 at 10:00 AM, R2 made inappropriate sexual advances and statements to staff when R2 wanted a female staff member to kiss him and touch his penis. 2. On 08/31/23 at 09:05 AM, R2 made inappropriate sexual advances and statements to staff when R2 asked a female staff member to undress and engage in sexual intercourse with him. 3. On 09/02/23 at 01:20 PM, R2 made inappropriate sexual advances to an unidentified female resident who had fallen asleep in a chair in the common area. R2 kissed the (unidentified) female resident on the lips without consent. 4. On 10/27/23 at 12:33 AM, R2 made inappropriate sexual statements to staff that he could have sex with children or any woman he wanted to because Santa [NAME] had told him to. 5. On 10/28/23 at 12:39 AM, R2 made inappropriate sexual statements to staff about having sexual relations with children. 6. On 11/08/23 at 06:08 PM, R2 made inappropriate statements to (unidentified) female residents. 7. On 11/25/23 at 06:35 PM, an unknown Certified Nurse Aide (CNA) reported to Licensed Nurse (LN) C that R2 purposefully urinated in the shower of the men's shower room and when confronted by staff, R2 claimed he had masturbated in the men's shower room. 8. On 12/12/23 at 11:57 PM, R2 made inappropriate sexual statements to (unidentified) female residents. R2 told the (unidentified) female residents that he was waiting for sex. 9. On 12/25/23 at 04:15 AM, R2 masturbated in a public area. LN J redirected R2 to his room. 10. On 12/25/23 at 04:40 AM, R3 reported to LN J that R2 grabbed her breast. When questioned about the incident by LN J, R2 admitted to grabbing R3's breast and stated that he did not know why he grabbed her breast. 11. On 12/25/23 at 05:01 AM, LN J observed R2 masturbating in a public area. LN J attempted to redirect R2 to the privacy of his room when R2 stated he could not help it and he got so horny around her (R3). 12. On 01/02/24 at 06:22 PM, R2 attempted to grab R3's breasts, but was redirected by staff. 13. On 01/04/24 at 02:33 PM, R2 made inappropriate sexual statements to an (unidentified) female resident. R2 asked the female resident if she wanted to be raped. Review of the facility's investigation and witness statements revealed no additional information. However, the investigation did have date stamp, by Administrative Staff A, on 12/25/23 that she had notified local law enforcement. On 01/11/24 at 10:41 AM, R3 reported she did not feel safe in her current environment, however, would not elaborate on why she felt unsafe. She reported she was uncomfortable with R2's sexual actions and did not want to further discuss any details. On 01/11/24 at 03:00 PM, Law Enforcement E revealed that no reports were on file related to the resident-to-resident sexual abuse that occurred on 12/25/23. Additionally, Law Enforcement E stated local law enforcement should be notified anytime there is an incident of unwanted sexual contact. On 01/11/24 at 03:39 PM, CNA D, CNA M, and CMA L revealed that if two or more residents were involved in an altercation of any type, they had been trained to physically separate the residents in question and to tell the licensed nurse on duty, then to follow the instructions given by the nurse. They further revealed if R2 and R3 got too close to each other, staff were to redirect one or both residents. On 01/11/24 at 03:45 PM, LN K revealed that if two or more residents were involved in an altercation of any type staff should separate the residents then investigate what happened, then relay the information to administration (Administrative Staff A, Administrative Nurse B and Physician Extender G). Administrative Nurse B was responsible to develop care plan interventions and instructions for staff to follow. Further stated that R2 has not made any unwanted sexual advances towards any peers other than R3. On 01/11/24 at 03:47 PM, Administrative Nurse B revealed staff were expected to keep R2 and R3 always separated per the communication notice in the EHR. Administrative Nurse B confirmed no interventions on the resident's care plan specific to inappropriate sexual contact/speech, sexual aggression, or sexual touching and stated that the staff have walking rounds after an incident and were to relay information from shift to shift with new interventions or that the new interventions placed on the communication notice in the EHR. Administrative Nurse B revealed that in the event of two or more residents being involved in an altercation of any type, staff were to separate the residents involved. The residents should be assessed by the LN on duty and investigate what happened. The LN was to notify all members of administration (Administrative Staff A, Administrative Nurse B, and Physician Extender G) who would then handle the remainder of the investigation and make the appropriate notifications of family/guardians, and if warranted, local law enforcement. On 01/11/24 at 03:58 PM, Physician Extender G stated the care plan entry dated 09/13/23 related to inappropriate speech addresses inappropriate sexual advances/speak/groping made towards peers or staff. R3 had attempted to go into R2's room since the incident on 12/25/23 but noted no documentation in R2 or R3's EHR to support this claim. Stated that law enforcement was not notified because R2 had the ability to call 911 herself and would have if she felt it necessary. On 01/11/24 at 04:00 PM, Administrative Staff A confirmed that she did not inform law enforcement on 12/25/23 as documented in the facility report. Stated that she did not notify local law enforcement because the resident and the resident's guardian did not want law enforcement involved. The undated facility policy Right to Consensual Sexual Activities documented that each resident has the right to a dignified existence, self-determination, and communication with persons/services inside and outside the facility and have all the rights provided to all citizens and residents of the United States of America, which includes affording all residents with privacy to engage in safe, consensual sexual expression. The policy defined sexual expression to include, but not limited to, hugs, kisses, masturbation, intimate touch, and intercourse. Further documented that sexual abuse was a non-consensual sexual contact of any type with a resident including but not limited to unwanted intimate touching of any kind especially of breasts or genitals, all types of sexual assault or battery, forced observation of masturbation and/or pornography. Further defined nonconsensual sexual contact as any resident who appears to want to contact to occur but lacks the cognitive ability to consent, or a resident who does not want the contact to occur. The facility failed to address steps for staff to take in the event of unwanted sexual contact. The undated facility Abuse, Neglect and Exploitation Policy documented that facility would prohibit and prevent abuse and that residents of the facility would remain free from abuse which may include verbal, mental, sexual, or physical abuse while residing at the facility. Documented that any staff that becomes aware of abuse should immediately report to the administrator who would report the abuse per state and federal requirements. Further, defined sexual abuse as non-consensual sexual contact of any type with a resident that included, but not limited to, unwanted intimate touching of any kind especially of the breasts or genitals and forced observation of masturbation. Additionally documented that willful abuse is defined that the individual must have acted deliberately, whether or not harm or injury was inflicted. Additionally documented that the administrator will file a report with the State Regulatory Agency immediately within 24 hours of the incident and any suspicion of abuse resulting in injury will be reported to the State Regulatory Agency within two hours and local law enforcement. Further documented that residents' sexual rights to not extend to acts which are non-consensual, acts with minors, or acts that impact negatively on the resident community as a whole through public display. Additionally documented that if there is any evidence of an incident that meets the definition of assault, battery, or other crime against a person that local law enforcement would be notified by the administrator or designee immediately. Additionally documented that if the alleged perpetrator of abuse is a facility resident, that a staff member will stay with the alleged perpetrator and wait for further instruction from administration. Further documented that all sexual assaults of a resident will be reported to local law enforcement immediately. The facility failed to provide a safe and secure living environment for the residents of the facility by the failure to provide adequate supervision and care planned interventions to prevent Resident (R)2, with a history of sexual behaviors since admission (August 2023), from sexually assaulting and harassing female residents in the facility. On 12/25/23, R2 grabbed R3's breast and masturbated in a public area, and the facility failed to place any interventions to protect R3 and other residents from R2's unwanted sexual advances/touching. R2 again on 12/25/23 masturbated in a public. On 01/02/24 R2 attempted to grab R3's breast with no interventions in place. These failures placed R3 and all other residents in immediate danger. On 01/11/24 at 05:30 PM, Administrative Staff A was provided the Immediate Jeopardy (IJ) template for failure to provide adequate supervision to prevent and care planned interventions to prevent Resident (R)2, with a history of sexual behaviors since admission (August 2023), from sexually assaulting and harassing female residents in the facility, placing them in immediate jeopardy. The facility submitted an acceptable plan for removal of the immediate jeopardy on 01/12/24 at 06:09 PM which included the following: 1. On 01/12/24 at 08:00 PM, the facility updated care plans for residents with sexually inappropriate behaviors by 01/16/24 completed for the four identified residents. 2. On 01/11/24 at 08:00 PM the facility educated staff on the policy Abuse, Neglect and Exploitation and completed 01/12/24 at 04:40 PM. 3. On 01/11/24 at 08:00 PM, the facility educated staff on the policy Sexual Consent and completed 01/12/24 at 04:40 PM 4. On 01/11/24 at 08:00 PM, the facility initiated an online training module for staff to complete on Relias with the topic of Preventing, Recognizing and Reporting Abuse and completed 01/13/24 at 03:08 AM 5. On 01/11/24 at 08:00 PM, the facility initiated an online training module for staff to complete on Relias with the topic of Abuse, Neglect and exploitation and completed 01/13/24 at 03:08 AM 6. On 01/11/24 at 08:00 PM, the facility initiated an online training module for staff to complete on Relias with the topic of Ethical Issues of Sexuality and the Older Adult and completed 01/13/24 at 03:08 AM 7. On 01/16/24 at 10:00 AM the facility initiated a process through which the Social Services Designee (SSD) would conduct resident interview questions related to abuse, neglect and exploitation 45 residents in the first week and had completed three of the 45 resident interviews on 01/16/24 at 12:05 PM with the remaining resident interviews ongoing. 8. On 01/11/24 at 08:00 PM the facility placed R2, with concerns of unwanted sexual advances under 1:1 observation until LEO investigated and resident would been assessed by Physician Extender G and/or Administrative Nurse B. Policy/procedure reviewed on 01/16/24 at 11:56 AM with Administrative Staff A. 9. On 12/22/23 at 05:00 AM the facility instructed staff to redirect/intervene/distract/encourage self-soothing activities in the privacy of R1's room and is an ongoing intervention. 10. On 01/12/24 at 08:00 PM, the facility instructed all staff instructed to maintain visual contact with R2 when out of his room and updated on care plan with this intervention. 11. On 01/12/24 at 05:51 PM, the facility placed a door alarm on R2's door to alert staff when R2 left his room and will be maintained for minimum of 30 days and reviewed at next QAPI meeting. 12. On 01/02/24 (at unknown time) R2 was seen by psychological provider for medication follow up and will be seen on an as needed basis until the 30 day review period, this included medication changes with Lithium (an antipsychotic medication) increased to 600 milligrams (mg) orally (PO) twice daily related to schizophrenia and started on trazodone (an antidepressant medication that is sometimes used to help with sleep) 100 mg po every night at bedtime related to insomnia. The surveyor verified the facility implemented the above corrective measures on-site during on 01/16/24 at 12:05 PM. The deficient practice remained at a scope and severity level of a E, following the implementation of the removal plan.

The facility reported a census of 45 residents, with one resident sampled for elopement (an incident in which a cognitively impaired resident with poor or impaired decision-making ability/safety awareness leaves the facility without the knowledge of staff). The facility identified six residents at risk for elopement. Based on observation, interview, and record review, the facility failed to provide adequate supervision, identify likely avenues of exit (including windows), and failed to ensure the windows were secured after Resident (R)1 broke the window out in his room, to prevent elopement. On 01/05/24, R1, who suffers from delusions/hallucinations and wandering, broke the window out in his room and reported he was scared and wanted to leave. Certified Nurse Aid (CNA) D did not provide the supervision of R1, as directed by Licensed Nurse (LN) C. At 08:00 PM, unsupervised R1 went to his room unaccompanied. At 08:01 PM, R1 climbed through the known broken window and eloped from the facility and injured his leg. The staff did not realize R1 was gone until 08:02 PM. At 08:16 PM the facility called local law enforcement to report R1 missing. At 08:39 PM the resident returned to the facility with law enforcement and the left leg wounds were discovered then. R1 required 13 stitches to his left leg. This deficient practice placed R1 in immediate jeopardy. Findings included: - The Electronic Health Record (EHR) documented that R1 had diagnoses which included unspecified schizophrenia (a psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), cannabis (marijuana) abuse and insomnia (inability to sleep). The 03/01/23 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R1 had hallucinations (sensing things while awake that appear to be real, but the mind created). R1 had no behaviors directed towards self or others during the seven-day look-back period and was independent for all cares. The resident took an antipsychotic (a class of medications used to treat psychosis and other mental emotional conditions) daily during the seven-day look-back period. The 12/02/23 Quarterly MDS documented a BIMS of 13 which indicated intact cognition. The resident had hallucinations and delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue). The resident had other behavioral symptoms not directed at others one-to-three days and wandered four-to-six days in the look back period. R1 received antipsychotic medication during the assessment look-back period. The Care Plan documented the following: On 10/14/20, staff were to assess the resident for fall risk. On 10/14/20, staff were to identify patterns of wandering and to intervene as appropriate. On 10/14/20, staff were to place a WanderGuard (a bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) on R1's right ankle. On 03/04/21, staff were to monitor the resident's location several times a day and document wandering behavior. The Wandering Risk Scale assessments revealed a low risk on 08/24/22, 11/24/22, 02/24/23, 05/25/23, 05/25/23 and 11/27/23. The Progress Notes documented the following: From 12/19/23 to 01/01/24 R1 displayed nine episodes where he had wandering behaviors and/or paced near the main entrance with and without talking to himself. On 01/02/24 at 12:12 PM, R1 requested to speak to a representative from pastoral services. On 01/03/24 at 02:48 AM, R1 displayed wandering behavior, talked to himself and occasionally yelled out. On 01/05/24 at 07:30 PM, R1 self-reported to CNA D he broke out the window in his room, and he expressed fear and his desire to leave the facility. CNA D reported the incident to LN C and LN C instructed R1 to stay out of his room. The EHR lacked documentation of any injury. R1 self-reported the incident to local law enforcement officers (LEO) who responded to the facility at approximately 07:50 PM. On 01/05/24 at 08:04 PM, staff were engaged with two different residents causing two different crisis events and R1 was not observed in the lounge area where he had been previously. Staff initiated a search of the facility and upon searching R1's room, staff noticed footprints in the snow on the ground outside R1's broken window. The footprints led to a six-foot wooden privacy fence on the south end of the courtyard. Staff then initiated a resident rollcall which revealed that R1 was missing and staff called 911 to notify LEO of the elopement. On 01/05/24 at 08:30 PM, R1 was brought back to the facility by LEO. There was snow on the ground and the resident wore a coat, shoes, socks and appropriate winter clothing. A skin assessment completed upon R1's return to the facility, identified lacerations (wounds to the skin) and were documented on the front and the back of R1's lower left leg. LN C cleansed the wounds and covered the wounds with a dry dressing. Documentation revealed the lacerations required sutures. On 01/05/24 at 09:40 PM, staff sent R1 to the Emergency Department (ED) in the facility-owned vehicle with staff assistance for treatment of injuries sustained during the elopement from the facility. On 01/06/24 at 02:24 AM, R1 returned from the ED where he received 13 sutures to his wounds with instructions to keep the sutures clean and dry and monitor wounds for signs of infection. Further documented that R1 was placed on 1:1 observation with a staff member. On 01/06/24 at 10:11 PM, R1 approached staff holding a hospital identification bracelet and asked when he had gone to the hospital. R1 had no memory of the events of the elopement on the previous day. Review of the facility investigation and video recordings revealed the following: On 01/05/24 at approximately 07:30 PM, R1 informed CNA D that he had kicked out the window in his room. CNA D then notified LN C who instructed CNA D to maintain visual contact with R1 and instructed R1 to stay out of his room. On 01/05/24 on 08:00:16 PM, via video recording timestamp, CNA C left R1 unattended in the common's area. On 01/05/24 at 08:00:38 PM, via video recording timestamp, R1 got up from the common area and walked calmly down the hall to his room. On 01/05/24 at 08:01 PM, via video recording timestamp, R1 exited the building through the broken window in his room and ran to the six-foot wooden privacy fence on the south edge of the courtyard. On 01/05/24 at 08:02 PM via video recording timestamp, R1 observed going over the six-foot wooden privacy fence on the south edge of the courtyard. Review of weather data for the facility area from Weather Underground (www.wunderground.com) on 01/05/24 at approximately 07:00 PM (approximately one hour prior to the elopement) was 33 degrees Fahrenheit (?) with winds 3-5 miles per hour (mph) out of the North-North-West (NNW), sunset was at 05:25 PM (approximately two and a half hours before the elopement) with approximately one inch of snow on the ground from snowfall earlier that day. Observation of the area around the facility revealed a highway with heavy traffic including semi-trucks and speed limit of 55 mph approximately 2100 feet (approximately one-third mile) to the north. On 01/10/24 at 12:29 PM, CNA H was unavailable for comment in the investigation. Review of facility investigation witness statements revealed that the investigation lacked a witness statement from CNA H. On 01/10/24 at 12:31 PM, Certified Medication Aide (CMA) I was unavailable for comment in the investigation. Review of facility investigation witness statement revealed that CMA I was passing medications at the time of the elopement and assisted with the rollcall of residents and subsequent search for R1 who was missing. The witness statement documented that after R1 was returned to the facility by LEO that CMA I performed 1:1 observation until the completion of her shift. On 01/10/24 at 12:40 PM, Administrative Nurse B revealed that approximately 15 minutes before the incident where R1 broke the window in his room, he seemed like his usual self. After R1 broke his window but before he eloped from the facility, staff reported to the provider (Physician Extender G) and Administrative Nurse B that R1 displayed psychotic behaviors and Physician Extender G ordered a one-time dose of Haldol (haloperidol - an antipsychotic) 5 milligrams (mg) by mouth (PO) for one dose, Ativan (lorazepam - a benzodiazepine - a class of medication used to treat anxiety, insomnia and temporary situational stress) 2mg, PO for one dose, and Zyprexa (olanzapine - an antipsychotic) 15mg PO for one dose. Since Law Enforcement F was in the facility because he had responded to the facility for the broken window Law Enforcement F helped staff persuade resident to take the medication. After R1 had kicked out his window, staff removed R1 and his roommate from their room and LN C directed them to stay out of their room. LN C also directed CNA D to stay with R1. Administrative Nurse B stated that per video footage CNA D was observed following R1 up and down the hallway due to R1's pacing. Further stated that at the time of the elopement there were two other residents having two individual crises and confirmed that CNA D left R1 unattended to respond to another crisis elsewhere in the facility. On 01/05/24 at around 08:02 PM, per video footage, staff noticed that someone was missing and called Administrative Nurse B who directed staff to perform a roll-call census of all residents. Staff then noticed the footprints in the snow leading from R1's room to the six-foot wooden privacy fence on the south edge of the courtyard. Additionally stated that upon the R1's return to the facility with LEO, R1 had blood on R1's pant leg and injuries of unknown origin were discovered on R1's left leg. Administrative Nurse B stated that the LN sent R1 to the ED for treatment of his wounds. Administrative Nurse B also stated that all residents get a WanderGuard on admission for the first 30 days and the WanderGuard is removed if the residents are not at risk for elopement. Further stated that R1 had not been at risk for elopement since admission. On 01/10/24 at 01:00 PM, Physician Extender G revealed she was also the owner of the facility and supplied video footage of the incident to establish the timeline of the elopement. Physician Extender G revealed at the time of the elopement R1 was not an elopement risk but was having a psychotic episode (a period in which an individual behaves in a confusing and unpredictable way, may harm themselves or become threatening or violent towards others, and may be experiencing hallucinations and/or delusions). On 01/10/24 at 01:23 PM, CNA D revealed on 01/05/24 at approximately 07:30 PM, she was walking another resident when R1 stopped her in the hallway and reported he had broken the window out in his room and R1 stated he was scared for his life/safety but would not let staff assess him for wounds. CNA D stated she immediately reported the broken window to LN C who removed R1 and his roommate from their room and told them to stay in the common area. CNA D stated that LN C directed her to perform 1:1 observation of R1. CNA D stated that she was performing 1:1 observation of R1 at a distance. CNA D confirmed that she failed to maintain visual contact with R1 when another disturbance in the facility erupted. CNA D stated that when she returned to where R1 had been seated that he had gone. CNA D reported this to LN C who ordered a rollcall of all residents. CNA D revealed that when she searched R1's room she observed the footprints in the snow and notified LN C. On 01/10/24 at 01:29 PM, LN C revealed that prior to the incident where R1 broke out the window in his room, R1 appeared to be normal for him. When R1 broke out the window, he told CNA D who reported it to LN C. LN C then directed CNA D to stay with R1 and initiate 1:1 observation. R1 was ambulating with a limp and allowed LN C to assess him for injuries and none were found. LN C revealed that around the same time as the assessment of R1 that two different residents were having two different crises and LN C confirmed that she left CNA D with R1 with instructions to CNA D to perform 1:1 observation to go assess the other situations in progress elsewhere in the facility. LN C stated that an unknown time later, CNA D reported that the resident was not able to be found and that there were footprints outside the broken window. LN C stated that she then notified Administrative Nurse B and LEO. LN C stated that she then performed a rollcall of all residents and R1 was not accounted for. The LEO were able to locate him and bring him back. LN C stated that upon R1's return to the facility he was limping, and there was blood on his pants and left leg. LN C then performed a skin assessment and discovered a quarter-sized wound on the front of his left leg with adipose (subcutaneous [below the skin] fat) exposed and two one-to-two-inch wounds on the back of his leg with adipose tissue exposed. LN C stated that she cleaned and placed dry dressings on his wounds, then sent him to the local ED for evaluation and treatment of his wounds. When R1 returned from the hospital, LN C placed R1 back on 1:1 observation and a CNA was to be with him at all times. On 01/10/24 at 02:31 PM, Law Enforcement F revealed that 911 dispatch received the call regarding R1's elopement on 01/05/24 at 08:16 PM (15 minutes after the resident left the facility) and R1 was located by LEO on 01/05/24 at 08:27 PM (26 minutes after the resident left the facility) and that R1 was returned to the facility by facility staff in facility vehicle on 01/05/24 at 08:39 PM (38 minutes after the resident left the facility). Law Enforcement F revealed that the area where R1 was found was approximately 2800 feet (approximately one-half mile) from the facility and approximately 400 feet from a highway with heavy traffic including semi-trucks and speed limit of 55 miles per hour (mph). Law Enforcement F revealed that in his contact with the resident, when R1 was located, he did not appear to be acting or behaving abnormally. On 01/11/24 at 04:00 PM, Administrative Nurse B revealed the WanderGuard for R1 was removed on 11/14/20 after R1 was assessed for elopement and deemed to not be an elopement risk. The facility's undated Accident Prevention policy documented that all staff members of the facility will ensure that the environment remains as free from accident hazards as possible and will receive adequate supervision to prevent accidents. The facility's undated Elopement Policy, documented that the facility wishes to ensure the safety of residents identified as being a risk for elopement and to take precautions to ensure safety and well-being. Upon discovering an unaccountable absence of a resident by a staff member they will inform the nurse, record the time that the resident was discovered missing and where last seen. The nurse will contact law enforcement, perform a resident roll call and direct other staff to search the facility and grounds. The facility failed to provide adequate supervision, identify likely avenues of exit, including windows, and failed to ensure the windows were secured after R1 broke the window out in his room, to prevent elopement when CNA D did not provide the supervision of R1, as directed by LN C. At 08:00 PM, unsupervised R1 went to his room. At 08:01 PM R1 climbed through the known broken window and eloped from the facility and injured his leg. This deficient practice placed R1 in immediate jeopardy. On 01/10/24 at 05:07 PM, Administrative Staff A was provided the Immediate Jeopardy (IJ) Template for failure to provide adequate supervision to prevent elopement. The facility provided an acceptable plan for removal of the IJ on 01/11/24 at 02:33 PM and the following corrective measures were verified by the surveyor on-site during the investigation on 01/16/24 at 12:05 PM: 1. R1 was placed on 1:1 upon return to facility from the ED after receiving sutures and will remain on 1:1 until deemed stable by Physician Extender G. 2. Plywood sheeting placed over broken window 01/05/24 at 08:39 PM. 3. A contractor was contacted by the facility about a permanent window replacement. The contractor responded on 01/11/24 at 12:56 PM and documents reveal that there is no set date for repair, but facility is placed on waiting list for repairs to be completed as soon as practical. 4. Staff education related to the elopement policy was initiated on 01/08/24 at 08:00 AM and completed on 01/11/24 at 02:06 PM 5. Computer learning module titled Understanding Wandering and Elopement was initiated on 01/10/24 at 06:00 PM and completed on 01/11/24 at 11:26 AM The surveyor verified the facility implemented the corrective actions to remove the immediacy, while onsite on 01/16/24 at 12:05 PM. The deficient practice remained at a scope and severity of G after removal of the jeopardy.

The facility reported a census of 45 residents with 13 selected for review, which included one resident reviewed for elopement. Based on observation, interview, and record review, the facility failed to prevent an elopement when the Resident (R)5 exited the facility unsupervised, through an employee exit on 12/30/22 at 07:52 PM, and remained outside of the building without staff knowledge for 16 minutes. When R5 exited the facility, the door alarmed and Certified Nurse Aide (CNA) M, looked outside of the door, but did not see the resident and shut the sounding alarm off. CNA M failed to notify any other staff members of the alarm sounding. The facility failed to immediately initiate a head count of the residents until the resident returned unaccompanied to the facility front door and knocked. While out of the facility unsupervised, the resident crossed the street, walked into a barbed wire fence, sustained scratches to the legs, and required a tetanus vaccine (a vaccine for a bacterium that enters the bloodstream from a wound on the skin from contaminated objects, which may cause serious muscle problems such as lockjaw). The facility failure to determine who went out the exit door when the alarm sounded placed this resident in immediate jeopardy. Findings included: - Review of Resident (R)5's Physician Order Sheet, dated 05/26/23, revealed diagnoses included schizoaffective disorder (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), bipolar disease (major mental illness that caused people to have episodes of severe high and low moods), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), restlessness, and agitation. The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident with normal cognitive status and no behaviors or wandering. The resident was independent with activities of daily living. The Activity of Daily Living [ADL] Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 05/22/22, assessed the resident required reminders and cueing for completion of self-care. The Quarterly MDS, dated [DATE], assessed the resident with normal cognitive function and no behaviors or wandering. The Care Plan, dated 10/22/22, instructed staff to complete a wandering assessment every 30 days. Staff were to monitor the location several times a day and document wandering behaviors. Staff were to attempt diversional interventions located in the behavior log. The care plan indicated the resident had a moderate elopement risk. The Wander Risk Scale assessment scores (0-8 low risk, 9-10 at risk, and 11 and greater at high risk) were noted as follows: On 11/01/22 staff assessed the resident with a score of 6 (low risk). On 12/05/22 staff assessed the resident with a score of 3 (low risk). On 12/31/22 staff assessed the resident with a score of 4 (low risk). A Nurse Progress Note, dated 12/30/22 at 09:20PM, documented the resident eloped from the facility and walked into a fence resulting in several scratches on her right lower leg. A Nurse Progress Note, dated 12/31/22 at 02:02AM, documented the scratches as 5 centimeters (cm), 17.5 cm and 5.5 cm with no depth to the scratches. Nursing staff cleansed the areas with wound cleanser and applied antibiotic ointment and applied a small sterile dressing to the 5.5 cm scratch. Interview on 06/13/23 at 08:13 AM, with R5 revealed the resident needed to get fresh air at times as a coping mechanism for anxiety and did remember exiting the building several months ago by pushing on the exit door by the laundry room, which set the alarm off. R5 did not ask staff to accompany them outside and began walking by themselves, crossed the street and went over a barbed wire fence, which caused cuts on their legs. The resident explained the decision to return to the facility and knocked on the front door to signal staff to let them back inside of the building. Interview on 06/13/23 at 11:02 AM, with Previous Administrative Staff B, stated the resident was not considered at high risk for elopement when the resident left the building unattended in December 2022. Previous Administrative Staff B explained the resident returned to the facility on their own after approximately 15 minutes. All staff were in-serviced and completed education on elopement, but Previous Administrative Staff B was not sure of the date of completion for the education. Interview on 06/13/23 at 11:10 AM, with Licensed Nurse (LN) R, revealed the resident did not currently have wandering behaviors, but did several months ago when R5 walked out of the facility, across the street, and fell into a barbed wire fence. Interview on 06/13/23 at 03:00PM, with Certified Medication Aide (CMA) S, revealed she worked in the kitchen the night R5 set off the alarm and exited the building unsupervised. CMA S stated another staff member shut off the alarm. CMA S stated staff should look for the person that set off the alarm, if not found, notify the charge nurse to do a head count of the residents to determine who was missing. Interview on 06/13/23 at 03:30 PM, with Administrative Nurse E, confirmed R5 left the building without staff knowledge by pushing on the exit door by the laundry and setting off the alarm on 12/30/22. Administrative Nurse E stated previous Certified Nurse Aide (CNA) M, shut off the alarm without looking around the building for the person who set off the alarm and did not notify the charge nurse of the elopement until approximately 16 minutes later when the resident returned to the facility and knocked on the front door for staff to let them back into the facility. Administrative Nurse E stated she thought the resident tried to follow a cat and walked across the street and over a fence and obtained scratches on her legs, which required cleansing, antibiotic ointment, and a tetanus vaccine. Administrative Nurse E stated she expected staff to look beyond the door and around the building when the exit door alarm sounded. She expected staff to notify the charge nurse immediately, perform a head count, and begin searching for the missing resident. She confirmed CNA M shut off the alarm without a thorough search and did not notify the charge nurse. Interview on 06/14/23 at 06:50 AM, with LN H, confirmed the elopement incident took place on 12/30/22 at approximately 09:00 PM. LN H further explained CNA M shut the exit door alarm off without looking past the door for the resident and did not notify her that he did not find the resident. LN H stated the resident exited the building by pushing on the exit door by the laundry because R5 wanted fresh air then, once outside, followed a cat across the street and over a barbed wire fence. LN H stated the resident was gone approximately 15 minutes before she returned to the facility on her own and sustained scratches on her legs from the fence. LN H stated upon return she placed a Wander Guard (a device that sounds to alert staff when resident approached an exit door) device on the resident's wrist. The undated facility policy titled Elopement, , instructed staff that under no circumstance will a door alarm be de-activated until the source of the activation has been determined. The nurses should immediately perform census verification and resident roll call to determine if there are any other missing residents. The facility failed to ensure R5 remained free of accidents when the resident exited the building, which activated the alarm system and staff failed to determine who exited the facility and shut off the alarm. The staff went on without searching for the resident and initiating elopement protocol. The resident who was injured after walking into barbed wire fence, returned to the facility after 16 minutes and knocked on the front door to notify staff they were back. These failures placed the resident identified as at risk for elopement in immediate jeopardy. The facility identified and implemented the following corrective actions beginning on 12/31/22 at 03:00 PM: 1. LN H performed a resident head count on 12/30/22 when notified of the resident return to the facility. LN H performed a skin assessment, treatment to scratches sustained, and education to the resident regarding leaving the building without supervision. The physician was notified of the elopement and injury to the resident with instruction given to LN H to obtain a tetanus vaccine as soon as possible (administered on 01/02/23.) 2. On 12/31/22 staff moved the resident to a room closer to the nurses' station. 3. On 01/02/23 Staff updated the resident's Care Plan to included moderate elopement risk and a wander guard was placed on the resident 4. On 01/06/23 all staff education and competency testing on the facility's Elopement Policy begun. 5. On 01/31/23 at 03:00PM last staff member completed the education and competency. During the survey on 06/14/23 the surveyors validated the completion date of the above items as of 01/31/23 at 03:00 PM, which deemed the deficient practice as past non-compliance.

The facility census totaled 44 residents (R). Based on observation, interview, and record review the facility failed to keep the facility heating unit in working condition to ensure comfortable and safe temperature levels in the facility of greater than 71 degrees Fahrenheit (F) for all 44 residents in the facility. On the evening of 10/31/21 the heating unit malfunctioned. After some repairs were made on the morning of 11/01/21, the heating unit malfunctioned again at approximately 08:00 PM. Upon surveyor observations on 11/02/21 at 05:00 PM all 44 resident rooms measured below 70 degrees F with resident wearing full clothing and shoes, while in bed to stay warm, with no mitigating factors implemented by the facility to prevent the drop in temperature. The facility did not have enough blankets to ensure all residents were kept warm and comfortable, leading to a risk of hypothermia, with outside temperatures around 38-40 degrees F, and no supplemental heating initiated by the facility. The failure to keep the environment in the facility at a safe and comfortable temperature placed all residents in the facility at risk for hypothermia and constituted immediate jeopardy. Findings included: - Observation upon entrance on 11/02/21 at 05:03 PM revealed most residents were in the commons room area, with the couches near the front doors of the building, where the wall heaters were working. Most of the residents wore coats and/or extra layers of clothing. The temperature in the building hallways and room felt cooler. There were indoor/outdoor type thermometers hanging from a nail on the walls in the hallways, above eye level. The thermometer near Administrative Nurse D's office read 70 degrees F, the Men's hall thermometer read 70 degrees F, but the Women's hall and the short hall thermometers read 68 degrees F. The resident rooms did not have thermometers placed in them, but the resident rooms cooler in temperature than the hallways. The kitchen doors were open and blower units blew the air from the kitchen towards resident rooms in the short hall. Observation of the laundry room on 11/02/21 at 06:48 PM revealed four clean facility blankets and 17 dirty facility blankets that needed to be laundered. Subsequent observation of the resident rooms revealed most resident beds only had one blanket, and the ones which had two or more blankets were the residents' own throws and blankets, and not facility blankets. Observation of R1 on 11/02/21 at 07:38 PM revealed she walked down the Women's hall in her bare feet with her pants pulled down to cover her feet, walking on her pants. When the surveyor asked if she was cold, she stated yes, I do not have any clean socks and my feet are freezing. R1 revealed the top of her foot and her skin appeared white and pale. Observation of R2 on 11/02/21 at 07:39 PM revealed he paced in his room (the farthest room down the Men's hall) with the room door open. He wore shoes, long sleeved clothing, and a coat. R2 stated it was too cold to sleep, and the facility had not told him, or anyone, what they would do for the night if the heat could not be fixed. His fingers were tucked in his coat, he told the surveyor to feel his fingers, and they were very cold to touch and pale in color. Observation of resident room ambient air temperatures on 11/02/21 between 06:45 PM and 06:55 PM revealed temperatures ranged from 58.8 degrees F to 67.4 degrees F and between 08:00 PM and 08:19 PM temperatures ranged from 58.6 degrees F to 67.2 degrees F (about an hour later). The hallway shower rooms and activity room revealed temperatures between 61.1 degrees F and 69.9 degrees F. Request on 11/02/21 for the facility's Heating Unit Maintenance Logs documentation from 01/01/21 through 11/02/21 revealed the facility did not have a log for the heating unit maintenance and verified no such documentation existed. The Heating Company Invoices revealed on 07/06/21, the facility received an estimate on a new heating/cooling pump and expected six weeks for delivery. The facility ordered the new pump on 07/28/21. The next day, on 07/29/21, the heating/cooling system was not working properly, and the technician came out and restarted the unit. Then on 09/02/21 the heating/cooling system was down again, and a technician fixed the issue. On 09/29/21 the heating/cooling system had to be reset and on 09/30/21 the facility received an estimate for a replacement part. No other invoices were provided by the facility. The 11/02/21 at 06:03 PM Receipt for blankets purchased revealed the facility purchased 52 blankets at a local store. Observation of the blankets purchased revealed soft fleece, lightweight, twin size blankets. Interview with residents on 11/02/21 between 06:46 PM and 08:00 PM revealed: R6 stated it was not cold as long as he kept his shoes, coat & hat on. R2, R10, R15, and R16 stated that their rooms were freezing and the facility had not given them any extra blankets. R3 stated that the heaters were working yesterday for a while, but it had been cold in his room all day today, and he had to wear his shoes and a jacket with a blanket wrapped around him to stay warm in bed because he could not sleep if the temperature in his room was below 60 degrees F. Interview with Certified Medication Aide (CMA) G on 11/02/21 at 05:08 PM revealed she worked until 10:00 PM the previous night in the facility and the temperature in the building felt normal. Then, when she arrived for her shift today, it was cooler, but the facility had supplies. Interview with Certified Nurse Aide (CNA) F on 11/02/21 at 05:13 PM revealed when she arrived for her shift today, it was cooler but not too cold. The staff encouraged residents to keep their blinds shut and turn off all units to preserve as much heat as they could. She stated, we have a lot of blankets. Residents have one to two blankets on their beds along with personal blankets there were maybe three residents complaining of the cold temperatures in the facility. Interview Administrative Nurse B with on 11/02/21 at 05:53 PM revealed the heating system had not been a problem until it started getting cold on Sunday night 10/31/21. The facility had a heating company come and fixed the issue on 11/01/21, but at about 08:00 PM staff noticed the heaters in the resident rooms and offices were blowing cold air. Maintenance staff could not get the heating system working, so the facility called the heating unit company again this morning (11/02/21). She stated, the facility had 90 blankets, and [Administrative Staff D] was out currently purchasing more blankets, so the facility should have another 90 blankets by tonight. The heat stopped working yesterday (11/01/21) at 07:47 PM, and the facility staff logged hallway temperatures starting on Monday morning, twice a day, down each hall. The kitchen and activity rooms were on a different heating unit, so the heat in those rooms were turned up and we used fans to distribute the heat. When asked about only four clean blankets in the laundry room, Administrative Nurse B stated that there were also 17 dirty blankets available, once laundered. The residents could leave their doors open to filter warm air into the rooms as well. She further stated the residents had to sleep in their rooms, but if the temperature goes below 40 degrees in the facility, staff would inquire about getting a motel that could handle 22 rooms for residents until the heating was fixed in the morning. Administrative Staff D further stated, if the temperature in the building was below 50 degrees they would move the residents, whatever the temperature regulation says we should do. The facility had ordered parts for the heating system in July 2021. The facility ordered these parts because it was known that the heating system needed to be changed, but it was not anticipated that the delivery would take so long. The facility did not keep a maintenance log for the heating system, they knew the parts were needed. Administrative Staff A consulted Fire Marshall H when the issue started and stated he told them to try other heating unit companies to come to fix the heating system, since companies in bigger areas may have different parts or to rent a mobile heating system, or an electric pump to heat the facility. The facility had not contacted or utilized other outside heating resources, other than the 52 purchased blankets, and on 11/03/21 at 08:38 AM, 23 of the 52 blankets purchased were still in their original packaging, unwrapped and located in the Director of Nursing's office. Observation of resident room temperatures on 11/03/21 between 06:00 AM and 06:48 AM revealed resident room temperatures between 55.4 degrees F and 64.4 degrees F. Observation on 11/03/21 at 09:33 AM revealed residents were still bundled up in coats, some with blankets wrapped around them, walking the hallways. Most of the resident room doors were open, and some residents remained in bed bundled in blankets. Interview with residents on 11/03/21 between 06:08 AM and 02:00 PM revealed the following: R5 stated last night was cold, [she] had to stay fully dressed and awake. She stated she was very upset about the cold temperatures in the facility and would refuse care soon. R3 had a temporal (forehead) temperature of 95.5 degrees F and R19's temperature was 93.7 degrees F. R19 stated it was kind of cold. R19 was lying in bed with a large comforter covering him. R9 had a temporal temperature noted as 96.4 degrees F and R14's temperature was 96.0 degrees F. R16 and R15 were both lying in bed, bundled in blankets. R16's temporal temperature was 95.9 degrees F and R15's temperature was 96.0 degrees F. R2 was not in his room. He was found in a commons area (ambient temperature was 68.7 degrees F), seated on couches with R1, R20, and R21. All wore layers of clothing or a coat. R7 and R8 were both bundled in blankets in bed, R7 temperature was 92.6 degrees F and R8 temperature was 96.6 degrees. R18 stated it was pretty cold last night, she had on two blankets. R11's temporal temperature was 94.6 degrees F and R10's temperature was 96.5 degrees F. R10 stated it was chilly last night, yeah, then covered his head with the blanket. R12's temporal temperature was 96.2 degrees F while wrapped up in his blankets and stated, it was cold last night. R13's temporal temperature was 96.6 degrees F, covered with a blanket and had on a hat. R1's temperature was 96.0 degrees F and she stated, it was not too bad last night, but definitely cold. R17's temporal temperature was 96.2 degrees F with a blanket covering him and a blanket under him while lying in bed. [of note, all resident temperatures were recorded by facility staff] Observation of resident room temperatures and hallway temperatures on 11/03/21 from 02:00 PM to 02:30 PM once the heating was working revealed temperatures ranging from 60.9 degrees F to 84.2 degrees F, depending on the area and resident preference. The Hallway Hourly Temperature Check logs started on 11/02/21 at 05:00 PM to 11/03/21 at 09:00 AM logs revealed temperatures in all hallways between 59.9 degrees F and 75 degrees F depending on the area. The Resident Room Temperature logs started on 11/02/21 at 07:00 PM to 11/03/21 at 08:00 AM revealed temperatures in resident rooms ranged between 54.1 degrees F and 69.2 degrees F with temperatures reaching 70.1 degrees F on 11/02/21 at 11:00 PM and 11/03/21 at 05:00 AM in some resident rooms. Interview with CNA I on 11/03/21 at 07:18 AM revealed some of the resident rooms were really cold. She arrived for her shift at about 06:30 AM, and it was cold in the facility, then stated I could not have slept here last night, and most residents were bundled up if they were in bed, in their rooms, or out in the hallways. She continued, down the Men's hall, R2 and R4's room was really cold, and all R4 had on his bed was a top sheet and bedspread which was really thin, so she got him another blanket this morning. Interview with CMA J on 11/03/21 at 07:26 AM revealed she arrived for her shift at 05:55 AM, and when she first walked in the facility it felt ok, but going down the hallways further away from the main area where the exit doors were, was really cold. No residents complained to her about last night. Staff obtained hourly resident room temperatures and obtained temperatures on residents if they were not feeling well, but obtained vital signs every shift. She did not know if the facility had any emergency heating equipment but knew there were extra blankets now. She stated, last night before the extra blankets were bought, the facility had about 35 total facility blankets, and about ten residents had more than one personal blanket in their room. Interview with Administrative Staff D and Maintenance/Administrative Staff E on 11/03/21 at 07:52 AM revealed the facility did not complete maintenance logs for the heating/cooling system. Parts were ordered for the two pumps that made the system that pump water inside the building through coils to heat/cool the building. They were not sure if the facility had any emergency heating equipment. In July 2021 the facility obtained an estimate on two new pumps that were supposed to arrive six weeks after ordering. One pump arrived a few weeks ago and the facility installed the pump. The heating unit for the system was on the northwest side of the building, and the areas further away from the unit were colder. Last week the electrician came to the facility to ensure all the electrical components were working, and then on 11/01/21, the heating company came out to ensure the heating system pumps ran properly. Later that night the pumps stopped, and on the morning of 11/02/21, the heating company came back out to find out why the pumps stopped. They found that the pumps blew the fuses, so those were replaced. The heating company arrived at 07:30 AM this morning and reported the new pump motor that was just installed went out, so they used a part from the other pump to replace the part on the new pump, and the facility would have heat today. Interview with Heating Technician K on 11/03/21 at 02:19 PM revealed last winter in 2020, the facility contacted the company because they were having problems with the heating system. The company recommended the facility update the heating/cooling systems or have a different system installed around February or March 2021. As time went on, the facility had further problems with the heating/cooling system that required work. The pumps that circulated for heating/cooling the building were in disrepair, so the company gave the facility an estimate for two new pumps and also had an engineer explain how to fix the problem and update the heating/cooling system. Administrative Staff E asked the company to order two new pumps, but since the company recommended the change in systems, two pumps would not be required. A new system would have individual room units, so the company ordered one pump to get them by. After installation of the new pump and a week later, Administrative Staff E called and stated there was water spraying everywhere. When the company arrived to the facility, water was spraying from the pumps, and then fixed the problem. Administrative Staff E called the company again and stated the pump was not working, but upon evaluation was found to be working fine. Then, Administrative Staff E called the company again stating that the heating system was not working due to the pump caught on fire on the night of 11/02/21. The heating company told Administrative Staff E that the heating/cooling system had the wrong fuses and they needed an electrician. The heating company took one of the systems pumps to their shop to see why it failed. The other pump could sustain the system, as long as the pump ran, the heating system would work. When asked how long the pump could sustain the system, he stated he did not know. Technician K also spoke to Administrative Staff D last night that the pumps were only a small part of the facility's heating/cooling system problem because the whole thing needed replaced. Interview with Administrative Nurse C on 11/03/21 at 02:42 PM revealed the company that would provide alternate heat if needed is a Heating Unit Rental Company about 3 hours away, who were available 24 hours a day, seven days a week. She also stated the heating/cooling system has had problems for the last four years. Interview with Heating Unit Rental Company Representative L on 11/03/21 at 03:20 PM revealed the company loaned heating units on a case-by-case basis and were able to loan 24-hours a day. During off hours, they had representatives who answered calls to send out the rentals when needed, and from the time of the phone call to delivery at the facility, it would take the company around four hours to load the equipment and arrive at the facility. The last revised 10/01/21 Facility Assessment Tool revealed average daily census of 43-45 residents. Part 3 Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies revealed the facility provided a safe and homelike environment for residents residing in the facility. Regarding the physical environment and building/plant needs noted to list contracts, memoranda of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies. The facility would consider including a description of the facility process for overseeing emergency resource services and how the services would meet the residents' needs and regulatory, operational maintenance, and staff training requirements. The 12/2014 Operational Policy and Procedure Manual for Long-Term Care Disaster and Emergency Preparedness plan revealed that the 05/2011 Preparations for Severe Weather policy included the facility would have extra blankets and emergency heating equipment. The facility failed to maintain comfortable and safe temperature levels of greater than 71 degrees F for all 44 residents in the facility. On 11/02/21 at 09:52 PM, Administrative Nurse B, Administrative Nurse C, Administrative Staff D, and Administrative Staff E were provided with the IJ template and notified that the failure to keep the environment in the facility at a safe and comfortable temperature placed all residents in the facility at risk for hypothermia and constituted immediate jeopardy at F584. The immediate jeopardy at F584 also constituted Substandard Quality of Care at 42 CFR 483.12. The immediate jeopardy was determined to first exist on 11/02/21 when temperatures in some resident rooms were 58.6 to 64 degrees F with a low outside temperature expected to drop to 38 degrees F and no supplemental heat utilized to mitigate the environmental temperature drop. On 11/03/21 the facility provided an acceptable Removal of Immediacy Plan which revealed nursing staff were to check resident rooms/hallway temperatures hourly. Residents would be allowed to sleep/sit in the warmest room where comfortable until the heat resumed and would be assessed if they were unable to sleep due to the cold temperatures. The provider would be notified of any residents with signs of hypothermia. Extra blankets were given to residents as needed. Staff education on safety plans to be completed 11/0/421 and submitted 11/05/21 to the State Agency. If the heating system problem was not fixed by 11/03/21 at 06:00 PM, the facility had the following options for outside heat sources to include renting an outside heating system that tied into the facility system, as needed. The facility could also rent electric heaters on trailers placed outside of the building with heat tubed into locations and fans to circulate. If those options failed, then the facility would follow the disaster plan to evacuate the residents from the facility. On 11/03/21 the onsite surveyor verified the implementation of the removal plan. The deficient practice remained at an F scope and severity, following the removal of the immediate jeopardy.

The facility reported a census of 44 residents with three residents included in the sample. Based on observation, interview, and record review, the facility failed to thoroughly investigate an allegation of sexual abuse (abusive sexual behavior by one person upon another), regarding an employee towards Resident (R)1, after an allegation of sexual misconduct was reported to the facility's administration on 08/22/21. The facility failed to protect the R 1 upon knowledge of the allegation of staff to resident sexual abuse pending an investigation by allowing Licensed Nurse (LN) H to continue working. Findings included: - Review of the Resident (R)1's electronic medical record (EMR), under the Med Diag [diagnosis] tab, included the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident had delusions (belief or impression that is firmly maintained despite being contradicted by what is generally accepted as reality or rational argument) and verbal behavioral symptoms toward others on one to three days of the assessment period. He was independent with Activities of Daily Living (ADLs) and received antipsychotic (medication used to treat [CONDITION(S)]) and antianxiety (medication used to treat anxiety) medications on seven of the seven days of the look back period. The Behavioral Care Area Assessment (CAA), dated 03/31/21 triggered, but was incomplete. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of 15. He had inattention and disorganized thinking which fluctuated. He had delusions and verbal behavioral symptoms directed towards others one to three days. He was independent with ADLs and received antipsychotic and antidepressant medications (medication used to assist with symptoms of depression) on seven of the seven days of the look back period. The Care Plan for impaired cognition, dated 04/07/21, instructed staff that the resident had difficulty making decisions. The Care Plan for psychosocial well-being related to [CONDITION(S)] instructed staff that the resident had difficulties with effective coping strategies. Staff were to encourage the resident to participate in setting realistic goals. The Care Plan for activities, dated 04/11/21, instructed staff the resident was dependent on staff at times for meeting his emotional, intellectual, physical, and social needs related to hallucinations (experience involving the apparent perception of something not present) and delusions. A Documentation of Concerns, dated 09/22/21, completed by Licensed Nurse (LN) G, included the following: LN G visited with R 1 regarding an incident with the resident and LN H about allegations that LN H displayed inappropriate behaviors with the resident at the facility such as kissing on the mouth and hugging. The resident expressed to LN G that he did not like these behaviors from LN H. R1 stated LN H would supply him with tobacco and other things, but he did not appreciate being taken advantage of in that way. LN G's observation of the resident during the conversation revealed the resident appeared embarrassed and shameful while speaking. The resident appeared uncomfortable and needed help to put a stop to the behaviors by LN H. Review of the facility's Investigation of the incident by Administrative Nurse D, dated 08/27/21 included documentation which R 1 stated he did not have any issues with LN H except he did not like the nurse hugging him all of the time. The facility's Investigation of the incident by Administrative Nurse D, dated 09/01/21 revealed documentation which included Administrative Nurse D visited with LN H and told her to only do side hugs with residents. The facility advised LN G to have a second staff member with her while doing cares for the resident in his room. On 09/13/21 at 09:30 AM, R 1 rested in bed fully covered with a blanket, except for his face. R 1 stated he had a headache and did not want to visit at that time. On 09/13/21 at 11:49 AM, R 1 entered the conference room to visit about the allegations. R 1 was calm, appropriate and made eye contact through the interview. On 09/13/21 at 11:49 AM, R1 stated LN H would hug him and he would hug her back. At times LN H would kiss him on the cheek or the mouth. R1 stated he told LN H the night before that he needed the hugging and kissing to stop. R1 denied ever going out to the nurse's van at nighttime. He enjoyed the special things LN H brought to him such as chewing tobacco and special treats, but did not want LN H to get into trouble. On 09/13/21 at 10:35 AM, LN J stated she had been informed by night shift Certified Nurse Aide (CNA) M that LN H touched R1 inappropriately a couple of weeks ago. LN J was unable to recall the exact date. LN J told CNA M to notify Administrative Nurse D of the incident, which the CNA reported she did a couple of weeks ago. LN J stated she also informed Administrative Nurse D of the inappropriate touching of LN H to R1. On 09/13/21 at 11:01 AM, LN I stated CNAs N and O informed her of inappropriate sexual touching by LN H to R1 within the past month. CNAs N and O stated LN H rubbed R 1's stomach and shoulders and brought him special treats from outside of the facility. LN I stated she informed Administrative Nurse D in the past of the allegations of sexual abuse. A Witness Statement provided by the facility, dated 09/13/21 by LN K included: LN K heard staff discuss the inappropriate behaviors with LN H and R1. LN K documented she informed Administrative Nurse D about the accusations. A Witness Statement provided by the facility, dated 09/14/21 by CNA O included: R1 came to the nurse's station (date unknown) and told staff LN H tried to kiss him. LN G filed a report and gave it to Administrative Nurse D. A Witness Statement provided by the facility, dated 09/14/21 by Certified Medication Aide (CMA) R included: Approximately two weeks ago, LN H made comments to this staff member regarding R1's private parts. A Witness Statement provided by the facility, dated 09/14/21, by CNA N included: Approximately two weeks ago CNA N entered R1's room and saw LN H sitting on the side of R1's bed. R1 was lying in the bed wearing pajamas and was partially uncovered. LN H had her hand on R1's right upper thigh. When CNA N entered the room, LN H quickly removed her hand from R1's thigh. CNA N stated she talked with Administrative Nurse D regarding her concerns with LN H approximately one month ago when LN H made a couple of comments regarding R1's private parts. CNA N stated she informed Administrative Nurse D again after walking into R1's room. On 09/13/21 at 02:07 PM, CNA MM stated, she heard R 1 went to LN G upset about what LN H had done with him. Other than that, CNA MM did not know any details except the resident was upset. On 09/13/21 at 02:16 PM, CNA NN stated, she had heard about LN H going into R 1's room and touching him inappropriately. CNA NN stated she told Administrative Nurse D about what she had been told a couple of weeks ago, but Administrative Nurse D stated the staff were on a witch hunt against LN H. On 09/13/21 at 02:46 PM Administrative Nurse D stated, staff informed her of the accusations of sexual abuse towards R1 on 08/22/21, however she did not investigate the allegation until 08/29/21, seven days later, because she forgot about the allegation. LN H continued to work until being suspended on 09/13/21, for a total of 10 shifts, from 08/22/21 through 09/12/21. Administrative Nurse D stated her investigation only included speaking with R 1 about the incident. She denied speaking with any other staff regarding the allegation and denied obtaining witness statements from any of the staff members. Nurse D stated she did not feel the matter warranted a full investigation, so the nurse was not suspended and no further investigation into the allegation of sexual abuse occurred. Administrative Staff D stated she did not feel any of the residents were in danger at the facility. On 09/13/21 at 06:05 PM, LN H stated, all of the residents asked her for hugs so she would hug them. LN H stated she does not feel like she had ever been overly friendly with any resident. LN H stated she would kiss the residents on the cheek, but had never purposefully aimed for a resident's lips. The facility policy for Protection of Residents During Abuse Investigations, revised September 2012, included: Employees accused of participating in alleged abuse will be immediately suspended. Reports of resident abuse shall be promptly and thoroughly investigated by facility management. The community staff will strive to protect residents from harm during investigations of abuse allegations. The facility failed to thoroughly investigate this allegation of staff to resident abuse. The facility further failed to protect R1 from sexual abuse by LN H, who continued to work with the resident for five shifts, on five days, after the administrative staff received the first allegation of sexual abuse to the resident by the employee on 08/22/21, that placed this resident at risk for serious injury or harm in immediate jeopardy. The facility provided an acceptable plan of removal on 09/22/21 at 12:07 PM. The plan included: On 09/13/21 at 06:00 PM, the facility suspended LN H. On 09/14/21 at 03:00 PM, the facility held an education to the residents of the faclity related to how to recognize signs of abuse. Interviews with staff completed on 09/14/21 at 04:45 PM for the investigation of the alleged abuse. On 09/16/21 at 03:25 PM, nursing staff completed Relias training (on line computer training program) related to abuse, exploitation, and sexual harrassment completed. On 09/21/21, when the survey team entered the facility to validate the removal of the immediate jeopardy, the facility failed to include all staff including management, housekeeping, dietary, maintenance, laundry, etc related to the abuse, exploitation and sexual harrassment training. Relias training (All staff inservice training), with all staff related to abuse, exploitation, and sexual harrassmet completed on 09/22/21 at 12:07 PM. Any incidences of alleged inappropriate conduct by staff or allegations of abuse, neglect and exploitation wil be investigated at the time the allegation reported, and ongoing by the Quality Assurance Performance Improvement (QAPI). Relias training on Abuse and Neglect will be done quarterly. The survey team validated the removal of the immediatel jeopardy as of 09/22/21 at 12:07 PM. The deficient practice was cited at a scope and severity of a J (isolated immediate jeopardy likely to cause serious injury, harm, impairment, or death) and was lowered to the scope and severity of D (isolated no actual harm) after validation of the removal plan.

The facility reported a census of 41 residents with six residents selected for review, which included 3 residents reviewed for nutrition. Based on observation, interview and record review, the facility failed to ensure Resident (R)2 (with a weight loss of 6.53 percent (%) from 07/27/20 to 09/01/20 or 12.7 % in 48 days 07/27/20 through 09/13/20) received nutritional interventions to prevent weight loss . The facility failed to ensure the resident received timely assessments by the registered dietician. Findings included: - Review of R2's Physician order [REDACTED]. The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident with modified independence with decision making. The resident had inattention constantly present. The resident was independent with ambulation, required set up assistance with eating, and had functional limitations in range of motion in the upper and lower extremities. The resident had no dental or swallowing issues. The resident was 68 inches tall and weighed 147 pounds (lbs). The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 08/14/20, assessed the resident could make his needs known, but required patience and more time to verbalize what he needed. The resident was on a regular diet with cut meats and set up assistance. The resident remained in his room most of the time and would only come out for meals or walking in the hallway. The Baseline Care Plan, dated 07/27/20, instructed staff the resident was on a regular diet with bite sized foods. The resident was at risk for weight loss and instructed staff to serve an ice cream shake at 03:00 PM and 10:00 AM. The resident ate in the dining area. The facility failed to develop a comprehensive care plan as of 09/17/2020, with instructions for any special individualized dietary needs of the resident. The Dietary History and Initial Screening, form, dated 07/27/20, completed by the dietary manager assessed the resident ate 50-100% of meals and instructed staff to monitor for weight loss. The resident's preferences included Kool Aid, water, Mexican food, salads, peanut butter, and jelly. The resident required bite size pieces of food and was hit and miss on meals related to his anxious behavior, being up and down, and constantly moving. Review of the Resident Care Flow Record for August and September 2020, lacked indication of snack consumption for 23 days and revealed one day of consuming all three snacks in 45 days. Review of the meal percentages from August and September 2020, revealed the resident ate variable intakes of 50-100%. No laboratory data was available for review. Facility staff faxed a note to the physician, dated 09/13/20, which documented the resident's weight at the beginning of the month was 137.4 pounds and currently was 128.2 pounds. The resident constantly walked and could not sit still even when eating. Staff requested a high protein shake three times a day. The physician returned the fax with an order for [REDACTED]. Review of the resident weights in the medical record revealed the following: On 07/27/20 (admission) the resident weighed 147 pounds. On 08/03/20, he weighed 145 pounds. On 09/01/20, he weighed 137.4 pounds, with a 6.53 % weight loss (9.6 pounds) in 35 days (07/27/20 through 09/01/20) or 5.2% (7.6 pounds) in 29 days (08/3/20 to 09/01/20). On 09/13/20, he weighed 128.2 pounds, which indicated a 12.7 % (18.8 pounds) weight loss in 47 days (07/27/20 through 09/13/20), or 6.69% (9.2 pounds) in 12 days (09/01/20 to 09/13/20). From admission 07/27/20 as of 09/17/20, the medical record lacked a registered dietician assessment of the resident's nutritional needs. Observation, on 09/16/20 at 05:57 PM, revealed the resident left his room and began walking to the dining room with a shuffling gait, but returned to his room after a few steps. The resident did not engage with staff or other residents. Observation, on 09/16/20 at 06:04 PM, revealed Certified Nurse Aide (CNA) M escorted the resident to the dining room. The resident ate bite sized pieces of sweet and sour chicken, rice, apple sauce, and a glass of milk. The staff failed to provide the resident with the physician ordered protein supplement. The resident stood at the table intermittently and moved his arms about, sat back down, took a few bites and stood again. CNA M sat across from the resident at the table and provided cueing to eat. CNA M stated dietary staff gave the resident the protein supplements at snack times. Interview, on 09/16/20 at 06:30 PM, with Licensed Nurse (LN) G, revealed the resident received a nutritional supplement at bedtime from the refrigerator in the nurses' station. LN G stated the resident usually drank the supplement. Interview, on 09/17/20 at 07:30 AM, with Certified Medication Aide (CMA) R, revealed she did not pass out Ensure (supplemental drink)/or health shakes, and verified the shakes were not recorded on the resident's medication administration record. Observation, on 09/17/20 at 10:00 AM, revealed the resident seated in the dining room, with a glass of juice and a cut up banana. The resident did not have a house shake to drink. Interview, on 09/17/20 at 11:20 AM with dietary staff BB, confirmed the resident lost weight, and staff attributed it to his constant motion. Dietary staff BB stated dietary staff provided the resident with nutritional supplements at snack time, at 10:00 AM and 03:00 PM. Nursing staff should provide the bedtime supplement. Dietary staff BB stated staff should document the supplement in the Resident Care Flowsheet under the snack category, by shift. Staff do not record the amount of supplement consumed. Dietary staff BB stated there was an Electronic glitch, and the registered dietician did not assess the resident's nutritional needs until 09/17/20. Dietary staff BB stated LN H reported to the physician the resident's weight loss on 09/13/20 and implemented high protein shakes on 09/13/20. Interview, on 09/17/20 at 12:30 PM, with Administrative Nurse D, revealed staff should document the amount of supplement taken to monitor the effectiveness of the intervention to prevent further weight loss. Administrative Nurse D stated the system needed an update to include this option and currently implementing an electronic medical record monitoring system. Interview, on 09/21/20 at 11:00 AM, with consulting staff GG, revealed she assessed the resident on 09/17/20 after dietary staff BB realized the lack of registered dietician assessment of this resident on 09/17/20. Consulting staff GG stated she would expect staff to monitor the resident's intake of the nutritional supplement to determine effectiveness of the intervention to prevent further weight loss. The Weight Monitoring policy, dated 05/2017, instructed staff to ensure all residents maintain acceptable parameters of nutritional status. Staff were instructed to weigh newly admitted residents weekly for four weeks. The facility failed to assess this resident at risk for weight loss with the registered dietician in a timely manner, and failed to assess and implement consistent interventions and assess the effectiveness of the interventions to maintain this resident's weight resulting in a significant weight loss.

The facility reported a census of 40 residents with 19 selected for review, which included three residents reviewed for elopement and one resident reviewed for choking accidents . Based on observation, interview and record review, the facility failed to assess for elopement risk and develop interventions for prevention of elopement for one resident (R) 86, who climbed over a fence in an unsupervised area, and was found 37 miles from the facility placing the resident in immediate jeopardy. Furthermore, the facility failed to ensure staff monitored resident R17 during meals, as care planned, to decrease the potential for choking. Findings included: - Review of resident (R) 86's Face Sheet, revealed the resident admitted to the facility on [DATE]. The unsigned, undated Physician order [REDACTED]. The Admission Minimum Data Set (MDS), was in progress. The Baseline Care Plan, dated 08/13/20, with a review date of 08/15/20 instructed staff the resident was alert and cognitively intact, with adequate vision and hearing, independent with bed mobility, transfer, and walking, and was continent of bowel and bladder. The resident was at risk for falls due to [MEDICAL CONDITION] drug use. The care plan indicated the resident was a smoker and at risk for smoking related injury. The care plan indicated the resident had a history of [REDACTED]. The resident admitted to the facility while on parole from prison. The Elopement Assessment, dated 08/15/20 (the resident admitted to the facility 08/13/20 and completed after the elopement), assessed the resident risk score of 24 (>10 at risk) and the resident ambulated independently. Review of a Nurses Note, dated 08/13/20 at 1:00 PM, revealed the resident arrived at the facility. A Nurses Note, dated 08/13/20 at 03:40 PM, revealed the resident borrowed a cell phone to call 911. This nurses note indicated the resident's speech was unclear, and the resident thought she could leave the facility whenever she wanted to. The resident stated there was a war going on in the jail and she needed to help a friend. A Nurses Note, dated 08/13/20 at 09:35 PM, indicated the resident was anxious and frequently went outside to smoke. A Nurses Note, dated 08/15/20 at 4:38 PM, indicated at 12:00 PM, the Certified Nurse Aide (CNA) could not locate the resident. All staff (including ancillary staff - other department staff) on duty looked for the resident. Licensed Nurse (LN) H and Certified Nurse Aide (CNA) P were the only nursing personnel on duty). At 12:18 PM LN H called emergency services to report the elopement and called administrative staff. A Nurses Note, dated 08/15/20 at 01:37 PM, documented that the police called the facility to inform them the resident was found in a town 37 miles from the facility. A Nurses Note, dated 08/15/20 at 02:20 PM, documented the resident returned to the facility and staff placed a wander guard bracelet (a device that alarms when the resident enters an area around a door to alert staff of the resident's presence) on the resident. The resident had sunburn on her face, neck, and bilateral arms from the elbow down. Interview on 08/19/20 at 02:00 PM, with LN H, revealed the elopement assessment lacked completion upon admission, so she completed it on 08/15/20 after the resident eloped and the assessment indicated the resident was an elopement risk. LN H revealed she was the charge nurse and CNA P was the only other nursing staff who worked on 08/15/20 day shift. LN H revealed the resident frequently went outside to smoke. LN H stated CNA P notified her at approximately 12:00 PM that she could not find the resident. Dietary staff, housekeeping staff, and CNA P searched the facility and surrounding area. LN H notified the local police department and administrative staff of the elopement at approximately 12:15 PM. The police found the resident in a town 37 miles from the facility, and the resident returned to the facility at approximately 02:30 PM. The resident sustained [REDACTED]. LN H placed a wander guard on the resident. Interview on 08/19/20 at 02:00 PM with CNA P, revealed she completed every two hour checks of the residents, and used a flow sheet to document she saw the resident and thought the last time she saw her as 10:00 AM. CNA P stated the resident was a smoker and frequently went to the fenced yard area to smoke. Interview on 08/19/20 at 03:45 PM with Administrative Nurse E revealed he spoke to the resident on 08/14/20 and felt the resident had normal cognitive status. Administrative Nurse E stated the admitting nurse should complete an elopement assessment and then document interventions on the care plan. Interview on 08/19/20 at 05:07 PM with Administrative Staff B revealed prior to the resident's elopement, staff unlocked the door to the fenced smoking area in the morning and the residents could smoke and ambulate as they wanted within the fenced yard area. Administrative Staff B stated there were set times for smokers that needed assistance. Administrative Staff B stated the facility had cameras of the fenced area that the nursing staff could view on a monitor at the nurses' station. Administrative Staff B confirmed only two nursing staff worked on 08/15/20 at the time of the elopement. Administrative Staff B stated usually two CNAs and a Certified Medication Aide (CMA) were scheduled. Administrative Staff B stated now the door to the smoking area remained locked at all times, and staff will supervise residents during set smoking times and during recreational activities. Staff removed all moveable chairs from the area. Interview on 08/19/20 at 05:15 PM with Administrative Staff A revealed review of the camera footage revealed on 08/15/20 at approximately 09:45 AM, the resident moved a plastic chair from the picnic table area to the fence and climbed over the fence. A state trooper made contact with the resident at approximately 10:56 AM, on a gravel road (speed limit on this gravel road 55 mile per hour), but at that time the facility had not made the elopement report (the facility realized the resident was missing at 12:00 PM). Administrative Staff A confirmed the resident would have to cross railroad tracks, and a two lane highway to get to a gas station in a neighboring town (10 miles from the facility). Administrative Staff A, stated that the resident described the gas station during a post elopement interview. From this gas station the resident obtained a ride, and was next seen by video surveillance at a truck stop in another town which was approximately 16 miles from the facility. The resident paid an unknown person to drive her to Hutchinson. The police were able to identify the car in(NAME) Kansas, approximately 37 miles from the facility. Upon return to the facility, the resident was anxious and pacing. The resident sustained [REDACTED]. The resident declined screening by mental health on 08/15/20. The mental health services subsequently screened the resident and she transferred to an acute care mental health facility on 08/17/20. Interview on 08/20/20 at 11:16 AM, with Social Service X, revealed the resident was pacing, very anxious, seeking cigarettes and drugs when she spoke with her on 08/13/20. Interview, on 08/20/20 at 11:30 AM with LN G revealed she worked as charge nurse on 08/13/20 and admitted the resident to the facility. LN G stated the resident paced and was anxious. LN G stated staff should complete the elopement screen upon admission and thought if the admitting staff did not complete the screen, the next shift should complete it. LN G stated prior to the resident's elopement, residents could go out into the fenced courtyard from approximately 07:30 AM to 08:00 PM at which time staff locked the door. LN G stated the resident was an elopement risk, but she did not implement interventions. Per Wunderground.com, the weather on 08/15/20 at 10:00 AM was 85 degrees. The facility policy Safety and Supervision of Residents, revised December 2007, instructed staff to use various sources to identify risk factors for residents, including the information obtained from the medical history, physical exam, observation of the resident and the MDS. The car team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for that resident. The facility failed to assess this resident's elopement risk upon admission and failed to develop interventions for the resident's behaviors. The resident eloped from the facility traveled on foot on rural roads/fields, obtained rides from unidentified motorists, and was found 37 miles from the facility approximately four hours after leaving the facility. The facility removed the immediate jeopardy on 08/15/20 at 01:45 PM by initiating the following: Elopement assessments will be completed at admission, quarterly, and as needed on all residents. The facility will complete an elopement assessment on all current residents by 8/27/2020. The Interdisciplinary team will audit new admission elopement assessment within 24 hours of admission/readmission. The Quality Assurance Performance Improvement Committee will review compliance of the elopement assessments on a monthly basis until February 2021. On 8/15/20 at approximately 12:30 PM All admissions/readmissions will have a wander guard for at minimum 30 days. This will be on the TAR for proper placement function/monitoring by nursing staff on each shift. The wander guard system will be checked each nursing shift. On 8/15/20 at 12:30 PM The decision was made for the outdoor courtyard secured by a door that has a mag-lock that you must use a keypad to release. Staff was posted in front of the door until maintenance arrived. The job was completed at 1900 by the maintenance tech and owner. The doors are checked by staff daily to ensure proper functioning. On 8/15/2020 at 12:30 PM the decision was made that the residents will be supervised by staff when in the back courtyard during smoking and recreational activity time. The residents were informed at supper time of the implementation of supervision by staff when utilizing the courtyard to included smoking and recreational time. A sign was made and given to each resident and posted throughout the facility. On 8/15/20 at 01:15 PM - Administrator gave direction to staff that chairs that were able to be moved easily be immediately removed from the courtyard even though residents were not allowed to be in the area without supervision. All other items were of significant weight and size and could not be moved easily. At approximately 1345- Administrator verified that this was completed. On 8/15/2020 at 01:45 PM, Staff that were on duty were educated by administrator that the courtyard had to be supervised by staff when residents were present. Staff will be present for smoking breaks and activities in the outdoor space. A sign was posted at the nurses station. All oncoming staff will be educated as they report to work. The immediate jeopardy was removed, on 08/15/20 at 01:45 PM, however the deficiency remained at a scope and severity of a D. - The signed Physician order [REDACTED]. The annual Minimum Data Set (MDS), dated [DATE], documented R17 as cognitively intact and requiring supervision during eating. The Nutrition Care Plan, dated 05/01/2019, instructed staff to sit with R17 at meals. On 08/12/20 09:32 AM n the dining room, R17 held a glass with both hands. He was tremulous and had difficulty obtaining liquid from the glass. He coughed repeatedly, and liquid flew from his mouth. There were no staff in the vicinity and no staff checked on the resident. Cameras in the nurses' station viewed the area. Licensed Nurse G, in the nurses' station, talked on the telephone and sat turned away from cameras. No other staff were present. On 08/12/20 at 12:15 PM Dietary Staff BB stated someone who needs more attention should not eat alone. Dietary BB specifically identified R17 as one such resident. On 08/12/20 at 02:26 PM Certified Nurse Aide M stated R17 had trouble controlling liquid in cups and spills liquids on his shirt. Someone should be in dining when residents are eating, and usually 2 aides are in the dining room. The facility policy titled Meal Service, revised 03/09/2015, instructs residents who require assistance with feeding will not have their trays delivered until a staff member is available to assist with feeding. Further instruction indicates that the Food Service Director will perform meal rounds in the dining room daily to observe for residents needing assistance. The facility failed to provide adequate supervision during meals as planned to monitor for potential aspiration and/or choking for this resident.

The facility reported a census of 32 residents, with 3 reviewed for elopement. Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent one Resident (R1) from leaving the facility without staff knowledge. The resident exited through a locked door, walked north crossing a busy highway (speed limit of 55 miles per hour), and walked approximately 3 and 1/2 miles from the facility. A community member noted R1 lying face down in a ditch and called local law enforcement and EMS (emergency medical service) for assistance. This placed R1 in immediate jeopardy. Findings included: - The facility Face Sheet evidenced the facility readmitted R1 on 09/10/19 following a psychiatric hospital discharge, with [DIAGNOSES REDACTED]. Review of the resident's quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score 10/15 which indicated moderately impaired cognition and was independent with ambulation . The Care Plan, dated 12/17/2019, documented the resident as independent with walking and all activities of daily living. The 03/19/2020, Elopement Risk Screening identified the resident at low risk for elopement due to [DIAGNOSES REDACTED]. Staff and resident interviews, revealed the resident was last seen in his room on 05/17/2020 at 07:35 AM as follows: Certified Nurse Aide (CNA) C, on 05/19/2020 at 10:40 AM, verified she talked with the resident in his room at 07:35 AM. Then at 08:30 AM, she noted he did not eat his breakfast, served in his room due to Covid -19 social distancing. She reported she did not find him in his room or bathroom. She then checked the TV area and the men's hall bathroom and could not locate him. Then she notified Licensed Nurse (LN) B and they began a facility search. At 08:40 AM, EMS (emergency medical service) staff called and notified the facility staff a community member found the resident. They returned the resident to the facility, at 08:57AM . Per the Facility Investigation, dated 05/17/2020, the facility immediately implemented a one on one supervised intervention upon his return. Staff evaluated all door alarms and found them to be in working order. The resident told Administrative Staff A he pushed on the front door until it opened and he walked out. All staff on duty were questioned and no one admitted they heard or shut off the door alarm. The resident wore a jacket, jeans, and hiking boots. The Facility Investigation, dated 05/17/2020, documented the resident finally allowed LN B to assess his vitals at 11:40 AM, on 05/17/2020. At 01:15 PM he allowed LN B to assess his skin. She documented a light scraped area to the right side of his face as 4.0 cm (centimeters) x 0.25 cm., with a 3.0 cm discolored area above the right eye. The left forehead displayed a 2.0 cm x 0.25 cm. scrape. The back of the right hand displayed an 0.25 cm round puncture area. The facility notified the primary care physician and received an order to send the resident to a psychiatric hospital. The resident left the facility at approximately 05:15 PM, taken to the hospital emergency room for evaluation and then on to the psychiatric hospital. According to www.Wunderground.com, on 05/17/2020 at 8:00 AM, the outside temperature was 75 degrees Fahrenheit. Per Administrative Staff A interview, on 05/19/2020 at 10:15 A.M., the facility staff identified the need for immediate action to prevent the resident and other residents, at risk for elopement, from leaving the facility without staff knowledge. Observation, on 05/19/2020 at 10:00 AM, revealed the front door had an egress which allowed the door to open after 15 seconds when pressure was applied to the bar. An audible alarm beeped while the bar was being held down and when the door lock released, a loud buzzing sound continued until manually reset by staff. Observation, on 05/19/2020 at 5:00 PM, revealed the route the resident walked as a gravel road up to the paved highway and then after crossing the highway, the terrain turned into another gravel road with grass lined ditches on either side. The facility's policy for Elopement, F689, dated 11/2017, documented regarding door alarms, should door alarm sound staff should verify who left the building. If it is uncertain who caused the alarm an immediate resident count should be initiated. Unverified alarms will be recorded in the door alarm book located at the nurses station. The facility failed to adequately monitor this cognitively impaired independent resident, the resident left the facility without staff knowledge, walked 3 ½ miles away from the facility, crossing a busy highway with a speed limit of 55 miles an hour, and was found face down in a ditch. This deficient practice placed the resident in immediate jeopardy. The deficient practice was cited as past non-compliance, as of 05/17/2020 as of 7:00 pm, when the facility completed the following: 1). The facility implemented one on one supervision for resident R1, until the resident transported to a psychiatric hospital. 2). All door alarms were checked and found to be in working order. Door alarms were changed to be checked daily. 3). All residents were re-assessed for elopement risk. Updated care plans appropriately. 4). Held a QAPI (Quality Assurance and Performance Improvement) meeting, on 05/17/2020 at 01:30 PM, which included the medical director, administrator, director of nursing, social service designee, and maintenance director. 5). Re-education of all staff regarding door alarms and re-setting of door alarms, unsafe resident wandering and what had the potential to make a resident unsafe, started on 05/17/2020 at 11:00 AM and completed at 07:00 PM on 05/17/2020. 6). Implemented elopement drills for each shift weekly and daily checking of door alarms.

The facility reported a census of 36 residents, with three selected for review for elopement (run off secretively). Based on record review, observation, and interview, the facility failed to provide adequate supervision for one Resident (R) 1, of the three selected, to prevent elopement. Staff failed to monitor the resident as care planned with one to one supervision, when on an outing from the facility. The staff left the resident unattended in the facility van and the resident eloped near a highway that was heavily traveled . The speed limit was 55 miles per hour. Findings included: - The signed physician order [REDACTED]. The annual Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 99, indicating impaired cognition. She had delusions and verbal behavioral symptoms directed at others that significantly interfered with the resident's participation in activities or social interactions. It was very important for her to go outside to get fresh air when the weather was good. She was independent with her activities of daily living (ADL's) and did not require mobility devices. She received routine antipsychotic (medication used to treat [MEDICAL CONDITION]) and antianxiety medications (medication used to treat anxiety ). The resident did not have alarms. The Cognitive Loss/ Dementia Care Area Assessment (CAA), dated 03/14/19, documented the resident had a long-standing history of mental health disorders. She had poor memory and spoke in a child-like voice. The resident heard voices no one else could hear, and she would speak to those voices. She required antipsychotic medications. The quarterly MDS, dated [DATE], documented the resident had a BIMS score of nine, indicating moderately impaired cognition. She hallucinated (an experience in which you see, hear, feel, or smell something that does not exist) and had delusions (fixed, false conviction in something that is not real or shared by other people). She had verbal behavioral symptoms directed towards others and behavioral symptoms not directed toward others. She received antipsychotic medications, antianxiety medications, and antidepressant medications. The resident required a wander/elopement alarm daily. The care plan, dated 12/11/19 , identified the resident was at risk for elopement due to poor decision making, auditory hallucinations, and a history of unauthorized leaving of the facility. Her goal was that she would not leave the building without staff presence. The resident required a WanderGuard (a wearable device to alert staff she was nearing a facility exit door). Staff should consider patterns of exit seeking need or behavior to alter the resident's schedules, treatment, medications or environment to manage behavior and ensure the resident's safety . Staff should complete an elopement assessment quarterly and as needed. Staff should encourage activity participation. Staff to re-direct the resident when she made attempts to leave the facility. In addition, staff should provide one to one supervision with the resident on outings or physician appointments. Staff should accompany the resident for occasional walks around the facility. The Wander Data Collections Tool, located in the resident's clinical records, revealed on 12/11/19 and on 03/06/2020, a score of three. A score of three or more documented a Definite Risk for Elopement. The summary on both assessments documented the resident was a definite risk for elopement, due to her ambulation, and her [DIAGNOSES REDACTED]. The nurse's notes, on 03/04/2020, documented the Resident returned from an outing this afternoon from Dollar General. Staff completed a skin assessment, blood pressure, pulse and respirations monitored, however, the resident's temperature was not obtained. Staff notified the physician of the Incident that happened on the resident's outing today. The records lacked documentation that the resident eloped when she was on an outing. The investigation report, reported 03/09/2020, documented staff took the resident, along with other residents, on a shopping trip, accompanied by activities staff Z and social services staff X. Activities staff Z was in the van with the residents, including the resident, when another resident, who was in the store with social service staff X, became dizzy. Social service staff X requested assistance with the resident in the store. Activity Staff Z left the van and six other residents, unattended, to assist with Social service staff X inside the store. After both staff returned to the van, a roll call determined the resident had left the van, unattended. Staff drove the van in attempts to locate the resident, however, was unsuccessful. Staff returned to the facility, called the local police department at approximately 01:47 PM, and was informed by the police department there was a call with the description of a female that matched the resident's description. Staff returned towards the store, located her, and brought the resident back into the facility at 01:52 PM. According to www.Wunderground.com, on 03/04/2020 at 12:53 PM, the outside temperature was 54-degree Fahrenheit. At 01:53 PM, the temperature was 58-degree Fahrenheit , with five miles per hour wind from the North East, cloudy, and no rain. On 03/09/2020 at 08:20 AM, the resident ambulated by herself with a swift, steady gait. The resident wore a sweatshirt with matching slacks. On 03/09/2020 at 11:40 AM, the resident ambulated with a swift, steady gait. She carried a plastic bag that contained clothing, shoes, and a stuffed animal. On 03/09/2020 at 01:05 PM, the resident was in her bed, with night clothing on. She was awake and spoke to herself. On 03/09/2020 at 04:40 PM, the resident stood in the hallway, faced toward the wall, and had a conversation with herself. On 03/09/2020 at 08:11 AM, Licensed Nurse (LN) G, reported the resident was an elopement risk. She had left the building unattended before. The resident enjoyed walking and was ambulatory ad lib. If the resident was On a mission, she could walk quick. LN G was unaware of what time staff transported the residents to the outing. She became aware the resident eloped when staff returned to the facility, without the resident. Social services staff notified the local police department, and the Police Chief reported the resident had been located, so both Social Service staff X and Activity Staff Z left the facility to transport the resident back to the facility. When staff returned with the resident, the resident walked into the facility and went to bed. The resident wore appropriate clothing for the weather, because she always wore a sweatshirt, and long pants. The resident refused to have her temperature monitored, because she did not like thermometers in her mouth. LN G reported facility staff should walk with her when she was out of the building, unless it was in the enclosed fenced area in the patio. On 03/09/2020 at 08:45 AM, Administrative Staff A, reported the facility system failure occurred when staff left the resident unattended, while out of the facility. Staff should have followed the resident's care plan. On 03/09/2020 at 10:50 AM, Social Services staff X, reported while on the outing, she assisted a Slow walking resident while in the store and they were the last ones to leave the store. The other residents were outside of the store, when Social Services Staff X motioned for Activity Staff Z to assist with the other resident. Social Services Staff X reported she paid for the merchandise as Activity Staff Z ambulated with the other resident to the van. After the residents were in the van, it was determined that R1 was not in the van. Social Services Staff X searched the inside and the outside parameter of the store, and the resident was not located. After staff searched for the resident, and was unable to find her, staff returned to the facility without the resident. The staff notified the local Police by phone. The local police informed the staff that there was a female located that fit the resident's description, and both staff drove to the area, located the resident across the street, and transported the resident back to the facility. The resident would have disappeared when both staff were in the store and left the resident unattended. She was aware the resident required one to one while on outings. On 03/09/2020 at 10:09 AM, Activity Staff Z, reported she was with the resident in the store, however, left the resident unattended while she returned to the store. She reported she May have forgotten to close the van door. It was determined the resident was gone when staff completed a roll call, and the resident was not in the van. Social Services staff searched inside and outside the store, and was unable to locate the resident, so staff drove around, looking for her. After the other residents returned back to the facility, the police informed staff there was a female that matched the resident's description, in the approximate location of the store. Staff located the resident on the opposite side of the street, from the store. She was standing in the grass, and had grass on her head, so she may have laid down in the grass, in the ditch. She verified a high traffic highway was close to the location the resident disappeared. Activity Staff Z verified she was aware the resident required one to one while on outings but reported I dropped the ball when another resident Had health issues. On 03/09/2020 at 11:53 AM, Outside Resource Staff KK, identified as the Chief of Police, reported he received a call two minutes prior to the facility calling in the report of the missing resident. The call came from a Citizens report of a female walking East on Highway 50. He gave the description of the female, and it matched the lost resident. The police did not go to that location, because he was on a previous call. He verified he did not make out a police report. On 03/09/2020 at 01:39 PM, Administrative Staff A, reported staff were aware the resident required one- to-one supervision on outings. Staff should follow the resident's care plan. The resident had a history of [REDACTED]. The resident is required to wear a WanderGuard, because she is at risk for elopement. On 03/09/2020 at 01:51 PM, Certified Medication Aide (CMA) R, reported staff should provide one to one supervision with the resident when on outings. On 03/09/2020 at 02:05 PM, R1 reported she remembered she left the van because she was Possessed and pushed to leave the van. She walked to the highway, but Didn't get hurt. On 03/09/2020 at 02:04 PM, Administrative Nurse D, reported staff failed to provide a one on one outing with the resident, and the resident eloped from the van, while both staff were inside the store. Staff should have provided one on one supervision with the resident, and Their eyes should not have been off her. On 03/09/2020 at 02:14 PM, reported the resident required one on one supervision with staff if she was out of the building on an outing. She can walk outside in the fenced patio by herself. On 03/09/2020 at 02:37 PM, Physician GG, reported he was aware the resident eloped. The resident was out on a supervised outing, and someone had a problem in the store. Staff got pre-occupied with another resident, turned their back on the resident, she took advantage of the situation, and left. On 03/09/2020 at 10:10 AM, R 2 reported he was on the outing when the resident Took off. Staff and residents rode in the van but were not able to locate her. When they (staff) could not locate her, they brought the residents back to the facility. On 03/09/20 at 10:14 AM, R 3 reported he was on the outing when the resident disappeared from staff. He reported he was outside, behind the van, smoking. Staff called out her name in the roll call, and she was not on the van. Staff searched for her, but was not able to locate her, so staff returned the residents back to the facility. On 03/09/2020 at 02:25 PM, R4 reported she was on the outing when the resident disappeared. Staff searched for her but was unable to locate her. The facility's policy for Wandering, Unsafe Resident, F 689, dated 11/2017, documented the resident's care plan would indicate the resident at risk for elopement and interventions to try to maintain safety would be included in the resident's care plan. Staff would institute a detained monitoring plan, as indicate for residents assessed to have a high risk of elopement or other unsafe behavior. The facility failed to adequately monitor this cognitively impaired, independent resident that required one to one supervision when on an outing from the facility, as care planned. The staff left the resident unattended in the facility van and the resident left unattended and walked near a highway that was heavily traveled , with a speed limit of 55 miles per hour, and was left unattended for a minimum of five minutes. The deficient practice cited as past non-compliance on 03/05/2020 at 03:40 AM, when the facility completed the following: 1. All staff education, started on 03/04/2020 and completed on 03/05/2020 at 03:40 AM. This education included unsafe resident wandering, elopement, safety and supervision of residents, abuse prevention training, and following the resident's individualized care plan . 2. Staff involved in the failure to follow the resident's care plan for one on one supervision were given a written disciplinary action. 3. The facility notified the medical director and conducted an immediate quality assurance/ performance improvement (QAPI) plan on 03/04/2020.

The facility reported a census of 39 with 3 residents selected for review of elopement risk. Based on observation, interview and record review the facility failed to ensure one resident (#1) received adequate supervision and appropriate interventions to prevent elopement. On 6/27/19 at 2:26 PM the facility received a phone call from a local store stating the resident was in the building. The resident was last seen at approximately 12:30 PM during a smoke time. Resident #1 left the unsecured smoking area without staff knowledge, walked approximately one mile, with an outside temperature of 91 degrees Fahrenheit and crossed a railroad track. This deficient practice placed the resident in immediate jeopardy. Findings included: - Resident #1's signed Physician order [REDACTED]. muscle wasting. The 6/13/19 Quarterly Minimum Data Set (MDS) revealed resident #1's Brief Interview for Mental status (BIMS) score of 13 which revealed he/she was cognitively intact. This assessment revealed the resident presented with hallucinations (sensing things while awake that appear to be real, but the mind created), delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), was verbally abusive to others 4 to 6 days of the 7- day look back period, and had behaviors not directed towards others daily. The resident did not experience wandering during the 7-day look back period. Resident #1 was independent with all activities of daily living, experienced shortness of breath with exertion (walking, bathing and transferring). He/she received antipsychotic (class of medications used to treat [MEDICAL CONDITION] and other mental emotional conditions), antianxiety (class of medications that calm and relax people with excessive anxiety, nervousness, or tension), and antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression) medications 7 out of 7 days during the look back period. The MDS showed the resident did not use a wander/elopement alarm. The 3/4/19 Cognitive Loss/Dementia, Psychosocial well-being, fall and [MEDICAL CONDITION] drug use Care Area Assessment all identified the resident had a long history of mental health issues and long and short-term memory deficits. The resident could make basic needs and wants known but required assistance with any type of major decision. Resident #1 was independent with ambulation, at risk for falls due to medications but had not sustained a fall during the review period. The CAA's further revealed the resident heard voices in his/her ears, had conversations with the voices, and staff would redirect but he/she quickly reverted to talking with the voices. The residents revised care plan dated 6/19/19 revealed the resident was at risk for elopement due to poor decision making, cognitive impairment, history of unauthorized leave and auditory hallucinations. The plan revealed the resident had a WanderGuards (bracelet that sets off an alarm when residents wearing one attempts to exit the building without an escort) on his/her right wrist, elopement assessment completed quarterly, picture ID placed in the elopement binder at the nurse's station, and staff provided 1 on 1 supervision when outside, on outings or physician appointments. The care plan further revealed the resident was a smoker, attended smoke pass at designated smoke time in the designated smoke area (back patio). An undated hand-written entry revealed please take me out either before or after my peers to keep me safe from eloping. A 5/15 hand written entry revealed I can go out and smoke with the other residents. The care plan further revealed the resident was at risk for falls related to [MEDICAL CONDITION] medications, history of falls, impaired gait and balance. A wandering and elopement risk assessment completed on 6/27/19 under the reason for assessment section revealed the resident had a change in status, independent with ambulation, episodes of elopement, pacing, searching, [DIAGNOSES REDACTED]. The assessment revealed the resident had a history of [REDACTED]. Review of the nurse's notes dated 2/4/19 revealed the resident eloped out of the bedroom window, carried the window screen around the building to the smoking patio, where he/she had cigarettes hidden under a blanket. A nurses noted dated 6/27/19 at 4:10 PM revealed the resident went out with smokers (no time listed) but did not return inside the building and walked away. The note revealed a local store called the facility and staff went and picked him/her up. Staff performed a head to toe assessment with no injuries noted. Vital signs were documented as Blood Pressure 137/87mmHg (millimeters of Mercury), pulse 121 beats per minute, respirations 18, temperature 99.3 degrees F and oxygen saturation 98 percent on room air. The note further revealed an intervention to place the resident on 1 on 1 with staff. He/she was very delusional and complained someone was stealing his/her money upon return. A note dated 6/27/19 at 5:08 PM revealed staff tested the WanderGuards and it functioned properly. A note dated 6/27/19 staff contacted resident's doctor was called to ensure he/she was aware of the incident. Review of the facility investigation dated 6/27/19 revealed that the facility recieved a phone call from a local store clerk who stated that he/she believed on of the facility resident's was in the store and had a bag of clothes in his/her possession. Staff immediatley responded to the call and found Resident #1 approximately one mile from the facility at 2:33 PM. The resident was assessed upon return and found no injury. The facility placed the direct care staff N on suspension pending investigation. The resident was placed on one on one supervison until facility staff could be trained on the elopement policy and the smoking policy changes. An observation on 7/1/19 at 9:30 AM revealed an un-enclosed, un-secured resident smoking area and staff and/or residents could walk around the building. An observation of Resident #1 on 7/1/19 at 9:58 AM revealed he/she was laid in bed, with the blanket/sheet up to his/her chin. When the resident sat up uncovered, he/she wore two pairs of pants, 1 shirt, 1 sweatshirt, socks and a pair of slip on shoes. An observation on 7/1/19 at 10:36 AM revealed social service staff X took the resident out to smoke. Resident #1 sat on the outside bench, quickly smoked the cigarette, then pushed the button to open the door and went in the building. His/her gait was steady, but he/she shuffled his/her feet. An interview on 7/1/19 at 10:00 AM with the resident revealed he/she wanted to take a walk the day he/she went to the store. He/she revealed that it was smoke break, and everyone was outside. Resident #1 stated that he/she had a bag with him/her and planned on going to see his/her parent that was dead (parent still alive) and lived 20 miles away. Resident #1 further revealed there was a pinochle in his/her ears that talked all the time. The pinochle told him/her that he/she needed to walk to visit the parent. When asked about the bracelet on his/her right arm, resident #1 revealed it beeped when he/she got close to the door. An interview on 7/1/19 at 10:38 with Social Service staff X revealed that the 2 residents who wore WanderGuards had separate smoke breaks from other residents to ensure their safety. Interview on 7/1/19 at 11:04 AM with Administrative staff A revealed that the resident had went out with the smokers to the patio. Staff A revealed that resident #1 did not make safe choices and was not given the opportunity to have a walking pass like other residents. Staff A further stated that the facility received a call from the local store that one of the residents may be in the store. Staff immediately left the facility and picked him/her up and transported the resident back to the facility. Staff A stated staff was present on the porch for supervision during the 12:30 PM smoke time and that staff had been suspended. An interview on with 7/1/19 at 11:26 AM interim maintenance staff U revealed that the code to the doors was changed immediately upon resident #1's return. Staff U further stated that all door alarms were checked daily by him/her as well as by the nursing staff on each shift. The facility failed to ensure the safety of this resident, identified as an elopement risk, when the resident left the designated smoking area, without staff's knowledge and walked approximately one mile to the local store, with the outside temperature of 90 degree's F and crossing a railroad track. This deficient practice placed this resident in immediate jeopardy. The deficient practice was cited as past non-compliance as of 6/27/19 when the facility completed the following: 1. Resident assessed for injuries and none noted 2. Resident #1 was placed 1:1 until staff were educated and door codes were changed. 3. Physician was notified of elopement 4. Mother was notified of elopement 5. Resident #1's bracelet was checked and was in working order 6. New elopement assessments were conducted on all residents 7. Elopement Risk Binder was checked for accuracy 8. Door codes were changed on all exit doors 9. All doors were checked for proper working condition following code changes 10. All staff on duty at the time were in-serviced on elopements, ANE (Abuse, Neglect and Exploitation) and smoke break protocols 11. All staff that were not on duty would be in-serviced before their next shift. 12. New process: A list of all residents who smoke was developed for checking residents in and out during smoke breaks 13. All residents with WanderGuards would out separately for smoke breaks to allow for more oversight 14. CMA that oversaw the smoke break when Resident #1 left has been suspended pending investigation 15. Incident would be taken to QAPI.

The facility reported a census of 42 residents with 3 residents selected for sample review of elopement. Based on observation, interview, and record review the facility failed to ensure one resident (#1) of 3 reviewed, received supervision and/or assistive devices to ensure the resident remained free of elopement. Resident #1 exited from the facility, without staff's knowledge on 12/7/18 at approximately 7:30 AM, with an outside temperature of 35-42 degrees Fahrenheit, and without safety awareness, walked along the road away from the facility, which placed the resident in immediate jeopardy. Findings included: - Resident #1's [DIAGNOSES REDACTED]. mental illness that caused people to have episodes of severe high and low moods). The MDS (minimum data set) was unavailable due to computer problems at the facility, however, a printed cognition CAA (care area assessment) dated 9/26/18, identified the resident with impaired cognition related to the [DIAGNOSES REDACTED]. An elopement risk assessment, dated 9/13/18, identified the resident without a history of wandering and determined the resident lacked risk for elopement. On 9/14/18 a second elopement risk assessment identified staff observed the resident wandering around the facility parking lot and attempting to cross the street. A reassessment determined the resident at risk for elopement and the facility placed a wanderguard alarm on the resident. Review of the resident's care plan, implemented on 9/14/18 and last reviewed on 12/7/18, instructed staff: 1.) WG (wanderguard) on resident's right wrist. 2.) Provide supervised smoking. 3.) Remind resident to not go outside without staff. 4.) Check WG each shift. 5.) Remind resident to verify with staff if hallucinations and hearing voices to tell him/her to remove the WG are true. Review of the facility investigation identified the resident was last seen in the facility, at approximately 7:30 AM on 12/7/18, by licensed nursing staff C. Administrative staff D, driving to work at 7:50 AM, observed the resident walking on the side of the road, 5 blocks from the facility. The employee stopped and asked the resident to return to the facility and the resident returned to the facility without resistance. The facility staff assessed the resident and found no injury, as the resident wore several layers of clothing while out in the cold weather. The investigation further identified through witness statements the resident's elopement lacked any witnesses, and the resident was unreliable in his/her statements to the facility, regarding the site of exit from the facility. On 12/13/18 at 10:35 AM, administrative staff A and maintenance staff F identified a concern with the service hall door. The staff put a code into the alarm box, opened and then allowed the door to return shut. The door, which appeared bent and warped, failed to close entirely and the staff pulled the door shut tightly and then the magnetic locks engaged to reveal a red light on the alarm box. Staff A demonstrated this and reported that the concern was that on the morning of 12/7/18 a delivery truck arrived and delivered goods to the facility. The staff were unsure if anyone ensured secure closure of the door at that time. The staff therefore believed this may be how the resident exited the building. Observation of the resident, on 12/13/18 at 10:10 AM, identified the resident in his/her room, and rehung clothing removed from the closet area. The resident refused to speak and/or make any eye contact at that time. On 12/13/18 at 11:50 AM, the resident ambulated to the dining room, sat down and began making motions with his/her hands as though he/she saw or heard things others did not. On 12/13/18 at 2:45 PM, the resident stood in the hallway, near the back-service hall. The resident who stood staring at his/her self in a mirror, agreed to be interviewed, at that time. The resident reported he/she never planned to do that again, knew it was wrong and then began talking in non-sensical speech. The resident stated she went out the smoke area door and stated they just let her go out. Resident was unable to explain who they were. On 12/13/18 at 9:55 AM, direct care staff E verified attending the resident with supervised smoking on the morning of 12/7/18 at approximately 7:00 AM. The staff verified the wanderguard alarm sounded when the resident exited outside and returned inside the building with the resident, from smoking. Interview, on 12/13/18 at 10:15 AM, with administrative staff E, reported he/she was driving to work when he/she observed the resident walking on the side of the road, about 5 blocks from the facility. The employee indicated he/she stopped and asked the resident if he/she would accept a ride back to the facility and the resident got into the car, without any further encouragement needed. The resident returned into the facility upon arrival back, without any direction needed. On 12/13/18 at 3:07 PM, licensed nursing staff C reported being on duty at the time of the elopement. Staff C reported after the resident returned to the facility, staff C observed the resident who continued to ambulate throughout the facility and on one occasion the resident went down the hall towards the service hall. Nurse C watched the resident from a distance and when the resident reached near the end of the hall, the resident turned and looked back (as though to see if anyone was watching), then seeing the nurse, made some other movements and returned up the hall and did not enter the service hall. The staff believed the resident exited through the non-functioning service hall door, however, when the nurse asked the resident about how he/she got out earlier, the resident did not say. On 12/13/18 at 4:15 PM maintenance staff F reported the facility had a quote for replacement of the back door, on 11/13/18, which needed replaced for some time. The facility failed to ensure the safety of this resident, identified at risk by the facility as an elopement risk with, when the resident exited the facility, without the staff's knowledge and walked at least 5 blocks from the facility in outside temperatures of 35-42 degrees, which placed the resident in immediate jeopardy. The facility abated the immediate jeopardy on 12/13/18 at 10:00 PM when the facility completed the following corrective actions: 1. The on-duty staff were immediately re-educated on wandering and missing residents, on 12/7/18. This education was continued until all staff employed received re-education on 12/13/18 before 10:00 PM. 2. Door alarm codes were changed on 12/7/18 at 2:00 PM and again on 12/13/18 at 6:45 PM. 3. Validation of the function of all door alarms at 12/13/18 at 9:30 PM. 4. Contact to Absolute Protection on 12/13/18 at 11:30 AM, for replacement/repair of the malfunctioning maglock and installing additional wanderguard monitors. The company is expected to arrive for consultation before 12/18/18. In the mean time the service hall door is locked and being checked every shift that it remained locked. 5. A QAPI meeting was held on 12/13/18 at 4:30 PM; the medical director was updated regarding the QAPI meeting on 12/14/18 at 5:30 PM. 6. Prominent signage was posted on all doors for checking of surroundings and caution regarding allowing unknown others exit was placed on 12/13/18 at 7:00 PM. 7. Education to all resident's regarding walking passes and to not let other residents out of the facility was completed on 12/13/18 at 7:45 PM. 8. Education to all staff conducted via phone or in person. No employee (agency or current staff) will work until re-training has occurred. This is on-going, however, the majority of the staff are re-trained at 8:00 PM on 12/13/18. 9. Verification of all wanderguard checking/monitoring was placed on the MARs regarding checking of placement and function was completed on 12/13/18 at 9:00 PM. 10. All residents reviewed and 1 resident identified at risk for elopement was reviewed and placed into the Elopement Risk Book on 12/13/18 at 10:00 PM. The facility abated the immediate jeopardy on 12/13/18 at 10:00 PM, to the scope and severity of a D.

The facility had a census of 47 residents. The sample included 6 residents. Based on observation, record review and interview the facility failed to adequately monitor and thoroughly assess respiratory status and seek physician involvement over a 2 day period for 1 sampled resident (#1), who had significant respiratory distress and decline in physical health. This failure placed the resident in immediate jeopardy. Findings included: - Resident #1's 10/4/16 physician order [REDACTED]. This thickened, stiff tissue makes it more difficult for the lungs to work properly). The significant change (MDS) Minimal Data Set assessment, dated 9/21/16, indicated the resident had a (BIMS) Brief Interview of Mental Status score for 15, which indicated the resident had intact cognition. The MDS indicated the resident required continuous oxygen therapy. The 9/26/16 care plan directed nursing to administer the resident's oxygen per rate and route of the physician's orders [REDACTED]. door and would change all the oxygen tubing weekly. The care plan instructed staff to monitor the resident for cyanosis (appearance of a blue or purple coloration of the skin), and [MEDICAL CONDITION] (a condition where the tissues are not [MEDICATION NAME] adequately, usually due to an insufficient concentration of oxygen in the blood). The care plan instructed staff to check the resident's oxygen tubing each shift to make sure it was free of kinks and ensure the tubing was secured (behind the resident's ear, ensure the resident's oxygen concentrator was in proper working order). The care plan instructed the nurse to keep the resident's call light within reach, and check the resident's humidifier jar on the oxygen concentrator each shift to ensure adequate water was in the container. The care plan instructed the nurse to keep the resident's oxygen saturation between 90-96%, and to notify the physician if the resident's oxygen saturation dropped below 70% or as specified by the physician. The 6/30/16 at 3:55 PM physician order [REDACTED]. (The previous order on 4/13/16 instructed staff to administer oxygen to the resident at 1 liter per nasal cannula during the day and 2 liters during the night for dyspnea (difficulty breathing). The 9/26/16 at 9:00 PM, nurse's note indicated the resident complained of being short of air and requested his/her prn (as needed) [MEDICATION NAME] inhaler (portable device for administering a drug that is to be breathed in, used for relieving asthma and other [MEDICATION NAME] or nasal congestion). The 9/27/16 at 6:30 AM, nurse's note indicated the resident's oxygen saturation was 88% on 2 liters of oxygen per nasal cannula. The note indicated the resident displayed slow movements, drowsiness and he/she admitted to forgetting to put his/her oxygen back on during the night after using the bathroom. The 9/27/16 at 1:15 PM nurse's note indicated the resident had a persistent dry cough, his/her lungs were clear, and his/her oxygen saturation dropped into the 70's after the resident had a coughing episode. The clinical record lacked evidence that staff assessed the resident after 1:15 PM, to follow up on the decreased oxygen saturation level. The 9/27/16 at 3:15 PM, physician order [REDACTED]. The 9/27/16 at 8:00 PM, nurse's note indicated the resident's oxygen saturation continued to decrease, the resident panted, had shortness of breath and the nasal cannula was not effective for the resident. The note indicated the nurse tried an oxygen mask, and with time and relaxation, the resident's oxygen saturation was 93% on 4 liters of oxygen. The clinical record lacked evidence the facility notified the physician or reassessed the resident in a timely manner. The 9/27/16 at 11:00 PM, nurse's note indicated the resident's oxygen saturation was 78% with simple mask. Staff reapplied the nasal cannula at 3 liters of oxygen, and the resident's saturation improved slowly to 93%. The note indicated the resident's respirations were shallow, labored, and his/her lungs were diminished (almost non existant breath sounds) in the bases. The resident had scattered wheezes in his/her upper lung lobes, heart rate in the 130's,(normal heart rate is 60-100 beats per minute), respirations 32 (normal respirations are 12 to 16 breaths per minute), and staff encouraged the resident to breath in through his/her nose and out through his/her mouth. This helped and the resident's respiration rate lowered to 24, and his/her heart rate came down to 116 beats per minute. The clinical record lacked evidence the facility notified the physician or reassessed the resident in a timely manner. The 9/27/16 at 12:50 PM, nurse's note indicated the resident's oxygen saturation was 89% on 2 liters of oxygen per nasal cannula. The nurse cut the resident's finger nails, which were long and curved under the tip of nail, and his/her oxygen saturation after the nurse trimmed his/her nails trimmed was 82%. The clinical record lacked evidence the facility notified the physician or reassessed the resident in a timely manner. The 9/28/16 at 07:00 AM, nurse's note (over 18 hours since last assessment) indicated the resident was hyperventilating (breathing that was deeper and more rapid than normal) and appeared to be purposeful. The note indicated the nurse encouraged the resident to slow down and concentrate on even respirations. The note indicated the resident had signs and symptoms of air hunger (respiratory distress marked by gasping, labored breathing), and his/her oxygen saturation was 72%. Staff placed oxygen on him/her at 3.5 liters per nasal cannula, and with coaching from the nurse his/her oxygen saturation increased to 94%. The note indicated the nurse told the resident to be conscious of what/how he/she was doing. The resident had a shower with assistance of staff, had no oxygen on while in the shower, and complained of being too cold to go out to breakfast, and the nurse encouraged the resident to warm up and independently go to breakfast later. The note indicated the nurse told the resident he/she needed to be as active as possible. The clinical record lacked evidence the facility reassessed the resident including checking the resident's oxygen saturation. Review of the medical record revealed no documentation the nurse contacted the physician for instructions regarding the care of the resident's change of status which included continued drops in oxygen saturations, hyperventilations, air hunger, shallow respirations, diminished lung sounds, and increased heart rate and respirations. The 9/28/16 at 10:16 AM, nurse's note (over 3 hours since the last assessment when the resident's oxygen saturation was 72% and the nurse increased the oxygen to 3.5 liters before his/her shower) indicated direct care staff called the nurse to the resident's room. When he/she arrived the resident was hypoxic (a condition in which the body or a region of the body is deprived of adequate oxygen supply at the tissue level), lips and nail beds were blue, respirations 46, and oxygen saturation 56%. The note indicated the nurse increased the resident's oxygen again to 3.5 liters, tried to slow the resident's breathing by breathing with him/her. The note indicated the resident seemed anxious, unable to slow breathing, tried breathing through a straw, and unable to follow the nurse's directions. The note indicated the resident had no anxiety medications. The note indicated the resident's blood pressure was 138/72, heart rate 42 beats per minute, oxygen saturation 73% and starting to fall. The note indicated the nurse called the physician and received order to send the resident to the (ER) emergency room . The 9/28/16 at 11:30 AM, emergency room nursing assessment indicated the resident arrived at the ER by ambulance with severe tachypnea (abnormally rapid breathing. In adult humans at rest, any rate between 12-20 breaths per minute is normal) at 50 breaths per minute, on 15 liters of oxygen by (NRB) non-rebreather (device used in medicine to assist in the delivery of oxygen therapy. An NRB requires that the patient can breathe unassisted, but unlike low flow nasal canula, the NRB allows for the delivery of higher concentrations of oxygen) mask. The resident's oxygen saturation was 93%, and the resident had a productive cough with green/yellow/red mucus, fever, chest pain, sore throat, headache, lungs had wheezes, used his/her accessory muscles to breathe, and had a heart rate of 128 beats per minute. The assessment indicated hospital staff obtained a urinalysis and chest x-ray. The assessment indicated the resident's [DIAGNOSES REDACTED]./sepsis (a life-threatening bacterial infection of the blood). The assessment indicated the local hospital transferred the resident to a regional hospital. On 10/13/16 at 10:30 AM, Nurse Aide A stated he/she was working on 9/28/16 and he/she thought the facility should have sent the resident to the hospital sooner. On 10/12/16 at 11:01 AM, Nurse B stated he/she was the nurse on duty on 9/28/16 and about 8:30 AM the resident put his/her call light on and reported his/her hands hurt, requested something for the pain, and he/she placed a warm towel on the resident's hands. Nurse B told the resident he/she would tell the (CMA) Certified Medication Aide to administer the resident's scheduled pain medication. Nurse B stated he/she meant to go back and check on the resident in about 10 minutes, but it was approximately 20 minutes before he/she returned to the resident's room, and the resident was asleep. Nurse B stated about 9:30 AM, a nurse aide came and told him/her the resident said he/she could not breathe. When he/she arrived the resident had his/her oxygen kinked on the oxygen concentrator, and his/her oxygen saturation was 89%. Nurse B stated once he/she unkinked the tubing the resident's oxygen saturation went up and the resident was breathing fine and he/she left the room. Nurse B stated at 10:15 AM an aide came and told him/her the resident was having trouble breathing, and when he/she arrived in the resident's room he/she was hyperventilating and kept saying he/she could not stop breathing fast. Nurse B stated he/she could not get the resident to stop hyperventilating, checked the resident's oxygen saturation and it was 54%. The resident couldn't get settled down, but his/her oxygen saturation did come up to 73%. Nurse B stated he/she was getting alarmed, but figured the resident was just mad at him/her for getting him/her in the shower earlier that morning, because that was the kind of thing the resident would do when he/she was mad at staff. Nurse B stated the resident had an as needed breathing treatment, but he/she did not give it to the resident because his/her lungs were clear. Nurse B stated the resident was having difficulty breathing, he/she told the aide to stay with the resident then went to call the physician and received an order to send the resident to the ER. On 10/13/16 at 2:55 PM, Administrative Nurse C stated on 9/27/16- 9/28/16 the resident had a change in condition and he/she expected the nurse to call the emergency room physician or notify the primary care physician immediately when the resident's heart rate was 130 bpm (the resident's heart rate was 130 bpm 16 1/4 hours prior to staff contacting the physician and transferring the resident to the emergency room ). Administrative Nurse C stated there was a paper taped in the nurse's station, at the time of the resident's change in condition, stating parameters that the nurse should have followed, regarding when the nurse should call the physician. The paper stated the following: Resting pulses >110(bpm) beats per minute, <55 bpm, or 110 bpm and patient has dyspnea or palpitations Respirations > 24, <10/minute. (unless has [DIAGNOSES REDACTED]. Call the physician, to report the above DO not fax. On 10/13/16 at 5:17 PM, Nurse D stated he/she was the nurse on duty in the hospital ER room on 9/28/16, when the resident was brought in by ambulance. Nurse D stated when the resident arrived at the ER he/she was lethargic (fell asleep while talking to the nurse), and in pretty serious shape. Nurse D stated the resident was on 15 liters of oxygen by nonrebreather mask and the resident's oxygen saturation was 91-92%. Nurse D stated generally when a person was on 15 liters with a nonrebreather mask, their oxygen saturation would be 99-100%. Nurse D stated the resident's respirations were 36, blood pressure was 92/66, and the resident's heart rate was [MEDICAL CONDITION] (a heart rate that exceeds the normal resting rate of 100 beats per minute) at 132 bpm. Nurse D stated he/she called the facility to ask what had been going on prior to the resident being brought to the ER. On 10/17/16 at 10:15 AM, Nurse Practitioner E stated he/she expected the staff to call the physician right away when the resident continued to have a decline in oxygen saturation requiring need for increased oxygen. Nurse Practitioner E stated the resident's outcome would have been different if the facility had sent the resident to the hospital sooner. The facility's 4/2011 Change in a Resident's Condition or Status policy stated the nurse supervisor/charge nurse will notify the resident's attending physician or on call physician when there was a significant change in the resident's physical/emotional/mental condition or need to transfer the resident to a hospital/treatment center. The facility's 4/2007 Measuring Respirations policy stated the following abnormal respirations should be promptly reported to the nurse supervisor when a resident had the following: Shallow respirations (breathes with only the upper part of the lungs). Abdominal respirations (breathing comes mostly from the stomach muscles). Irregular respirations (the resident's breathing changes and the rate of the rise and fall of the chest is irregular(not steady).The policy stated normal respirations for an adult is from 12 to 18 bpm. Stertorous respirations (noisy). The facility failed to adequately monitor and accurately assess the respiratory status for Resident #1, who had significant respiratory distress without physician notification over a span of 2 days. The facility's failure to adequately monitor, thoroughly assess, provide consistent interventions and to promptly obtain medical intervention placed Resident #1 in immediate jeopardy. The immediate jeopardy was abated on 10/18/16, when the facility implemented inservice education to staff regarding physical assessment of the resident, facility's policy for notification of change in condition, and notifying the nurse of a change in resident condition. This deficient practice remains at a scope and severity of a G.

The facility had a census of 50 residents. The sample included 4 residents. Based on record review and interview the facility failed to adequately monitor elevated temperatures, provide fever medication as ordered by the physician, accurately and thoroughly assess respiratory status and notify the physician for 2 sampled residents (#1 and #2), who had significant respiratory distress and decline in physical health. This failure placed the resident in immediate jeopardy. Findings included: - Review of the [DATE] Physician's Progress Note for Resident #2 indicated his/her lungs were clear and the resident had no respiratory distress or health concerns. Resident #2's quarterly (MDS) Minimum Data Set 3.0 assessment, dated [DATE], indicated the resident had a (BIMS) Brief Interview for Mental Status score of 7 (severe impairment) with physical and verbal behaviors and inattention. The MDS also indicated the resident was independent with eating, transfers, ambulation, dressing, toileting and personal hygiene. The MDS further indicated the resident received no oxygen therapy and had no shortness of breath or trouble breathing. The [DATE] care plan directed the staff to report changes in the resident's health status to the physician as needed. The care plan also directed the staff to administer medications to the resident as ordered by the physician. The [DATE] at 11:20 PM, nurse's note indicated the staff noted the resident was stumbling around his/her room. The nurse's note also indicated the resident had an elevated temperature of 100.8 degrees and received 2 tablets of Tylenol 325 (mg) milligrams (per the physician's orders [REDACTED]. The [DATE] at 4:30 PM, nurse's note indicated the resident had an elevated temperature of 102.2 degrees and received 2 tablets of Tylenol 325 mg. review of the resident's medical record revealed [REDACTED]. The [DATE] at 10:25 PM, nurse's note indicated the resident had a dry, nonproductive cough. The [DATE] at 5:00 AM nurse's note indicated the resident had laid on the floor 2 times this shift and required two staff assistance to transfer from the floor. The [DATE] at 6:00 AM, nurse's note indicated the resident had an elevated temperature of 102.6 degrees and received 2 tablets of Tylenol 325 mg (14 hours after the last dose of Tylenol 650 mg for fever). The [DATE] at 1:00 PM, nurse's note indicated the resident was lethargic and weak and the staff had to assist the resident with sitting up and "fed the resident" (resident usually independent with transfers, positioning and eating). The nurse's note also indicated the resident had a loose stool and an elevated temperature of 103.1 degrees (7 hours after the last temperature check and dose of fever medication). The [DATE] at 1:15 PM, nurse's note indicated the resident had a dry, nonproductive cough and received 2 tablets of Tylenol 325 mg. The [DATE] at 2:15 PM, nurse's note indicated the resident was confused, refused to stay in bed and kept stumbling around his/her room. The nurse's note also indicated the resident had pulse 116 (elevated - normal pulse 60 to 80), respirations 20 and temperature 104.1 degrees. The [DATE] at 3:15 PM, nurse's note indicated the nurse witnessed the resident stumble backwards, fall and hit his/her head. The nurse's notes indicated the resident's neurological assessment was within normal limits and the resident had a blood pressure ,[DATE], pulse 122, respirations 22 and temperature 103.8 degrees. The [DATE] at 5:00 PM, neurological assessment indicated the resident had a blood pressure ,[DATE], pulse 112, respirations 22 and temperature 103.6 degrees (4 hours after last dose of Tylenol 650 mg for fever). review of the resident's medical record revealed [REDACTED]. The [DATE] at 10:00 PM, nurse's note indicated the resident had an elevated temperature of 104.1 degrees (9 hours after last dose of Tylenol 650 mg for fever). review of the resident's medical record revealed [REDACTED]. The [DATE] at 6:10 AM, nurse's note indicated the resident needed assistance to sit up in bed and was unable to ambulate safely. The nurse's note indicated the resident had a blood pressure ,[DATE], pulse 96, respirations 28 (elevated - normal respirations 16 to 20 per minute), temperature 103.3 degrees (17 hours after last dose of Tylenol 650 mg for fever). The nurse's note indicated the staff administered 2 tablets of Tylenol 325 mg to the resident. The Neurological Assessment Flow Sheet indicated the staff assessed the resident for the following elevated respirations: [DATE] at 6:00 PM - 26 respirations [DATE] at 10:00 PM - 26 respirations [DATE] at 2:00 AM - 24 respirations [DATE] at 6:00 AM - 28 respirations [DATE] at 10:00 AM - 34 respirations review of the resident's medical record revealed [REDACTED]. The [DATE] at 7:45 AM, nurse's note indicated the facility received a physician's orders [REDACTED]. Review of the resident's medical record lacked any documentation from [DATE] to [DATE], the facility notified the physician regarding the resident's change in condition. The [DATE] at 12:45 PM, nurse's notes indicated the resident was unresponsive, had rhonchi (coarse, abnormal lung sounds) in both lungs and oxygen levels were 76 percent (oxygen levels below 88 percent indicate respiratory distress). On [DATE] at 12:50 PM, nurse's notes indicated the staff called 911 and notified the emergency room and the physician. On [DATE] at 1:18 PM, Emergency Department Nursing Assessment indicated the resident was unresponsive and had an elevated temperature of 104.0. The assessment also indicated the resident had rapid, labored respirations with use of accessory muscles and crackles (coarse, abnormal sounds) in both lungs. The assessment further indicated the resident had a [DIAGNOSES REDACTED]. The [DATE] at 12:15 AM, nurse's note indicated the resident had died at the hospital. On [DATE] at 3:41 PM, Nurse B stated the staff should closely monitor and assess changes in the resident's condition such as elevated temperatures and respiratory distress. Nurse B also stated the staff should notify the physician to ensure the resident received the appropriate cares and treatments. On [DATE] at 8:11 AM, Nurse C stated the staff should frequently assess and record the resident's elevated temperatures and respiratory distress. Nurse C also stated medications for elevated temperatures should be administered as ordered by the physician. Nurse C further stated the staff should provide comprehensive assessments and notify the physician when the resident had elevated temperatures and/or respiratory distress. On [DATE] at 9:44 AM, Nurse D stated the facility had no standing orders or policies to direct the staff to notify the physician when a resident had changes in condition. Nurse D also stated the staff should administer medications as physician ordered to control elevated temperatures. Nurse D further stated the staff should provide comprehensive assessments when the resident had changes in condition and notify the physician. The facility failed to adequately monitor elevated temperatures, provide fever medication as ordered by the physician and accurately assess the respiratory status for Resident #2., who had significant respiratory distress and decline in physical health. - Resident #1's quarterly (MDS) Minimum Data Set 3.0 assessment, dated [DATE], indicated the resident had a (BIMS) Brief Interview for Mental Status score of 15 (cognitively intact). The MDS also indicated the resident was independent with transfers, ambulation, toileting and personal hygiene. The MDS further indicated the resident received no oxygen therapy and had no shortness of breath or trouble breathing. The [DATE] care plan directed the staff to report changes in the resident's health status to the physician as needed. The care plan also directed the staff to administer medications to the resident as ordered by the physician. The [DATE] at 4:45 PM, nurse's note indicated the resident had a temperature of 100.8 degrees and received 2 tablets of Tylenol 500 (mg) milligrams (per the [DATE] physician's orders [REDACTED]. The [DATE] at 10:25 PM, nurse's note indicated the resident had a temperature of 103.5 degrees and received 2 tablets of Tylenol 500 mg for elevated temperature. The [DATE] at 6:30 AM, nurse's note indicated the resident's voice was hoarse and the resident had a sore throat. The [DATE] at 1:25 PM, nurse's note indicated the resident had a temperature of 103.5 degrees and received 2 tablets of Tylenol 500 mg (15 hours after the last temperature check and dose of fever medication). The [DATE] at 2:20 PM, nurse's note indicated the facility notified the physician and received an order to administer [MEDICATION NAME] (anti-influenza medication) 75 mg, twice a day, for 5 days to the resident. The [DATE] at 8:40 PM, nurse's note indicated the resident had an elevated temperature of 103.9 degrees and received 2 tablets of Tylenol 500 mg (7 hours after the last temperature check and dose of fever medication). The [DATE] at 3:30 AM, nurse's note indicated the resident had an elevated temperature of 101.5 degrees and received 2 tablets of Tylenol 500 mg (7 hours after the last temperature check and dose of fever medication). The [DATE] at 1:00 PM, nurse's note indicated the staff assisted the resident to the bathroom due to his/her weakness. The [DATE] at 2:40 PM, nurse's note indicated the resident had an elevated temperature of 102.8 degrees and received 2 tablets of Tylenol 500 mg (11 hours after the last temperature check and dose of fever medication). review of the resident's medical record revealed [REDACTED]. [DATE] - ,[DATE] [DATE] - ,[DATE] [DATE] - ,[DATE] [DATE] - ,[DATE] [DATE] - ,[DATE] [DATE] - ,[DATE] [DATE] - ,[DATE] [DATE] at 6:20 AM - ,[DATE] (normal ,[DATE]) [DATE] at 2:40 PM - ,[DATE] [DATE] at 9: 45 PM - ,[DATE] review of the resident's medical record revealed [REDACTED]. The [DATE] at 9:45 PM, nurse's note indicated the resident had an elevated temperature of 102.7 degrees and received 2 tablets of Tylenol 500 mg (7 hours after the last temperature check and dose of fever medication). The nurse's note also indicated the resident had an oxygen level of 81 percent (oxygen levels below 88 percent indicate respiratory distress). The nurse' s note indicated the staff provided oxygen to the resident at 3 liters/minute per a nasal cannula. review of the resident's medical record revealed [REDACTED]. The [DATE] at 6:30 AM, nurse's note indicated the resident continued to receive oxygen at 3 liters/minute. The nurse's note also indicated the resident complained of his/her upper chest muscles hurting. Continued review of the nurse's note revealed no documentation the staff further assessed the resident's lung sounds, although the resident had discomfort. The [DATE] at 3:40 PM, nurse's note indicated the resident's oxygen level was 91 percent on 3 liter/minute oxygen Continued review of the nurse's note revealed no documentation the staff further assessed the resident's lung sounds, although previously the resident had complained of his/her upper chest muscles hurting. The [DATE] at 10:00 PM, nurse's note indicated the resident was confused and had an oxygen level of 90 percent on 3 liter/minute. Continued review of the nurse's note revealed no documentation the staff further assessed the resident's lung sounds. The [DATE] at 6:35 AM, nurse's note indicated the staff found the resident deceased in his/her room. review of the resident's medical record revealed [REDACTED]. Continued review of the resident's medical record revealed [REDACTED]. distress. On [DATE] at 3:41 PM, Nurse B stated the staff should closely monitor and assess changes in the resident's condition such as elevated temperatures and respiratory distress. Nurse B also stated the staff should notify the physician to ensure the resident received the appropriate cares and treatments. On [DATE] at 8:11 AM, Nurse C stated the staff should frequently assess and record the resident's elevated temperatures and respiratory distress. Nurse C also stated medications for elevated temperatures should be administered as ordered by the physician. Nurse C further stated the staff should provide comprehensive assessments and notify the physician when the resident had elevated temperatures and/or respiratory distress. On [DATE] at 9:44 AM, Nurse D stated the facility had no standing orders or policies to direct the staff to notify the physician when a resident had changes in condition. Nurse D also stated the staff should administer medications as physician ordered to control elevated temperatures. Nurse D further stated the staff should provide comprehensive assessments when the resident had changes in condition and notify the physician. The facility failed to adequately monitor, thoroughly assess, provide consistent interventions and to promptly obtain medical intervention for Resident #1, who had significant respiratory distress without physician notification. The facility's failure to adequately monitor, thoroughly assess, provide consistent interventions and to promptly obtain medical intervention placed Resident #1 and #2 in immediate jeopardy. The immediate jeopardy was abated on [DATE], when the facility implemented policy and procedures for Acute Change in condition (ACOC); assessing and identifying its nature, severity and cause (s); physician and responsible party notification; monitoring the resident's response to the treatment implemented for ACOC; documentation of assessment findings, actions taken and resident response to the treatments implemented including the effectiveness of as needed medications. The facility implemented the CMS (Center for Medicare and Medicaid Services) INTERACT SBAR Communication Form and Progress Note, INTERACT Care Paths, (dehydration, fever, change in mental status, symptoms of lower respiratory infections and symptoms of UTIs (urinary tract infections) and "when to notify the physician", will be posted at each nurses station. a "hot rack" sticker will be implemented for residents who are to be monitored each shift. The facility Director of Nursing and Medical Director have established parameters for physician notifications which will be posted at each nursing station. The facility completed implementation of the new policies and procedures and inservice of the staff on [DATE]. The deficient practice remains at a scope and severity of a G.

The facility had a census of 50 residents. The sample included 4 residents. Based on record review and interview the facility failed to adequately assess elevated temperatures, changes in condition and respiratory distress and notify the physician for 2 sampled residents. (#1 and #2) Findings included: - Review of the [DATE] Physician's Progress Note for Resident #2 indicated his/her lungs were clear and the resident had no respiratory distress or health concerns. Resident #2's quarterly (MDS) Minimum Data Set 3.0 assessment, dated [DATE], indicated the resident had a (BIMS) Brief Interview for Mental Status score of 7 (severe impairment) with physical and verbal behaviors and inattention. The MDS also indicated the resident was independent with eating, transfers, ambulation, dressing, toileting and personal hygiene. The MDS further indicated the resident received no oxygen therapy and had no shortness of breath or trouble breathing. The [DATE] care plan directed the staff to report changes in the resident's health status to the physician as needed. The care plan also directed the staff to administer medications to the resident as ordered by the physician. The [DATE] at 11:20 PM, nurse's note indicated the staff noted the resident was stumbling around his/her room. The nurse's note also indicated the resident had an elevated temperature of 100.8 degrees and received 2 tablets of Tylenol 325 (mg) miligrams (per the physician's orders [REDACTED]. The [DATE] at 4:30 PM, nurse's note indicated the resident had an elevated temperature of 102.2 degrees and received 2 tablets of Tylenol 325 mg. review of the resident's medical record revealed [REDACTED]. The [DATE] at 10:25 PM, nurse's note indicated the resident had a dry, nonproductive cough. The [DATE] at 5:00 AM nurse's note indicated the resident had laid on the floor 2 times this shift and required two staff assistance to transfer from the floor. The [DATE] at 6:00 AM, nurse's note indicated the resident had an elevated temperature of 102.6 degrees and received 2 tablets of Tylenol 325 mg (14 hours after the last dose of Tylenol 650 mg for fever). The [DATE] at 1:00 PM, nurse's note indicated the resident was lethargic and weak and the staff had to assist the resident with sitting up and "fed the resident" (resident usually independent with transfers, positioning and eating). The nurse's note also indicated the resident had a loose stool and an elevated temperature of 103.1 degrees (7 hours after the last temperature check and dose of fever medication). The [DATE] at 1:15 PM, nurse's note indicated the resident had a dry, nonproductive cough and received 2 tablets of Tylenol 325 mg. The [DATE] at 2:15 PM, nurse's note indicated the resident was confused, refused to stay in bed and kept stumbling around his/her room. The nurse's note also indicated the resident had pulse a 116 of (elevated - normal pulse 60 to 80), respirations 20 and temperature 104.1 degrees. The [DATE] at 3:15 PM, nurse's note indicated the nurse witnessed the resident stumble backwards, fall and hit his/her head. The nurse's notes indicated the resident's neurological assessment was within normal limits and the resident had a blood pressure ,[DATE], pulse 122, respirations 22 and temperature 103.8 degrees. The [DATE] at 5:00 PM, neurological assessment indicated the resident had a blood pressure ,[DATE], pulse 112, respirations 22 and temperature 103.6 degrees (4 hours after last dose of Tylenol 650 mg for fever). review of the resident's medical record revealed [REDACTED]. The [DATE] at 10:00 PM, nurse's note indicated the resident had an elevated temperature of 104.1 degrees (9 hours after last dose of Tylenol 650 mg for fever). review of the resident's medical record revealed [REDACTED]. The [DATE] at 6:10 AM, nurse's note indicated the resident needed assistance to sit up in bed and was unable to ambulate safely. The nurse's note indicated the resident had a blood pressure ,[DATE], pulse 96, respirations 28 (elevated - normal respirations 16 to 20 per minute), temperature 103.3 degrees (17 hours after last dose of Tylenol 650 mg for fever). The nurse's note indicated the staff administered 2 tablets of Tylenol 325 mg to the resident. The Neurological Assessment Flow Sheet indicated the staff assessed the resident for the following elevated respirations: [DATE] at 6:00 PM - 26 respirations [DATE] at 10:00 PM - 26 respirations [DATE] at 2:00 AM - 24 respirations [DATE] at 6:00 AM - 28 respirations [DATE] at 10:00 AM - 34 respirations review of the resident's medical record revealed [REDACTED]. The [DATE] at 7:45 AM, nurse's note indicated the facility received a physician's orders [REDACTED]. Review of the resident's medical record lacked any documentation from [DATE] to [DATE], the facility notified the physician regarding the resident's change in condition. The [DATE] at 12:45 PM, nurse's notes indicated the resident was unresponsive, had rhonchi (coarse, abnormal lung sounds) in both lungs and oxygen levels were 76 percent (oxygen levels below 88 percent indicate respiratory distress). On [DATE] at 12:50 PM, nurse's notes indicated the staff called 911 and notified the emergency room and the physician. On [DATE] at 1:18 PM, Emergency Department Nursing Assessment indicated the resident was unresponsive and had an elevated temperature of 104.0. The assessment also indicated the resident had rapid, labored respirations with use of accessory muscles and crackles (coarse, abnormal sounds) in both lungs. The assessment further indicated the resident had a [DIAGNOSES REDACTED]. The [DATE] at 12:15 AM, nurse's note indicated the resident had died at the hospital. On [DATE] at 3:41 PM, Nurse B stated the staff should closely monitor and assess changes in the resident's condition such as elevated temperatures and respiratory distress. Nurse B also stated the staff should notify the physician to ensure the resident recieved the appropriate cares and treatments. On [DATE] at 8:11 AM, Nurse C stated the staff should frequently assess and record the resident's elevated temperatures and respiratory distress. Nurse C also stated medications for elevated temperatures should be administered as ordered by the physician. Nurse C further stated the staff should provide comprehensive assessments and notify the physician when the resident had elevated temperatures and/or respiratory distress. On [DATE] at 9:44 AM, Nurse D stated the facility had no standing orders or policies to direct the staff to notify the physician when a resident had changes in condition. Nurse D also stated the staff should administer medications as physician ordered to control elevated temperatures. Nurse D further stated the staff should provide comprehensive assessments when the resident had changes in condition and notify the physician. The facility's failure to notify the physician of elevated temperatures, changes in condition and respiratory distress for Resident #2 caused the resident harm due to an unnecessary delay for the resident to recieve treatment. - Resident #1's quarterly (MDS) Minimum Data Set 3.0 assessment, dated [DATE], indicated the resident had a (BIMS) Brief Interview for Mental Status score of 15 (cognitively intact). The MDS also indicated the resident was independent with transfers, ambulation, toileting and personal hygiene. The MDS further indicated the resident received no oxygen therapy and had no shortness of breath or trouble breathing. The [DATE] care plan directed the staff to report changes in the resident's health status to the physician as needed. The care plan also directed the staff to administer medications to the resident as ordered by the physician. The [DATE] at 4:45 PM, nurse's note indicated the resident had a temperature of 100.8 degrees and received 2 tablets of Tylenol 500 (mg) milligrams (per the [DATE] physician's orders [REDACTED]. The [DATE] at 10:25 PM, nurse's note indicated the resident had a temperature of 103.5 degrees and received 2 tablets of Tylenol 500 mg for elevated temperature. The [DATE] at 6:30 AM, nurse's note indicated the resident's voice was hoarse and the resident had a sore throat. The [DATE] at 1:25 PM, nurse's note indicated the resident had a temperature of 103.5 degrees and received 2 tablets of Tylenol 500 mg (15 hours after the last temperature check and dose of fever medication). The [DATE] at 2:20 PM, nurse's note indicated the facility notified the physician and received an order to administer [MEDICATION NAME] (anti-influenza medication) 75 mg, twice a day, for 5 days to the resident. The [DATE] at 8:40 PM, nurse's note indicated the resident had an elevated temperature of 103.9 degrees and received 2 tablets of Tylenol 500 mg (7 hours after the last temperature check and dose of fever medication). The [DATE] at 3:30 AM, nurse's note indicated the resident had an elevated temperature of 101.5 degrees and received 2 tablets of Tylenol 500 mg (7 hours after the last temperature check and dose of fever medication). The [DATE] at 1:00 PM, nurse's note indicated the staff assisted the resident to the bathroom due to his/her weakness. The [DATE] at 2:40 PM, nurse's note indicated the resident had an elevated temperature of 102.8 degrees and received 2 tablets of Tylenol 500 mg (11 hours after the last temperature check and dose of fever medication). review of the resident's medical record revealed [REDACTED]. [DATE] - ,[DATE] [DATE] - ,[DATE] [DATE] - ,[DATE] [DATE] - ,[DATE] [DATE] - ,[DATE] [DATE] - ,[DATE] [DATE] - ,[DATE] [DATE] at 6:20 AM - ,[DATE] (normal ,[DATE]) [DATE] at 2:40 PM - ,[DATE] [DATE] at 9: 45 PM - ,[DATE] review of the resident's medical record revealed [REDACTED]. The [DATE] at 9:45 PM, nurse's note indicated the resident had an elevated temperature of 102.7 degrees and received 2 tablets of Tylenol 500 mg (7 hours after the last temperature check and dose of fever medication). The nurse's note also indicated the resident had an oxygen level of 81 percent (oxygen levels below 88 percent indicate respiratory distress). The nurse' s note indicated the staff provided oxygen to the resident at 3 liters/minute per a nasal cannula. review of the resident's medical record revealed [REDACTED]. The [DATE] at 6:30 AM, nurse's note indicated the resident continued to receive oxygen at 3 liters/minute. The nurse's note also indicated the resident complained of his/her upper chest muscles hurting. Continued review of the nurse's note revealed no documentation the staff further assessed the resident's lung sounds, although the resident had discomfort. The [DATE] at 3:40 PM, nurse's note indicated the resident's oxygen level was 91 percent on 3 liter/minute oxygen Continued review of the nurse's note revealed no documentation the staff further assessed the resident's lung sounds, although previously the resident had complained of his/her upper chest muscles hurting. The [DATE] at 10:00 PM, nurse's note indicated the resident was confused and had an oxygen level of 90 percent on 3 liter/minute. Continued review of the nurse's note revealed no documentation the staff further assessed the resident's lung sounds. The [DATE] at 6:35 AM, nurse's note indicated the staff found the resident deceased in his/her room. review of the resident's medical record revealed [REDACTED]. Continued review of the resident's medical record revealed [REDACTED]. distress. On [DATE] at 3:41 PM, Nurse B stated the staff should closely monitor and assess changes in the resident's condition such as elevated temperatures and respiratory distress. Nurse B also stated the staff should notify the physician to ensure the resident recieved the appropriate cares and treatments. On [DATE] at 8:11 AM, Nurse C stated the staff should frequently assess and record the resident's elevated temperatures and respiratory distress. Nurse C also stated medications for elevated temperatures should be administered as ordered by the physician. Nurse C further stated the staff should provide comprehensive assessments and notify the physician when the resident had elevated temperatures and/or respiratory distress. On [DATE] at 9:44 AM, Nurse D stated the facility had no standing orders or policies to direct the staff to notify the physician when a resident had changes in condition. Nurse D also stated the staff should administer medications as physician ordered to control elevated temperatures. Nurse D further stated the staff should provide comprehensive assessments when the resident had changes in condition and notify the physician. The facility's failure to notify the physician of elevated temperatures, changes in condition and respiratory distress for Resident #1 caused the resident harm due to an unnecessary delay for the resident to recieve treatment.