Every finding on record at Apex Secure Care Brownfield

Based on observation, interview, and record review, the facility failed to establish and maintain an effective Infection Control Program designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable diseases and infections for 2 of 11 residents (Resident #32 and Resident #36) reviewed for infection control. LVN A provided wound care to Resident #32 with contaminated supplies: scissors and dermal wound cleanser (often no-rinse spray solutions designed to remove dirt, debris, and exudate from acute and chronic wounds) after she had used the same supplies to provide wound care for Resident #36 who had a positive wound culture on 4/8/26 for STREPTOCOCCUS AGALACTIAE (GROUP-B) (an opportunistic bacteria that can cause skin and soft tissue infections, including cellulitis, abscesses, and occasionally, severe necrotizing infections) and STAPHYLOCOCCUS AUREUS ( a bacteria that can cause infections ranging from minor skin abscesses to life-threatening bloodstream infections).LVN A failed to follow enhanced barrier precautions and hand hygiene practices when providing wound care for Resident #32 and Resident #36. The facility failed to implement EBP for Resident #36 after receiving a positive wound culture on 4/8/2026. An Immediate Jeopardy (IJ) was identified on 4/13/2026 at 4:50pm. The IJ template was provided to the facility Administrator on 4/13/2026 at 4:56pm. While the immediate jeopardy was lifted on 4/14/2026 at 5:01pm, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated, because all nursing staff had not been trained on 4/14/2026. These failures could place residents at risk for infection and cross contamination of pathogens and illness, which could lead to worsening of their condition, hospitalization, or death. Findings include: Resident #36Record review of Resident #36's face sheet revealed a [AGE] year-old male originally admitted to the facility on [DATE]. Resident #36 had a medical history of Alzheimer's disease (a progressive, irreversible brain disorder), chronic venous hypertension with ulcer of right lower extremity and left lower extremity (chronic, often painful, sores on the leg or ankle resulting from poor circulation), type 2 diabetes and chronic obstructive pulmonary disease (a progressive, incurable lung disease). Record review of Resident #36's quarterly MDS assessment dated [DATE] Section C- Cognitive Patterns revealed a BIMS score of 5 which indicated Resident #36's cognition was severely impaired. Record review of Resident #36's care plan revealed [Resident #36] have stasis ulcers to BLE r/t [related to] lymphedema (tissue swelling) .enhanced barrier precautions. Staff members will wear a clean gown and gloves while performing high contact resident care activities to include: .providing wound care last revised on 4/06/2026. Record review of Resident #36's physician orders reviewed on 4/13/2026 at 10:58am reveal no order for enhanced barrier precautions. Resident #36 had an order for wound care to the bilateral lower extremities, with a start date of 4/07/2026. Resident #36 had an order for clindamycin (antibiotic used to treat serious bacterial infections, including skim infections) 300mg Give 1 capsule by mouth four times a day for + [positive] culture to stasis ulcers to BLE for 7 Days. Record review of Resident #36's progress note from 4/05/2026 at 1907 [7:07pm] revealed sent info to [MD], DON, ADON on resident's wounds to, BLE shins. right wound 15cm x 15cm x 1.2cm raised wound. Left wound 18cm x 24cm x 1.2cm raised wound. slight drainage from both wounds with slight smell. warm to touch. C/O (complained of) pain when wounds are cleaned and wounds are pressed down. LVN [E] can not feel pedal pulse. BLE generalized edema from knees down to feet. wound seem to be growing up the leg slightly. mostly growing around the thigh toward the back of the leg. can feel some small nodules around the back. [MD] contacted this LVN [E], that he would see resident tomorrow when making his round. signed by LVN E. Progress note from 4/08/2026 at 1749 [5:49pm] revealed stasis wounds are staph + [positive], ADON has notified [MD] waiting for new orders signed by LVN A. Record review of Resident #36's wound test results revealed STAPHYLOCOCCUS AUREUS- DETECTED and STREPTOCOCCUS AGALACTIAE (GROUP-B)- DETECTED with a date reported of 4/08/2026. Resident #32Record review of Resident #32's undated face sheet revealed a [AGE] year-old female originally admitted to the facility on [DATE]. Resident #32 had a medical history of dementia, pressure ulcer of left buttock stage 2 (a shallow, open wound), and muscle weakness. Record review of Resident #32's quarterly MDS dated [DATE] Section C- Cognitive patterns revealed a BIMs score of 99 which indicated Resident #32 was unable to complete the interview. Section C1000 Cognitive Skill for Daily Decision Making revealed Resident #32 was severely impaired and never/rarely made decisions. Record review of Resident #32's physician orders dated 4/04/2026 revealed Cleanse left lower buttocks with wound cleanser.daily and PRN. Physician order dated 4/13/2026 revealed an order for EBP for Resident #32. Record review of Resident #32's care plan dated 4/13/2026 revealed [Resident #32] have a pressure ulcer to left buttock.enhanced barrier precautions, staff members will wear a clean gown and gloves while performing high contact resident care activities to include. providing wound care. During a wound care observation for Resident #36 on 4/13/2026 at 9:42am, LVN A gathered dermal wound cleanser spray, gauze, 3 packets of kerlix (crinkle-weave gauze dressing), 1 large calcium alginate (a highly absorbent wound dressing), and approximately 8 packets of xeroform (a non-adherent, petrolatum-impregnated gauze dressing) from treatment cart A. Resident #36 did not have EBP sign or PPE available outside or inside of the room. LVN A placed the supplies on Resident #36's bedside table, that was not cleaned prior to use. LVN A put on a clean gloves and used the dermal wound cleanser spray directly on Resident #36 bilateral legs, spraying the wound sites multiple times to saturate the wounds (spraying wound cleanser directly onto a wound can potentially contaminate the bottle nozzle if the spray nozzle touches the skin or if splash-back from the wound hits the nozzle). LVN A cleaned the legs with gauze and removed her gloves. LVN A put on a new pair of gloves without using hand hygiene in between. LVN A utilized the scissors to open the xeroform packets for the right leg. LVN A placed the xeroform onto Resident #36's right leg, and touched the wound to ensure the dressing fully covered the wound. LVN A used the scissors multiple times to open the remaining packages of xeroform for the left leg and dressed the left leg. LVN A did not change her gloves or use hand hygiene before applying wound dressings to the right leg. LVN A completed wound care with Resident #36, and after removing her contaminated gloves and using hand hygiene, LVN A grabbed the contaminated scissors and dermal wound cleanser spray and placed them on treatment cart A. LVN A placed the dermal wound cleanser inside treatment cart A on the bottom drawer. LVN A did not use EBP during Resident #36's wound care. LVN A did not sanitize the scissors before or after use with Resident #36. During a wound care observation for Resident #32 on 4/13/2026 at 10:07am, LVN A gathered supplies from treatment cart A. LVN A gathered gauze, skin barrier cream, scissors and dermal wound cleaning spray. LVN A grabbed the same contaminated scissors and dermal wound cleaning spray that were utilized during wound care for Resident #36. LVN A entered Resident #32's room, along with the contaminated items, and placed them on the dresser beside Resident #32's bed. Resident #32 had a sign for EBP and PPE was hanging on Resident #32's door, visible upon entering the room. LVN A put on gloves (LVN did not utilize a gown while providing wound care) and grabbed the wound supplies and contaminated scissors from the dresser and placed them directly on Resident #32's bed. LVN A removed dirty dressing from Resident #32s wound, and grabbed the dermal wound cleanser bottle, spraying directly onto Resident #32's wound. LVN A used her right hand and cleaned the wound with gauze. LVN A grabbed gauze with her left hand and grabbed the dermal wound cleanser spray with her contaminated right hand and sprayed it onto the gauze. LVN A changed her gloves, but did not use hand hygiene between glove changes. LVN A completed wound care and removed her gloves, but did not use hand hygiene. LVN A grabbed the contaminated scissors and contaminated dermal wound cleansing spray and placed them on [NAME] of treatment cart A. LVN A placed the contaminated bottle of dermal wound cleansing spray back into the bottom drawer of treatment cart A. During an interview on 4/13/2026 at 12:02pm, LVN A stated she had been trained on infection control and the infection preventionist was the ADM. She stated she did not know when her last in-service on wound care or infection control was, but she felt they did them all the time. She stated about a week ago, the ADM had gone over EBP and what it was for and when to use it. She stated EBP was for staff to utilize gowns and gloves when providing any care that had contact with bodily fluids. She stated she was not sure if EBP was needed for wound care, but if it did not have bodily fluids then she would only wear gloves. She stated she believed Resident #36 and Resident #32 did have EBP signs on their doors, but because she didn't handle bodily fluids, she only wore gloves. She stated she obviously did not wear a gown for wound care for Resident #32 or Resident #36. She stated she had changed her gloves during wound care but did not use hand hygiene but her hands were not visibly soiled, so she didn't believe she needed to. LVN A stated Resident #36 currently had an active staph infection (bacterial skin infection) to his legs and that was why she was doing wound care on Resident #36's legs. She stated she had received the results of his wound cultures (a laboratory test that identifies bacteria) the week prior but was unsure what treatment he was on. She stated she was not sure if taking the dermal wound cleanser was right or wrong because no one had told her she couldn't do that. She stated she used the same spray for all the residents. She stated she did not think it came in contact with the resident's wounds so it wouldn't be contaminated. She stated she usually cleaned her supplies after use, but was not aware she had not cleaned her scissors when she took them into Resident #32's room. She stated she had not used the scissors during Resident #32's wound care, but she had grabbed them and brought them into Resident #32's room after she used them in Resident #36's room. She stated she thought she had cleaned the wound cleansing spray after use with Resident #36 but was not sure if she had or not. She stated she was not aware she contaminated the bottle when doing wound care with Resident #36 or Resident #32 by grabbing it after cleaning or touching the wounds. She stated the potential negative outcome of not following infection control practices could be spreading bacteria, especially if they have an infection. She stated by not using EBP she could spread bacteria between residents. She stated she was aware Resident #36 had the infection, and she could potentially spread the same infection to other residents. She stated she felt she could spread infection between residents by not cleaning the dermal wound cleanser or the scissors between residents use. She stated everything the dermal wound cleanser came into contact in treatment cart A could be contaminated. During an interview on 4/13/2026 at 2:51pm with the ADON, he stated they did not have a DON at that time. He stated staff had been trained on infection control and wound care. He stated the training typically covered contact precautions, PPE, EBP, and hand hygiene. He stated Resident #36 had stasis ulcers (a slow-healing, shallow wound usually occurring on the lower leg) to bilateral legs, and he was being treated for an infection to those wounds. He stated he expected staff to utilize EBP for any wound care. He stated if equipment was used between residents, it should be cleaned before and after use. He stated the dermal wound cleanser spray should not have been taken into the room. He stated staff should have prepped their wound supplies outside the room and placed the gauze inside a clean cup and saturated the gauze with dermal wound cleansing spray to use during wound care. He stated the dermal wound cleanser should not have been placed back into the treatment cart, as it was contaminated after use in Resident #36's room. He stated he should have ensured the EBP signs and PPE were placed, but staff should also know that any wound care required EBP. He stated the potential risk of using contaminated supplies or equipment between residents could be infection of another residents' open wound or spreading the same bacteria to another resident. He stated staff should be utilizing hand hygiene between glove changes to prevent the spread of infection. He stated that infection control was monitored through resident assessments, infection trends, and physician rounding. During an interview on 4/13/2026 at 3:08pm with the ADM, he stated he was currently the infection preventionist. He stated the infection control training or in-service training was done as needed. He stated he did have an in-service on 1/09/2026 for standard precautions and infection control. He stated he had also reviewed EBP with the nursing staff approximately one week ago. He stated the facility used EBP to prevent the spread of infection and it was used on residents who had invasive devices, or who had wounds. He stated any equipment used inside residents' rooms, should be sanitized after use and before use on another resident. He stated dermal wound cleanser should not be used inside the rooms during wound care because it would be considered cross contamination. He stated staff should spray the gauze inside of a cup when they were prepping for the wound care. He stated EBP meant staff should use gowns and gloves before starting care, and removing it before exiting the room. He stated hand hygiene should be used between glove changes and before and after care. He stated Resident #36 was on EBP due to his bilateral stasis ulcers to his lower extremities (legs). He stated he believed he did have drainage coming from the wounds and staff should have used EBP. He stated staff should utilize EBP on any wound regardless of an infection or not. He stated the incident was a systemic failure and Resident #36 should have been on EBP. He stated LVN A had been trained on infection control and should have worn the EBP with Resident #36 and Resident #32. During an interview on 4/13/2026 at 3:50pm with the MD, he stated LVNA A shouldn't have taken those items into the resident's room without following EBP and infection control policies. He stated the policies were there to prevent infection, and although Resident #36's wounds were caused by a common bacteria, LVN A should have still utilized universal knowledge. Record review of the facility's policy titled Enhanced Barrier Precautions dated August 2022 revealed Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply.a. Gloves and gowns are applied prior to performing the high contact resident care activity (as opposed to before entering the room).b. Personal protective equipment (PPE) is changed before caring for another resident.c. Face protection may be used if there is also a risk of splash or spray.3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: .h. wound care (any skin opening requiring a dressing).5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization.10. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required.11. PPE is available outside of the resident rooms. Record review of the facility's policy titled Standard Precautions revised October 2018 revealed: Policy StatementStandard Precautions are used in the care of all residents regardless of their diagnoses, or suspected or confirmed infection status. Standard Precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. 2. Gloves.h. After gloves are removed, wash hands immediately to avoid transfer of microorganisms to other residents or environments.5. Resident-Care Equipmenta. Resident-care equipment soiled with blood, body fluids, secretions, and excretions are handled in a manner that prevents skin and mucous membrane exposure, contamination of clothing, and transfer of microorganisms to other residents and environments.b. Reusable equipment is not used for the care of more than one resident until it has been appropriately cleaned and reprocessed.c. Single use items are properly discarded. The ADM was notified an IJ situation was identified due to the above failures on 4/13/2026 at 4:56pm and the IJ template was provided, and plan of removal was requested. The following Plan of Removal was accepted on 4/13/2026 at 6:58pm: Document the facility's actions taken to remove the immediacy in an IJ or IT situation *- Must address the specific failure(s) that caused or led to the IJ /IT -Incident that occurred due to nurse failure to follow policy and procedures for infection control and wound care. *- Must be actions the facility has DONE (not are going to do) to remove the threat - LVN A was immediately removed / suspended from direct patient care and wound care duties. *Must have dates of completion for each component - Inhouse training complete 4/14/26; Wound Care Competencies to be completed 4/14/26 Inservice and training to be complete prior shift begins by Assistant Director; All EBP signs will be placed by Director of Nursing / ADON and taking off by DON / ADON. Infection control monitoring will throughout the night by Charge Nurse. *Must address the specific resident(s) affected by the IJ/IT - what has the facility done to protect them? - Conduct an immediate clinical assessment of Resident #32 and Resident #36 for any signs or symptoms of localized or systemic infection. Notify the attending physician and family of the findings and the breach in protocol. *- Must address who else could be affected by the IJ/IT - has the facility determined that anyone else could be affected? Have they assessed other residents? -Facility residents with infections and wounds have the potential of being affected by this alleged deficient practice. Assessments completed 4/13/26 upon alleged deficient practice. *- Should address any policy review/update/creation to address the situation - Mandatory in-service for all nursing staff regarding: Infection Control Policy, Enhanced Barrier Precautions (EBP): ensuring EBP is initiated on residents who meet criteria. Correct use of personal protective equipment (PPE), specifically gown and glove use for residents with chronic wounds or MDROs. Hand Hygiene: Strict adherence before and after resident contact and dressing changes. Immediately remove the contaminated supplies (scissors, wound cleaner). Ensure all multi-use wound care equipment is either discarded or undergoes high-level disinfection per manufacturer and CDC guidelines. On 4/14/2025 the state surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by:Record review of facility document titled Employee Disciplinary Report Action dated 4/13/2026 revealed [LVN A] was suspended on 4/13 Specific reasons .Employee failed to follow job performance after serval in-services and training. Employee failed to ensure infection control protocols were followed and adhere to; Employee failed to provide privacy while providing wound care. Record review of facility documentation titled Wound Care- Competency Assessment revealed ADON, LVN B, LVN C, and LVN E had completed competency assessment for wound care on 4/14/2026. The competency assessment revealed the following areas of assessment included preparation, equipment and supplies, steps in the procedure, documentation and reporting. Record review of facility document titled Infection Control Monitoring dated 4/13/2026 6pm-4/14/2026 6am revealed LVN B monitored for infection control practices, EBP, and PPE and no concerns for infection control were observed during those hours. Record review of facility progress note for Resident #32 dated 4/13/2026 at 1748 [5:48pm] revealed, wound observed and noted to have no s/s of infection, granulated tissue noted, skin intact around wound with no s/s of infection signed by the ADON. Record review of facility progress note for Resident #36 dated 4/14/2026 at 7:15am revealed, resident wound noted to be dry with no drainage, noted to be without any s/s of infection.resident denied pain at this time signed by the ADON. Record review of facility progress note for Resident #32 dated 4/13/2026 at 1632 [4:32pm] revealed received call back from resident family and this nurse notified [family member] of finding found during wound care. [family member] voiced appreciation. This nurse notified [family member] of MD order to monitor site of infection and notify him of findings. Voiced appreciation signed by the ADON. Record review of facility progress note for Resident #36 dated 4/14/2026 at 11:07am revealed [family member] made aware of recent abx [antibiotic] therapy that has been in place since positive culture. [family member] also made aware of barrier precautions that will be in place until wound resolved, voiced appreciation. No questions asked signed by the ADON. During an observation and interview on 4/14/2026 at 10:53am, Treatment Cart A wound care supplies had been discarded along with dermal wound spray. The ADON stated they had cleaned and sanitized the drawer and would be restocking it with new clean supplies. During observations conducted on 4/14/20256 between 3:00pm-4:00pm revealed Residents #1,2,32,36,40,46,3,50,54,4 and 63 had EBP signs outside of their rooms and PPE available for use during high contact resident care.Record review of the physician orders for Residents #1,2,32,36,40,46,3,50,54,4 and 63 revealed they all had an order for enhanced barrier precautions. Record reviews of residents with active wound treatments revealed Residents #1, 3, 54, 32 and 36 did not have signs and symptoms of infection on 4/14/2026.Record review of facility in-service titled Handwashing/Hand Hygiene; Standard precautions; infection prevention policies and practices/enhance barrier precautions dated 4/13/2026 revealed 30 staff signatures. The in-service document revealed ensuring EBP is initiated on residents who meet criteria. Correct use of [PPE], specifically gown and glove use for residents with chronic wounds or MDRO's. Hand hygiene: strict adherence before and after resident contact and dressing changes. Immediately remove the contaminated supplies (scissors, wound cleaner). Ensure all multi- use wound care equipment is either discarded or undergoes high level disinfection per manufacturer and CDC guidelines. During interviews conducted on 4/14/2026 from 2:35pm- 4:33pm revealed the ADON, LVNs A,B,C,E,G, CNAs H,J,L,P,R,T,U,X and CMAs S,W had been trained on infection control practices. They stated they had been trained to utilize hand hygiene between glove changes and before and after any resident care. They stated EBP was initiated for residents who have wounds, invasive devices or a history of infections. They stated the potential negative outcome of not utilizing infection control practices could be spreading infection between residents and staff members. They stated they had been trained in putting on and removing PPE. They stated if they knew a resident had a wound or invasive device and there were no PPE or EBP signs, they would notify the ADON and follow up to ensure all precautions were implemented. They stated any equipment used between residents such as scissors, or blood pressure cuffs must be cleaned before and after use with the sanitizing wipes and allowed to airdry before using on a resident to prevent the spread of infection. They stated if they were responsible for wound care they would ensure dermal wound spray would be kept outside the room and used the spray on the gauze before entering the room as part of their wound preparation. They stated dermal wound spray should not be taken into the resident's room and used directly on the wound as it could potentially lead to cross contamination. On 4/14/2026 at 5:01pm, the Administrator was notified that the IJ was removed. However, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public, in 1 of 1 dining rooms, 1 of 2 dry pantries (Dry Pantry A), around 1 of 1 nursing stations and 1 of 7 Hallways (Hall C), in that: The facility failed to ensure the dining room floors were in good condition.The facility failed to ensure the dining room ceiling was in good condition and not leaking.The facility failed to ensure Dry Pantry A's ceiling was in good condition and not leaking.The facility failed to ensure the floors around the nursing station were in good condition.The facility failed to ensure Hall C did not have water damage on the ceiling tiles outside Room C9. These failures could lead to resident injuries, falls, spread of infections and cause the facility to have an unsightly appearance. The findings include: Observations on 04/12/26 beginning at 9:58 AM, revealed the dining room was noted to have an area on the ceiling near the kitchen that was leaking water with 3 buckets on the floor with water noted in each bucket, 2 blankets were noted on the floor around the buckets and Caution Wet signs were noted around the water on the floor. The dining room floors were noted to have large white/black scratches/marks in several different areas on the brown flooring. The dry pantry area in the kitchen next to the dining room was noted to have an area on the ceiling that was slowly leaking water with 2 buckets noted on the floor with water in the buckets. Observation on 04/12/26 at 11:25 AM, revealed the floors around the nursing station were noted to have several areas of white/black marks on the brown flooring. Interview on 04/12/26 at 1:06 PM, the Maintenance Supervisor stated the ceiling had started leaking this weekend (04/11/26) with the rain. The Maintenance Supervisor stated the area was blocked off from the residents. The Maintenance Supervisor stated he had been working with a roofing company in town and was waiting for them to give a quote to fix the roof damage. Observation on 04/13/26 at 11:26 AM in C Hall, revealed brown water spots noted on 5 ceiling tiles outside Room C9. During a confidential family interview on an undisclosed dated at an undisclosed time revealed the facility was in bad shape and dirty. Interview on 04/14/26 at 1:35 PM, the Maintenance Supervisor stated the floors in the dining room and around the nursing station, he was working on pieces to get them replaced. The Maintenance Supervisor stated some areas on the floors were walked on a lot by residents and family members and their wheelchairs. The Maintenance Supervisor stated the roof and ceilings were a problem and a company had gone out about a month or two ago and he was still waiting for them to contact him with the quote. The Maintenance Supervisor stated the leaking areas were blocked off to the residents, so no one slipped. Interview on 04/14/26 at 2:44 PM the ADM stated the facility had spoken with two companies regarding the roof damage and it had been a while since they had gone back and forth, asking the Maintenance Supervisor about it needing the estimates. The ADM stated last week there was still no reply and he did not know what the hold-up was. The ADM stated the Maintenance Supervisor was trained on repairs, but he would start fixing one thing and then another area would need immediate attention. The ADM stated the building was old and had chronic issues. The ADM stated a potential negative outcome to the residents was a bad appearance or not homelike. Record review of the facility document titled, Maintenance Work Order Log from 3/16/26 to present revealed: 4/12 - Roof in dining room leaking Record review of the facility's policy titled, Maintenance Service, with a revised date of 12/09 reflected the following: Policy Statement: Maintenance service shall be provided to all areas of the building, grounds, and equipment.Policy Interpretation and Implementation:1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.2. Functions of maintenance personnel include, but are not limited to:a. maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines.b. maintaining the building in good repair and free from hazards .3. The maintenance director is responsible for developing and maintaining a schedule of maintenance services to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner.

Based on interviews and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week in the facility for 6 (10/4/2025, 10/5/2025, 10/11/2025, 10/12/2025, 10/19/2025, and 11/9/2025) of 67 days reviewed for RN coverage. The facility failed to maintain RN coverage of eight hours a day for 6 days. This failure could place residents at risk of not having their nursing and medical needs met and receiving improper care.Findings included: Record review of the facility's employee survey roster dated 4/12/26 revealed there were three RNs employed at the facility. Record review of Punch Detail Reports, dated 10/4/2025, 10/5/2025, 10/11/2025, 10/12/2025, 10/19/2025, and 11/9/2025, revealed there were no hours logged for RN coverage. Record review of an email dated 4/13/2026 at 10:53 AM, revealed the ADM's response to the surveyor read, unfortunately, facility did not have RN coverage dates requested, when punch-in details for RN coverage were requested for 10/4/2025, 10/5/2025, 10/11/2025, 10/12/2025, 10/19/2025, and 11/9/2025. During an interview on 4/15/26 at 3:42 PM, the ADM stated he was aware there was no RN coverage for 6 days in October and November 2025 He stated the RN who was scheduled to work chose not to work on those days. He stated the RN was contracted to work at the facility through an agency they had a contract with. The ADM stated the facility policy required RN coverage 7 days a week for 8 hours per day. He stated there currently was no DON employed at the facility. He stated he had hired a new DON who would start soon. He stated the facility DON resigned without notice on 4/09/2026. He stated the DON usually monitored RN coverage and would contact an agency to ensure there was RN coverage. He stated staff had been trained in RN coverage requirements. He stated there was a DON employed at the facility during the time RN coverage was not met. He stated he expected there to be RN coverage daily or filled by the DON. He stated a potential negative outcome was that there would be lack of supervision from an RN to ensure quality of care and quality of life to every resident. He stated the punch details sheets he had would reflect no hours for RN Coverage on those dates. During an interview on 4/15/26 at 4:54 PM, the BOM stated the documents provided for RN coverage on the dates requested had the date at the top of the document and were blank to show there was no RN coverage on those dates. Record review of the policy provided by the facility titled, Registered Nurse, undated, revealed the following: Purpose: Ensure that a Registered Nurse is available for supervision in the facility. Procedure: Except when waived, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week.

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served in a safe and sanitary manner to prevent cross contamination and the potential for foodborne illness for (64 of 64) residents reviewed for food and nutrition services. 1. The facility failed to ensure opened food items open in the refrigerator and dry storage areas were labeled with the open or use by date.2. Food transportation carts were dirty.3. Clean plates, serving utensils, and pans were stored facing upwards stored on a table.4. The facility failed to ensure staff followed hygienic practices for proper hand hygiene and use of hair restraints.5. The facility failed to ensure [NAME] D used gloved hands instead of utensils to handle prepared food, 6. Bleach, lime scale, and soak tank concentrate were stored on the floor in the food prep area. These failures could place residents at risk for food contamination and foodborne illness. Findings include: On 4/12/26 at 9:58 AM an initial kitchen observation tour began. The tour ended at 10:44 AM and revealed the following:Outside the kitchen door were two food tray carts. Cart A had brown /sticky substances on 1 slot and light brown substance on 4 slots. Cart B had red liquid substance on 3 slots, and sticky dried food on bars to push carts.In front of the refrigerator #1 a package of opened precooked sausage patties in an opened plastic bag without an open or use by date and not stored in the refrigerator or freezer. There was a 5-gallon bucket of kosher dill slices - keep refrigerated on the label on the bucket. The following items were inside refrigerator #1. The items had been opened and did not have an open or use by date:1 opened container of Silk Almond milk 1 opened bag of cheddar cheeses shredded, the top of the bag was turned down but not in a sealed container.1 opened container of Lyon's ready care thickened sweetened tea 1 opened bag of 5 cheese pizza blend with the top of the bag rolled over and not in a sealed container.1 opened and undated jar Dijon mustard 1 opened bag of lunch meat dated 4/7, that did not indicate if it was date opened or use by date. 3 opened blocks of sliced cheese. 2 of 3 were stored in a clear storage bag without an opened or used by date, and 1 of 3 blocks was opened, undated, and not in a sealed container. 1 opened bag of American cheese shredded with the top of the bag rolled over and not in a sealed container. The following items were observed unsealed, without an open or use by date in the dry pantry:1 opened bag of tortilla round chips, not stored in a sealed container, undated, with the top of the bag rolled down. 1 opened jar of granulated garlic without an opened or use by date1 opened container of black pepper without an opened or use by date1 opened container of onion powder without an opened or used by date1 opened bottle of classic syrup cinnamon without an open or use by date2 opened containers of salt free seasoning without an opened or use by date. 1 of 2 was sticky to touch1 opened gallon of sweet red chili wing sauce without an open or use by date and label indicated best flavor refrigerates after opening2 opened, 1-gallon containers of liquid butter, without an opened or use by date1 opened gallon Worcestershire sauce without an opened or use by date1 opened gallon of golden Italian dressing without an opened or use by date2 opened 1/2 gallon bottles of sweet and sour sauce without an opened or use by date. Bottle labeled refrigerate after open 1 opened gallon canola oil without an opened or use by date1 opened container of dried parsley flakes without an opened or use by date1 opened 1.5 lb. container whey protein without an opened or use by date1 opened 7.9 lb. container of chicken bouillon without an opened or use by date2 unopened packages of dinner rolls, with an expiration date of 3/17/26 and without a date received and had an expiration date of 3/17/261 unopened case of individual containers of orange juice with received date 4/10/26 the label indicated keep frozen on a shelf thaw overnight in 38 F cooler The following items were opened in the freezer without an open date or use by date:1 opened bag of frozen burritos not in a sealed container and without an opened or use by date1 opened bag country fried breaded beef patty not in a sealed container without an open or use by date The following equipment was observed in the kitchen stored in unsanitary ways:1 4 slice toaster with brown residue spots2 sticky medium size plates1 stack of large plates and 1 stack of divided plates sitting right side up2 clear containers containing serving utensils stored with serving surfaces up outside of the container. 1 stack of clear lids that was visibly wet, stored stacked and wet inside.1 reusable water bottle under the three-compartment sink Refrigerator #2 did not have a thermometer inside and the last date the temperature was checked was 4/9/26.Freezer #3 did not have a current temperature log last date the temperature was checked 4-9-26. Sitting on the floor near the sink by the dishwasher:1 gallon bleach 1 gallon Lime scale1 gallon of soak tank concentrate During an observation on 4/12/26 at 10:30 AM, the DM took the temperature of the kosher pickles in the 5 gallon bucket the temperature was 72 Fahrenheit. An observation on 4/12/26 at 12:01 PM of the lunch meal service revealed:12:01 PM [NAME] B put on new gloves without preforming any hand high before she started the puree cornbread. 12:03 PM [NAME] B with gloves on, touched the lid of trash can, then opened the oven door, picked up oven mitts and took the pan of chopped ham out of the oven. [NAME] B removed the oven mitts and started to remove the pan liner from the chopped ham and tempted the ham at 165 F. The pan liner fell on the floor and picked it up and placed it back in the box. 12:09 PM [NAME] B began to serve the lunch meal, placed new gloves on hands, but did not practice hand hygiene before she put the new gloves on. 12:11 PM Dietary Aide C entered the kitchen without a hair restraint on and did not wash his hands. He walked behind [NAME] B and went around the kitchen and entered the office. Dietary Aide C walked out of the office, put a hair restraint on and then walked around the kitchen to the hand-washing sink and washed his hands. 12:20 PM Dietary Aide C put gloves on, grabbed two bags of sliced bread and placed them on the prep table. He walked to the refrigerator, removed a container of lunch meat and sliced cheese. He returned to the prep table and placed the sliced bread on the pan liner. He opened the container of lunch meat and placed one slice on one slice of bread. He returned to the refrigerator and took out another bag of lunch meat. He walked back to the prep table, picked up a knife, opened the package of lunch meat with the knife, and continued to take slices of lunch meat out of the container and placed it on slices of bread. He opened the container and removed sliced cheese and placed cheese on the sliced bread. He picked up a coffee cup that had keys attached and exited the kitchen wearing gloves. He returned to the kitchen wearing the same gloves and had two additional bags of bread. He placed the bags of bread on the prep table and set the coffee cup with keys on it on another prep table. He went to the refrigerator and removed 2 plastic clear bins with lids on them and placed them on the prep table, removed his gloves and washed his hands. He replaced his gloves and returned to the prep table and cut the sandwiches and placed them in one of the clear containers. He picked up the two bags of bread, opened them and placed sliced bread out on a pan liner to make peanut butter and jelly sandwiches. He picked up the grape jelly that was sitting on the shelf behind the prep table and started to squeeze jelly on the bread. He walked to the dry pantry and grabbed another grape jelly returned to the prep table, opened the jelly and continued making sandwiches. He stepped away from the prep table and returned with a rubber spatula, smeared the jelly on the bread, then placed the rubber spatula in the peanut butter, and smeared peanut butter over the jelly. He continued this process until the sandwiches were done. Jelly residue was observed inside the container of peanut butter. Dietary Aide C then used the same knife, he cut the meat and cheese sandwiches, to cut the peanut butter and jelly sandwiches. During an observation on 4/13/26 at 5:15 PM, the evening meal was served. [NAME] D did not use utensils for the bun, fish patty, and chicken nuggets. [NAME] D touched plates, meal tickets and handles of other serving utensils then used her gloved hand to serve the bun, fish patty, and chicken nuggets. She did not change gloves after handling non-food items and handling ready-to-eat food items. During an interview on 4/12/26 at 10:24 AM, [NAME] B stated she threw the sausage patties in the trash. She stated that she forgot to place them back in the refrigerator and they had been sitting out for about one hour. [NAME] B stated she had been trained to put things up or residents could get sick. She stated the DM was unable to get a temperature for the sausage patties because staff threw them away. During an interview on 4/12/26 at 10:32 AM, the DM stated, with the 5-gallon bucket of kosher dill pickles, he bought the kind that didn't require refrigeration. He then looked at the label and stated, keep refrigerated. He stated the last time they used the pickles was 2-3 weeks ago when they had hamburgers. He stated he was not sure why the freezer did not have a thermometer in it because they usually do. He stated that when they receive the case of frozen orange juice containers, it took about 5 days for them to thaw so they leave them sitting out in the dry pantry area so they will thaw faster. He stated they did not follow the recommendations on the case of orange juice that said to thaw overnight in 38 F cooler. He stated that process took too long and the case of orange juice had been sitting in the dry pantry area since Friday 4/10/26. He stated, as far as frozen items were not stored properly in the freezer, they used the breaded beef patty on 4/29/26, and the burritos were alternate food and used often. During an interview on 4/12/26 at 12:35 PM, the DM stated there were a few residents that asked for peanut butter and jelly sandwiches in the morning. He stated he thought maybe staff left the jelly out that they had forgotten to put it in the refrigerator. The DM temped the grape jelly and it was 76.3 F. During an interview on 4/13/26 at 8:49 AM, the DM stated, per policy, everything in the kitchen should have a received date, opened date and they kept most items 7 days after they were opened. He stated they use a first in first out rotation. He stated as far as the food items are not labeled or dated, they used a different tag and maybe they fell off. He stated he was not sure why dietary staff did not label and date opened food items. He stated they could serve expired food and residents could get sick. He stated the ADM was going to order something for them to hang the serving utensils on so staff would not touch the serving ends. He stated for now staff would place the serving utensils in the dishwasher before they used them. He stated it was everyone's responsibility to make sure food was labeled and dated correctly. During an interview on 4/14/26 at 1:51 PM, the DM stated staff should practice hand hygiene when they entered the kitchen, go from clean to dirty or the task changed. Staff would need to remove gloves and wash their hands before putting gloves back on. DM stated staff have been trained to practice hand hygiene. DM stated he thought maybe staff were nervous and frantic and they forgot. He stated staff should have done everyday practices, and follow the rules set for the kitchen. He stated staff were trained and in-serviced in storing food appropriately. He stated staff told him the reason they had not labeled the opened food items with dates was they didn't have pens or didn't know where labels were located. He stated staff told him the reason they did not refrigerate some of the food, that was labeled refrigerate after opened, was there was not enough room in the refrigerator. He stated food borne illness could happen if food was served at the incorrect temperature. He stated if staff did not perform proper hand hygiene it could cause cross contamination. He stated chemicals stored in the kitchen, should be stored away from food and off the floor a little bit, that way the chemicals could not leak into any food. He stated he planned to move the chemicals off the floor. He stated there was not enough room on that storge shelf to store all the chemicals. He stated the chemicals were not stored appropriately at that time. He stated staff cleaned the floors every day after every meal. He stated the staff in the kitchen probably didn't see that reusable water bottle was on the floor under the 3-compartment sink. He stated staff should have noticed the reusable water bottle when they cleaned. He stated when staff did not use utensils when they served buns, fish patties, and chicken nuggets, [NAME] D forgot. He stated he discussed, with the staff, that utensils had to be used to prevent cross-contamination. He stated it was his responsibility to monitor staff, and make sure they followed sanitation practices in the kitchen. He stated he monitored that; he watched staff do their work but would monitor them even more. During an interview on 4/14/26 at 3:25 PM, ADM stated staff should label food with the appropriate dates. He stated staff should store food appropriately, and refrigerate after it is opened, if required. He stated unlabeled and undated food could cause food borne illness, and cross contamination. He stated staff should have practiced hand hygiene when they worked in the kitchen and handled food. He stated staff failure to do so could cause cross-contamination. He stated staff should use utensils when they serve ready-to-eat food and not use their hands with a glove. He stated staff did not follow the facility's policy for sanitation of kitchen, handling food, or storing food properly. During a telephone interview on 4/14/26 at 4:16 PM with Dietary Aide C, he stated he worked in the kitchen for 2 years. Dietary Aide C stated he received training on washing his hands and he washed them when he entered the kitchen, and if he touched something with his gloves, he should have taken them off and washed his hands. He stated there was no excuses for him not practicing hand hygiene on 4/12/26. He stated, residents could get sick or get something bad. He stated he was in-serviced and trained to label and date food when opened. He stated he was not sure why food was not dated, because they had labels and were supposed to use them. He stated he did read labels to see if items needed to be refrigerated once opened. During a telephone interview on 4/14/26 at 4:32 PM, [NAME] B stated she was in-serviced on dating and labeling opened food in the kitchen, and didn't know why food was opened and not dated. She stated, some staff do it and some don't. She stated she knew about hand hygiene and knew when to wash her hands before she handled any food items when she changed to a different job, or when dirty, and that her hands were so dry from washing them. She stated she was nervous on 4/12/26, during meal service, and she just forgot to wash her hands when she was changing gloves. She stated that not washing her hands could cause residents to get sick with nausea and vomiting. She stated she was not sure why chemicals were on the floor in the kitchen chemicals should have been stored on the racks, not on the floor She stated that staff cleaned the kitchen after each meal. Record review of the labels for the chemicals stored on the floor revealed the following:Lime scale, multipurpose lime scale remover, to avoid food contamination during application and storage. Do not store in food processing areas.Clorox Germicidal Bleach- Danger, keeps out of reach of children. Deluge soak tank concentrate - Medical emergency, warning causes eye irritation. Keep out of reach of children. Record review of the facility's policy Food and Nutrition Services dated 2001 Revised October 2017 reflected:Policy Statement Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident.Policy Interpretation and Implementation .b. Foods that are left without a source of heat (for hot foods) or refrigeration (for cold foods) longer than 2 hours will be discarded. Record review of the facility's policy Food Preparation and Service dated 2001 Revised April 2019Policy Statement Food and nutrition services employees prepare and serve food in a manner that complies with safe food handling practices. Policy Interpretation and ImplementationFood Preparation Area .5. Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness.Thawing Frozen Food .1. Foods will not be thawed at room temperature. Thawing procedures include:Thawing in the refrigerator in a drip-proof container.Completely submerging the item in cold running water (70 F or below) that is running fast enough to agitate and remove loose ice particles;Thawing in a microwave oven and then cooking and serving immediately; orThawing as part of a continuous cooking process. Food Preparation, Cooking and Holding Time/Temperatures .1. The danger zone for food temperatures is between 41 F and 135 F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illnesses.3. The longer foods remain in the danger zone the greater the risk for growth of harmful pathogens. Therefore, PHF must be maintained below 41 F or above 135 F. Food Service/Distribution Bare hand contact with food is prohibited. Gloves are worn when handling food directly and changed between tasks. Disposable gloves are single-use items and are discarded after each use.3.Food and nutrition services staff, including nursing services personnel, wash their hands before serving food to residents. Employees also wash their hands after collecting soiled plates and food waste prior to handling food trays.6. Food and nutrition services staff wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food. Record review of the facility's policy Sanitization dated 2001 revised October 2008Policy StatementThe food service area shall be maintained in a clean and sanitary manner.1. All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects.1. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners will be kept in good repair.16. Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime.17. The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment.Texas Food Establishment Rules The container of ready-to-eat food shall be marked to indicate the date by which food shall be consumed on the premises, sold or discarded, The ready -to-eat food if held at 41 degrees Fahrenheit can only be held for a maximum of 7 days, with day of preparation being day 1.

Based on observation, interview, and record review, the facility failed to ensure each resident had a right to a safe, clean, comfortable, and homelike environment in the facility and failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior in 3 of 24 resident rooms (E2, E9, and F3) and 1 of 1 areas for visitation reviewed for environment. 1. The facility failed to ensure residents that used common areas and rooms were clean, safe, and did not need repair. 2. The facility failed to have a designated visitation area with adequate seating for visitors and residents. These failures could place residents at risk of living in an unsafe, unclean, uncomfortable, and unhomelike environment which could cause a decline in resident psychosocial well-being.The findings included: During an observation and interview on 4/12/26 at 10:32 AM, Resident #37 in room F3 said there was water leaking from the ceiling in his room and he worried about the ceiling falling down. Resident #37 stated he hated the leak in the ceiling and that it needed to be repaired because it was ugly. Observation revealed a thick layer of paint on the ceiling in front of the closet that was bubbled out with a couple of large holes in the paint. Water was observed dripping from the holes in the bubbled paint. During an observation on 4/12/26 at 10:54 AM in room E9 it was revealed to be occupied by two residents. A hole in the ceiling above the bed near the window that was approximately 1 to 2 inches long. Additionally, the restroom sink was filled with dark grey water. There was nothing observed in the sink to prevent the water from draining. During an observation on 4/12/26 at 11:20 AM in room E2 it was revealed to be occupied by one resident. A thick layer of paint on the ceiling in front of the window that was bubbled out with a large hole in the paint. Water was observed dripping from the hole in the bubbled paint and along the privacy curtain rails that were secured to the ceiling. Record review of a document titled, Maintenance Work Order Log, undated, revealed no repair requests for ceiling repairs in rooms E2, E9, and F3. Additionally, there was no repair request for a stopped-up sink in room E9. During a confidential interview on 4/13/26 at 12:01 PM a visitor stated they were concerned that the facility was dirty and needed to be cleaned, updated, and needed new paint. They stated the only place to sit for visitors was outside and that was not always an option. They stated that sitting outside got too hot at times and people smoked outside and they were allergic to the smoke. They stated it would be nice if the facility had chairs available for visitors to sit in inside the facility. During an interview on 4/14/26 at 2:52 PM, the MS stated he assessed the building for daily repairs that included the floors, rooms, ceilings, and all other basic repairs needed. He stated all staff were trained to write repairs needed in the maintenance logbook that was kept at the monitoring station. He stated all pending and completed repairs were logged in the maintenance logbook. He stated the timeframe of a repair being made was prioritized based on the nature of the request. The MS stated the ADM also reviewed the maintenance log monthly. He stated he was responsible for ensuring repairs were completed. He stated he was not sure if there was a policy regarding repairs. The MS stated he was aware about a month ago of a leak in the ceiling of a resident room on E-hall. He stated he was not aware of leaks in any other resident rooms. The MS stated he called a roofing company to get quotes about a month ago and they had not gotten back to him. He stated he called them again today and was told they would come sometime today to look at the roof. The MS stated he was not aware of the stopped-up sink in room E9. He stated he had repaired the hole in the ceiling in room E9, but the rain damaged the repair he made, and it began to leak again. He stated he believed the roof needed to be repaired to stop the leaks. The MS stated he would fix the sheetrock in the ceilings after the roof was repaired because it would damage repairs made to the ceilings as long as the roof continued to leak. He stated staff had in-services once a month, and he also reminded his staff weekly that he expected them to log all repairs needed in the logbook even if they verbally told him about the issue. He stated his direct staff were the Monitoring Technicians and housekeeping staff. The MS stated he had a meeting about his expectations of logging and reporting repairs with staff last Wednesday (04/08/26). He stated he was not aware of the complaints about not having a place with chairs for residents to sit with visitors. He stated visitors usually visited residents in their rooms or the dining room, and there was also a gazebo outside they could visit at. He stated he was not aware of complaints about the facility not being clean. The MS stated the housekeeping staff cleaned rooms daily. He stated he inspected rooms after staff cleaned them to ensure they had been cleaned after he received complaints. He stated there were residents that put food and stuffed paper down the sinks which caused them to get stopped up, however that was the nature of what happened at the facility. He stated a potential negative outcome was that water leaks could cause a fall. The MS stated stopped up sinks caused bad odors, and sitting water could grow bacteria which could cause infection on skin that had an open cut. The MS stated it was important for there to be a clean environment and inviting visitation area because this was the residents' home and it was important that the facility felt comfortable for them. The MS stated visitors were important because they help residents to not feel abandoned, so it was important for them to have a clean space with chairs to visit that had some privacy. He stated the chairs were important as they encouraged visitors to visit the residents. During an interview on 4/14/26 at 3:42 PM, the ADM stated assessing the building for repairs was done daily by all staff. The ADM stated he expected staff to write all repairs needed in the maintenance logbook as that was their system to monitor all needed and completed repairs. He stated any urgent matters needed to be reported to himself or the MS. He stated the MS was responsible for ensuring all repairs were completed timely and the timeliness of repairs being completed was based on the nature of how extensive the repair was. He stated for example, a leak in the wall was about 3 days minimum, however a leak in a resident's rooms needed to be repaired immediately but the leaks in the ceiling would continue to be an issue because the roof was old and needed repairs. He stated he was told a repairman would come today or tomorrow to try and fix roof. He stated the roof needed to be fixed first before ceiling could be fixed. He stated the MS would fix the ceilings once the roof was fixed. He was not aware resident's rooms had leaks, and he was not aware the sink was backed up in a resident's room. He stated the MS was responsible for fixing ceilings and clogged sinks. He stated he was not aware there were complaints about the lack of seating and not having a clean area for visitation. He stated he was only aware of one regular visitor as there were not many visitors at the facility. He stated visitors could visit outside in the front of the building or the gazebo area outside. He stated there was the front lobby or the residents' rooms where people could visit. He stated visitors could also meet with residents in the dining room. He stated there was no private area for them to visit. He stated there were a couple of recliners in the lobby for people to sit and staff could bring chairs from the dining room if visitors requested them. He stated it was important for there to be chairs for visits to sit in so they could visit with their loved ones and it was also important to have a sitting area so the visitation experience could be more homelike. The ADM stated a potential negative outcome of leaks in the ceiling was that the ceiling could fall and hurt someone or a resident. He stated stopped up sinks were a sanitation and hygiene issue. He stated not having a sitting area could prevent families from being able to spend quality time with their loved one. Record review of the facility policy, Housekeeping, undated, revealed the following in part: Purpose: Establish standards of cleanliness and consistency in the way in which resident rooms and common areas are cleaned and maintained. The facility will be cleaned on a regular basis according to a specified cleaning schedule and according to Federal/state guidelines. 2. Resident Rooms- Resident's room floors are to be clear of spills, stains, and debris.- Porcelain sinks are to be free of cracks, chips, or stains.- Sink drainpipes are to be free of dust and dirt.- If nursing personnel notice any of these sanitary violations occurring in the resident's room, housekeeping and/or maintenance should be notified promptly. Record review of the facility policy, Safe Environment, undated, revealed the following in part: Purpose: The resident has a right to a safe, clean, comfortable and homelike environment1 including but not limited to receiving treatment and supports for daily living safely.Procedure: This facility will provide -Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. 1. A safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.2. Housekeeping and maintenance services necessary to maintain a sanitary, including, but not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored, orderly (uncluttered physical environment that is neat and well-kept) and comfortable interior.

Based on observation, interview and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 21 residents (Resident #32) reviewed for respect and dignity.LVN A failed to provide privacy for Resident #32 when LVN A failed to close the window blinds, the door, or the privacy curtain during wound care. This failure could place residents at risk of emotional distress, embarrassment, and lower self-esteem.Findings include: Record review of Resident #32s undated face sheet revealed a [AGE] year-old female originally admitted to the facility on [DATE]. Resident #32 had a medical history of dementia, pressure ulcer of left buttock stage 2 (a shallow, open wound), and muscle weakness. Record review of Resident #32's quarterly MDS dated [DATE] Section C- Cognitive patterns revealed a BIMs score of 99 which indicated Resident #32 was unable to complete the interview. Section C1000 Cognitive Skill for Daily Decision Making revealed Resident #32 was severely impaired and never/rarely made decisions. During a wound care observation on 4/13/2026 at 10:07am, revealed LVN A entered Resident #32's room and performed wound care to Resident #32's left buttock. LVN A did not close the door to Resident #32's room which allowed any staff, visitor or wandering resident to enter the room. Resident #32 was visible from the hallway. LVN A did not close the privacy curtain between Resident #32 and Resident #23, the roommate, who was sleeping in the room, facing away from Resident #32. LVN A did not close the window blinds, that had direct view to the street and to the facility exterior premises. During an interview on 4/13/2025 at 6:27pm with LVN A, she stated she had been trained to provide privacy but was unsure of her last training. She stated she did not close the door, but she had pulled the curtain enough so Resident #32 was not visible from the hallway. LVN A stated she did not close the curtain between Resident #32 and Resident #23 because Resident #23 was sleeping and was rolled the other direction. LVN A stated, I never close the windows or the blinds because it is a locked facility anyways. LVN A stated the purpose of providing privacy to residents during care was to for dignity and because no one wants to be exposed. LVN A stated a potential negative outcome of not providing privacy to residents could be residents feeling embarrassed or exposed. On 4/13/2026 at 6:44pm an interview was attempted with Resident #32. Resident #32 was not cognitively intact and was not interviewable.During an interview on 4/14/2026 at 3:13pm with the ADM, he stated he expected the staff to provide full privacy when providing care. He stated privacy meant having the door closed, the blinds closed and the privacy curtain pulled. He stated he was unsure if LVN A had been trained on privacy and dignity. He stated LVN A's actions were careless. He stated the potential negative outcome would be dignity issues for the residents. He stated they did not have a policy for privacy/dignity, but they had a quality-of-life policy that had information related to privacy and dignity. Record review of facility policy titled Quality of life- Dignity last revised February 2020, revealed; Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem. 10. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. 11. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents. 12. Staff are expected to treat cognitively impaired residents with dignity and sensitivity.

Based on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food that was palatable, attractive and at a safe, and appetizing temperature for 3 of 3 food forms (Regular, Mechanical Soft, and Pureed) for 1 of 1 (Dinner) meal reviewed for food and nutrition services. The facility failed to provide food that was palatable for the dinner meal on 04/13/26. This failure could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings included: During confidential individual interviews 2 of 10 residents voiced concerns related to food palatability. One resident stated the food was cold. One resident stated the food was not good. Observation on 04/13/26 at 6:03 PM the test trays arrived at the family dining room and were sampled by three surveyors at 6:05 PM with the following results: Regular Meal - Regular TextureFish Sandwich - mushy texture, freezer tasteTator tots - cold/lukewarmSalad - okay Regular Meal - Mechanical Soft TextureFish - lukewarm beans - cold Regular Meal - PureeFish - okay, smoothTator tots - lukewarmBeans - okay, smooth During an interview on 04/14/26 at 2:33 PM, the DM stated he tasted the food before and after it was served about two to three times a month. The DM stated he also asked the residents about the food and had not heard a lot of negative feedback. The DM stated he was always in contact with the Dietician regarding the food and he was trained to follow the recipe. The DM stated a potential negative outcome to the residents was it could cause food borne illness if the food was cold or malnutrition if they did not want to eat all of it. During an interview on 04/14/26 at 2:44 PM, the ADM stated he expected the food to be tasteful, at an appetizing temperature and presentable. The ADM stated he tasted the food every once in a while. The ADM stated the DM had been trained on food palatability periodically. The ADM stated the Dietician had been out to the facility recently and he was still awaiting her report on the kitchen services. The ADM stated a potential negative outcome to the residents was they could get sick. Record review of the facility's policy titled, Food and Nutrition Services, with a revised date of 10/17 reflected the following: Policy Statement: Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident.Policy Interpretation and Implementation:.7. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature.

Based on observation, interview and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition in 1 of 1 kitchen, in that: The facility failed to ensure the kitchen oven door remained closed and secure. This failure could place residents at risk for receiving unevenly cooked meals and at risk for fire emergencies.The findings included: During the initial kitchen observation on 04/12/26 beginning around 10:09 AM, the left oven door was opened, and a cardboard square came out from between the bottom of the stove and the top of the oven door and fell on the floor. The oven door did not close and had about two to three inches gap between the door and the stove.During an interview on 04/12/26 at 10:25 AM, [NAME] B stated the spring went out on the oven door about two to three weeks ago. [NAME] B stated she thought it had been reported. [NAME] B stated they had been using the cardboard square to help keep the oven door closed all of the way. During an interview on 04/14/26 at 1:35 PM, the Maintenance Supervisor stated he was aware of the broken oven door and he would get it fixed that day. The Maintenance Supervisor stated he asked the staff to write all repairs in the maintenance log, so he did not forget them. The Maintenance Supervisor stated that the oven door needed a spring, but he would find another way to keep the oven door closed without using the cardboard square. During an interview on 04/14/26 at 2:33 PM, the DM stated the left oven door had a broken spring. The DM stated the left oven door has been broken for about a month. The DM stated he was using towels to help keep the oven door closed, but the kitchen staff was using a cardboard square. The DM stated the maintenance supervisor did know about the broken oven door. The DM stated the facility had ordered a spring to fix the broken door, but he was not able to find an invoice related to it. The DM stated a potential negative outcome to the residents was that their food could not be cooked thoroughly or some of it could be burned. During an interview on 04/14/26 at 2:44 PM the ADM stated he expected the kitchen equipment to be operational and functional. The ADM stated the left oven door had been an issue and the DM had told him it needed a new spring. The ADM stated he would need more information on the oven to order a spring for the door due to how old the oven was. The ADM stated a potential negative outcome to the residents was bad food, food that was not fully cooked or was burned. Record review of the facility's policy titled, Maintenance Service, with a revised date of 10/09 reflected the following: Policy Statement: Maintenance service shall be provided to all areas of the building, grounds, and equipment.Policy Interpretation and Implementation:1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.

Based on observations, interviews, and record reviews, the facility failed to ensure the hallways were equipped with firmly secured handrails on each side for 1 of 6 (Hall C) hallways reviewed in that: The facility failed to ensure the handrail in Hall C between Rooms C3 and C4 was firmly attached to the wall. This failure could lead to resident injuries or falls. The findings include: Observation on 04/13/26 at 10:12 AM, the handrail in C Hall between Rooms C3 and C4 was noted to be loose/wobbly and not firmly attached to the wall. Interview on 04/14/26 at 1:35 PM, the Maintenance Supervisor stated he did not know about the handrail in C Hall or the water damage on the ceiling tiles. The Maintenance Supervisor stated if it was not written in the Maintenance logbook, then he did not know about it. The Maintenance Supervisor stated a resident could fall with a loose handrail. Interview on 04/14/26 at 2:44 PM, the ADM stated the Maintenance Supervisor was trained on repairs, but he will start fixing one thing and then another area will need immediate attention. The ADM stated the building was old and had chronic issues. The ADM stated a potential negative outcome to the residents was a bad appearance or not homelike. Record review of the facility document titled, Maintenance Work Order Log from 3/16/26 to present revealed no work orders related to the handrail between Rooms C3 and C4. Record review of the facility's policy titled, Maintenance Service, with a revised date of 12/09 reflected the following: Policy Statement: Maintenance service shall be provided to all areas of the building, grounds, and equipment.Policy Interpretation and Implementation:1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.2. Functions of maintenance personnel include, but are not limited to:a. maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines.b. maintaining the building in good repair and free from hazards .3. The maintenance director is responsible for developing and maintaining a schedule of maintenance services to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner.

Based on interviews and record review, the facility failed to maintain sufficient nursing staff with appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 5 (LVN C) nursing staff reviewed in that: The facility failed to ensure LVN C maintained an active nursing license while working as a nurse. The failure could place residents at risk of receiving care from an unlicensed professional. The findings include: Record review of the facility employee records on [DATE] at 4:20 PM, revealed LVN C had an LVN/LPN license with an expiration date of [DATE]. Record review of the facility's punch-detail report from [DATE] to [DATE] revealed the following:LVN C worked:[DATE] - 11.1 hours[DATE] - 11.08 hours[DATE] - 11.93 hours[DATE] - 11.17 hours[DATE] - 12.07 hours[DATE] - 9.07 hours[DATE] - 5.0 hours[DATE] - 10.92 hours[DATE] - 3.03 hours[DATE] - 12.82 hours Interview on [DATE] at 4:33 PM, the BOM stated that she had checked LVN C's license and the expiration date was correct. The BOM stated LVN C was sent home yesterday ([DATE]) when the facility checked her license and showed that it was expired. The BOM stated it was her responsibility to check the nursing staff's licenses and certificates. The BOM stated she checked the license for the nursing staff upon hire and that was how she was trained. The BOM stated it could be a problem for the residents if their nurse did not have a current license. Interview on [DATE] at 4:38 PM, the ADM stated the BOM was responsible for checking the license/certificate for the nursing staff. The ADM stated he expected all licensed individuals to be up to date when required. The ADM stated the BOM had been trained to check the employees' licenses regularly. The ADM stated a potential negative outcome to the residents was that they could be dealing with someone who did not have a license. Record review of the facility's policy titled, Licensure, Certification, and Registration of Personnel, with a revised date of 04/07 reflected the following: Policy Statement: Employees who require a license, certification, or registration to perform their duties must present such verification with their application for employment.Policy Interpretation and Implementation1. Personnel who require a license, certification, or registration to perform their duties must present verification of such license/certification/registration to the human resources director/designee prior to or upon employment.2. A copy of the current license, certification, or registration number must be filed in the employee's personnel record.3. A copy of recertifications (e.g. annual, bi-annual, etc., as applicable) must be presented to the human resources director/designee upon receipt of such recertifications and prior to the expiration of current licensure, certification, and/or registration. A copy of the recertification must be filed in the employee's personnel record.

Based on observation, interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 8 of 16 residents (Residents #1, #2, #3, #4, #5, #6, #7, #8) reviewed for clinical records. The facility failed to ensure evening medications refused by Residents #1, #2, #3, #4, #5, #6, #7 and #8 were accurately documented in the Medication Administration Record by CMA A, on 09/21/25. This failure could place residents at risk of not receiving the intended therapeutic effects of their medications and could contribute to possible adverse reactions.Findings include: 1. Record review of Resident #1's, undated, face sheet revealed in part, an [AGE] year-old female with an original admission date of 08/27/24. Resident #1 had diagnoses which included: unspecified dementia (loss of cognitive functioning), unspecified severity with other behavioral disturbance and Intermittent Explosive Disorder (mental health condition characterized by sudden, intense episodes of anger or aggression). Record review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS score of 99, which indicated the resident's cognitive status could not be determined using the BIMS assessment as the assessment may have been completed properly or the resident required a different evaluation method to assess cognitive function. Record review of Resident #1's active physician orders, as of 10/01/2025, revealed in part: Mirtazapine Oral Tablet 7.5mg, give one at bedtime for appetite stimulation, start date 10/07/24. Olanzapine Oral Tablet, give 2.5mg one by mouth at bedtime related to Intermittent Explosive Disorder, start date 03/22/25. Divalproex Sodium Oral Capsule Delayed Release Sprinkle 125mg, Give 4 capsules two times daily related to Intermittent Explosive Disorder, start date 03/22/25. Record review of Resident #1's Medication Administration Record, dated 09/01/25-09/30/25, revealed in part CMA A documented the following medications as taken by the resident on 09/21/25: Mirtazapine 7.5mg Give one at bedtime for appetite stimulation, start date 10/07/24 at 1900 (7:00PM). Olanzapine 2.5mg Give one at bedtime related to Intermittent Explosive Disorder, start date 03/22/25 at 1900 (7:00PM). Divalproex 125mg Give 4 capsules twice daily related to Intermittent Explosive Disorder, start date 03/22/25 at 1900 (7:00PM). 2. Record review of Resident #2's, undated, face sheet revealed in part, a [AGE] year-old male with an original admission date of 07/31/25. Resident #2 had the following diagnoses which included: anoxic brain damage, not elsewhere classified (brain injury), cognitive communicate deficit (inability to communicate), and tremor unspecified (involuntary shaking). Record review of Resident #2's annual MDS, dated [DATE], revealed a BIMS score of 05, which indicated the resident's cognitive ability was severely impaired. Record review of Resident #2's active physician orders, as of 09/30/2025, revealed in part: Sinemet Oral Tablet 25/100mg (Carbidopa/Levodopa), Give one two times daily related to tremor, unspecified, start date 07/31/25. Record review of Resident #2's Medication Administration Record, dated 09/01/25-09/30/25, revealed in part CMA A documented the following medications as taken by the resident on 09/21/25: Sinemet Oral Tablet 25/100mg (Carbidopa/Levodopa), Give one two times daily related to tremor, unspecified, start date 07/31/25 at 1900 (7:00PM). 3. Record review of Resident #3's, undated, face sheet revealed in part, a [AGE] year-old male with an original admission date of 09/02/22. Resident #3 had the following diagnoses: Bipolar disorder, current episode manic without psychotic features, severe (mental health disorder), intermittent explosive disorder (mental health condition characterized by sudden, intense episodes of anger or aggression), and hyperlipidemia, unspecified (plaque in the blood vessels). Record review of Resident #3's annual MDS, dated [DATE] revealed a BIMS score of 02, which indicated the resident's cognitive ability was severely impaired. Record review of Resident #3's active physician orders, as of 10/01/2025, revealed in part: Carbamazepine ER Oral Tablet Extended Release 12-hour 400mg. Give one tablet by mouth every 12 hours related to bipolar disorder, current episode manic without psychotic features, severe, do not crush or chew, start date 01/05/24. Depakote Oral Tablet Delayed Release 125mg (Divalproex Sodium). Give one tablet two times a day related to intermittent explosive disorder, start date 08/27/25. Gemfibrozil Oral Tablet 600mg. Give one two times a day related to hyperlipidemia unspecified, start date 04/02/24. Record review of Resident #3's Medication Administration Record, dated 09/01/25-09/30/25, revealed in part CMA A documented the following medications as taken by the resident on 09/21/25: Carbamazepine ER Oral Tablet Extended Release 12-hour 400mg. Give one tablet by mouth every 12 hours related to bipolar disorder, current episode manic without psychotic features, severe, do not crush or chew, start date 01/05/24 at 2000 (8:00PM). Depakote Oral Tablet Delayed Release 125mg (Divalproex Sodium). Give one tablet two times a day related to intermittent explosive disorder, start date 08/27/25 at 1900 (7:00PM). Gemfibrozil Oral Tablet 600mg. Give one two times a day related to hyperlipidemia unspecified, start date 04/02/24 at 1900 (7:00PM). 4. Record review of Resident #4's, undated, face sheet revealed in part, a [AGE] year-old male with an original admission date of 09/08/24. Resident #4 had the following diagnoses: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety unspecified dementia (decline in cognitive function, which may include memory loss, difficulty in problem-solving, and impaired judgement), generalized anxiety disorder (mental health condition), impulse disorder (difficulty controlling behaviors), major depressive disorder (persistent low mood and loss of interest in activities), and gastro-esophageal reflux disease without esophagitis (backflow of stomach acid in the esophagus). Record review of Resident #4's annual MDS, dated [DATE], revealed a BIMS score of 09, which indicated the resident's cognitive ability was moderately impaired. Record review of Resident #4's active physician orders, as of 10/01/2025, revealed in part: Buspirone HCL Oral Tablet 5mg. Give one tablet by mouth two times a day related to generalized anxiety disorder, start date 08/09/24. Memantine HCL Oral Tablet 5mg. Give 2 tablets by mouth two times a day related to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, start date 10/28/24. Protonix Oral Tablet Delayed Released 40mg (Pantoprazole Sodium). Give one tablet by mouth two times a day related to gastro-esophageal reflux disease without esophagitis, start date 2/18/25. Record review of Resident #4's Medication Administration Record dated 09/01/25-09/30/25 revealed in part CMA A documented the following medications as taken by the resident on 09/21/25: Buspirone HCL Oral Tablet 5mg. Give one tablet by mouth two times a day related to generalized anxiety disorder, start date 08/09/24 at 1900 (7:00PM). Memantine HCL Oral Tablet 5mg. Give 2 tablets by mouth two times a day related to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, start date 10/28/24 at 1900 (7:00PM). Protonix Oral Tablet Delayed Released 40mg (Pantoprazole Sodium). Give one tablet by mouth two times a day related to gastro-esophageal reflux disease without esophagitis, start date 2/18/25 at 1900 (7:00PM). 5. Record review of Resident #5's, undated, face sheet revealed in part, an [AGE] year-old male with an original admission date of 05/21/2020. Resident #5 had the following diagnoses which included: Alzheimer's disease with late onset (memory loss and cognitive decline), Intermittent Explosive Disorder (mental health condition characterized by sudden, intense episodes of anger or aggression), hypercholesterolemia, unspecified (high cholesterol), and benign prostatic hyperplasia without lower urinary tract symptoms (enlarged prostate gland). Record review of Resident #5's annual MDS, dated [DATE], revealed a BIMS score of 02, which indicated the resident's cognitive ability was severely impaired. Record review of Resident #5's active physician orders, as of 10/01/2025, revealed in part: Atorvastatin Calcium Tablet 10mg. Give one tablet by mouth at bedtime related to hypercholesterolemia, unspecified, start date 05/21/20. Tamsulosin HCL Capsule 0.4mg. Give one capsule by mouth in the evening related to benign prostatic hyperplasia (enlarged prostate gland) without lower urinary tract symptoms, start date 01/21/25. Depakote Sprinkles Oral Capsule Delayed Release 125mg (Divalproex Sodium) Give 4 capsules by mouth two times a day related to intermittent explosive disorder, start date 09/09/25. Memantine HCL Tablet 10mg. Give 1 tablet by mouth two times a day related to unspecified dementia, without behavioral disturbance, start date 05/21/20. Record review of Resident #5's Medication Administration Record, dated 09/01/25-09/30/25, revealed in part CMA A documented the following medications as taken by the resident on 09/21/25: Atorvastatin Calcium Tablet 10mg. Give one tablet by mouth at bedtime related to hypercholesterolemia, unspecified, start date 05/21/20 at 1900 (7:00PM). Tamsulosin HCL Capsule 0.4mg. Give one capsule by mouth in the evening related to benign prostatic hyperplasia without lower urinary tract symptoms, start date 01/21/25 at 1800 (6:00PM). Depakote Sprinkles Oral Capsule Delayed Release 125mg (Divalproex Sodium) Give 4 capsules by mouth two times a day related to intermittent explosive disorder, start date 09/09/25 at 1900 (7:00PM). Memantine HCL Tablet 10mg. Give 1 tablet by mouth two times a day related to unspecified dementia, without behavioral disturbance, start date 05/21/20 at 1800 (6:00PM). 6. Record review of Resident #6's, undated, face sheet revealed in part, a [AGE] year-old male with an original admission date of 09/13/2023. Resident #6 had the following diagnoses: paranoid schizophrenia (experience of paranoia of delusions), extrapyramidal and movement disorder, unspecified (unvoluntary movements caused by side effects from certain medications), hypercholesterolemia, unspecified (high cholesterol), and other seizures (abnormal electrical activity in the brain). Record review of Resident #6's annual MDS, dated [DATE], revealed a BIMS score of 02, which indicated the resident's cognitive ability was severely impaired. Record review of Resident #6's active physician orders, as of 10/01/2025, revealed in part: Mirtazapine 7.5mg Give one tablet by mouth at bedtime related to hypercholesterolemia, unspecified, start date 05/21/20. Levetiracetam Oral Tablet 500mg. Give one tablet by mouth two times daily related to other seizures, start date 09/13/23. Benztropine Mesylate Oral Tablet 0.5mg. Give one tablet by mouth two times a day for extrapyramidal side effects (unvoluntary movements caused by side effects from certain medications), related to extrapyramidal and movement disorder, unspecified, start date 09/13/23. Oxcarbazepine Oral Tablet 300mg. Give 1 tablet by mouth two times a day related to other seizures, start date 09/09/25. Zyprexa Oral Tablet 10mg (Olanzapine). Give 10mg by mouth two times a day related to paranoid schizophrenia, start date 12/08/23. Record review of Resident #6's Medication Administration Record, dated 09/01/25-09/30/25, revealed in part CMA A documented the following medications as taken by the resident on 09/21/25: Mirtazapine 7.5mg Give one tablet by mouth at bedtime related to hypercholesterolemia, unspecified, start date 05/21/20 at 1900 (7:00PM). Levetiracetam Oral Tablet 500mg. Give one tablet by mouth two times daily related to other seizures, start date 09/13/23 at 1900 (7:00PM). Benztropine Mesylate Oral Tablet 0.5mg. Give one tablet by mouth two times a day for extrapyramidal side effects related to extrapyramidal and movement disorder, unspecified, start date 09/13/23 at 1900 (7:00PM). Oxcarbazepine Oral Tablet 300mg. Give 1 tablet by mouth two times a day related to other seizures, start date 09/09/25 at 1900 (7:00PM). Zyprexa Oral Tablet 10mg (Olanzapine). Give 10mg by mouth two times a day related to paranoid schizophrenia, start date 12/08/23 at 1900 (7:00PM). 7. Record review of Resident #7's, undated, face sheet revealed in part, a [AGE] year-old female with an original admission date of 04/11/2024. Resident #7 had the following diagnoses which included: Alzheimer's disease with late onset (memory loss and cognitive decline) and mood disorder due to known physiological condition, unspecified (mood disturbances caused by a medical condition) . Record review of Resident #7's quarterly MDS, dated [DATE], revealed a BIMS score of 99, which indicated the resident's cognitive status could not be determined by using the BIMS assessment as the assessment may have been completed properly or the resident required a different evaluation method to assess cognitive function. Record review of Resident #7's active physician orders, as of 10/01/2025, revealed in part: Trileptal Oral Tablet 150mg (Oxcarbazepine). Give 1 capsule by mouth two times a day related to mood disorder due to known physiological condition, unspecified, start date 05/19/25. Depakote Sprinkles Oral Capsule Delayed Release 125mg (Divalproex Sodium) Give 1 capsule by mouth two times a day related to mood disorder due to known physiological condition, unspecified, start date 04/10/25. Record review of Resident #7's Medication Administration Record, dated 09/01/25-09/30/25, revealed in part CMA A documented the following medications as taken by the resident on 09/21/25: Trileptal Oral Tablet 150mg (Oxcarbazepine). Give 1 capsule by mouth two times a day related to mood disorder due to known physiological condition, unspecified, start date 05/19/25 at 1900 (7:00PM). Depakote Sprinkles Oral Capsule Delayed Release 125mg (Divalproex Sodium) Give 1 capsule by mouth two times a day related to mood disorder due to known physiological condition, unspecified, start date 04/10/25 at 1900 (7:00PM). 8. Record review of Resident #8's, undated, face sheet revealed in part, a [AGE] year-old male with an original admission date of 06/11/2025. Resident #8 had the following diagnoses which included: paranoid schizophrenia (experience of paranoia of delusions), hyperlipidemia, unspecified (plaque in the blood vessels), and benign prostatic hyperplasia with lower urinary tract symptoms (enlarged prostate gland). Record review of Resident #8's quarterly MDS, dated [DATE], revealed a BIMS score of 05, which indicated the resident's cognitive ability was severely impaired. Record review of Resident #8's active physician orders, as of 09/30/2025, revealed in part: Zyprexa Oral Tablet 10mg (Olanzapine). Give 1 tablet by mouth two times a day related to paranoid schizophrenia, start date 08/18/25. Tamsulosin HCL Capsule 0.4mg. Give 0.4mg by mouth at bedtime related to benign prostatic hyperplasia with lower urinary tract symptoms, start date 07/16/25. Atorvastatin Calcium Tablet 40mg. Give 40mg by mouth at bedtime related to hyperlipidemia, unspecified, start date 06/11/25. Record review of Resident #8's Medication Administration Record, dated 09/01/25-09/30/25, revealed in part CMA A documented the following medications as taken by the resident on 09/21/25: Zyprexa Oral Tablet 10mg (Olanzapine). Give 1 tablet by mouth two times a day related to paranoid schizophrenia, start date 08/18/25 at 1900 (7:00PM). Tamsulosin HCL Capsule 0.4mg. Give 0.4mg by mouth at bedtime related to benign prostatic hyperplasia with lower urinary tract symptoms, start date 07/16/25 at 1900 (7:00PM). Atorvastatin Calcium Tablet 40mg. Give 40mg by mouth at bedtime related to hyperlipidemia, unspecified, start date 06/11/25 at 1900 (7:00PM). During an interview on 9/30/25 at 8:31AM, CMA B said she was in the process of preparing her assigned medication cart to begin passing out medications to residents and found several unopened unit-dose medication packages, dated 9/21/25, that were supposed to be given to residents at night in the top drawer. She said she initially thought it was trash but realized the packages were unopened and still contained pills. She said she logged onto the computer and noticed the medications were documented as given to the residents by CMA A. She said she notified LVN E, and they counted the medication cart together. All medications were accounted for. She said she also notified LVN C and LVN D about the incident. She said LVN E was the off-going charge nurse that morning. She said she notified the ADON as soon as he arrived to the facility that morning and he took the unopened medication packets. She said CMA A was already gone because she left at 2:00AM, so she was not able to ask her about the medications. She said she and the ADON then reviewed the narcotics book and medications. She said she worked until 5:00 PM that day and there were no residents who reported any adverse effects or had medical issues that day. She said there were no residents who reported pain or any additional concerns to her regarding not receiving their medications. During an interview on 09/30/25 at 12:24 PM, the ADON said CMA B showed him the unopened unit-dose medication packages, dated 9/21/25, and CMA A was the nurse responsible to pass them to the residents. The ADON said he took the unopened unit-dose medication packages and compared them to the resident's MARs. He said he determined CMA A documented she gave the medications to the residents. He texted CMA A and asked her to explain why the packages weren't passed out and why she documented she gave them to the residents. The ADON said CMA A responded she needed to fix her documentation because those medications were refused by the residents . The ADON said he told CMA A it appeared she did not try to pass them to the residents because the packages were unopened. The ADON said CMA A said she thought she documented the refusals but could correct it. The ADON said he told the ADM about the situation that same day and was instructed to gather more information and to follow up with him after he was done. He said he followed up with the ADM with CMA A's response that the medications were refused by the residents and he also made all of the notifications to family members and to the medical director. He said there had not been any reported adverse effects from the residents from not taking the medications. He said all narcotic medications were all accounted for after being inventoried. He said there were no missing medications from the medication cart. He said CMA A already went home when the situation brought to his attention. During an observation and interview on 09/30/25 at 2:30 PM revealed several unopened unit-dose medication packages, dated 9/21/25, labeled with the names of Residents #1, #2, #3, #4, #5, #6, #7, and #8. The ADON said the unopened medication packages were found in the top drawer of the medication cart. The ADON said CMA A documented the medications were taken by the resident in their MARs, however, CMA A told him the medications were refused by the resident. Photographs were taken of the unopened unit-dose medication packages. During an interview on 09/30/25 at 9:09 PM, LVN E said he was a charge nurse on the other hallways on the night of 09/21/25. He said he was contracted to work at the facility for several months. He said he had not witnessed CMA A's not pass the medications and he only recalled he saw her push the medication cart down the halls that night. He said he worked from 6:00 PM to 6:00 AM. He said CMA B told him she found medications in the medication cart drawer that were not given to residents on 09/22/25 at around 5:00 AM. He said CMA A charted (documented) she gave the medications to the residents. He said none of the residents complained of pain or were observed to have any adverse reactions during his shift. During an interview on 09/30/25 at 9:30 PM, LVN D said she could see CMA A and LVN C were talking so she approached them and CMA B showed her the medications and appeared to be upset. She said when CMA B told her she found medications that should have been given to residents in her medication cart she would report it to the ADM and ADON . During an interview on 10/01/25 at 12:48 PM, CMA A said she was contracted to work at the facility and had worked at the facility several times since March 2025. She said on 09/21/25, she passed out medications to residents on halls D, E and F. She said she worked from 5:00 PM to 2:00 AM. She said during her shift she passed out medications and then documented the MARs afterwards. She said she was late documenting and forgot to go back and check her drawer for the refusals. She said she normally documented the medications as they were given to the residents as this was how she was trained to pass medications properly. She said the appropriate procedure to pass out medication was, she was to document as she administered them to the residents. She said the protocol was to compare the medications to the MAR, then double check them. Then she would open the medication pouch and check the pills in the pouch to make sure they were correct. She said then she would put the pills in a cup and offer them to the residents. She said she understood it looked like she did not offer them to the residents since the packages were not opened. She said that night she asked the residents if they were going to take their medications before she opened the packages. She said those residents refused to take the medications. She said it was a very hectic night and she knew she was not supposed to do it that way . She said she normally did not report refusals to the nurs e so she did not think to do that. She said she only was supposed to document the refusals in the resident's medical records. She said she had not worked at the facility since she was contacted by the ADON about it, since there was a pending investigation. She said the potential negative outcome of inaccurate documentation was they would not receive proper care which could lead to the resident being neglected. During an interview on 10/02/25 at 2:25 PM, the ADON said the facility policy to pass out medication was the staff was to first open MAR, verify the resident's medications, date, time, and route. Then staff were to approach the resident, verify their identity and tell them about the medications they were going to be given and answer questions. Then staff were to offer the medications to the residents. The ADON said while doing that, the process for preparing the medications to be given to the resident was staff were to verify the medications belonged to the resident, compare them to the MAR to ensure they matched. Then open the pill packets and put them in a cup. Take them to the resident and offer them. The ADON said, the staff should document the correct outcome. He said he was not aware the nurse documented after passing out all of the medications to residents prior to this investigation. He said staff were trained in nursing school on how to give medications, they received annual competencies, and also the pharmacist completed training with staff periodically. He said it was the nurses responsibility to ensure their documentation was correct. He said he was also responsible to ensure medications were passed correctly and documentation was accurate. He said he expected nurses to accurately document what they did and to follow the treatments as ordered by the physician. He said inaccurate documentation could potentially cause a resident to have a medical emergency, behaviors could occur, or the resident could have unresolved pain. During an interview on 10/02/25 at 3:15 PM, the ADM said he expected nurses to ensure MARs and TARs were completed accurately. He said he was not aware staff were post-documenting during medication pass. He said the proper procedure was staff were to pull the medication, ensure it was the right resident and medication, then document immediately afterwards to ensure compliance. He said the nurse who passed out the medications were also responsible to inventory them. He said the system in place to ensure compliance was the pharmacist did spot checks on MARs and TARs, and she also did random medication passes with the nurses and provided them with feedback on any issues or concerns. He said the staff member, the DON, and the ADON were all responsible to ensure documentation was accurate. He said he expected staff to document accurately and maintain compliance with their documentation. He said a potential negative outcome of inaccurate documentation was medications may not be given properly, residents may not receive the proper treatment, which could cause the resident to end up with worse behaviors or go to the hospital for a medical issue. Record review of the facility-provided policy titled Documentation of Medication Administration, revised April 2007, revealed: Policy Statement The facility shall maintain a medication administration record to document all medications administered. Policy Interpretation and Implementation 1. A Nurse or Certified Medication Aide (where applicable) shall document all medications administered to each resident on the resident's medication administration record (MAR).2. Administration of medication must be documented immediately after (never before) it is given.3. Documentation must include, as a minimum:a. Name and strength of the drug;b. Dosage;c. Method of administration (e.g., oral, injection (and site), etc.);d. Date and time of administration;e. Reason(s) why a medication was withheld, not administered, or refused (as applicable);f. Signature and title of the person administering the medication; andg. Resident response to the medication, if applicable (e.g ., PRN , pain medication, etc .).

Based on observation, interviews, and record review, the facility failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 of 2 treatment carts (treatment cart for Hall A, B and C) reviewed for proper medication storage.LVN C failed to ensure the treatment cart, which contained medications, was not left unlocked and unsupervised in the hallway near the nurse's station.This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm, drug overdose, or drug diversions.During an observation on 10/02/25 at 1:59 PM, the treatment cart for Hall A, B and C was observed sitting outside the nurse's station and was unlocked and unsupervised. The cart was located in close proximity to residents and no staff were present to supervise the cart. Upon inspection of the drawers in the cart with LVN C, prescription medications, creams, and supplies were observed. During an interview on 10/02/25 at 2:02 PM with LVN C, she stated she was the charge nurse on duty and was responsible for the unlocked treatment cart. She stated she was unsure why the cart was unlocked and she was not supervising the cart at the time it was observed to be unlocked. LVN C stated she had been trained on properly securing treatment carts through periodic in-services conducted at the facility. She stated carts should be locked at all times when unsupervised. LVN C stated a potential negative outcome for failure to lock the treatment cart would be a resident could open the cart and get ahold of a medication or something that could cause them harm in some way. During an interview on 10/02/25 at 2:29 PM, the ADON stated the treatment carts should be locked at all times when unattended or unsupervised. He stated the treatment carts contained insulin and diabetic supplies, over the counter medications, tube feeding supplies and wound care supplies. He stated the charge nurse was responsible to assure unsupervised carts were locked at all times. He stated staff were trained on properly securing carts through facility in-services, but he did not recall the date of the last training. He stated carts were kept in designated areas and he conducted rounds and random cart checks to monitor cart security. The ADON stated a potential negative outcome for failure to lock the treatment cart was a resident could access the cart and obtain a medication or object that could cause them harm. During an interview on 10/02/25 at 3:10 PM, the ADM stated the policy for treatment carts was that they were locked at all times when unsupervised. He stated the charge nurse was responsible to assure carts were locked when unattended. The ADM stated carts were monitored for security by random rounds conducted by himself and the ADON. He stated his expectation of staff was to follow the facility's policy at all times by assuring unsupervised carts were locked. The ADM stated a potential negative outcome for failure to secure unsupervised carts would be a resident could get into the cart and take something that could result in harm to the resident. Record review of the facility's policy titled, Storage of Medications, revised April 2019, revealed the following: Policy StatementThe facility stores all drugs and biologicals in a safe, secure, and orderly manner.Policy Interpretations and Implementation1. Drugs and biologicals used in the facility are stored in locked compartments.8. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use.9. Unlocked medication carts are not left unattended.

Based on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 12 of 21 confidential residents. The facility failed to ensure 12 of 21 confidential residents were provided, through postings in prominent locations; the Grievance Procedure, were provided access to the Grievance form, were provided information in regards to who the facility grievance officer was, their contact information, how to file an anonymous grievance, and their right to obtain a written decision related to their grievance. This failure could place the residents at risk of unresolved grievances and decreased quality of life. Findings include: Interviews and Record Review during Resident Council on, 02/10/2025 at 2:00pm, 12 of 21 confidential residents, stated they did not have access to the Grievance form, they did not know they could file a Grievance anonymously, the Grievance procedure had never been discussed in Resident Council, and they had not observed a posting of the Grievance procedure in prominent locations. Residents attending Resident Council did not know where to acquire a grievance form, who to turn the form into, and what happens once a grievance was filed. The Residents did not know they had the right to receive a written decision once their grievance was resolved. Twelve Residents attended the meeting, the 12 Residents in attendance had all been Residents of the facility for 6 plus months. Record Review of the facility Grievance policy on 2/11/2025 at 1:07pm; according to the facilities' Grievance policy a copy of the Grievance/complaint procedure should be posted on the resident bulletin board. Observed prominent postings on 2/10/2025 at 1:30pm; the facility did not include instructions regarding the Grievance procedure with any of the prominent postings. Grievance forms were not available and there was no access to submit a Grievance anonymously. Interview with the ADM on 2/11/2024 at 2:35pm; the ADM stated he was the Grievance Officer for the facility. The ADM stated he was responsible for the review of Grievances and assign them to department heads. The ADM stated the Grievance form was kept at the Nurses' Station and in the ADM's office. The ADM stated the Residents can access the Grievance form at the Nurses' station, they would have to ask for the notebook and the Residents would have to know the Grievance form was available at the Nurses' station. The ADM stated staff completed Grievance forms for Residents, Residents do not ask for forms and complete them on their own. The ADM stated there was no procedure for Residents to submit Grievances anonymously. The ADM stated the facility has 72 hours to resolve Grievances once they were submitted. The ADM stated he assigned the Grievance to the appropriate department, that department addresses the grievance with the complainant, resolved the grievance, and explained the resolution to the complainant. The resolution was documented on the Grievance form and the completed form was submitted to the ADM for review. The ADM stated completed Grievance forms were kept in a notebook. The ADM stated he monitored the Grievance process for success by following up with the staff member assigned to resolve the Grievance, the ADM stated he will also meet with the complainant to ensure they were satisfied with the resolution. The ADM stated he was responsible for ensuring staff were trained on the Grievance process. The ADM stated he was not aware the Grievance procedure was not being discussed in Resident Council. Grievance Policy Record Review of the Grievance Policy last updated in 2009. Policy Statement: Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or their representative. The Resident and/or the representative has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents; and other concerns regarding their LTC facility stay. The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have. Policy Interpretation and Implementation: 1. Any resident, family member, or representative may file a grievance or complaint. 2. Residents, family, and representatives have the right to voice or file grievances without discrimination or reprisal in any form, and without fear of discrimination or reprisal. 3. All grievances from resident or family concerning issues of residents' care in the facility will be considered. Actions will be responded to in writing. 4. Upon admission residents are provided with written information on how to file a grievance. 5. Grievances may be submitted orally or in writing and may be filed anonymously. 6. The contact information for the individual with whom a grievance may be filed is provided to the resident or representative upon admission. 7. The ADM has delegated the responsibility of grievance investigation to the ADM. 8. The grievance officer will review and investigate the allegations and submit the written report of such findings to the ADM with five working days of receiving the grievance. 9. The grievance officer will coordinate actions with the appropriate state and federal agencies depending on the nature of the allegations. 10. The ADM and staff will take immediate action to prevent further potential violations of resident rights while the alleged violation is being investigated. 11. The ADM will review the findings with grievance officer to determine what corrective actions need to be taken. 12. The resident or person filing the grievance on behalf of the resident, will be informed (verbally or in writing) of the findings of the investigation and actions will be taken to correct any identified problems. A written summary of the investigation will be provided to the resident and a copy will be filed in the business office. 13. If the grievance is filed anonymously the grievance officer will inform the resident that a grievance has been anonymously filed on his or her behalf and the steps that will be taken to investigate the grievance and report the findings. 14. The results of all grievances files investigated and reported will be maintained on file for a minimum of three years from the issuance of the grievance decision. 15. This policy will be provided to the resident or the resident's representative upon request.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services, in that: 1. The facility failed to store and date foods stored in the refrigerator. 2. The facility failed to ensure foods were served at temperature above 135 degrees Fahrenheit. These failures could place residents at risk for food contamination and foodborne illness. The findings included: The following observations were made on 02/09/25 beginning at 09:45 AM during initial observation of the kitchen: Observed the following in the walk-in refrigerator: Styrofoam cup covered with tin foil on top shelf no label and no date. Bag of white shredded cheese opened with no label and no date. Pie uncovered and no date. Styrofoam cup with lid on top shelf with no label and no date. Observed the following in the panty: Personal jacket on top of open backet with individual syrup condiments. Home cookies in open container in paper sack no date. Personal drink on shelf with spices. During an observation and interview on 02/09/25 beginning at 12:15 PM with [NAME] A she took temperature of puree chicken on steam table. Temperature was 103.4 degrees Fahrenheit. [NAME] A stated she needed to reheat the puree chicken. Observed [NAME] A prepare puree meal tray and send to the window to serve. Did not observe [NAME] A or any other staff reheat puree chicken. During an interview on 02/09/25 at 01:35 PM with [NAME] A she stated she did not temp or reheat the puree chicken. She stated she was nervous and forgot. She stated the puree should have been served at 160 degrees Fahrenheit. She stated she had been trained on how to reheat food to proper temperature. She stated serving food below 160 degrees Fahrenheit could cause harm to residents. During an interview on 02/11/25 at 02:15 PM with the DM, he stated all items in the refrigerator should be dated. He stated all staff have been trained to date items in the refrigerator. He stated the potential negative outcome could be serving spoiled food to residents. He stated no personal items should be placed in the panty. He stated all staff have been trained on proper storage of food in the panty. He stated the potential negative outcome could be cross contamination of food causing residents to get sick. He stated [NAME] A should have reheated the food in the microwave before serving. He stated the puree process using the blender causes the food to lose heat. He stated staff have been trained on how to reheat food. He stated the potential negative outcome could be food poisoning. During an interview on 02/11/25 at 02:30 PM with the ADM, he stated all food should be dated in the refrigerator. He stated all food should temp at 165 degrees Fahrenheit or higher. He stated the DM is responsible for training all kitchen staff. He stated all staff were trained and had safe serve certificates. He stated the potential negative outcome of serving food below 165 degrees Fahrenheit could be illness in residents. He stated the potential negative outcome of storing personal items and undated food could be cross contamination and food spoilage. Record review of the facility policy, titled Food Receiving and Food Storage, revised November 2022 reflected the following: Policy: Foods shall be received and stored in a manner that complies with safe food handling practices . Refrigerated/frozen Storage: 1. All foods stored in the refrigerator or freezer are covered, labeled, and dated (use by date) . 7. Refrigerator foods are labeled, dated, and monitored so they are used by their use by date, frozen or discarded . Record review of the facility policy, titled Food Preparation and Service, revised November 2022 reflected the following: Policy: Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices . General Guidelines . Food Preparation, Cooking and Holding Time/Temperatures 1. The danger zone for food temperatures is above 41 degrees Fahrenheit and below 135 degrees Fahrenheit. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. 2. Potentially hazardous foods include meats, poultry, seafood, cut melon, eggs, milk, yogurt and cottage cheese. 3. The longer foods remain in the danger zone the greater the risk for growth of harmful pathogens. Therefore, PHF (Potential Hazardous Food) must be maintained at or below 41 degrees Fahrenheit or at or above 135 degrees Fahrenheit. 11. Mechanically altered hot foods prepared for a modified consistency diet remain above 135 degrees Fahrenheit during preparation or they are reheated to 165 degrees Fahrenheit for at least 15 seconds if holding for hot service .

Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 4 of 20 residents (Resident #27, #51, #328, and Resident #16) reviewed for infection control. 1. CNA A failed to utilize hand hygiene when assisting Residents #27, #51, and #328 with their meals on 2/09/2025. 2. LVN B failed to utilize hand hygiene between glove changes when providing wound care to Resident #16 on 2/10/2025. These failures could place residents at risk for infection, and cross-contamination. Findings include: Resident #27 Record review of Resident #27 undated face sheet revealed a [AGE] year-old male originally admitted to the facility on [DATE]. Resident #27 had a medical history of muscle wasting and atrophy (a condition where muscles shrink and lose mass, resulting in weakness and decreased functionality), hemiplegia (a condition that causes paralysis or weakness on one side of the body), and muscle weakness. Record review of Resident #27 quarterly MDS dated [DATE] revealed Section C- Cognitive Patterns a BIMS score of 04 which indicated Resident #27 was not cognitively intact. Record review of Resident #27 care plan dated 11/23/2024 revealed resident required eating set up and clean up assistance. Resident #51 Record review of Resident #51 undated face sheet revealed a [AGE] year-old female originally admitted to the facility on [DATE]. Resident #51 had a medical history of muscle wasting and atrophy (a condition where muscles shrink and lose mass, resulting in weakness and decreased Functionality), dysphagia (difficulty swallowing), and atresia of foramina of Magendie and Luschka (malformation of the brain). Record review of Resident #51 quarterly MDS dated [DATE] Section C- Cognitive patterns revealed a BIMs score of 06 which indicates resident was not cognitively intact. Record review of Resident #51 care plan dated 12/01/2024 revealed Resident #51 required eating assistance with support provided one-person physical assist. Resident #328 Record review of Resident #328 undated face sheet revealed [AGE] year-old female originally admitted to the facility on [DATE]. Resident #328 had a medical history of muscle weakness, lack of coordination, and profound intellectual disabilities. Record review of Resident #328 Admission MDS dated [DATE] revealed Section C- Cognitive patterns revealed a BIMs score of 00 which indicates resident was not cognitively intact. Record review of Resident #328 care plan dated _revealed Resident #328 required eating assistance with support provided one-person physical assist. Resident #16 Record review of Resident #16 undated face sheet revealed a [AGE] year-old male originally admitted to the facility on [DATE]. Resident #16 had a medical history of muscle weakness, unspecified head injury, and Charcot's joint (nerve damage to the foot). Record review of Resident #16 MDS dated [DATE] revealed Section C- Cognitive patterns revealed a BIMs score of 10 which indicated resident had moderate cognitive impairment. Record Review of Resident #16's Physician orders revealed the following wound care order dated 1/02/2025: TX to Right medial plantar wound- (wound on the inner part of the foot) Cleanse wound and peri wound skin with wound cleanser, pat dry with gauze, apply Calcium Alginate Silver to wound, cover with super absorbent dressing and secure every other day. During a dinning observation on 2/09/2025 between 12:38pm and 1:02pm, CNA A was observed feeding Resident #27, #52, and #328. CNA A was observed setting up each of the residents' trays with utensils, condiments, and drinks. CNA A provided a spoonful of food to a resident, and proceeded to move to another resident and provided a spoonful for that resident. CNA A used the resident's napkin and cleaned the resident's mouth. CNA A proceeded to assist the residents with their meals, going between each resident and assisting as needed with their meals. During this time CNA A did not utilize hand hygiene with ABHS or soap and water, prior to assisting the residents with their meal and when moving from one resident to another to assist with feeding. During an interview with CNA A on 2/10/2025 at 3:21pm, she stated she was assisting three residents with feeding on 2/9/2024. She stated the infection preventionist was the DON. She stated she had been trained on infection control and utilizing ABHS when moving from one resident to another during feedings. She stated she did use ABHS a few times but not all the time. She stated the potential negative outcome could be spreading germs between the residents. During a wound care observation on 2/10/2025 at 4:41pm for Resident #16, LVN B did not utilize hand hygiene prior to donning (putting on) clean gloves. LVN B removed soiled dressing from Resident #16's right foot and discarded the soiled dressing in the trash. LVN B grabbed a disinfecting wipe and cleaned the bedside table. LVN B allowed table to air dry for approximately 4 minutes and doffed (took off) dirty gloves. LVN B did not utilize hand hygiene prior to donning clean gloves. During an interview with LVN B on 2/10/2025 at 5:00pm, she stated she had been trained on infection prevention and handwashing. She stated she believed her infection preventionist was the DON, but she was not sure. She stated she was PRN at the facility. She stated she had been trained on handwashing between glove changes but did not remember the last in-service. She stated she realized she had not been washing her hands between glove changes and caught herself towards the end of the wound care. She stated the potential negative outcome of not utilizing hand hygiene between glove changes could be spreading infection towards the residents and staff. During an interview with the DON on 2/11/2025 at 2:45pm, she stated she was the infection preventionist. She stated she was unsure when the facility nursing staff had their last training on hand washing as she had just been hired in November of 2024, but it should be done quarterly. She stated they would be having training prior to the end of this month. She stated she expects staff to sanitize their hands between feeding residents, each time. She stated she expects staff to sanitize their hands between glove changes. She stated compliance was monitored through observation and when she was on the floor, she monitors the staff for hand hygiene. She stated the potential negative outcome of staff not utilizing hand hygiene can be the spread of germs and spread of infection. During an interview with the ADM on 2/11/2025 at 3:00pm, he stated the DON was the infection preventionist. He stated staff are trained periodically and once a month on infection control and handwashing. He stated staff are trained to wash their hands between glove changes. He stated during feeding if they staff are assisting residents, and they don't touch the residents, they can continue assisting others. He stated if they stop to feed, or utilize utensils for the residents, they are supposed to use ABHS between each resident. He stated compliance was monitored by observation and throughout the day. He stated his expectation of staff was for them to utilize the infection control practices they have been trained on. He stated a potential negative outcome of not following those infection control practices could be sickness and spreading germs or infection. Record review of facility undated polity titled Infection Control During Feeding revealed: The purpose of this policy is to provide guidelines for infection control practices during resident feeding, focusing on hand hygiene, equipment sanitation, and overall food safety to minimize the risk of infections and foodborne illness in the nursing home setting . 1. Hand Hygiene Importance of Handwashing Handwashing is the most effective method of preventing the spread of infections. Proper hand hygiene should always be performed before and after assisting a resident with feeding. Additionally, it is crucial after various activities to prevent contamination. When to Wash Hands Hand hygiene is required at the following times: o Before assisting residents with eating or drinking. o After touching any part of the body (e.g., hair, face, nose). o After touching utensils, food containers, dishes, or drinking cups. o After clearing away used dishes or utensils . Record review of facility policy titled Policy Statement revised October 2023 revealed: .1. Hand hygiene is indicated: a. immediately before touching a resident; b. before performing an aseptic task (for example, placing an indwelling device or handling an invasive medical device); c. after contact with blood, body fluids, or contaminated surfaces; d. after touching a resident; e. after touching the resident's environment; f. before moving from work on a soiled body site to a clean body site on the same resident; and g. immediately after glove removal. Record review of facility policy titled Procedure last revised October 2023 revealed: .Applying and Removing Gloves l. Perform hand hygiene before applying non-sterile gloves. 2. When applying, remove one glove from the dispensing box at a time, touching only the top of the cuff. 3. When removing gloves, pinch the glove at the wrist and peel away from the hand, turning the glove inside out. 4. Hold the removed glove in the gloved hand and remove the other glove by rolling it down the hand and folding it into the first glove. 5. Perform hand hygiene.

Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 facility reviewed for environmental concerns. 1. The residents' hand sink in room D5 was not operational for 2 of 3 days. 2. The hand sink in the women's restroom was not operational for 2 of 3 days. 3. The hand sink and toilet in room A8 was not operational for 1 of 3 days. 4. The hand sink and toilet in room A6 was not operational for 1 of 3 days. These failures could place residents and the public at risk of a diminished quality of life due to exposure to an environment that is nonfunctional, uncomfortable, unsanitary, and unsafe. The findings included: During an observation on 2/9/2025 at 10:32 AM the hand sink in residents' room D5 was observed with standing water in the basin of the sink. The water continued to rise in the basin of the sink as the water ran, after being turned on. During an observation on 2/9/2025 at 12:05 PM the toilet in resident's room A6 was observed to be full of feces. The toilet was not able to be flushed. The toilet had no cover on the tank of the toilet. The plumbing of the inside of the toilet tank was visible and accessible. During an observation on 2/9/2025 at 1:17 PM the hand sink in the public women's restroom, located near the nurse's station, was observed with standing water in the basin of the sink. The water continued to rise in the basin of the sink as the water ran, after being turned on. During an observation on 2/9/2025 at 1:20 PM the hand sink in resident's room A8, occupied by state surveyors during the survey, was observed to have standing water in the basin of the sink. The water continued to rise in the basin of the sink as the water ran, after being turned on. During an observation on 2/10/2025 at 10:06 AM the hand sink in resident room D5 had standing water in the basin of the sink. The water continued to rise in the basin of the sink as the water ran, after being turned on. During an interview on 02/10/2025 at 10:15 AM the MS was informed of the standing water in resident's room A5 and the women's restroom,. The MS stated he would check on the concerns immediately. During an interview and observation on 02/10/2025 at 10:25 AM the MS was observed in resident's room A5 with a plunger,. The MS stated he used the plunger on the sink and was able to drain the water. During an observation on 2/10/2025 at 1:00 PM standing water was observed on the floor in the bathroom of resident room A8, occupied by state surveyors during the survey. It was observed that the toilet would not drain when flushed. Standing water was observed in the basin of the hand sink. During an interview and observation on 02/10/2025 at 4:00 PM the MS stated he was working on the plumbing in the facility and stated the plumbing lines were clogged on 3 of 6 hallways. The MS stated they were able to get the plumbing lines cleared and stated the toilet in resident room A8 (occupied by state surveyors) should be working. It was observed the toilet in resident room A8 was able to flush. The MS stated clothing items were pulled from the plumbing lines while they were working on them. The MS stated he believed that was what caused the plumbing lines to be clogged. During an interview on 2/11/2025 at 9:48 AM the MS stated the toilet in resident's room A6 was full of feces and would not flush because the toilet was stopped up. The MS stated he was aware of the missing toilet tank top. The MS stated he was concerned the resident would break the toilet tank top again, so he did not replace it. The MS stated this was reported to the ADM. During an interview on 2/11/2025 at 2:00 PM the MS stated he was responsible for maintenance of the building as well as supervising the housekeeping staff. The MS stated the housekeeping staff was responsible for cleaning bathrooms daily, so they were responsible for reporting any concerns they saw regarding maintenance, to the MS. The MS stated sometimes housekeeping staff plunged a toilet themselves, but he still required this to be reported to him, so he could ensure it was done properly. The MS stated there was a maintenance log, kept in the monitor room, that all staff used to report maintenance concerns. The MS stated there was nothing reported prior to 2/10/2025 regarding the plumbing in resident rooms A6, A8, or D5 or the women's restroom not functioning properly. The MS stated the plumbing was stopped up off and on lately, and they were working on it. The MS stated it was his expectation for staff to report any plumbing concerns immediately and to record it in the maintenance log. The MS stated it was important for staff to report any plumbing concerns as it could pose as a safety concern if toilets overflow, resulting in falls, and a sanitation concern for residents. During an interview on 2/11/2025 at 2:20 PM HKA stated housekeeping staff cleaned toilets and hand sinks in all rooms daily. The HKA stated all housekeeping staff should have reported any concerns of stopped up sinks or toilets to the MS. The HKA stated there was a maintenance log in the monitor room for housekeeping staff to report any maintenance needs. The HKA stated she was not aware of any sinks or toilets that were stopped up recently. The HKA stated if she observed a clogged sink or toilet she tried to unclog it herself, and she reported it to the MS. The HKA stated it was common for the toilet in resident room A6 to become stopped up, as the resident was known to place non-flushable items in the toilet. The HKA stated if this occurred, she reported it to the MS. The HKA stated if the hand sinks and toilets in the facility were not functioning, the residents would not be able to use them and could get sick. The HKA stated if water overflows from toilets onto the floor, this could have caused an accident and a resident could have fell . During an interview on 2/11/2025 at 3:55 PM the ADM stated the housekeeping staff were responsible for cleaning all bathrooms in the facility, daily. The ADM stated the MS supervised the housekeeping staff. The ADM stated any staff could have reported a clogged toilet or a clogged sink, but the housekeeping staff should have seen it, as they clean bathrooms daily. The ADM stated any maintenance request should have been recorded in the maintenance log in the monitor room. The ADM stated the MS was responsible for ensuring maintenance requests were completed. The ADM stated he expected any maintenance request to be reported as soon as it was seen by any staff. The ADM stated he was unaware of the clogged sinks and toilets throughout the facility. The ADM stated the MS completed plumbing maintenance on 2/10/2025, and to his knowledge everything was now functioning properly. The ADM stated he believed the plumbing issues began from residents placing non-flushable items in their toilets. The ADM stated if toilets overflow, this would have been a safety concern as it could have led to falls. The ADM stated if sinks were not functioning properly, this would have been a sanitation concern and could result in germs being spread. During an interview on 2/11/2025 at 4:51 PM the ADM stated he was unaware of the missing toilet tank cover in resident's room A6. The ADM stated the housekeeping staff were expected to handle maintenance requests such as plunging toilets when maintenance staff was unavailable, such as on weekends. The ADM stated if a resident's toilet was left unmaintained, containing feces, the resident could be at risk of infections. Record review of the facility policy titled, Maintenance Service revised December 2009 revealed the following: Policy Statement Maintenance service shall be provided to all areas of the building, grounds, and equipment. 1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include, but are not limited to: a. maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. b. maintaining the building in good repair and free from hazards.

Based on observation, interviews, and record reviews, the facility failed to ensure each resident was treated with respect, dignity, and care for each resident in a manner and in an environment that promotes the maintenance or enhancement of their quality of life, recognizing each resident's individuality for 1 (Resident #2) of 21 residents. The facility failed to ensure Resident #2 was treated with respect, dignity, and care when they failed to ensure Resident #2's room was cleaned daily, furnished with a covering on her bedroom window, and a furnished with a privacy curtain. This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth, psychosocial harm and distrust with staff. Findings Included: Record review of Resident #2 's face sheet dated 02/20/2024 revealed she was [AGE] years old and was originally admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: Traumatic subarachnoid hemorrhage with loss of consciousness of 31 minutes to 59 minutes, subsequent encounter (bleeding in the space around the brain), unsteadiness on feet, unspecified lack of coordination, major depressive disorder, recurrent severe without psychotic features (mood disorder that caused a persistent feeling of sadness and loss of interest), osteoarthritis, unspecified site (degenerative joint disease), anxiety disorder, unspecified (excessive worry and fear), type 2 diabetes mellitus with other diabetic ophthalmic complication (eye condition that can cause vision loss and blindness in people who have diabetes), paranoid schizophrenia (experiencing strong, persistent paranoia or suspicion), cognitive communication deficit (difficulty paying attention, remembering, and responding accurately), need for assistance with personal care, difficulty in walking, schizoaffective disorder, bipolar type (mental health condition characterized by a mix of symptoms from schizophrenia and a mood disorder). The face sheet also revealed Resident #2 was in a room on Hall A. Record review of Resident #2 quarterly MDS dated [DATE] Section C - Cognitive Patterns revealed Resident #2 had a BIMS of 01 which indicated the resident's cognition was severely impaired. Additionally, Section GG - Functional Abilities revealed Resident #2 was independent and completed the following activities by herself with no assistance from a helper: eating, oral hygiene, toileting hygiene, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. Record Review of Resident #2's Care Plan, dated 01/08/25, revealed Resident #2 had a focus area that Resident #2 had a behavior of destroying things in my room. Resident #2 sometimes tried to flush clothes etc. in the toilet to stop it up and tore down privacy curtains, blinds, etc. Resident #2 also sometimes refused allow staff to clean her room. The goal was the Resident #2 would allow staff to maintain her room as to provide a safe environment for her through the review date. Interventions were to encourage Resident #2 to not destroy property and to allow staff to clean her room, and to offer pleasant diversions such as snacks or listening to music with a therapist to allow staff to go in and clean when not present. Secondly, Resident #2 had a potential for an ADL self-care performance deficit related to schizoaffective disorder. Resident #2's activities of daily living self-performance fluctuated related to schizoaffective disorder but Resident #2 usually required assistance with activities of daily living as follows: Please adjust support. The goal was Resident #2 would maintain the current level of function in all activities of daily living through the review date. Interventions were that Resident #2 was independent with the following activities of daily living: chair/bed-to-chair transfer, eating, lower body dressing, lying to sitting on side of bed, oral hygiene, personal hygiene, putting on/taking off footwear, roll left and right, sit to lying, sit to stand, toilet hygiene, toilet transfer, tub/shower transfer, upper body dressing, and walk 150 feet. Third, Resident #2 was resistive to care (at times refused glucose checks (sugar), medication, baths being weighed) related to schizoaffective disorder. The goal was to give clear explanation of all care activities prior to and as they occur during each contact, if resident resists with activities of daily living, reassure resident, leave and return 5-10 minutes later and try again, praise the resident when behavior is appropriate. Fourth, Resident #2 had potential to be verbally aggressive related to schizoaffective disorder. The goal was the resident would verbalize understanding of need to control. Interventions were to monitor behavior each shift and document observed behavior and attempted intervention, and to provide frequent monitoring of Resident #2. Also, when the resident became agitated: Intervene before agitation escalated; Guide away from source of distress; Engage calmly in conversation; If response was aggressive, staff were to walk calmly away, and approach later. Fifth, Resident #2 had risk for falls related to psychoactive medication use. Goal was that resident would not sustain a serious injury related to falls through the review date. Goals were to be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Reinforce the of use of verbal cues for the resident. Ensure that the resident was wearing appropriate footwear, when ambulating transferring. The resident needs a safe environment floor free from spills and clutter; adequate, glare-free light; a working and reachable call light. Sixth, was that Resident #2 had a problem with vision related to history of cataracts. The goal was the resident would show no decline in visual function through the review date. Interventions were to Monitor/document/report as needed any signs or symptoms of acute eye problems: Change in ability to perform activities of daily living, decline in mobility, sudden visual loss, pupils dilated, gray or milky, complaints of halos around lights, double vision, tunnel vision, blurred or hazy vision. Finally, there was no documentation in the Care Plan for Resident #2 to not have a window covering, privacy curtain, call light due to pulling them down. Record Review of Resident #2's progress notes from 01/09/24 to 02/10/25 revealed there was no documentation of Resident #2 refusing to allow staff to clean her room or pulling the blinds off the window. During an observation on 2/9/25 at 12:05 PM Resident #2 sat on her bed. There was a strong smell of feces and urine throughout the room. The call light cord and button were observed to be wrapped and tied up hanging against the wall and out of Resident #2's reach. There was clothing, trash, and pullups scattered all over the floors through the room and restroom. The bedroom window did not have a covering and there was no privacy curtain in the room. A gate and house were visible through the window and the glass of the window was clear. The was no dresser in the room. The closet floor had a pile of clothes and briefs and there was no clothing hanging. There were no sheets on the mattress. There was dried and sticky red and brown stains on the floor. There was chicken strips and potatoes thrown on the floors and stains on the walls. There was a bedside table that had three wheels and was soiled with dried food and liquid. There was a food tray in the room with a tray ticket labeled as breakfast from 2/9/25. The was trash scattered on the floor and a meal ticket dated 1/31/25. In the restroom, there was square hole in the dry wall where the toilet paper dispenser previously was. The toilet tank did not have a lid which exposed the internal plumbing of the toilet. The toilet was filled with feces. The was no television or radio in the room and there were no decorations on the walls or in the room. During an interview on 2/9/25 at 12:15 PM, the ADM stated Resident #2 often did not allow staff to enter her room. He stated she had a history of destroying her room by throwing pullups, trash, clothes, and food throughout the room. He stated she had thrown food trays in the hallway. He stated she ripped blinds, curtains, and anything else she could off the walls. He stated she also put un-flushable objects in the toilet and clogged it. During an interview and observation on 2/9/25 at 12:25 PM, HK C was observed sweeping the floors of Resident #2's room. HK C stated Resident #2 often did not allow her to clean her room. She stated Resident #2 yelled at staff to get out of her room. She stated Resident #2 often tore things off the walls and threw things all over the room. During an interview on 2/10/25 at 11:32 AM, the Hospice RN stated she worked for a Hospice Provider and provided services to Resident #2. The Hospice RN stated Resident #2 received services from hospice CNA's on Monday, Wednesday and Friday. The Hospice RN stated Resident #2 was seen by one of their nurses weekly, and the chaplain and social worker every 4 weeks. The Hospice RN stated hospice CNA's showered, provided incontinent care, applied lotion, provided hair care, dressing, companion care, brushed her teeth, and filed her nails on hands and feet. The Hospice RN stated her staff gave report to the facility before they left to the charge nurse for each day they came. The Hospice RN stated Resident #2 was receptive to her most of the time, sometimes she becomes combative or agitated and would hit and swing her arms. The Hospice RN stated Resident #2 took medication to calm her. The Hospice RN stated her staff would try to go back before they leave the facility if she was calmed down and provide services she refused. The Hospice RN stated they notified the facility when Resident #2 refused baths. The Hospice RN stated their agency had an agreement with the facility that the facility would attempt to provide services that Resident #2 refused by hospice staff. The Hospice RN stated Resident #2 was legally blind. The Hospice RN stated she had not seen a privacy curtain in her room. The Hospice RN stated she had seen a curtain on Resident #2's window but could not remember when she last saw it. The Hospice RN stated she last saw Resident #2 January 29th. The Hospice RN stated she had not been able to contact the family. The Hospice RN stated she did not think she was able to dress herself. The Hospice RN stated she had seen pillows in Resident #2's room before. During an interview on 2/10/25 at 2:50 PM, CNA B stated she worked on Hall A. She stated Resident #2 preferred to be independent and did not allow staff to help her very much. She stated Resident #2 yelled at staff to get out of her room. CNA B stated Resident #2 used the toilet independently. She stated staff checked on Resident #2 every hour during rounds. She stated Resident #2 ate all meals and snacks in her bedroom. She stated Resident #2 had yanked the call light out of the wall previously. She stated she did not know why there were no blinds or privacy curtains in the room. She stated she did not know why there were no sheets or pillows on the bed and was supposed to have them. CNA B stated Hospice staff were supposed to come and shower Resident #2 and change her linens. She stated Hospice staff reported to the facility when Resident #2 refused care. She stated she would try to provide services Resident #2 refused by hospice staff later in the day. She stated she was trained to document every time Resident #2 refused care in her chart. She stated Resident #2 changed her own pullups. She stated Resident #2 ambulated in her room by feeling around the walls and furniture because she was blind. During an interview on 2/10/25 at 3:21 PM, CNA C stated Resident #2 was blind and she believed she could only see shadows. She stated Resident #2 preferred to do things herself independently such as dressing herself and toileting, and she was receiving hospice services. She stated Resident #2 screamed and yelled when given food trays. She stated Resident #2 had been refusing care and had mood swings and threw her food trays. She stated the dresser was removed from her room because she flipped it over several times. She stated she believed the privacy curtain was missing because it was in Resident #2's way and was hazardous. She stated Resident #2's door was always shut to keep residents that wander out of her room and Resident #2 from wandering out. CNA C stated she checked on Resident #2 every 1-2 hours. She stated the MT's also checked on her every twenty minutes. CNA C stated Resident #2 yanked on her call light cord off the wall before but Resident #2 knew how to use the call light. She stated she had helped Resident #2 change clothes in her room before. She stated CNA's and MT's passed out food trays on the halls. She stated Resident #2 always ate in her room. CNA C stated there not being a window covering or privacy curtain was a privacy concern as anyone passing by or looking in could see Resident #2 through the window or door while she was exposed. During an interview on 2/10/25 at 4:10 PM, RN A stated Resident #2 had told her to get out of her room before and refused to be examined, to have her blood sugar levels checked, showers, and refused medications. She stated Resident #2 was paranoid and had said she believed someone was trying to kill her. She stated Resident #2 regularly slept with the sheets and blankets over her head. She stated she checked on Resident #2 every 2 to 2.5 hours. She stated the CNA's also checked on Resident #2 when they heard her yelling and during their rounds. She stated Resident #2 tore down the privacy curtain and the soap and toilet paper dispensers in her restroom. She stated Resident #2 had ripped the call light cord out of the wall before. She stated she did not know why there were no blinds on the window in Resident #2's bedroom. She stated the MT's also checked on Resident #2 when they walked the floor. RN A stated staff were trained to document all refusals of care in Resident #2's chart. She stated hospice staff had told them when Resident #2 refused care from them before they leave and facility staff were supposed to document that information in the resident's chart. RN A stated facility staff could try to offer to provide Resident #2 the services she refused by hospice staff but she had never been told they were expected to offer to provide Resident #2 the services she refused by hospice staff. RN A stated Resident #2 was legally blind, therefore a potential negative outcome from not having a covering on the bedroom window could affect Resident #2's state of mind as she could think she saw something or someone outside her window. RN A stated Resident #2 dressed herself in her room and it did not allow her to have privacy. She stated the facility was gated however the bedroom windows were still visible through the bars of the gate and anyone that passed by could see though the window. She stated Resident #2 touched the furniture and walls when she walked. RN A stated they could not force Resident #2 to shower or be groomed. She stated the DON and hospice staff were aware that Resident #2 often refused care. During an interview on 2/10/25 at 4:35 PM, the Hospice CNA with stated she had worked with Resident #2 for four months. She stated Resident #2 had good and bad days. She stated initially Resident #2 loved to shower, talk, and read the bible however, about a month and a half ago, she began refusing showers and activities. She stated she saw Resident #2 three times a week. The Hospice CNA stated she would shower or give Resident #2 a bed bath, changed her linens, threw the trash, cleaned up if needed, and provided companion care. The Hospice CNA stated she also would cut Resident #2's fingernails and shave, if needed. She stated she notified the facility when Resident #2 refused care. She stated Resident #2 did not like to be touched. She stated Resident #2 often threw objects and food. She stated she had helped Resident #2 change clothes in her bedroom or in the shower room. She stated Resident #2 tore down or broke her blinds. She stated Resident #2 did not like it when people went in her room. She stated staff usually cleaned the room quietly. She stated she did not believe Resident #2 could see at all. The Hospice CNA stated Resident #2 toileted herself and flushed the toilet without being prompted. During an interview on 2/11/25 at 9:48 AM, the MS stated he supervised the MT's, maintenance staff, and housekeeping staff. The MS stated he expected housekeeping staff to clean the resident's rooms daily. The MS stated he expected for housekeeping staff to take advantage of times when residents were not in their rooms to clean them for those residents that would not allow housekeeping staff to clean their rooms. The MS stated they cannot ignore a residents room when it was dirty. They must figure out how to clean it. The MS stated Resident #2 was blind. The MS stated Resident #2 pulled the privacy curtain and blinds down in her room and she pulled the call light cords out of the wall every time he tried to re-install them so he stopped re-installing them. He stated he replaced the blinds on her window yesterday and she's already pulled them down. He stated he replaced the new call light cord yesterday. The MS stated that the potential negative outcome of not having privacy curtains and blinds on the window was that it did not allow Resident #2 to have privacy. The MS stated he would try to figure out another way to cover the window to ensure her privacy. During an interview on 2/11/25 at 10:48 AM, CMA A stated she attempted to pass medications to Resident #2 this morning twice, but she refused both times. She stated Resident #2 refused her medication yesterday as well. She stated sometimes she could get Resident #2 to take her medications by giving her a soda. She stated she must tell the nurse whenever Resident #2 refused her medications. She stated she believed the reason Resident #2 didn't have blinds on her windows and a privacy curtain in her room was because she tore them down. She stated she did not know how long ago that was. During an interview on 2/11/25 at 11:33 AM, CNA A stated she did rounds every two hours. She stated Resident #2 walked and sometimes used the wheelchair to ambulate and did not like to have help with anything. She stated Resident #2 touched the walls to get around when she walked and when in her wheelchair. CNA A stated Resident #2 dressed herself. CNA A stated hospice staff showered her and most of the time she refused. CNA A stated she did not follow up with Resident #2 to provide services she refused from hospice. CNA A stated she could ask Resident #2 if she wanted to provide the refused services but her answer was always no. She stated she was trained that they were required to follow up with Resident #2 if she refused hospice services. CNA A stated Resident #2 was supposed to wear socks but she did not keep them on. CNA A stated Resident #2 pulled the privacy curtains off the ceiling and blinds off the window. CNA A stated a potential negative outcome of not having a window covering was that Resident #2 would not have privacy. CNA A stated that CNA's were responsible for putting linens on the beds. CNA A stated she did not try to put sheets on Resident #2's bed on 2/9/25 because she yelled at her to get out of her room. CNA A stated Resident #2 used to have a pillow in her room but did not know where it was. During an interview on 2/11/25 at 3:15 PM, LVN B stated she was the charge nurse for Hall A on Sunday, 2/9/25. LVN B stated Sunday was the second time she had worked on that hall and was vaguely familiar with Resident #2. LVN B stated she went into Resident #2's room to check on her to verify she was breathing around approximately 10:00 AM. LVN B stated at that time, she did not speak to Resident #2 but she recalled Resident #2 grunted and had not spoken to her. LVN B stated she did not notice Resident #2's bedroom window did not have blinds. LVN B stated CNA's completed rounds every 2 hours. LVN B stated the window not having a covering caused Resident #2 to be exposed, not given privacy, and it also affected the temperature control in her bedroom. LVN B stated she would be concerned with Resident #2's safety with a privacy curtain in her room. LVN B stated she did not know if the facility provided an alternative to cover the window or provided a privacy screen for Resident #2 to ensure she had privacy and dignity in her room. LVN B stated hospice staff reported any concerns to the charge nurse before they left the facility. LVN B stated she expected staff to document refusals on the behavior monitoring logs and to notify family members of any concerns. During an interview on 2/11/25 at 4:20 PM the DON stated Resident #2 rejected care and would not allow anyone to go in her room. The DON stated Resident #2 tore up her room and tore things off the walls. The DON stated Resident #2 received hospice services. The DON stated she did not know how often nursing staff did rounds. The DON stated she was aware that Resident #2's window did not have blinds because Resident #2 ripped them off. She stated blinds were installed on the window yesterday and she had already ripped them down. She stated she could not recall seeing a window covering on her window prior to the one that was installed yesterday. The DON stated she did not know if there was a requirement for resident's room windows to have a covering. The DON stated a potential negative outcome to not having a window covering could be that Resident #2 did not have privacy which would cause her to be embarrassed if someone were to see her unclothed. The DON stated she expected staff to go back and try to provide care or get another staff to go back and try when Resident #2 refused care. The DON stated a potential negative outcome of there being a miscommunication between the facility and hospice could be that Resident #2's needs would not be met. The DON stated staff should be trained to follow up on refusals reported by hospice staff. The DON stated she was not aware staff were not aware they were required to follow up refusals reported by hospice. During an interview on 2/11/25 at 4:51 PM the ADM stated Resident #2 tore up and destroyed her room regularly. The ADM stated CNA's did rounds and checked on resident's every 2 hours. The ADM stated MT's were expected and trained to knock on the door and open to check on residents. The ADM stated the MS replaced the call light cord in Resident #2's room yesterday because she ripped them out of the wall the day before. The ADM stated Resident #2 had a habit of putting her sheets in the toilet and ripping them off her bed which could be why she did not have any sheets the past three days. The ADM stated a potential negative outcome of Resident #2 not having a window covering could put her at risk of exposure when she changed clothes. The ADM stated he was aware bedroom windows were supposed to be operable but he was not sure if there was a requirement for them to have a covering. The ADM stated the facility was responsible for ensuring privacy and dignity needs were being met. The ADM stated they had tried putting drapes, blinds, and tint on Resident #2's window to ensure her privacy and dignity but she kept ripping them down. The ADM stated there was no documentation in the Care Plan that Resident #2's room was approved to not have a privacy curtain or blinds on her window due to her behaviors. The ADM stated they would try to figure out how to cover the window and ensure Resident #2 had privacy. The ADM stated the staff that completed Care Plans was not available today. The ADM stated he expected staff to follow up and provide care to Resident #2 on care she refused from hospice staff. The ADM stated staff not following up could be a system failure as Resident #2 would not receive the care she needed. Record review of the facility policy titled Resident Rights, Revised December 2016, revealed in part the following documentation, Policy Statement. Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: 1. a dignified existence; 2. be treated with respect, kindness, and dignity; 3. be free from abuse, neglect, misappropriation of property, and exploitation; . 20. privacy and confidentiality;

Based on interviews and record reviews, the facility failed to ensure all Pre-Admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with an accurate PASRR Level I for 1 of 6 residents (Resident #16) reviewed for PASRR screening, in that: Resident #16 did not have an accurate and updated PASRR Level 1 assessment reflecting a diagnosis of mental illness. These failures could place residents, with an inaccurate PASRR Level 1 and no PASRR Level 2 Evaluation, at risk for not receiving care and services to meet their needs. The findings included: Resident #16: Record review of Resident #16's electronic face sheet dated revealed a [AGE] year-old male admitted to the facility on [DATE]. The face sheet included the following diagnoses: Type 2 Diabetes (problem in the body where blood sugar levels are not regulated, leading to high blood sugar levels) with Diabetic Neuropathic Arthropathy (nerve damage caused by high blood sugar levels), Unspecified Head Injury, Generalized Anxiety Disorder(excessive, ongoing worry that is hard to control), Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and Intermittent Explosive Disorder (a mental disorder that causes people to have periods of intense anger and sudden outbursts without any reason). Record review of Resident #16's Quarterly MDS dated [DATE], revealed under section I, indicated Resident #16 had a Psychotic Disorder, as well as an active diagnoses of Intermittent Explosive Disorder. Additionally, under Section C Cognitive Patterns, Resident #16's MDS revealed a BIMS of 10, indicating the resident was moderately, cognitively impaired. Record review of Resident #16's care plan dated 11/23/2024, under Diagnoses, indicated Resident #16 had a diagnosis of Major Depressive Disorder and Intermittent Explosive Disorder. Additionally, the care plan included a focus area that began on 09/08/2020 which stated, The resident has episodes of verbal and physical aggression r/t intermittent explosive disorder., with a goal that began on 09/08/2020 which stated, The resident will verbalize understanding of need to control physical and verbal aggressive behavior through the review date., with the Interventions/Tasks that included the following: Administer medications as ordered. Monitor/document for side effects and effectiveness.; Monitor/document/report PRN any s/sx of resident posing danger to self and others. When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. The care plan also included a focus area that began on 09/08/2020 which stated The resident has potential for psychosocial well-being problem r/t little or no interest in doing activities. , with a goal that began on 05/24/2023 which stated, I will express satisfaction with type of activities and level of activity involvement when asked through the review date., with the Interventions/Tasks that included the following: Explain to the resident the importance of social interaction, leisure activity time and encourage participation in group activities. Remind him when food socials, bingo and movie/popcorn activities are scheduled as he enjoys these.; Provide resident with activity calendar monthly.; Remind resident when and where activities are scheduled. The care plan also included a focus area that began on 09/08/2020 which stated, The resident has an ADL self-care performance deficit r/t psychosis., with a goal that began on 09/08/2020 that stated, The resident will improve current level of function AEB independence in all ADLs through the review date. The care plan also included a focus area that began on 07/09/2018 which stated, I use antidepressant medications(Zoloft) r/t depression., with a goal that began on 08/02/2021 which stated, I will be free from discomfort or adverse reactions related to antidepressant therapy through the review date., with the Interventions/Tasks that included the following: Administer ANTIDEPRESSANT medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT.; Monitor/document/report PRN adverse reactions to ANTIDEPRESSANT therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt loss, n/v, dry mouth, dry eyes. The care plan also included a focus area that began on 09/08/2020 which stated, I have depression and anxiety. I take meds to help me feel less anxious and to stabilize my mood. Current med-Zoloft, Depakote., with a goal that began on 09/08/2020 that stated. The resident will remain free of s/sx of distress, symptoms of depression, anxiety or sad mood by/through review date., with the Interventions/Taks that included the following: Administer medications as ordered. Monitor/document for side effects and effectiveness.; Monitor/document/report PRN any risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to CNA LPN. Record review of Resident #16's physician's Order Summary as of 02/11/2025 revealed under Diagnoses Major Depressive Disorder Recurrent, Severe Without Psychotic Features, Intermittent Explosive Disorder, and unspecified Psychosis Not Due To A Substance Or Known Psychological Condition. Resident #16 was prescribed Sertraline HCl Oral Capsule 150 MG once a day r/t Major Depressive Disorder Recurrent, Severe Without Psychotic Features, and Depakote Oral Tablet Delayed Release 125 MG r/t Intermittent Explosive Disorder. Record review of Resident #16's Preadmission Screening and Resident Review Level One (PL1) form dated 04/23/2015 revealed under section C0100 Mental Illness an answer of NO, indicating the resident does not have a mental illness. There were no additional PL1 screenings provided by the facility for Resident #16. There were no additional documents provided to suggest Resident #16 had a completed PASRR Evaluation. Record review of Resident #16's Diagnostic Report, undated, revealed the following under Diagnosis: Major Depressive Disorder Single Episode, Severe Without Psychotic Features with an onset date of 02/15/2018 and a received date of 06/7/2024; Intermittent Explosive Disorder with an onset date of 11/16/2016 with no received date; unspecified Psychosis Not Due To A Substance Or Known Psychological Condition with an onset date of 12/17/2014 with no received date; Major Depressive Disorder Recurrent, Severe Without Psychotic Features with an onset date of 3/1/2024 with no received date. During an interview conducted on 02/11/2025 at 3:30 PM the VPO stated the staff that was assigned to PASRR tasks was unavailable for interview. The VPO verified Resident #16 did not show to have a mental illness identified on his PL1 screening. The VPO verified Resident #16's active diagnoses included Major Depressive Disorder and Intermittent Explosive Disorder. The VPO stated, to her knowledge, Resident #16's PL1 should have been updated to reflect his mental illness once a mental illness diagnosis was received. The VPO stated PL1 screenings should have been reviewed during a residents' quarterly care planning meetings and as updates were received. The VPO stated Resident #16 was receiving psychiatric services. The VPO stated it was important for a residents PL1 screening to be accurate in case the resident wanted additional services. The VPO stated she could not speculate what a negative outcome could have been for a resident if their PL1 was not accurate. During an interview conducted on 02/11/2025 at 3:55 PM the ADM stated he was not aware what Resident #16's PL1 screening indicated. The ADM stated Resident #16 was receiving psychiatric services. The ADM stated he believed Resident #16 did have a diagnosis of Major Depressive Disorder and Intermittent Explosive Disorder. The ADM stated he believed Resident #16's PL1 should have indicated yes to a mental illness for the resident since he had a mental illness diagnosis. The ADM stated it was important for residents to have an accurate PL1 so the residents would have access to services. The ADM stated he could not say what a negative outcome could be for a resident that did not have an accurate PL1 as PASRR was not his area of expertise. Record review of the facility's policy titled, Admission Criteria, revised March 2019 revealed the following: 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-Admission Screening and Resident Review (PASARR) process. a. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID or RD. b. If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process. (1) The admitting nurse notifies the social services department when a resident is identified as having a possible (or evident) MD, ID or RD. (2) The social worker is responsible for making referrals to the appropriate state-designated authority. c. Upon completion of the Level II evaluation, the state PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate. d. The state PASARR representative provides a copy of the report to the facility. e. The interdisciplinary team determines whether the facility is capable of meeting the needs and services of the potential resident that are outlined in the evaluation. f. Once a decision is made, the state PASARR representative, the potential resident and his or her representative are notified. Record review of the document titled, Preadmission Screening and Resident Review (PASRR) Process for Individuals with Mental Illness located at https://www.hhs.texas.gov/sites/default/files/documents/pasrr-process-for-people-with-mental-illness.pdf, revealed the following: Examples of MI Examples of MI diagnoses are: o Schizophrenia o Mood Disorder (Bipolar Disorder, Major Depressive Disorder or other mood disorder) o Paranoid Disorder o Severe Anxiety Disorder o Schizoaffective Disorder o Post Traumatic Stress Syndrome What is a PASRR Evaluation? o Completed by the local intellectual and developmental disability authority (LIDDA), local mental health authority (LMHA) or local behavioral health authority (LBHA) to confirm or deny the suspicion of MI, ID or DD/RC. o Face to face evaluation of the person with a positive PASRR Level 1 (PL1) screening form who is suspected of having a MI, I, or DD/RC.

Based on observation, interviewn and record review, the facility, failed to ensure sure each resident had a right to a safe, clean, comfortable, and homelike environment in the facility and failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior in 1 (Resident #2) of 21 resident's rooms and restrooms reviewed for environment. The facility failed to ensure Resident #2's room was cleaned daily, homelike, clean, safe, and did not need repairs. These failures could place residents at risk for living in an unsafe, unclean, uncomfortable, and unhomelike environment which could cause a decline in resident psychosocial well-being. The findings included: Record review of Resident #2 's face sheet dated 02/20/2024 revealed she was [AGE] years old and was originally admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: Traumatic subarachnoid hemorrhage with loss of consciousness of 31 minutes to 59 minutes, subsequent encounter (bleeding in the space around the brain), unsteadiness on feet, unspecified lack of coordination, major depressive disorder, recurrent severe without psychotic features (mood disorder that caused a persistent feeling of sadness and loss of interest), osteoarthritis, unspecified site (degenerative joint disease), anxiety disorder, unspecified (excessive worry and fear), type 2 diabetes mellitus with other diabetic ophthalmic complication (eye condition that can cause vision loss and blindness in people who have diabetes), paranoid schizophrenia (experiencing strong, persistent paranoia or suspicion), cognitive communication deficit (difficulty paying attention, remembering, and responding accurately), need for assistance with personal care, difficulty in walking, schizoaffective disorder, bipolar type (mental health condition characterized by a mix of symptoms from schizophrenia and a mood disorder). The face sheet also revealed Resident #2 was in a room on Hall A. Record review of Resident #2 quarterly MDS dated [DATE] Section C - Cognitive Patterns revealed Resident #2 had a BIMS of 01 which indicated the resident's cognition was severely impaired. Additionally, Section GG - Functional Abilities revealed Resident #2 was independent and completed the following activities by herself with no assistance from a helper: eating, oral hygiene, toileting hygiene, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. Record Review of Resident #2's Care Plan, dated 01/08/25, revealed Resident #2 had a focus area that Resident #2 had a behavior destroying things in my room. Resident #2 sometimes tried to flush clothes etc. in the toilet to stop it up and tore down privacy curtains, blinds, etc. Resident #2 also sometimes refused staff to clean. The goal was the Resident #2 would allow staff to maintain her room as to provide a safe environment for her through the review date. Interventions were to encourage Resident #2 to not destroy property and to allow staff to clean her room, and to offer pleasant diversions such as snacks or listening to music with a therapist to allow staff to go in and clean when not present. Second, resident #2 was resistive to care (at times refused glucose checks (sugar), medication, baths being weighed) related to schizoaffective disorder. The goal was to give clear explanation of all care activities prior to and as they occur during each contact, if resident resists with activities of daily living, reassure resident, leave and return 5-10 minutes later and try again, praise the resident when behavior is appropriate. Third, Resident #2 had potential to be verbally aggressive related to schizoaffective disorder. The goal was the resident would verbalize understanding of need to control. Interventions were to monitor behavior each shift and document observed behavior and attempted intervention, and to provide frequent monitoring of Resident #2. Also, when the resident became agitated: Intervene before agitation escalated; Guide away from source of distress; Engage calmly in conversation; If response was aggressive, staff were to walk calmly away, and approach later. Fourth, Resident #2 had risk for falls related to psychoactive medication use. Goal was that resident would not sustain a serious injury related to falls through the review date. Goals were to be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Reinforce the of use of verbal cues for the resident. The resident needs a safe environment floor free from spills and clutter; adequate, glare-free light; a working and reachable call light. Fifth, was that Resident #2 had a problem with vision related to history of cataracts. The goal was the resident would show no decline in visual function through the review date. Interventions were to Monitor/document/report as needed any signs or symptoms of acute eye problems: Change in ability to perform activities of daily living, decline in mobility, sudden visual loss, pupils dilated, gray or milky, complaints of halos around lights, double vision, tunnel vision, blurred or hazy vision. Finally, there was no documentation in the Care Plan for Resident #2 to not have a window covering, privacy curtain, call light due to pulling them down. Record Review of Resident #2's Fall Risk assessment dated [DATE] revealed Resident #2 had not fallen in the past 3 months, was legally blind, and had a balance problem while standing/walking. Record Review of Resident #2's progress notes from 01/09/24 to 02/10/25 revealed there was no documentation of Resident #2 refusing to allow staff to clean her room or pulling the blinds off the window. During an observation on 2/9/25 at approximately 9:45 AM HK C went into the room that the state surveyors were working in a room on Hall A and asked if she could collect the trash in the room. During an observation on 2/9/25 at 12:05 PM, Resident #2 sat on her bed. There was a strong smell of feces and urine throughout the room. There was clothing, trash, and pullups scattered all over the floors through the room and restroom. The bedroom window did not have a covering and there was no privacy curtain in the room. A gate and house were visible through the window as the glass of the window was clear. The was no dresser in the room. The closet floor had a pile of clothes and pullups and there was no clothing hanging. There were no sheets on the mattress. There was dried and sticky red and brown stains on the floor. There was chicken strips and potatoes thrown on the floors and stains on the walls. There was a bedside table that had three wheels and was soiled with dried food and liquid. There was a food tray in the room with a tray ticket labeled as breakfast from 2/9/25. The was trash scattered on the floor throughout the room and restroom. There was a meal ticket dated 1/31/25 found on the bedroom floor. In the restroom, there was square hole in the drywall where the toilet paper dispenser previously was. The toilet tank did not have a lid which exposed the plumbing. The toilet was filled with feces. The was no television or radio in the room and there were no decorations on the walls or in the room. During an interview on 2/9/25 at 12:15 PM, the ADM stated Resident #2 often did not allow staff to enter her room. He stated she had a history of destroying her room by throwing pullups, trash, clothes, and food throughout the room. He stated she had thrown food trays in the hallway. He stated she ripped blinds, curtains, and anything else she could off the walls. He stated she also put un-flushable objects in the toilet which clogged it. During an interview and observation on 2/9/25 at 12:25 PM, HK C was observed sweeping the floors of Resident #2's room. HK C stated Resident #2 often did not allow her to clean her room. She stated Resident #2 yelled at staff to get out of her room. She stated Resident #2 often tore things off the walls and threw things all over the room. During an observation on 2/9/25 from 12:15 PM to 12:34 PM, Resident #2 sat quietly on her bed and drank an orange soda while three housekeeping staff and the MS were in her room. Housekeeping staff picked up trash, clothing, pullups, and old food scattered on the floors throughout the bedroom and restroom areas. Housekeeping staff cleaned the walls and swept, scraped, and mopped the floors. Housekeeping staff rolled Resident #2's bed to the middle of the room while she sat quietly on it. Housekeeping staff swept and mopped the area where the bed was located and then rolled the bed back to its original location. The MS unclogged the toilet filled with feces in the restroom that was inside the bedroom. Resident #2 said, thank you have a nice day, as the staff left her room. The call light cord and button were observed to be wrapped and tied up hanging against the wall and out of Resident #2's reach. During an interview on 2/10/25 at 10:07 AM, the DM stated the kitchen served chicken strips and potatoes on Friday (2/7/25) for dinner as a substitute for the residents that did not want the steak fingers. During observation on 2/10/25 at 10:30 AM Resident #2 sat quietly on her bed and drank an orange soda while two housekeeping staff were in the room sweeping and mopping the floors and emptying the trash. The call light cord and button were observed to be wrapped and tied up hanging against the wall and out of Resident #2's reach. During an interview on 2/10/25 at 11:32 AM, the Hospice RN stated she worked at a Hospice Provider and provided services to Resident #2. The Hospice RN stated Resident #2 received services from hospice CNA's on Monday, Wednesday and Friday. The Hospice RN stated she had not seen a privacy curtain in her room. The Hospice RN stated she had seen a curtain on Resident #2's window but could not remember when she last saw it. The Hospice RN stated she had concerns about the cleanliness of the room during time she came to see Resident #2. She stated almost every time she had come there had been food and drinks thrown on the floor. During an interview on 2/10/25 at 2:50 PM, CNA B stated she worked on Hall A. She stated Resident #2 preferred to be independent and did not allow staff to help her very much. She stated Resident #2 yelled at staff to get out of her room. She stated Resident #2 destroyed her room and had thrown pullups, clothes, toilet paper, trash, and food all round her room. CNA B stated Resident #2 used the toilet independently. She stated staff checked on Resident #2 every hour during rounds. She stated Resident #2 ate all meals and snacks in her bedroom. CNA B stated Resident #2 had flushed the toilet without being prompted. She stated Resident #2 had yanked the call light out of the wall previously. She stated she did not know why there were no blinds or privacy curtains in the room. She stated she did not know why there were no sheets or pillows on the bed and was supposed to have them. CNA B stated Hospice staff were supposed to come and shower Resident #2 and change her linens. She stated Hospice staff reported to the facility when Resident #2 refused care. She stated she would try to provide services Resident #2 refused by hospice staff later in the day. She stated Resident #2 changed her own pullups. She stated Resident #2 ambulated in her room by feeling around the walls and furniture because she was blind. She stated housekeeping staff were supposed to clean resident's rooms daily and more if requested. CNA B stated CNA's passed out food trays to residents that ate in their rooms and were supposed to notify housekeeping of rooms that needed to be cleaned. CNA B stated she was trained that CNA's were also responsible to clean rooms when needed. During an interview on 2/10/25 at 3:18 PM, HK B stated she was responsible for cleaning rooms on Hall A. She stated she had not worked on 2/2/25. She stated she swept and mopped the floors and threw out trash in resident's rooms. She stated she checked Resident #2's room three times (after each meal) during her shifts because Resident #2 threw her food trays on the floor. She stated Resident #2 ate all her meals in her bedroom. She stated she was not trained to clean the room three times a day but this was her preference due to Resident #2 having behaviors of throwing food trays, trash, and clothes. She stated there were times that Resident #2 would not let her in to clean the room but she was trained to leave and go back later if that happened. During an interview on 2/10/25 at 3:21 PM, CNA C stated Resident #2 was blind and she believed she could only see shadows. She stated Resident #2 preferred to do things herself independently such as dressing herself and toileting, and she was receiving hospice services. She stated Resident #2 screamed and yelled when given food trays. She stated Resident #2 had been refusing care and had mood swings and threw her food trays. She stated the dresser was removed from her room because she flipped it over several times. She stated she believed the privacy curtain was missing because it was in Resident #2's way and was hazardous but did not specifically know why. She stated Resident #2's door was always shut to keep residents that wander out of her room and Resident #2 from wandering out. CNA C stated she checked on Resident #2 every 1 to 2 hours. She stated the MT's also checked on her every twenty minutes. CNA C stated Resident #2 yanked on her call light cord before but Resident #2 knew how to use the call light. She stated Resident #2 threw water at her the other day. She stated she had helped Resident #2 change clothes in her room before. CNA C stated Resident #2 was supposed to have sheets and a pillow on her bed. She stated there was no clean linen when she arrived at work this morning. CNA C stated she was trained to clean up resident's room if she saw a mess and she was also supposed to locate the cause of any odors she smelled in resident's rooms. She stated she was trained to tell maintenance staff when toilets were clogged. She stated CNA's and MT's passed out food trays on the halls. She stated Resident #2 always ate in her room. CNA C stated Resident #2 could slip and fall on any trash, clothes, food, pullups, and liquids scattered on the floor. CNA C stated old food and liquids, and feces could attract bugs and rodents. She stated feces was also a hazard to Resident #2's health. She stated a potential negative outcome of not having sheets and pillows could cause Resident #2 to have skin irritation from the plastic mattress. During an interview on 2/10/25 at 4:10 PM, RN A stated Resident #2 threw trays of food and water on the floors. She stated housekeeping staff must clean the room daily and must try again if the resident refused. She stated Resident #2 had clogged up the bathroom and flooded her sink in her bedroom before. She stated Resident #2 tore down the privacy curtain and the soap and toilet paper dispensers in her restroom. She stated Resident #2 had ripped the call light cord out of the wall before. She stated she did not know why there were no blinds on the window in Resident #2's bedroom. RN A stated staff were trained to document all refusals of care in Resident #2's chart. RN A stated Resident #2 was legally blind, therefore a potential negative outcome from not having a covering on the bedroom window could affect Resident #2's state of mind as she could think she saw something or someone outside her window. RN A stated Resident #2 dressed herself in her room and it did not allow her to have privacy. She stated the facility was gated however the bedroom windows were still visible through the bars of the gate and anyone that passed by could see though the window. She stated the CNA's could clean up food on the bedroom floors and then call housekeeping to prevent attracting roaches and other bugs. She stated housekeeping was supposed to clean bedrooms every day. She stated a potential negative outcome of feces left in the toilet could cause infection or get all over the floor which was a sanitary issue. RN A stated staff were trained to identify odors smelled in resident's room and clean it up. RN A stated a potential negative outcome of having clothing, trash, food, liquid, and pullups scattered all over the floor could cause Resident #2 to trip and fall because she could not see and a fall would be bad for her. She stated Resident #2 could hit her head or break a leg. She stated Resident #2 had not fallen that she was aware of. She stated Resident #2 touched the furniture and walls when she walked . During an interview on 2/10/25 at 4:35 PM, the Hospice CNA with the Hospice Provider stated she had worked with Resident #2 for four months. She stated Resident #2 had good and bad days. She stated initially Resident #2 loved to shower, talk, and read the bible however, about a month and a half ago, she began refusing showers and activities. She stated she saw Resident #2 three times a week. The Hospice CNA stated she would shower or give Resident #2 a bed bath, changed her linens, threw the trash, cleaned up if needed, and provided companion care. The Hospice CNA stated about a week and a half ago, Resident #2 was agitated and she shattered the lid of the toilet tank. She stated she told RN A and the Hospice RN about it. She stated facility staff cleaned up the mess. She stated Resident #2 often threw objects and food. The Hospice CNA stated there was almost always food on the bedroom floor when she came. She stated she had never seen feces in her toilet. She stated she had helped Resident #2 change clothes in her bedroom or in the shower room. She stated Resident #2 tore down or broke her blinds. The Hospice CNA stated Resident #2 could be at risk of falling if trash, blankets, clothes, pullups, liquids, and food were on the floors. She stated Resident #2 did not like when people went in her room. She stated staff usually cleaned the room quietly. She stated she did not believe Resident #2 could see at all. The Hospice CNA stated Resident #2 toileted herself and flushed the toilet without being prompted. She stated Resident #2 left pullups all over her room. During an interview on 2/11/25 at 9:48 AM, the MS stated he supervised the MT's, maintenance staff, and housekeeping staff. The MS stated he expected housekeeping staff to clean the resident's rooms daily. The MS stated he expected for housekeeping staff to take advantage of times when residents were not in their rooms to clean them for those residents that would not allow housekeeping staff to clean their rooms. The MS stated they cannot ignore a residents room when it was dirty. They must figure out how to clean it. The MS stated leaving old food and liquids on the floor and feces in the toilet was an infection and safety issue. The MS stated Resident #2 was blind. The MS stated rooms must be cleaned every day even if the resident throws them out and he expected them to try to go in again later and clean the room quietly. The MS stated trash and clothing on the floor was a trip hazard to Resident #2. The MS stated and he pulled out shirts from the pipes yesterday and that's why the plumbing and toilets were clogged up. The MS stated he had unclogged the pipes for Resident #2's room through the ceiling as well as plunged her toilet on Sunday (2/9/25) to unclog it. The MS stated Resident #2 threw the lid to the toilet tank and it broke all over the floor in her room sometime in December so he was afraid to put another lid on the toilet tank because he felt she could hurt herself. The MS stated he had spoken to the ADM about it and wasn't instructed to replace the lid of the toilet tank. The MS stated Resident #2 pulled the privacy curtain and blinds down in her room and she pulled the call light cords out of the wall. He stated he replaced the blinds on her window yesterday and she already pulled them down. He stated he replaced the new call light cord yesterday. The MS stated he expected housekeeping staff to attempt to clean Resident 2's room multiple times a day due to her behaviors of throwing things. The MS stated HK B and HK C were the staff that worked on Sunday and were responsible to clean resident's rooms. He stated the MT's walking the floor were expected to walk the hall and observe and listen for the resident's to ensure they're safe. He stated MT's were not expected to open the doors to resident's rooms each time they passed by. The MS stated MT's would only open the bedroom doors if they heard something that caused them to have a concern. The MS stated he was not aware the chicken strips and the potatoes that were found on the floor in Resident #2's room on Sunday were served on Friday. He stated that was a health and safety hazard. The MS stated a potential negative outcome of the issues in the room was that it would be unsanitary, it could cause odors, and it could attract insects and other pests. The MS stated that the potential negative outcome of not having privacy curtains and blinds on the window was that it did not allow Resident #2 to have privacy. The MS stated he would try to figure out another way to cover the window to ensure her privacy. During an interview on 2/11/25 at 10:30 AM, HK A stated housekeeping staff were supposed to get carts ready with chemicals and supplies when they first arrived for their shift in the mornings and then to the dining room to clean after breakfast every morning. She stated they usually start cleaning the dining room around 8:30 AM. HK A stated afterwards they cleaned resident's rooms. HK A stated all housekeeping staff should've cleaned in every room before 12:00 PM. HK A stated she was not aware Resident #2's room had not been cleaned prior to 12:00 PM on 2/9/25. HK A stated she was not aware of the extent of the mess in Resident #2's room. HK A stated HK C was responsible to clean all the rooms on Hall A that morning. HK A stated she would tell the nurse if a resident did not allow her to clean their room. HK A stated she could also continue to try to go back later to clean the room or try to go in when she was asleep. HK A stated she was trained to clean restrooms, look under beds for trash, sweep and mop the floors, and clean food or spills in the rooms. HK A stated Resident #2 could slip and fall because she could not see. HK A stated Resident #2's toilet and sink were stopped up sometimes because she stuffed paper towels in them. HK A stated there had been issues with pipes being stopped up. HK A stated housekeeping was supposed to check the restrooms and toilets and log repairs needed in the maintenance logbook. During an interview on 2/11/25 at 11:33 AM, CNA A stated she went into Resident #2's bedroom on 2/9/25 between 6:00 AM and 6:30 AM when doing rounds and saw the mess in her room. CNA A stated she opened the door to check if Resident #2 was breathing, but she did not go all the way into the room. CNA A stated Resident #2 was asleep in the bed. CNA A stated Resident #2 did not say anything to her when she went into the room. CNA A stated she recalled she smelled the odor of feces in Resident #2's bedroom when she opened the door but she did not go into Resident #2's restroom or check to identify what caused the odor. She stated she did not recall where the call light button was located. CNA A stated Resident #2 drank soft drinks, tea, and some water. She stated she reported the mess in Resident #2's room to RN B afterwards. CNA A stated she was expected to pick up the trays and clean food she observed on the floors. She stated she did rounds every two hours. She stated Resident #2 walked and sometimes used the wheelchair to ambulate and did not like to have help with anything. She stated Resident #2 touched the walls to get around when she walked and when in her wheelchair. CNA A stated she did not notify anyone from housekeeping about the condition of Resident #2's room that morning. CNA A stated all CNAs could clean food on the floor. CNA A stated she went back into Resident #2's room that morning before 12:00PM to check on Resident #2 but could not recall the time. CNA A stated Resident #2 dressed herself. CNA A stated hospice staff showered her and most of the time she refused. CNA A stated she did not follow up with Resident #2 to provide services she refused from hospice. CNA A stated she could ask Resident #2 if she wanted to provide the refused services but her answer was always no. She stated she was trained that they were required to follow up with Resident #2 if she refused hospice services. She stated Resident #2 clogged up her toilet with objects before. CNA A stated a potential negative outcome of food and debris being scattered all over the floor was that Resident #2 could trip and fall and hurt herself. CNA A stated Resident #2 pulled the privacy curtains off the ceiling. CNA A stated a potential negative outcome of not having a window covering was that Resident #2 would not have privacy. She stated a potential negative outcome of the toilet being clogged with feces in it was that Resident #2 could get sick. CNA A stated that CNA's were responsible for putting linens on the beds. CNA A stated she did not try to put sheets on Resident #2's bed on 2/9/25 because she yelled at her to get out of her room. CNA A stated Resident #2 used to have a pillow in her room but did not know where it was. During an interview on 2/11/25 at 11:56 AM, RN B stated she was not aware of the mess in Resident #2's room the morning of 2/9/25. She stated the CNA's would let them and housekeeping know if residents refused to let them clean their rooms. She stated CNA's and housekeeping staff cleaned resident's rooms. She stated all staff were expected to identify any odors coming from a resident's room and to let the charge nurse know if they could not find it. RN B stated the CNA's could write maintenance related issues they identified in the maintenance logbook . She stated CNA's and housekeeping staff could use a plunger to unclog a toilet. RN B stated clogged toilets could overflow, which put the resident's at risk of falling and infection. RN B stated trash left on Resident #2's bedroom floor put her at risk of falling because she was blind. RN B stated CNA's were supposed to check on resident's every two hours. During observation on 2/11/25 at 2:20 PM Resident #2 was lying in bed with the blanket covering her face. Housekeeping staffing was in the room sweeping and mopping the floors and emptying the trash . During an interview on 2/11/25 at 3:15 PM, LVN B stated she was the charge nurse for Hall A on Sunday, 2/9/25. LVN B stated Sunday was the second time she had worked on that hall and was vaguely familiar with Resident #2. LVN B stated she was not aware Resident #2's room had not been cleaned until it was brought to her attention by a CNA when the State surveyors arrived that morning around 9:00 AM. LVN B stated she responded that housecleaning was cleaning down that hall (Hall A). LVN B stated she saw that HK C was cleaning the rooms on Hall A that morning when the State surveyors first arrived. LVN B stated she went into Resident #2's room to check on her to verify she was breathing around approximately 10:00 AM. LVN B stated at that time, she did not speak to Resident #2 but she recalled Resident #2 grunted but had not spoken to her. LVN B stated she could not smell currently and did not smell the odor in Resident #2's bedroom. She stated she saw clothes on the floor. LVN B stated she assumed HK C had cleaned every room on that hall so she went to check the rooms on Hall's B and C. She stated she did not follow up with housekeeping to verify Resident #2's room was cleaned because HK C was still working on Hall A the last time, she saw her. LVN B stated she did not notice Resident #2's bedroom window did not have blinds. She stated she expected CNA's to pick up items on the floor such as trash, water, clothes, anything that could be a safety concern and cause a resident to trip and fall. LVN B stated CNA's completed rounds every 2 hours. LVN B stated she was trained to pick up mess and food from the floors. LVN B stated she was trained to clean up safety hazards and housekeeping sanitized it. LVN B stated she was responsible to ensure residents were provided with a sanitary and safe living environment as the charge nurse assigned to that hall that morning. LVN B stated she should have redirected housekeeping staff or been more diligent and observed the full extent of the mess in Resident #2's room during her rounds. LVN B stated food on the floors could place Resident #2 at risk of infection control, safety risk, and it was also and integrity issue for Resident #2 in her home as her space should have been clean. LVN B stated trash and clothes on the floor could cause a fall. LVN B stated feces left in the toilet was an infection control and integrity issue and could cause a resident to contract clostridium difficile (bacterium in the colon that caused diarrhea and inflammation). LVN B stated the window not having a covering caused Resident #2 to be exposed, not given privacy, and it also affected the temperature control in her bedroom. LVN B stated she would be concerned with Resident #2's safety with a privacy curtain in her room. LVN B stated she did not know if the facility provided an alternative to cover the window or provided a privacy screen for Resident #2 to ensure she had privacy and dignity in her room. LVN B stated a potential negative outcome of a clogged toilet was that it could overflow and cause feces to get on the floor, which could cause resident's to slip and fall, and it was also unsanitary. LVN B stated hospice staff reported any concerns to the charge nurse before they left the facility. LVN B stated she expected staff to document refusals on the behavior monitoring logs and to notify family members of any concerns. During an interview on 2/11/2025 at 3:55 PM the ADM stated the housekeeping staff were responsible for cleaning all bathrooms in the facility, daily. The ADM stated the MS supervised the housekeeping staff. During an interview on 2/11/25 at 4:20 PM the DON stated she came to the facility on Sunday (2/9/25) after she was notified that state surveyors were at the facility. She stated she was not aware of the condition of Resident #2's bedroom until she was told about it sometime in the afternoon. She stated she last worked on 2/7/25. The DON stated Resident #2 rejected care and would not allow anyone to go in her room. The DON stated Resident #2 tore up her room and tore things off the walls. The DON stated Resident #2 received hospice services through Interim. The DON stated Resident #2 could slip and fall from liquids and food on the floor. She could trip on clothes and trash on the floor. The DON stated Resident #2 had not fallen in her room. The DON stated she was not aware of nursing staff being aware of the condition of that room and being aware it had not been cleaned. The DON stated she expected nursing staff to attempt to clean the rooms. The DON stated she expected nursing staff to follow up and ensure Resident #2's room was cleaned after they saw housekeeping were done cleaning rooms on the hall. The DON stated she had worked that this facility since mid-November and had not trained staff on that yet. The DON stated staff were responsible for the hallways they were assigned to during their shift. The DON stated she did not know how often nursing staff did rounds. The DON stated she was aware that Resident #2's window did not have blinds because Resident #2 ripped them off. She stated blinds were installed on the window yesterday and she had already ripped them down. She stated she could not recall seeing a window covering on her window prior to yesterday. The DON stated she did not know if there was a requirement for resident's room windows to have a covering. The DON stated a potential negative outcome to not having a window covering could be that Resident #2 did not have privacy which would cause her to be embarrassed if someone were to see her unclothed. The DON stated she expected staff to go back and try to provide care or get another staff to go back and try when Resident #2 refused care. The DON stated a potential negative outcome of there being a miscommunication between the facility and hospice could be that Resident #2's needs would not be met. The DON

Based on observation, record reviews, and interviews, the facility failed to ensure each resident had a right to reside and recieve services in the facility with reasonable accomodation of the resident's needs and preferences for 1 (Resident #2) of 21 residents reviewed for accomodation of needs. The facility failed to provide a working communication system, that was easily at reach at the bedside, that would allow Resident #2 the ability to safely call for staff for assistance. This failure could place residents at risk of not having a means of directly contacting caregivers in an emergency or when they needed support for daily living. Findings included: Record review of Resident #2 's face sheet dated 02/20/2024 revealed she was [AGE] years old and was originally admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: Traumatic subarachnoid hemorrhage with loss of consciousness of 31 minutes to 59 minutes, subsequent encounter (bleeding in the space around the brain), unsteadiness on feet, unspecified lack of coordination, major depressive disorder, recurrent severe without psychotic features (mood disorder that caused a persistent feeling of sadness and loss of interest), osteoarthritis, unspecified site (degenerative joint disease), anxiety disorder, unspecified (excessive worry and fear), type 2 diabetes mellitus with other diabetic ophthalmic complication (eye condition that can cause vision loss and blindness in people who have diabetes), paranoid schizophrenia (experiencing strong, persistent paranoia or suspicion), cognitive communication deficit (difficulty paying attention, remembering, and responding accurately), need for assistance with personal care, difficulty in walking, schizoaffective disorder, bipolar type (mental health condition characterized by a mix of symptoms from schizophrenia and a mood disorder). Record review of Resident #2 quarterly MDS dated [DATE] Section C - Cognitive Patterns revealed Resident #2 had a BIMS of 01 which indicated the resident's cognition was severely impaired. Additionally, Section GG - Functional Abilities revealed Resident #2 was independent and completed the following activities by herself with no assistance from a helper: eating, oral hygiene, toileting hygiene, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. Record Review of Resident #2's Care Plan, dated 01/08/25, included revealed Resident #2 had risk for falls related to psychoactive medication use. Goal was that resident would not sustain a serious injury related to falls through the review date. Interventions were to be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Reinforce the of use of verbal cues for the resident. Ensure that the resident was wearing appropriate footwear, when ambulating transferring. The resident needs a safe environment floor free from spills and clutter; adequate, glare-free light; a working and reachable call light. Record Review of Resident #2's Fall Risk assessment dated [DATE] revealed Resident #2 had not fallen in the past 3 months, was legally blind, and had a balance problem while standing/walking. During an observation on 2/9/25 at 12:05 PM Resident #2 sat on her bed. The call light cord and button were observed to be wrapped and tied up hanging against the wall and out of Resident #2's reach. During an interview on 2/9/25 at 12:15 PM, the ADM stated Resident #2 often did not allow staff to enter her room. He stated she had a history of destroying her room by throwing pullups, trash, clothes, and food throughout the room. He stated she had also thrown food trays in the hallway. He stated she also ripped blinds, curtains, and anything else she could off the walls. During an observation on 2/9/25 from 12:15 PM to 12:34 PM Resident #2 sat quietly on her bed and drank an orange soda while three housekeeping staff and maintenance staff were cleaning her room. The call light cord and button were observed to be wrapped and tied up hanging against the wall and out of Resident #2's reach. During an observation on 2/9/25 at approximately 1:31 PM Resident #2 was lying in bed. The room was clean. The call light cord and button were observed to be wrapped and tied up hanging against the wall and out of Resident #2's reach. During an observation on 2/10/25 at approximately 9:15 AM Resident #2 was lying in bed. The call light cord and button were observed to be wrapped and tied up hanging against the wall and out of Resident #2's reach. During observation on 2/10/25 at 10:30 AM Resident #2 sat quietly on her bed and drank an orange soda while two housekeeping staff were in the room sweeping and mopping the floors and emptying the trash. The call light cord and button were observed to be wrapped and tied up hanging against the wall and out of Resident #2's reach. During an interview on 2/10/25 at 2:50 PM, CNA B stated she worked on Hall A. She stated Resident #2 preferred to be independent and did not allow staff to help her very much. She stated Resident #2 yelled at staff to get out of her room. She stated staff checked on Resident #2 every hour during rounds. She stated Resident #2 had pulled the call light string in the bathroom in the past. She stated she was trained that the call light button in the bedroom was supposed to always be located at the bedside and within Resident #2's reach. She stated Resident #2 had yanked the call light out of the wall previously. She stated Resident #2 ambulated in her room by feeling around the walls and furniture because she was blind. During an observation on 2/10/25 at 3:20 PM Resident #2 was lying in bed with the blanket covering her face. HK B entered Resident #2's room. A tray of food and dishes were observed to be thrown on the floor. The call light cord and button were observed to be wrapped and tied up hanging against the wall and out of Resident #2's reach. During an interview on 2/10/25 at 3:21 PM, CNA C stated Resident #2 was blind and she believed she could only see shadows. She stated Resident #2's door was always shut to keep residents that wandered out of her room and Resident #2 from wandering out. CNA C stated she checked on Resident #2 every 1-2 hours. She stated the MT's also checked on her every twenty minutes. She stated she was trained that the call light button was supposed to always be placed by Resident #2's side within her reach. She stated Resident #2 had pressed the call button before for help. She stated the call light was not supposed to be rolled up against the wall. CNA C stated Resident #2 yanked on her call light cord before but Resident #2 knew how to use the call light. She stated a potential negative outcome of the call light button being out of Resident #2's reach prevented her the ability to call for help when needed. During an interview on 2/10/25 at 4:10 PM, RN A stated she checked on Resident #2 every 2-2.5 hours. She stated the CNA's also checked on Resident #2 when they heard her yelling and during their rounds. She stated Resident #2 had ripped the call light cord out of the wall before which could have been why the call light cord was wrapped up on the wall. She stated the MT's also checked on Resident #2 when they walked the floor. RN A stated Resident #2 pulled the call light string in the restroom when she needed assistance. She stated staff were able to determine which call light was activated because the noise it made for the bedrooms and restrooms were different. During an interview on 2/10/25 at 4:35 PM, the Hospice CNA with the Hospice Provider stated she had worked with Resident #2 for four months. The Hospice CNA stated the call light was normally placed in her bed and in her reach. She stated Resident #2 would not be able to call for help if there was an emergency while in her bed if the call light button was not placed within her reach. During an observation on 2/10/25 at approximately 5:15 PM Resident #2 was lying in bed with the blanket covering her face. The call light cord and button were observed to be wrapped and tied up hanging against the wall and out of Resident #2's reach. During an observation on 2/11/25 at approximately 9:08 AM Resident #2 was lying in bed with the blanket covering her face. The call light cord and button were observed to be wrapped and tied up hanging against the wall and out of Resident #2's reach. During an interview on 2/11/25 at 9:48 AM, the MS stated he supervised the MT's, maintenance staff, and housekeeping staff. The MS stated Resident #2 was blind. The MS stated Resident #2 pulled the privacy curtain and blinds down in her room and she pulled the call light cords out of the wall. He stated he replaced the new call light cord yesterday. He stated the MT's walking the floor were expected to walk the hall and observe and listen for the resident's to ensure they're safe. He stated MT's were not expected to open the doors to resident's room each time they passed by. The MS stated MT's would only open the bedroom doors if they heard something that caused them to have a concern. During an interview on 2/11/25 at 11:33 AM, CNA A stated she went into Resident #2's bedroom on 2/9/25 between 6:00 AM and 6:30 AM when doing rounds and did not recall where the call light button was located. CNA A stated she was trained that the call light button was supposed to be beside her bed in her reach. She stated Resident #2 touched the walls to get around when she walked and when in her wheelchair. She stated Resident #2 had used the call light in the past in the restroom. During an interview on 2/11/25 at 11:56 AM, RN B stated the call light button was supposed to be placed within Resident #2's reach and where she could find it. RN B stated CNA's were supposed to check on resident's every two hours. During observation on 2/11/25 at 2:20 PM Resident #2 was lying in bed with the blanket covering her face. Housekeeping staff were in the room sweeping and mopping the floors and emptying the trash. The call light cord and button were observed to be wrapped and tied up hanging against the wall and out of Resident #2's reach. During an interview on 2/11/25 at 3:15 PM, LVN B stated she was the charge nurse for Hall A on Sunday, 2/9/25. LVN B stated she went into Resident #2's room to check on her to verify she was breathing around approximately 10:00 AM. LVN B stated at that time, she did not speak to Resident #2 but she recalled Resident #2 grunted and had not spoken to her. LVN B stated the call light was supposed to be on the resident's bedside on their chair, it was not supposed to be rolled up on the wall. LVN B stated a potential negative outcome of the call light not being within the resident's reach was a safety issue because the resident could fall and could not use the call light to call for help. During an interview on 2/11/25 at 4:20 PM the DON stated she did not know how often nursing staff did rounds. The DON stated call lights were supposed to be within a resident's reach but from her understanding Resident #2 tried to wrap it around her neck before which could be why it was not placed within her reach. The DON stated she expected call light buttons to always be placed within residents reach while in their room or bed. The DON stated the resident would not be able to call for help if needed. The DON stated Resident #2 had not fallen in her room. During an interview on 2/11/25 at 4:51 PM the ADM stated CNA's did rounds and checked on resident's every 2 hours. The ADM stated MT's were expected and trained to knock and open doors to check on residents. The ADM stated the MS replaced the call light cord in Resident #2's room yesterday because she ripped them out of the wall the day before. The ADM stated he was not aware the call light was wrapped on the wall and not within Resident #2's reach for the past three days. The ADM stated staff were trained to ensure residents could reach the call button when in the room. Record review of the facility policy titled Call System, Resident, Revised September 2022, revealed in part the following documentation, Policy Heading. Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. Policy Interpretation and Implementation. 1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. 49154

Based on observations, interviews, and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents and supervision. 1. The facility failed to ensure Resident #1 received direct supervision from staff on while smoking when Monitor Tech A was observed on a cell phone while assigned to monitor residents in the smoking area on 11/22/2024. 2. Monitor Tech A failed to follow protective measures put in place to use cigarette extenders and smoking aprons for residents' safety while residents were outside smoking, resulting in a burn to Resident #1 on 11/22/2024. 3. An Immediate Jeopardy situation was determined to have existed on 11/22/24. It was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance on 11/27/24 before the beginning of the survey. This failure could place residents at risk for physical harm, pain, mental anguish, emotional distress, and serious injury. Findings included: Record Review of Resident #1's face sheet dated 12/03/24 revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #1 had a medical history of unspecified dementia (loss of thinking, remembering, and reasoning interferes with daily life activities), anxiety (feeling of fear, dread, and uneasiness) restlessness and agitation (feeling uneasy, unable to relax, experiencing inner tension, often accompanied by physical movement), bipolar disorder (mental illness that causes unusual shifts in mood from extreme highs to lows), dystonia (involuntary muscle contractions that cause repetitive or twisting movement), seizures (abnormal burst of electrical activity in the brain that causes temporary changes in behavior, muscle control and awareness), tremor (a neurological condition that includes shaking or trembling movements in one or more parts of the body), altered mental status (a noticeable change in a person's mental function, often characterized by confusion, decreased alertness, unusual behavior), weakness (loss of strength), muscle weakness (loss of muscle strength or the inability to move a muscle normally), lack of coordination (disorder that cause clumsy, awkward movements), cognitive communication disorder (difficult to communicate), drug induced subacute dyskinesia (movement disorder as a result of taking certain drugs), and drug induced secondary parkinsonism (movement disorder). Record review of Resident #1's MDS dated [DATE] revealed, Section C - Cognitive patterns revealed a BIMS score of 1 which indicated Resident #1 had severe cognitive impairment. Record review of Resident #1's care plan dated 08/07/24 revealed focus: Resident #1 was at risk for injury while smoking and required supervised smoking, date initiated 08/07/24, Goals: Resident #1 will not smoke without supervision through the review date, date initialed 08/07/24, revision date 08/21/24, target date 11/15/24. Interventions: Resident #1 required supervision while smoking date initiated 08/07/24, observe clothing and skin for signs of cigarette burns date initiated 08/07/24, Resident #1 requires a smoking apron while smoking date initiated 09/22/24, use of cigarette extender when smoking date initiated 10/15/24. Record review of Resident #1's smoking assessments dated 10/11/2024 revealed under Section E Safety, 7a Smoking Apron, 7b Cigarette Holder, and 7c Supervision; and under Section F IDTC Decision 1. All residents are supervised smoking and resident uses a smoking extender and apron. Record review of progress notes for Resident # 1 dated 11/22/24 revealed Resident #1 noted to have a burn to left middle finger measuring 0.3 x 0.3 x 0. Contacted physician and order received to start Silvadene Cream (antibiotic used to treat and prevent wound infections in people with severe burns) BID x 7 days and monitor for infection. Notified Family Member. No issues or concerns at this time. Record review of Resident #1's physician orders dated 12/03/24 revealed an order for Silvadene external cream 1% (silver sulfadiazine) apply to left middle finger topically every shift to promote wound healing and prevent infection for 7 days, order date 11/22/24, start date 11/22/24, end date 11/29/22. Monitor left middle finger burn for signs and symptoms of infection every shift until healed every shift for infection prevention and wound healing, order date 11/22/24, start date 11/22/24. During an interview on 12/03/24 at 2:51 PM the DON, stated she was notified on 11/22/24 of the injury to Resident #1's middle finger on her left hand. She stated the facility had a care plan meeting with Resident #1 and her family member the morning of the incident, but prior to the incident. She stated it was after the meeting that the resident reported the burn. She stated she assessed Resident #1's middle finger then called the doctor and received an order for treatment. She stated Resident #1 told her the burn happened when the Family Member helped her smoke. She stated Resident #1's Family Member denied the incident happened while he helped her smoke, but Resident #1 stated it happened when her Family Member helped her smoke. The DON stated that the next time her Family Member comes to visit she is going to talk with the Family Member about supervision when Resident #1 smokes. She stated that he needs to be made aware of the issues with her smoking and that she is too shaky, and he would need to hold the cigarette and use an extender. She stated the Family Member was adamant he held the cigarette the whole time, but Resident #1 stated she let it burn down too far when smoking with her Family Member. During a call on 12/03/24 at 12:18 PM, Family Member stated he did help Resident #1 smoke when he was at the facility. He stated the burns happened on a day he was not there. He stated when he helped her smoke at the facility, he would hold the cigarette for her the entire time because of her tremors. He stated the facility does have a cigarette extender, but he did not know if they used it or not. He stated the facility called and notified him of the burn, but he was not sure when that happened. During an interview on 12/03/24 at 12:51 PM, ADM stated, Resident #1 had always had cigarette extenders, and they have more on hand in case they are needed. He stated, Resident #1's Family Member denied being out there when she burned her hand, but Resident #1 said her Family Member was with her when it happened. He stated he was not sure when the incident happened. He stated the incident was not witnessed. He stated the facility staff reported the burn to the nurse and the physician was contacted for treatment. He stated, the facility initiated the use of the cigarette extender because of her tremors. During an interview on 12/03/24 at 2:00 PM, Resident #1 stated she burned her finger while smoking. She was able to lift her hand up and showed her middle finger on her left hand. The burn was visible and looked to have a scab over it. Resident stated she was in no pain at that time. During an interview on 12/04/24 at 2:54 PM the DON stated she assessed Resident #1 after the burn was reported. She stated, Resident #1 told her she let her cigarette burn down too far. During an interview on 12/03/24 at 3:55 PM, Monitor Tech B stated he worked when the burn incident occurred with Resident #1. He stated he was not the monitor tech outside monitoring the residents at that time. He stated he stayed inside the facility and monitored the live stream of the cameras in and around the facility. He stated Monitor Tech A was assigned to monitor residents when the burn happened, and that Monitor Tech A was fired over the burn. He stated that since the incident two staff members have to go outside and monitor residents when they smoke. He stated staff monitor residents while they smoke, and staff must make sure they do not burn themselves or their clothing. He stated that staff would place the residents' cigarette in the cigarette extender and monitor the residents with their cigarettes when they smoke. He stated that he recently started going out as a second staff to monitor residents during smoke breaks, and that before the burn happened, only one staff would go out to monitor residents. During an interview on 12/3/24 at 4:05 PM, The ADM stated Monitor Tech A no longer works at the facility. The ADM stated he was terminated due to failure, failure to supervise. He stated on 11/22/2024 he saw him outside, in the smoking area, while taking residents out to smoke, and he saw him get on his phone. He stated he told the Maintenance Supervisor, he was not going to have that because they had an incident report where a resident had an injury from smoking, so he was not going have staff on their phones because they are hired to monitor residents. He stated, he was not sure if this was when burn occurred, but Monitor Tech A had too many write ups for being on his phone. During an interview on 12/03/24 at 4:33 PM, RN D stated the facility had 3 monitor techs during the day, but only one monitor tech would take the residents out to smoke. She stated with Monitor Tech A, they had to tell him to get off his phone when at work, and they had to report him to the supervisor for being on his phone often. She stated since the incident with Resident #1, staff were in-serviced over abuse, neglect, reporting, incident reports, residents smoking and monitoring residents. During an interview on 12/03/24 at 4:51 PM, Monitor Tech A stated he did work on the day of the incident with Resident #1. He stated he was outside monitoring residents and Resident #1 was smoking and there were around 20 something residents outside smoking. He stated, her cigarette burned her hand. He stated, the facility used to have bats (cigarette extenders) these things to put the cigarettes in so residents would not burn their fingers and for some reason they were thrown away by the Maintenance Supervisor. He stated he gave her the cigarette and lit it for her, but he did not see it get short or burn her finger. He stated, he did not place the cigarette in the cigarette extender because they did not have any. He stated he did not place the smoking apron on her that day either. He stated, he could not recall why he did not place the apron on her, he just did not. He stated, he knew her Family Member had been at the facility that day and outside for one of the smoke breaks, but he was not sure which one. He stated, about an hour later he was made aware of the burn to Resident #1's finger, he stated he was not sure when or how recent she had gotten the burn just that she had burned herself. He stated, he was told he was suspended and had too many write ups, so he assumed it was over this incident. He stated then a few days later he received a text message saying he was fired. He stated the text message was from the Maintenance Supervisor. He stated, the Maintenance Supervisor and the ADM knew the extenders were thrown away, and the facility was out of them, but after the burn happened he guessed someone had to take the fall for it, so they fired him. During an interview on 12/03/24 at 5:05 PM the ADM stated he was not aware that staff had taken residents to smoke the week or possibly two weeks before 11/22/24 and allowed the residents to smoke without the use of cigarette extenders. He stated he was not aware the staff allowed Resident #1 to smoke the week before Thanksgiving without the smoking apron placed over her. He stated he did order more extenders after the incident with Resident #1 when her finger was burned. He stated he purchased 36 cigarette extenders on 11/22/224 after the incident with Resident #1 and additional smoking aprons. The cigarette extenders were received on 11/25/24. He stated that after the incident with Resident #1 he in-serviced staff over abuse and neglect, resident rights, monitoring residents while they smoke, reporting incidents with staff, and the Maintenance Supervisor in-serviced the monitor techs after the incident with Resident #1. During an observation on 12/03/24 at 5:05 PM, two boxes of cigarette extenders were observed in the ADM's office, in his desk drawer. During an interview on 12/03/24 at 5:10 PM, the Maintenance Supervisor stated, the ADM asked him to look at the cameras the day after the incident to see who the monitor tech was and if the monitor tech had done their job, and to make sure they had monitored the residents. He stated all the ADM wanted him to look for was, which monitor techs had worked and if the monitor techs were doing their jobs. Stated he looked at the camera footage and saw Monitor Tech A was on his phone while outside monitoring residents during the smoke break. He stated Monitor Tech A was standing near the coke machine and he saw him pull out his phone then hung it up, then he got on his phone again. He stated Monitor Tech A was then on his phone while the residents smoked. He stated he had spoken with Monitor Tech A, prior, about him being on his phone and warned him to not be on his phone when he monitored residents. He stated he let Monitor Tech A know he was suspended. He stated he was not told about the burn for incident with Resident #1, and he was only told to look to see what the monitor techs were doing in the video. He stated he did not look to see if Resident #1 did or did not have the apron on or if she was using the extender because he was only told to look to monitor the monitor techs. He stated he had Monitor Tech A throw away 1 cigarette extender around 2-3 weeks ago because it had some paint on it, so he told Monitor Tech A to throw that extender away. He stated the ADM had cigarette extenders in the office, and he gave them to the monitor techs. He stated he told the monitor techs if residents refuse the apron or extender to make sure and report it to the nurses and the administrators. He stated he did a training on Monday or Tuesday of last week with the monitor techs and he gave the ADM the in-service where everyone (staff) signed. He stated Monitor Tech A was suspended because he saw him on his cell phone while outside monitoring residents during smoke breaks. He stated he did not know if Resident #1 smoked without the apron on or if she smoked without using the extender, but she was supposed to have the apron on. He stated they administrative staff would do daily compliance checks of the smoking box. During an interview on 12/03/24 at 5:40 PM Monitor Tech C stated after the incident with Monitor Tech A the facility ordered the cigarette extenders. He stated he was told Monitor Tech A took the residents out to smoke and was on his cell phone. That Monitor Tech A wasn't paying attention to the residents, and the facility let him (monitor Tech A) go. He stated, staff are not to be on their phones when taking residents out to smoke because burns could happen and if you don't pay attention residents could get burned. He stated the facility did have cigarette extenders before the incident but ran out of them, and after the incident with Monitor Tech A, the facility ordered more. He stated he was unsure how long the facility was out of the cigarette extenders, be he thought it was maybe a week or two before the incident happened. Monitor Tech C was unsure of the date and he was asked to check dates he worked and he stated it was before the incident on 11/22/24 possibly they ran out the week of 11/17/24 - 11/23/24. He stated he thought it was reported to the Maintenance Supervisor. He stated he was told that staff had to keep a closer eye on the residents when they were smoking while the facility was out of extenders. He stated, during the time the facility did not have the cigarette extenders, Resident #1 did smoke without the cigarette extender while he was the monitor tech that monitored them. He stated the new extenders had the resident's names on them, so they knew who used them. He stated the Maintenance Supervisor had provided him with training on how to monitor smoke breaks and to use the smoking aprons and cigarette extenders. He stated since the incident, he was in-serviced over abuse, neglect, monitoring residents when out smoking and they cannot be on their cell phones. During an interview on 12/04/24 at 1:20 PM LVN E stated, he was told in report that Resident #1 had burned herself with a cigarette and there were orders for burn care. He stated that within the last month she had gone out to smoke regularly since she had gotten cigarettes regularly. He stated smoking assessments are done for all residents if they smoke or not and the assessment will document if they require supervision when they smoke. He stated all of the residents that smoke required supervision. He stated Resident #1 required supervision, the use of a smoking apron, and cigarette extender. He stated Resident #1 should have worn a smoking apron at all times when outside to smoke, He stated he had not observed her smoke without one. He stated he believed the cigarette extender was incorporated as another intervention and was in place at the time she received the burn. He stated since the time of the burn incident, the facility added an additional monitor tech to monitor during smoke breaks, a log to write down and check off indicating staff have placed the apron on the resident and extender on the cigarette, and to notify the nurse if the items are not available and that the nurse needs to be nodified if the resident is not complying with the interventions. He stated Resident #1 used the extender for the cigarette and smoking apron when she smoked. He stated, on 11/25/24, when he returned to work a few days after the incident happened, he provided wound care for Resident #1, and she did not indicate pain, but the area was still fluid filled. He stated he provided wound care to Resident #1 on 11/26/24, and the wound no longer had fluid in it, and the resident denied any pain. He stated he was told that Monitor Tech A was on his phone while he monitored residents for a smoke break. He stated he was told that there was an incident where Resident #1 had burned herself, and the camera footage showed Monitor Tech A was on his phone during that time. He stated it was told to him by the Maintenance Supervisor. During an interview on 12/04/24 at 1:50 PM, CNA F stated, she was told about the incident with Resident #1, and her finger was burned when she was outside to smoke. She stated the facility needed more monitor techs outside when resident's smoke. She stated the facility has changed it now, and they will have two staff going out to monitor residents when they smoke. She stated the facility had cigarette extenders for the residents to use. She stated she didn't know if the facility had always had them but knew they have them now. She stated they should store them in the toolbox with the cigarettes. She stated since the incident they have placed more staff outside to watch during the smoke breaks. She stated if a resident did refuse an apron or extender, a supervisor would need to be told and staff should not let the resident smoke until the supervisor went out there. She stated the facility in-serviced staff over abuse, neglect, reporting abuse or neglect, incidents and accidents, and residents that smoke, and to monitor residents when they smoke. During an interview on 12/04/24 at 2:00 PM CNA G stated she worked on 11/22/24, and she walked into the dining room while Resident #1 was talking with another resident. She stated the other resident asked if they could get ice for Resident #1's finger because she burned her finger. She stated she looked at Resident #1's finger, and it was red. She stated she knew Monitor Tech A was the monitor tech that supervised the smoke break the day of the incident. She stated she observed Monitor Tech A on his phone when he was outside assigned to monitor residents during smoke breaks. She stated every now and then she would see residents wear an apron when they were outside for a smoke break. She stated she never saw Resident #1 wear a smoking apron when she would go outside to smoke. She stated she was not sure how long the facility had cigarette extenders, but she had seen them. She stated since the incident, as far as she knew, the facility will have more staff outside during the smoke breaks, and the facility in-serviced staff over abuse and neglect, reporting, incident, monitoring residents, and reporting to the nurse or administrator. During an interview on 12/04/24 at 2:25 PM CNA I stated she had worked with Resident #1 over the past weekend. She was told about the burn on her finger, and Resident #1 had burn marks on her wheelchair cushion over the past weekend. She stated she was told they (facility staff) Resident #1 was smoking and maybe something happened, that a monitor tech wasn't paying attention and Resident #1 burned herself. She stated she wasn't out there when Resident #1 was smoking and never saw her smoke. She stated she doesn't know if Resident #1 wore an apron while smoking and was told she refused the apron. She stated the facility had smoking extenders and aprons for residents to use while they smoked. She stated, when she first started ,she was a monitor tech, and the residents had extenders then. She stated she received new training after Resident #1 burned her finger. She stated the training was regarding monitor techs supervising and checking for aprons and extenders, abuse and neglect, and reporting. During an interview on 12/04/24 at 2:36 PM Monitor Tech J stated he was not working the day of the incident with Resident #1 but was told they didn't have an extender the day she burned herself. He stated he heard she dropped the cigarette and burned herself. He stated as a monitor tech, when they go outside to monitor the residents on a smoke break, staff are to put smoking aprons on residents, give cigarettes to residents, and monitor the residents. He stated they were to watch for cigarette falls, burns, fires, and possible altercations between residents. He stated, since the incident, he was in-serviced on cigarette count, extenders, aprons, to pay attention to residents, and to not have phones. He stated all monitor techs were present for the in-service training. He stated they were told they needed to be better at watching residents and to not horse around. He stated they discussed using aprons and extenders for residents. He stated the training was held because of burns residents received and cigarettes falling while residents were smoking. During an interview on 12/04/24 at 2:50 PM Monitor Tech H stated he was told about the incident with Resident #1. He stated he was told that she was outside on the back patio area smoking, and staff (Monitor Tech A) was supposed to monitor her, but he was not because he was on his cell phone. He stated he knew Resident #1 tended to hold her cigarette in a downward position, in her hand, and cigarette ash would fall on her fingers. He stated he told the other monitor techs, in the past, to keep an eye on her. He stated , since the incident, he was in-serviced over abuse and neglect, monitoring residents when they smoke, that two staff have to be outside during smoke breaks, that staff have to place the aprons on the residents and use the extenders, and if a resident refuses to use them they have to have the nurse come outside and the nurse will handle how the resident will smoke. Observation on 12/03/24 at 1:10 PM, two staff members were observed with residents outside in the smoking area. Observed Monitor Tech C, place the smoking apron on Resident #1. Monitor Tech C, assisted Resident #1 with making sure the apron covered her left lap/leg area before he handed her the cigarette in the extender. Monitor Tech C lit the cigarette for her, and she used her left hand to hold the cigarette in the extender. Resident #1 continued to have tremors while she smoked the cigarette, and she was observed moving her left hand up and down and touched the cigarette to the apron on her left side. Monitor Tech C was observed assisting her hold her hand up and he made sure the apron continued to cover her. Two staff were observed outside assisting and monitoring residents during the smoke break. Resident #1 continued to smoke the cigarette and held it with her left hand and the cigarette was in the extender. Resident #1 observed with several black marks on the left side of the smoking apron from where her hand moved the cigarette up and down against the apron. Observation on 12/03/24 at 3:02 PM. Residents were outside smoking. Two staff members were observed outside monitoring residents. Resident #1 was observed outside with the smoking apron on and using the cigarette extender. Resident #1 was observed not having tremors and not touching the cigarette to her apron like she did at the 1:00 PM smoke break. Staff was observed monitoring Resident #1 and assisting her to lift her arm up to keep the cigarette away from her wheelchair. Two staff remained outside with residents during the smoke 3 PM break. The smoking box was observed with cigarette extenders in the box and smoking aprons with the box, as well as aprons on the resident and cigarette extenders were used. Record review of in-service: Verbal, physical, sexual, neglect, abuse policy and protocol, resident rights, injuries of unknown source, and incidents of staff and or misappropriation of resident's property, and reporting abuse and neglect no exception, dated 11-26-24 with 28 staff members signatures. Record review of in-service: safety and supervision of resident, accident and incident investigating and reporting, dated 11-26-24 with 27 staff members signatures. Record review of in-service for monitor techs dated 11-27-24: monitor tech, cigarette count daily, smoking aprons being worn, smoke extenders, paying attention to residence, and no phone during smoke breaks with 11 monitor tech signatures. Record review of Monitor Tech A's employee file documented a suspension date of 11/22/24 and termination date of 11/25/24. The following policy reviewed: Safety and Supervision of Residents dated 2001 revised date July 2017 Policy Statement: The facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Policy Interpretation and Implementation Facility-Oriented Approach to Safety l. Our facility-oriented approach to safety addresses risks for groups of residents. 4. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents. Individualized, Resident-Centered Approach to Safety l. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. 4. Implementing interventions to reduce accident risk and hazards shall include the following: b. Assigning responsibility for carrying out interventions. c. Ensuring-that interventions are implemented. 5. Monitoring the effectiveness of interventions shall include the following: a. Ensuring that interventions are implemented correctly and consistently. System approach to Safety 2. Resident supervision Is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. Resident Risk and Environmental Hazards l. Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed ln dedicated policies and procedures. These risk factors and environmental hazards include: d. Smoking The following policy reviewed: Smoking Policy - Residents dated 2001 revised date July 2017 Policy Statement: The facility shall establish and maintain safe resident smoking practices. Policy Interpretation and Implementation: 6. The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker the evaluation will include: d. Ability to smoke safely with or without supervision, (per a completed Safe Smoking Evaluation). 9. Any smoking related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. 11. Ant resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, a family member visitor or volunteer worker at all times during smoking. The ADM was notified on 12/04/24 at 12:25 PM, that a past non-compliance IJ situation had been identified due to the above failures. It was determined these failures placed Resident #1, in an IJ situation on 11/22/24. The facility implemented the following interventions: in-serviced staff over: Verbal, Physical, Sexual, Neglect, Abuse Policy & Protocol, Resident Rights, Injuries of Unknown Source AND Incidents of Theft and / or Misappropriation of Resident Property all on 11/26/24. In-serviced staff over: Safety and Supervision of Residents on 11/22/24, Accident and Incident Investigating and Reporting on 11/26/24. The facility implemented with a start date 11/26/24 that two staff members to be present during resident smoke breaks to monitor residents. Maintenance Supervisor in-serviced the monitor techs with additional in-service for cigarette count daily, smoking aprons being worn, use of smoke (cigarette) extenders, pay attention to residents no phones during smoke breaks on 11/27/24. The facility purchased 36 cigarette extenders on 11/22/24 and received them on 11/25/24, and additional smoking aprons for resident use. Monitor Tech A was suspended on 11/22/24 and terminated on 11/25/24.

Based on observation, interviews and record review, the facility failed to ensure the resident's environment remained as free from accidents and hazards as possible, and each resident received adequate supervision and assistance to prevent incidents for 5 of 5 residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) reviewed for incidents of aggression. Staff failed to consistently implement one to one supervision for Resident #1 to prevent her from being punched in the throat by Resident #2: however, no injuries were noted. Staff failed to ensure Resident #3, who had a history of wandering into rooms, did not enter Resident #2's room where he was hit in the eye by Resident #2, sustaining a bloodshot eye. Staff failed to ensure Resident #4, who has a history of wandering into rooms, did not enter Resident #5's room. Resident #5 pushed Resident #4 out of his room and hit him on his head; no injuries were noted. An Immediate Jeopardy (IJ) was identified on 05/13/2022. While the IJ was removed on 05/16/2022 at 10:17 a.m., the facility remained out of compliance at severity of no actual harm with the potential for more than minimal harm with a scope identified as pattern because the facility needed to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could affect the residents at the facility by placing them at risk for accidents that lead to injuries such as bruising, skin tears, fractures, suffocation, and subdural hematomas. Findings include: Record review of Resident #1's Admission Record (undated) indicated she was a [AGE] year-old female, who was admitted into the facility on [DATE] with the following diagnosis: language disorder, inappropriate involuntary laughing and crying due to a nervous system disorder, mental disorder, feeling of worry, anxiety, or fear that interfere with one's daily activities, parkinsonism caused by antipsychotic medications, sudden uncontrolled electrical disturbance in the brain, and mental health disorder causing significant impairment in daily life. Record review of quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating she had severe cognitive impairment. This MDS indicated Resident #1 had delusions (misconceptions or beliefs that are firmly held, contrary to reality; she had physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, grabbing, abusing others sexually) that occurred 1 to 3 days; verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) that occurred 1 to 3 days, and other behavior symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, packing rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily waste, or verbal/vocal symptoms like screaming, disruptive sounds) that occurred 1 to 3 days, rejected evaluation of care, occurring daily, and wandering behavior that occurred 4 to 6 days. This MDS indicated Resident #1 required supervision with setup help only for bed mobility, transfer, walking in room and corridor, and locomotion on and off the unit (Resident #1 walked and used her wheelchair). Record review of Resident #1's Wandering Risk Scale, dated 04/26/22, indicated she scored a 9, indicating she was at risk to wander. The Wandering Risk Scale, dated 04/06/22, indicated she scored a 13, indicating she was a high risk to wander. Record review of Resident #1's Care Plan dated 01/17/22 indicated she hit a resident in the face, while they were in the dining area. The intervention included monitoring Resident #1 closely when in the dining area; when wandering around and when agitated; redirect her to another area and offer a snack/drink; and notify the Family Nurse Practitioner (FNP) when she refused medications. On 12/19/21 Resident #1 slapped a resident in the face while trying to take a candy bar away from her. The intervention was to monitor Resident #1 closely when around residents, especially if they have snacks, she likes to take from them; and provide her with a snack when she is observed trying to take them from residents. Resident #1 had a behavior problem of going into residents' rooms and taking objects that did not belong to her, 2-3 times weekly. She also wandered around in the dining room and tried to pick food off resident's plates. The intervention was for the caregiver to provided opportunity for positive interaction and attention; stop and talk with her; if reasonable, discuss her behavior; explain/reinforce to her why her behavior was inappropriate and/or unacceptable to the resident. Intervene as necessary to protect the rights and safety of others; approach/speak in a calm manner; divert attention; remove from situation and take her to alternate location as needed and monitor closely, when in the dining area, to prevent her from taking food from residents. Resident #1 was physically aggressive at times due to [CONDITION(S)] disorder. The intervention was to monitor for physically aggressive behavior once per shift; document observed behaviors and attempted interventions in behavior log; monitor/document report PRN and signs/symptoms of resident posing danger to self and others; nurses/DON to notify FNP of any exacerbation in behaviors and follow any orders for medication as needed; when she becomes agitated intervene before agitation escalated; guide away from source of distress; engage calmy in conversation if response was aggressive, staff to walk calmly away, and approach later. - Record review of Resident #1's Progress Note, dated 04/26/22 written by LVN E indicated at 5:00 P.M. she was transported to the facility from Facility A, (where she was treated for behaviors from 04/08/22 until 04/26/22). Resident #1 was wandering in and out of rooms and was placed on one-on one monitoring (which was carried out within arm's length by Monitoring Techs A and C). During an interview with Administrator on 04-28-22 at 3:02 P.M. indicated QAPI had investigated the current problem with Resident #1's aggression; the legal state guardian was assisting with finding Resident #1 alternative placement; and he issued Resident #1 a thirty-day discharge notice. In addition, Resident #1 was sent to a behavioral unit 04/08/22 to address her behaviors, when she returned to the facility 04/26/22, Resident #1 was not immediately placed on one-to-one supervision until after she displayed behaviors of aggression and wandering. Record review of Resident #2's Admission Record (undated) indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with the following diagnoses: kidneys not meeting the body's needs, blood lacks adequate healthy red blood cells, uncontrolled drinking and preoccupation with alcohol, drug dependence in remission, disorder that affects a person's ability to think, feel, and behave clearly, mental disorders, abnormal thinking and perceptions, persistent feeling of sadness and loss of interest, excessive, ongoing anxiety and worry that are difficult to control and interfere with day-to-day activities, repeated, sudden, episodes of impulsive, aggressive, violent behavior or angry verbal outburst in which you react grossly out of proportion to the situation, abnormal sexual desires, typically involving extreme or dangerous activities, persistent, recurrent difficulty with sexual response, desire, orgasm, or pain, and damage to or dysfunction of the central nervous system. Record review of Resident #2's quarterly MDS resident assessment, dated 04/02/22, reflected a Brief score of 10 out of 15, which indicated resident was moderately impaired. This MDS indicated Resident #2 had delusions, misconceptions, or beliefs that are firmly held, contrary to reality); had verbal behavioral symptoms directed towards others (e.g., threatening other, screaming at others, cursing at others) that occurred 1 to 3 days, and had wandering behavior that occurred 4 to 6 days. This MDS indicated Resident #2 required supervision with setup only for bed mobility, transfer, walking in the room, walking in the corridor, and locomotion on and off the unit (Resident #2 walked independently). Record review of Resident #2's Care Plan dated 04/18/22 included focused area I have verbal and physical aggression due to poor impulse control. The interventions for this aggression would be addressed by monitoring for physical and verbal aggressive behavior once per shift. Document observed behavior and attempted intervention in behavior log. Monitor/document/report as needed any signs/symptoms of me posing a danger to self and others. When I become agitated: intervene before agitation escalates; guide away from source of distress, engage calmly in conversation; if response is aggressive, staff to walk calm away and approach later. This plan included that on 03/13/22 Resident #2 hit another resident on the mouth when that resident (Resident #8) tapped him on his stomach. The interventions for this incident were to remind him that he cannot hit other residents for any reason and encourage him to stay away from this resident. On 03/19/22 Resident #2 was hit (punched in the face by Resident #2) after a dispute over a chair, (no injuries noted). The interventions for this resident were to monitor Resident #2 for decreased range of motion or increased pain and notify MD if indicated and remind Resident #2 to call for staff when approached by this resident (Resident #1). -Review of the facility's' video recording that was not time stamped but occurred on 04/27/22 at approximately10:15 A.M., indicated Resident #1, who was in her wheelchair and did not have a staff near her, approached Investigator and lunged forward. (This video did not include Resident #1 grabbing and pulling investigator's face mask, while attempting to grab the investigator's face.) This Investigator yelled out for assistance and that's when a staff came forward and pushed Resident #1, who was in her wheelchair, away from this area. -Review of the facility's video recording that was not time stamped but occurred on 04/27/22 at approximately 9:15 A.M., indicated Resident #2 was sitting at a dining table when Resident #1, who was in her wheelchair and did not have a staff near her, entered the dining area. Resident #1 approached Resident #2 and grabbed an item from his dining table. Resident #2 responded by punching Resident #1 around the face/neck area (no injuries noted). Record review of Resident #1's Physical Aggression (Incident/Accident report) report dated 04/27/22 and written by LVN-C, indicated on 04/27/22 at 9:15 A.M. Resident #1 approached Resident #2's area and grabbed his snack, and Resident #2 shoved her away. Employees intervened and separated these residents (assessment revealed no injuries). Record review of Resident #1's Progress Note, dated 04/27/22, indicated nurse (LVN C) was notified by the COTA-A that Residents #1 and #2 had an altercation, when Resident #1 approached Resident #2 and grabbed his snack. Resident #2 responded by shoving her away. Staff intervened and separated these residents, and assessment revealed no injuries. During an interview with Resident #2 on 04/27/22 at 9:30 A.M. indicated he was being kicked out of the facility, because this morning he hit Resident #1 after she took his soda and his fruit loops (cereal) from his dining table. Resident #2 said he hit her in the face with his fist or opened hand, but could not remember, and then staff ran towards them and separated them. During an interview with Certified Occupational Therapy Assistant-A (COTA-A) on 04/28/22 at 12:16 P.M. indicated he and Speech Therapist-A were at a dining table conducting a therapy game with two residents on 04/27/22 at approximately 9:15 A.M., when he heard Residents #1 and #2 yelling. COTA-A said he went to Residents #1 and #2 and separated them. He said Resident #2 was visibly upset and cursing out loud, and Resident #1 had her hands on her throat. COTA-A indicated he did not see Resident #2 hit Resident #2 because his view was blocked by a column in the dining area. During an interview with Speech Therapist-A (SP-A) on 04/28/22 at 1:34 P.M. indicated she and COTA-A were at a dining table assisting two residents with a therapy game on 04/27/22 at 9:15 A.M., when she heard yelling and looked up and saw Resident #2 hit Resident #1 on the throat with a closed fist. SP-A stated the residents were separated but Resident #2 was yelling and cursing at Resident #1, who had her hands on her throat area and was crying. During an interview with LVN-C on 04/27/22 at 2:23 P.M. indicated he was informed by COTA-A that Residents #1 and #2 got into an altercation on 04/27/22 at 9:15 A.M., afterwards, he assessed and informed the Administrator. LVN-C said during shift report on 04/27/22 at 6 A.M. he was informed Monitoring Tech-C had to provide Resident #1 one-to-one supervision due to her behaviors of throwing trash on the floor, taking items from nurses' hands, and going into residents' rooms. LVN-C said the night monitoring techs have their own shift report they shared with the days monitoring techs. The monitoring techs were responsible for continuing Resident #1's one-to-one supervision. LVN-C said at the start of his shift, he conducted his rounds and observed Resident #1 asleep in her bed. He stated later he saw Resident #1 exit her room and go towards Hall C, where there was an entrance into the dining area, and did not see her after that. LVN-C said he was not informed Resident #1 was to be monitored every 15 minutes or that she was on any special supervision, because the monitoring techs share this information during their shift report with their own reports. During an interview with LVN-D on 04/27/22 at 10:47 P.M. indicated when she started her shift on 04/26/22, Resident #1 was on one-to-one supervision, which was carried out by Monitoring Tech-C. LVN-D indicated she gave shift report to LVN-C and could not recall if her report included one-to-one for Resident #1. LVN-C indicated the information on the shift report (24-Hour Report/Change of Condition Report) is what is shared with the oncoming nurse. Review of the 24-Hour Report/Change of Condition Report (shift report shared between the nurses) dated 04/26/22 indicated Resident #1 returned to the facility at 5 P.M. And this report included that Resident #2 should be monitored and to intervene immediately if he has noted physical aggression with other residents. The 24-Hour Report/Change of Condition Report dated 04/27/22 indicated Resident #1, who continues with aggression, wandering and taking her clothes off, was readmitted from previous facility with wrong medications; however, they will send her medications. The 24-Hour Report/Change of Condition Report dated 04/28/22 indicated Resident #1 was one-to-one monitor, and she had sustained a physical altercation from Resident #2. And this report included that Resident #2 was involved in a physical altercation initiated by Resident #1. Observation and interview of Resident #1 on 04/27/22 at 9:48 A.M. revealed she attempted to enter the patio area from the dining area without a staff near her. Monitoring Tech-A who was assisting approximately 12 residents during their smoking break, informed Resident #1 she did not have any cigarettes, and asked her if she still wanted to enter the patio, and she replied yes. Monitoring Tech-A opened the patio door and Resident #1 entered the patio in her wheelchair, sat next to Resident #12, who had her back turned to Resident #1. Resident #1 reached over and jerked Resident #12's cigarette out of her mouth then ambulated herself between Residents #13 and #14, while Resident #12 yelled out she took my cigarette and she hit me on my eye, my eye hurts. Monitoring Tech-A walked over to Resident #12, who yelled out that dirty [OBSCENITY] , I'm going to kill her, and gave her a cigarette that calmed her down. Resident #12 had no visible injuries but was rubbing her eye. During an interview with Resident #12 on 04/17/22 at 10 A.M. indicated Resident #1 stole her cigarette and asked, why did she have to come back? We were all praying she did not come back; I'm going to kill her ass. During an interview with Monitoring Tech-A on 04/28/22 at 1:45 P.M. indicated on 04/27/22 at 9:15 A.M., he was not near Resident #1 when she entered the dining area and took Resident #2's drink. Monitoring Tech-A indicated he started his shift on 04/27/22 at 6:45 P.M. and received a shift report that included Resident #1 going to residents' doorways and digging trash out. Monitoring Tech-A indicated as soon as Resident #1 woke up about 7:45 A.M, she was supposed to have one-to-one supervision but did not, because he was monitoring the hallways. Monitoring Tech-A indicated after the 10:00 A.M. smoking break, he initiated Resident #1's one-to-one supervision until CNA-A took over at 10:45 A.M. Monitoring Tech-A indicated he allowed the resident to enter the patio, during the smoking break; even though, she did not have any cigarettes. Monitoring Tech-A said he did not see Resident #1 take Resident #2's cigarette but did see Resident #1's hand come down with a cigarette, as she sat near Resident #12. And that's when Resident #12 screamed, yelled, and threatened to kill Resident #1. Monitoring Tech-A indicated Resident #12 alleged Resident #1 hit her on her eye and it was hurting. Monitoring Tech-A indicated one of the CNAs should have provided Resident #1 with supervision, because he was assisting 12 residents with their smoke break. Afterwards, Monitoring Tech-A reported this incident to the Administrator, who directed him to write a statement. Monitoring Tech-A defined one-to-one supervision to mean a staff should be staying with Resident #1 within two arm-lengths, and regular supervision meant keeping her within eyesight. During an interview with Monitoring Tech-E on 04/27/22 at 9:44 A.M. indicated she was monitoring the video cameras in the monitoring room and did not see Resident #1 enter the dining area. If she had she would have alerted through the walkie talkies, the nurses and monitoring techs that Resident #1 was near Resident #2. Monitoring Tech-E said she was informed that Resident #1 took a soda from Resident #2, and that's when he hit her but did not see it on her TV monitor. Monitoring Tech-E missed seeing Resident #1 enter the dining area, because she must view 4 TV monitors, which were approximately 42 inches each. One TV had 9 small screens, 2nd TV had 16 small screens, 3rd TV had 9 screens, and the 4th TV has 6 screens and is mounted above TVs 1, 2 and 3. Monitoring Tech E indicated she has to observed 40 small screens on these 4 TVs, and it's possible to miss something. On 04/27/23 at 4:03 P.M. Monitoring Tech-E indicated she was informed on 04/27/22 at 7 A.M. that Resident #1 was on one-to-one supervision due to yelling and following staff and residents and entering residents' rooms uninvited. Monitoring Tech-E indicated Monitoring Tech-A was supposed to carryover Resident #1's one-to-one supervision on the 7 A.M. to 7 P.M. shift. Monitoring Tech-E indicated one-to-one for Resident #1 meant staying by her side within arms- length. Monitoring Tech-E confirmed she saw Resident #1 take Resident #12's cigarette and used her walkie talkie to alert Maintenance Director-A there was an incident involving Resident #1 and Resident #12 on the patio. During an interview with CNA D on 04/28/22 at 2:01 P.M. indicated at the start of her shift on 04/27/22 at 6 A.M. she was not informed Resident #1 was on one-to-one supervision, and at 6 am Resident #1 was asleep in her bed. CNA-D indicated at approximately 10 A.M. on 04/27/22 she saw that Resident #1 was on one-to-one supervision due to her behaviors. During an interview with CNA E on 04/28/22 at 2:17 P.M. indicated she was not assigned as Resident #1's one-to-one. During an interview with CNA A on 04/28/22 at 2:23 P.M. indicated she was assigned as Resident #1's one-to-one from 10 A.M. until 5 P.M. on 04/27/22. During an interview with Monitoring Tech-C on 04/26/22 at 10:35 P.M. indicated Resident #1 returned to the facility from Facility-A on 04/26/22 at approximately 5 P.M. and was placed on one-to-one supervision on 04/26/22 from 7 P.M. to 7 A.M., which he provided. During an interview with CNA-C on 04/27/22 at 4:38 P.M. indicated Resident #1 returned to the facility from Facility-A on 04/26/22 during the evening meal and was uncooperative. CNA-C indicated on 04/27/22 at 6 A.M. Resident #1 was asleep and later she saw Monitoring Tech-A following Resident #1 from a distance. CNA-C indicated supervising Resident #1 one-to-one meant staff should have eyes on her. During an interview with Human Resources-A (HR-A) indicated Resident #1, who was sent to a psychiatric facility due to behaviors, returned to the facility on [DATE] after 5 P.M. with monitoring because she was not a threat to herself or others. HR-A indicated during the night (04/26/22 from 7 P.M. to 7 A.M.) Monitoring Tech-C was assigned as Resident #1's one-to-one supervision. Monitoring Tech-C on 04/27/22 at 7 A.M. was responsible for assigning Resident #1's one-to-one supervision for the next shift. HR-A indicated she was not in the dining area when Resident #1 was hit by Resident #2, because she was in the morning meeting. During an interview with FNP-A on 04/28/22 at 3:25 P.M. indicated when Resident #1 returned to the facility on [DATE], the DON requested she have one-to-one supervision. FNP-A, who approved sending Resident #1 to psychiatric facility, said he agreed Resident #1 needed one-to-one supervision because she was still violent, aggressive, and irritable. FNP-A indicated one-to-one for Resident #1 required staff to be with her to prevent her from hurting herself, hurting others, 'and/or entering residents' rooms uninvited During an interview with DON on 04/28/22 at 3:30 P.M. indicated Resident #1 returned to the facility and was placed one-on-one, and should have had one-to-one, when she went to the dining area and had an altercation with Resident #2 on 04/27/22. -Record review of Resident #1's Physical Aggression report, dated 03/29/22, indicated Resident #1 rammed her wheelchair into Resident #8's knees, causing him to stumble to the floor. The Residents were separated, and Resident #1 said she hit him because Resident #8 was trying to hit Monitoring Tech B. The aggressor was separated from the situation. Resident #8 sustained a small abrasion to his left knee. -Review of the facility's video recording not time stamped indicated (on 03/19/22 at 9:44 P.M.) Resident #1 was standing in the lobby area near two chairs. Resident #2 went towards one of the chairs and Resident #1 quickly sat in the chair. Resident #2 walked around to the next chair when Resident #1 grabbed the chair and pulled it closer to her, while Resident #2 attempted to pull it away from her. Resident #2 released the chair, walked over to Resident #1 and punched her with a closed fist on the right side of her face causing her to lean sideways in her chair. Resident #2 walked backwards as Resident #1 grabbed the chair and attempted to swing it at him, but Resident #2 blocked it with his foot. Afterwards, a staff ran into the lobby to escort Resident #1 out of the lobby. Record review of Resident #1's Physical Aggression report, dated 03/19/22 at 10:11 P.M., indicated Resident #1 was trying to pick up chair and hit Resident #2 but did not make contact. These residents were separated. Resident #1 was administered a [MEDICATION(S)] injection 15 minutes prior to this incident due to increased agitation that included verbal and physical aggression directed at staff and residents. -Record review of Resident #1's Physical Aggression, report dated 03/19/22 at 10:39 P.M., indicated Resident #1 was sitting near the nurses' station when a resident walked by and shouted obscenities at her. Resident #1 responded by kicking the resident in the leg and hitting him on the arm with a closed fist. The residents were separated and taken to their rooms. -Record review of Resident #1's Physical Aggression report, dated 03/07/22, indicated Resident #1 was combative most of the shift. She was verbally and physically aggressive towards staff and residents and numerous attempts to redirect her were unsuccessful. Resident #1 physically assaulted staff, yelled profanities at staff and residents, entered resident rooms and being verbally aggressive. FNP was notified and Resident #1 was administered [MEDICATION(S)] injection. -Record review of Resident #1's Physical Aggression report, dated 02/12/22 at 3:08 P.M., indicated Resident #1 hit a female resident on the head in the dining room, after Resident #1 had accused her of taking her chair. -Record review of Resident #1's Physical Aggression report, dated 02/12/22 at 11:30 A.M., indicated Resident #1 hit a resident, who was walking by her, on the face, resulting in a scratch and knocking her glasses off her face. Resident #1 said the resident was trying to kill her son, and all the chairs in the facility were given to her by her mama and [NAME]. The residents were separated, and Resident #1 was administered injection of [MEDICATION(S)]. During an interview with Physician-A on 04/27/22 at 11:34 A.M. indicated he was not at the facility to see Resident #1; however, in passing was asked if he could evaluate her for psychological services. Physician-A, who had not met Resident #1, but was informed of her behaviors and said she needed a higher level of care due to her behaviors of aggression and entering residents' rooms uninvited During an interview with Resident #15 on 04/27/22 at 12:38 a.m. indicated Resident #1 had entered his room, uninvited, and taken his snacks. Resident #15 said he and the other residents did not want Resident #1 returned to the facility because she went into the rooms and took their snacks, personal belongings, yelled at them, and tried to hit them. During an interview with Resident #16 on 04/28/22 at 10:51 A.M. indicated he did not like Resident #1 to enter his room, because she took his personal items, including his dentures. Resident #16 stated that made him feel anxious and uncomfortable. During an interview with Resident #10 on 04/28/22 at 10:53 A.M. indicated he did not like Resident #1, who stayed awake for days, to enter his room and take his personal items, and did not like that she walked up and down the hall yelling and talking. During an interview with Resident #2 on 04/28/22 at 12:16 P.M. indicated he did not like residents to enter his room, and if they did and took his stuff he would slap or punch them, because he used to box in the Golden Gloves. During an interview with Physician-A on 04/27/22 at 11:34 A.M. indicated he was familiar with Resident #2, who had anger outburst, but was unsure on the type of supervision he had, because he was not included on the facility's management meetings. During an interview with Resident #7 on 04/28/22 at 10:58 A.M. indicated he did not like Resident #1 to enter her room, because she entered her room uninvited and took her personal items, including her blanket. Resident #7 stated, in addition, Resident #1 hit her in the lobby, but she did not hit her back, and this made her feel just horrible. (no injures) -Review of the facility's' video recording, not time stamped, that occurred on 04/27/22 at 9:15 A.M., indicated Resident #2 was sitting at a dining when Resident #1, who was in her wheelchair and did not have a staff near her, entered the dining area. Resident #1 approached Resident #2 and grabbed an item from his dining table. Resident #2 responded by punching Resident #1 around the face/neck area. Record review of Resident #2's Physical Aggression report, dated 04/27/22, indicated Resident #2 was eating when Resident #1 took something off his plate, and he shoved her away. -Record review of Resident #2's Physical Aggression report, dated 04/23/22, indicated Resident #2 slapped Resident #3 across the face because he entered his room, and when he told him to get out, he did not leave, instead he grabbed his cookies on his bedside table. Record review of Resident #2's Progress Notes, dated 04/23/22, indicated a CNA (Monitoring Tech E) overheard yelling; she entered Resident #2's room and found Resident #3 in the room, and she separated Resident #2 and Resident #3. Resident #2 reported Resident #3 entered his room uninvited, he told him to get out, but Resident #3 would not leave, instead he grabbed his cookies and that's when he slapped him across the face. The residents were assessed, and Resident #3 sustained a red, bloodshot right eye with mild [CONDITION(S)], and Resident #2 had no injuries. -Record review of Resident #2's Physical Aggression report, dated 04/15/22, indicated Resident #2 punched a male resident on the right temporal area after he told resident he was in his chair. Resident #2 said he hit him because he wanted his chair back. -Review of the facility's video recording revealed on 03/19/22 at 9:44 P.M. Resident #1 was standing in the lobby area near two chairs, when Resident #2 went towards one of the chairs; however, Resident #1 quickly sat in the chair. Resident #2 walked around the chair to sit in the second chair when Resident #1 grabbed the chair and pulled it closer to her, while Resident #2 attempted to pull it away from her. Resident #2 released the chair, walked over to Resident #1, and punched her with a closed fist on the right side of her face. Resident #2 walked backwards as Resident #1 grabbed the chair off the floor and attempted to swing it towards him, but Resident #2 blocked it with his foot. Afterwards, a staff ran into the lobby to escort Resident #1 out of the lobby (no injuries noted). Record review of Resident #2's Physical Aggression report, dated 03/19/22, indicated Resident #2 said Resident #1 tried to pick up a chair and throw it at him. -Record review of Resident #2's Physical Aggression report, dated 03/13/22, indicated Resident #2, who was at the nurses' station, was tapped on his stomach by Resident #8, who was walking by, and Resident #2 responded by punching him on the mouth. -Record review of Resident #2's Progress Note, dated 03/07/22, indicated he had declined in problem solving abilities, orientation, and decision-making skills with recent increased in agitation and aggression. -Record review of Resident #2's Physical Aggression report, dated 02/24/22, indicated a staff notified the nurse that Resident #2 punched a female (Resident #7) resident on the face because she hit him on his stomach. During an interview with LVN-C on 04/27/22 at 2:23 P.M. indicated Resident #2 has a history of hitting residents for getting in his space, his room, taking an item from him, or not getting what he wants from them. Resident #3 Record review of Resident #3's Admission Record (undated) indicated he was a [AGE] year-old male, who was admitted into the facility on [DATE] with the following diagnosis: group of thinking and social symptoms that interferes with daily functioning, language disorder marked by deficiency in the generation of speech, and sometimes also in its comprehension, due to brain disease or damage, change in water balance and sodium levels in the blood, failure of kidneys to filter waste and excess fluid, digestive disease in which the stomach's acid or bile irritates the food pipe lining, muscle weakness, unsteadiness of feet, abnormal weight loss, muscle wasting and atrophy, lock of coordination and anxiety disorder. Record review of Resident #3's quarterly MDS, dated [DATE], indicated he BIMS scored a 3 of 15 indicating he was severe cognitive impact. This MDS indicated he hallucinated (perceptual experiences in the absence of real external sensory stimuli), delusions (misconceptions or beliefs that are firmly held, contrary to reality), rejection of care that occurred 1 to 3 days, and wandering that occurred 1 to 3 days. This MDS indicated Resident #3 required extensive assistance with two- person physical assist for transfers, walking in room an [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure the resident had the right to be free from neglect for 1 of 5 residents (Resident #1) reviewed for Neglect. The facility failed to ensure care, observations or assessment was made for Resident #1 during a12-hour shift after the staff had reported a change in condition (running a fever, nauseated, low oxygen stats). Resident #1 was found expired after staff failed to check on or provide care for a 12-hour shift. This failure was determined to be past non-compliance, with an immediate jeopardy situation that was identified on [DATE] and removed on [DATE] due to the facility implementing actions which corrected the non-compliance prior to the beginning of the investigation. This failure could affect residents by placing them at risk of not receiving services necessary to avoid physical harm, pain, mental anguish, emotional distress or death. Findings Include: Record review on [DATE] at 3:00 PM of Resident #1's face sheet documented he was a [AGE] year-old male who was admitted to the facility on [DATE] with a readmission date of [DATE]. Resident #1 was admitted with [DIAGNOSES REDACTED].-[MEDICAL CONDITION] reflux disease without esophagitis, end stage [MEDICAL CONDITION], acquired absence of the eye, chronic [MEDICAL CONDITION], history of COVID, need for assistance with personal care, difficulty in walking not elsewhere classified, unspecified abnormalities of gait and mobility, cognitive communication deficit, infection and [MEDICAL CONDITION] reaction due to other cardiac and vascular devices, implants and grafts, initial encounter. Record review of residents Quarterly Minimal Data Set ((MDS) dated [DATE] documented resident requires supervision, limited assistance and one-person physical assistance with activities of daily living with Brief Interview Mental Status (BIMS) score 8. Record review of Resident #1's progress notes dated [DATE] documented resident was placed on oxygen for low O2 saturation. Record review of Resident #1's progress notes date [DATE] documented Resident #1 was running a low fever, body aches, and nausea. Record review of the facility Provider Investigation Report dated [DATE] documented the incident happened on [DATE] at 6:51 AM. The report documented LVN A (Licensed Vocational Nurse) went to Resident #1's room to check his blood sugar, upon arrival into room resident noted to be unresponsive. Immediately facility began emergency response on resident and called Emergency Medical Services (EMS). At 7:00 AM EMS arrived at the facility and chest compressions stopped. The Provider Investigation Report (PIR)documented on [DATE] Resident #1 had a fever, body aches and chills. The PIR documented further into the investigation facility camera's reviewed on [DATE] regarding 6PM-6AM shift, determined that staff members LVN B & NA (Nurse Aide) never attempted or entered Resident #1's room. The PIR documented during an interview with the Director of Nursing (DON), LVN B did not deny the allegation of not going into Resident #1's room for the entire 12-hour shift. During an interview with LVN A on [DATE] at 7:15 PM revealed that LVN A had worked on [DATE] and [DATE] 6AM-6PM and was told in report that Resident #1 had been placed on oxygen on [DATE] for low O2 saturations. LVN A stated during the day shift on [DATE] Resident #1 was running a fever, had body aches and nausea. LVN A stated, Resident #1 had not been feeling well on [DATE] had been moaning and groaning all day. LVN A stated she had gone in that morning and provided Resident #1 Tylenol and continued to monitor him throughout the day. LVN A stated she last checked on Resident #1 around 5:45 PM near the end of her shift and his temperature at that time was 99.7 degrees Fahrenheit. LVN A stated she gave report to LVN B the night nurse and told her how Resident #1 was not feeling well throughout the day and told LVN B they had been monitoring Resident #1's temperature and he had been placed on oxygen Tuesday night because his O2 sats had dropped. LVN A stated the next morning, on [DATE], she returned to the facility at 6AM and received report from LVN B, the night nurse, and asked how Resident #1 was doing. LVN A stated LVN B stated, everyone is fine I didn't have any problems last night. LVN A stated she received report then counted the medication cart with LVN B then set up her computer and around 6:45 AM she started her rounds on B Hall to check blood sugars and insulin. LVN A went in Resident #1's room and stated the following she noticed he was sitting up in his recliner, his head was down he was pail in color his nasal cannula was on his ear but out of his nose just hanging there. LVN A didn't see rise fall of Resident #1's chest LVN A continued to announce herself, called Resident #1's name, then did a sternal rub no response. LVN A requested help for Resident #1 then placed the blood pressure cuff on Resident #,1 along with the pulse oximeter and no response staff brought the crash cart into the room and then placed Resident #1 on the backboard and started chest compressions, EMS was called, and they arrived around 7:00 AM and said to stop compressions due to rigor mortis had already set in. LVN A verified in an interview that she had received training and in-service on making rounds and frequent checks on residents, abuse and neglect, resident rights, and making notifications, after the incident with Resident #1 occurred. During an interview with Certified Nurse Aide (CNA)-A on [DATE] at 11:43 AM revealed that she worked [DATE] & [DATE]. CNA-A worked [DATE] and she took care of Resident #1. When CNA-A arrived for her shift on [DATE] the off going shift reported to her that Resident #1 was not doing good and so CNA-A worked with LVN A to make sure they checked on Resident #1 often because he was not feeling good. CNA-A frequently went in to check Resident #1 and he told her he was not feeling good. CNA-A did her last round around 5:45 PM and Resident #1 told her he was not feeling good and so she went and reported that to LVN A. CNA-A then gave report to NA around 6:00 PM and told NA that Resident #1 was not doing good that he didn't really want to eat his meals that day had juice that morning and some breakfast but didn't eat his lunch or evening meal. CNA-A stated NA said ok and that she would check on him. CNA-A came to work on [DATE] at 6:00 AM and NA told her some residents got up but she didn't tell her anything about Resident #1, CNA-A emphasized I mean nothing about him. CNA-A verified in an interview that she had received training and in-service on making rounds and frequent checks on residents, abuse and neglect, resident rights, and making notifications, after the incident with Resident #1 occurred. During an interview on [DATE] at 5:20 PM with NA revealed she did work on [DATE] from 6PM to 6AM. NA stated she made her last round at 4:00AM and made rounds on the residents she knew needed brief changes and she didn't make visual rounds on Resident #1. NA stated CNA-A came in around 5:00 AM and they didn't make visual or walking rounds only a verbal report. NA was unaware if Resident #1 had used his call light while she was on break or lunch break. NA was not aware if LVN B went in Resident #1's room or not that night to check on him. NA stated she was tired that night and she knew Resident #1 wasn't doing well from a few days before when she worked with Resident #1, and Resident #1 would usually use his call light for help during the night. NA noticed the weekend of [DATE] and [DATE] Resident #1 was not doing well, he was just using the call light more and needing more assistance. NA knew in the past Resident #1 would use his call light and tell staff if he thought his blood sugar was dropping, or say he wasn't feeling right like chest was hurting or needing a coke or candy. NA mentioned on any other night she would come to work for her shift and then around 7:,[DATE]:00 PM go see if Resident #1 wanted a snack or a drink, then only go back if Resident #1 pushed the call light or if the nurse told her he was not feeling well. NA verified in an interview that she had received training and in-service on making rounds and frequent checks on residents, abuse and neglect, resident rights, and making notifications, after the incident with Resident #1 occurred. Record review of witness statement form 4825-A from NA on [DATE] at 5:35 PM documented she did not bother Resident #1 that night ([DATE] - [DATE]) because he never pulled his call light. NA wrote she made her last round at 4:30 AM only on her incontinent patients, not on the patients that could do for themselves. Record review of Employee Disciplinary Report Action dated infraction date [DATE] documented the following for employee NA: Employee failed to ensure the following: 1. To ensure the safety and wellbeing of our residents, nursing staff should make a routine resident check on each hall at least every two hours or randomly per shift. 2. Routine resident checks which involved entering the residents room and / or identifying the resident elsewhere on the unit to determine if the resident's needs are being met, identify any change in the resident's condition, identify whether the resident has any concerns, and see if the resident is sleeping, needs toileting assistance, etc. 3. Cameras reviewed [DATE] regarding 6PM-6AM shift; determined that no staff member attempted or entered residents room. During an interview on [DATE] at 2:03 PM with LVN B revealed she worked on [DATE] during the 6PM-6AM shift and she worked on B hall where Resident #1 resided. LVN B stated she arrived for work at 6:00PM and did not do rounds or go in Resident #1's room when she came in for her shift. LVN B received report and was told Resident #1 was running a slight fever and had been placed on oxygen the night before for low O2Sats. LVN B stated did a medication pass for B hall between 7:00 - 9:00 PM. LVN B stated she did go do a medication pass for Resident #1 between 7:00 -9:00 PM. LVN B verified the time frame of 7:00PM - 9:00 PM several times as that is when she entered Resident #1's room. LVN B stated that was the only time she went in Resident #1's room that shift. LVN B, first stated Resident #1 was sitting in his recliner and then later stated he was standing at the table with his iPad and hand held magnifying glass in his hand. LVN B verified she has been trained and in-serviced by the facility to go do rounds every two or three hours on residents. LVN B reported Resident #1 would usually call on the call light if he needed something. LVN B do not recall Resident #1's call light going off any that night. LVN B verified in an interview that she had received training and in-service on making rounds and frequent checks on residents, abuse and neglect, resident rights, and making notifications, after the incident with Resident #1 occurred. Observation on [DATE] at 2:25 PM of the camera footage from [DATE] 6:00 PM -10:00 PM was reviewed with Maintenance Supervisor. These times were reviewed after verifying with LVN B that is when she went in Resident #1's room for medication pass. The video footage revealed LVN B did not enter Resident #1's room at all during the time frame she provided or any other time during the 6PM-6AM shift. During an interview on [DATE] at 2:45 PM with Maintenance Supervisor revealed he was asked by Administrator to review the camera footage for the 6PM-6AM shift for [DATE] going on to [DATE]. He was asked to review B Hall and to review any activity for Resident #1. Maintenance Supervisor first started to review from 12:00 AM-6:00 AM and there was not very much activity in B Hall so he went on and looked at the entire shift for 6:00 PM-6:00 AM. Maintenance Supervisor stated he did see the staff going down B Hall and in rooms but none of the staff entered Resident #1's room and Resident #1 did not come out of his room. He did see NA and CNA B going in rooms in B Hall but never in Resident #1's room. He did see LVN B one time in B hall and she went in three rooms but none of the rooms were Resident #1's room. Maintenance Supervisor stated he watched the entire 12-hour shift from 6PM-6AM two times to verify that staff never entered Resident #1's room. He then overheard the DON and Assistant Director of Nursing (ADON) say that maybe medication for Resident #1 was given earlier so he rewound the video and found that the last staff that entered Resident #1's room was around 5:45 PM from the day shift on [DATE]. During an interview on [DATE] at 2:00 PM with Administrator revealed he was informed that LVN A found Resident #1 unresponsive while making early morning rounds on [DATE]. Administrator received a text message from ADON around 7:00 AM on [DATE] making him aware that Resident #1 was expired. Administrator stated we started an investigation to see when Resident #1 was last checked on and the information we were receiving was he was last checked on [DATE] around 5:45 PM before change of shift. We were finding out that the 6PM-6AM shift might not have entered his room or provided care for him. Administrator stated, he asked Maintenance Supervisor to check the camera footage and see if the footage showed the 6PM-6AM staff assigned to B Hall entered Resident's #1 room. Administrator stated the Maintenance Supervisor reviewed the footage twice and stated the footage showed staff on 6PM-6AM never entered Resident #1's room. Administrator stated DON interviewed LVN B who worked 6PM-6AM and LVN B stated she went in Resident #1's room to do a medication pass between 7:00 PM and 9:00 PM. Administrator stated he asked Maintenance Supervisor to show him the camera footage for that time frame and LVN B was in the hall with her medication cart but never entered Resident #1's room. Administrator revealed NA assigned B Hall and when interviewed she stated Resident #1 was independent and that the CNA's would not go in and check on him unless he used the call light because he would get upset. Administrator knew that on [DATE] Resident #1started to run a low fever and have body aches and nausea. Administrator stated the Nurse Practitioner (NP) had been to see Resident #1 on [DATE] and did an assessment on him on that day. Administrator stated, his expectations for staff is to come in get report and go do rounds on the residents, then to make rounds every two hours or as needed if before two hours. Administrator verified the facility immediately started in-servicing and training staff on making rounds and frequent checks on residents, abuse and neglect, resident rights, and making notifications, after the incident with Resident #1 occurred. During an interview on [DATE] at 10:55 AM with DON revealed, her expectations on staff making rounds is every two hours and our nursing job description states that. DON stated, she found about Resident #1 on a text message from ADON saying Resident #1 had passed away. DON stated she arrived at the facility on [DATE] and staff was reviewing the camera footage for the 6PM-6AM shift on [DATE]. DON stated she has seen bits and pieces of the footage but not all of the footage for the entire 12-hour shift. DON had been told by Administrator that the camera footage had shown LVN B and NA did not enter Resident #1's room and they were assigned his hall B hall. DON stated she did review some of the camera footage and she did see LVN B on B hall with her treatment cart and looked like she was on her cell phone and then saw LVN B take her cart right past Resident #1's room. LVN B did not enter Resident #1's room during the 8:00 PM-9:00 PM hour. DON and ADON spoke with LVN B and let her know the camera footage revealed she did not enter the room or do any treatments with Resident #1 and LVN B did not seem surprised and she only asked (am I the only one being suspended). DON stated Resident #1 is a diabetic, on [MEDICAL TREATMENT], has heart issues, legally blind and hard of hearing but could hear with hearing aids if close to him and speaking very loudly. DON stated she knew Resident #1 was receiving insulin, and not having blood sugar checks or insulin for 12 hours it could have been very bad for Resident #1. DON verified the facility immediately started in-servicing and training staff on making rounds and frequent checks on residents, abuse and neglect, resident rights, and making notifications, after the incident with Resident #1 occurred. During an interview on [DATE] at 12:15 PM with ADON revealed she spoke with NA and asked if she went in Resident #1's room on [DATE] from 6PM-6AM shift. She stated NA told her no she did not go in Resident #1's room the entire shift. ADON verified the facility immediately started in-servicing and training staff on making rounds and frequent checks on residents, abuse and neglect, resident rights, and making notifications, after the incident with Resident #1 occurred. During an interview [DATE] at 1:36 PM with Medical Director revealed per policy staff should be checking on residents every two hours or as needed. He stated he didn't really understand all this because Resident #1 was quick on pushing the call light button when something was wrong, and staff should have known something was wrong by the absence of him not pushing the button. He stated that what happen to Resident #1 must have happened quickly. He stated for the staff to not check on Resident #1 was substandard care. Observation made on [DATE] at 10:45 AM staff making rounds, going in resident's rooms providing care. Observation on [DATE] at 3:10 PM staff going in resident's rooms, going in the dining room and locating residents, providing care. Observation on [DATE] staff in facility hallways at the nurses station talking with residents, staff going in the dining room checking on residents and making rounds. Record review of the facility's policy Recognizing Signs and Symptoms of Abuse/Neglect dated revised [DATE] documented: Policy Statement Our facility will not condone any form of resident abuse or neglect. To aide in abuse prevention, are personnel are to report any signs and symptoms of abuse/neglect to their supervisor or to the Director of Nursing services immediately. Policy Interpretation and Implementation 2.Neglect is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish or mental illness 3. b. Signs of Actual Physical Neglect (6) Inadequate provision of care; (7) Caregiver indifference to resident's personal care and needs (9) Leaving someone unattended who needs supervision. It was determined these failures placed Resident #1 in an Immediate Jeopardy (IJ) situation from [DATE] through [DATE]. The facility took the following action to correct the non-compliance from [DATE] through [DATE]: The following facility documents were reviewed: In-serviced the facility staff on Resident Routine Checks every two hours or more frequent if needed dated [DATE]. In-serviced staff on appropriate arrival and departure times from work: 15 minutes prior to shift and 15 minutes after shift, clocking in and out, making rounds every two hours on all residents, dated [DATE]. In-serviced the facility staff on Verbal/Physical/Sexual/Neglect Abuse Policy and Protocol dated [DATE]. In-serviced facility staff on Resident Rights dated [DATE]. The facility interviewed staff and obtained witness statements & made notifications to family and physician dated [DATE].

Based on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice. The facility failed to provide care, observation or assessment for 1 of 5 residents (Resident #1) reviewed for Quality of Care. The facility failed to ensure care, observations or assessment was made for Resident #1 during a 12-hour shift after the staff had reported a change in condition (fever, body aches, nauseated, low O2 stats) for Resident #1. Resident was found expired after the 12-hour shift. This failure was determined to be Past Non-Compliance, with an Immediate Jeopardy situation identified on [DATE] and removed on [DATE] due to the facility having implemented actions which corrected the non-compliance prior to the beginning of the investigation. This failure could affect all residents in the facility by placing them at risk of not receiving treatment and care in accordance with professional standards resulting in decline in health or death. Findings Include: Record review on [DATE] at 3:00 PM of Resident #1's face sheet documented he was a [AGE] year-old male who was admitted to the facility on [DATE] with a readmission date of [DATE]. Resident #1 was admitted with [DIAGNOSES REDACTED].-[MEDICAL CONDITION] reflux disease without esophagitis, end stage [MEDICAL CONDITION], chronic [MEDICAL CONDITION], history of COVID, need for assistance with personal care, difficulty in walking not elsewhere classified, unspecified abnormalities of gait and mobility, cognitive communication deficit, infection and [MEDICAL CONDITION] reaction due to other cardiac and vascular devices, implants and grafts, initial encounter. Record review of residents Quarterly Minimal Data Set ((MDS) dated [DATE] documented resident requires supervision, limited assistance and one-person physical assistance with activities of daily living, with a Brief Interview for Mental Status (BIMS) score of 8. Record review of Resident #1's progress notes dated [DATE] documented resident was placed on oxygen for low O2 saturation. Record review of Resident #1's progress notes date [DATE] documented Resident #1 was running a low grade fever, body aches, and nausea. Record review of the facility Provider Investigation Report dated [DATE] documented the incident happened on [DATE] at 6:51 AM. The report documented LVN A (Licensed Vocational Nurse) went to Resident #1's room to check his blood sugar, upon arrival into room resident noted to be unresponsive. Immediately facility began emergency response on resident and called Emergency Medical Services (EMS). At 7:00 AM EMS arrived at the facility and chest compressions stopped. The Provider Investigation Report (PIR)documented on [DATE] Resident #1 had a fever, body aches and chills. The PIR documented further into the investigation facility camera's reviewed on [DATE] regarding 6PM-6AM shift, determined that staff members LVN B & NA (Nurse Aide) assigned to Resident #1, never attempted or entered Resident #1's room. The PIR documented during an interview with the Director of Nursing (DON), LVN B did not deny the allegation of not going into Resident #1's room for the entire 12-hour shift. During an interview with LVN A on [DATE] at 7:15 PM revealed that LVN A had worked on [DATE] and [DATE] 6AM-6PM and was told in report that Resident #1 had been placed on oxygen on [DATE] for low O2 saturations. LVN A stated during the day shift on [DATE] Resident #1 was running a fever, had body aches and nausea. LVN A stated Resident #1 had not been feeling well on [DATE] had been moaning and groaning all day. LVN A stated she had gone in that morning and provided Resident #1 Tylenol and continued to monitor him throughout the day. LVN A stated she last checked on Resident #1 around 5:45 PM near the end of her shift and his temperature at that time was 99.7 degrees Fahrenheit. LVN A stated she gave report to LVN B the night nurse and told her how Resident #1 was not feeling well throughout the day and told LVN B they had been monitoring Resident #1's temperature and he had been placed on oxygen Tuesday night because his O2 sats had dropped. LVN A stated the next morning, on [DATE], she returned to the facility at 6AM and received report from LVN B, the night nurse, and asked how Resident #1 was doing. LVN A stated LVN B stated, everyone is fine I didn't have any problems last night. LVN A stated she received report then counted the medication cart with LVN B then set up her computer and around 6:45 AM she started her rounds on B Hall to check blood sugars and insulin. LVN A went in Resident #1's room and stated the following she noticed he was sitting up in his recliner, his head was down he was pail in color his nasal cannula was on his ear but out of his nose just hanging there. LVN A didn't see rise fall of Resident #1's chest LVN A continued to announce herself, called Resident #1's name, then did a sternal rub no response. LVN A requested help for Resident #1 then placed the blood pressure cuff on Resident #,1 along with the pulse oximeter and no response staff brought the crash cart into the room and then placed Resident #1 on the backboard and started chest compressions, EMS was called, and they arrived around 7:00 AM and said to stop compressions due to rigor mortis had already set in. LVN A verified in an interview that she had received training and in-service on making rounds and frequent checks on residents, abuse and neglect, resident rights, and making notifications, after the incident with Resident #1 occurred. During an interview with Certified Nurse Aide (CNA)-A on [DATE] at 11:43 AM revealed that she worked [DATE] & [DATE]. CNA-A worked [DATE] and she took care of Resident #1. When CNA-A arrived for her shift on [DATE] the off going shift reported to her that Resident #1 was not doing good and so CNA-A worked with LVN A to make sure they checked on Resident #1 often because he was not feeling good. CNA-A frequently went in to check Resident #1 and he told her he was not feeling good. CNA-A did her last round around 5:45 PM and Resident #1 told her he was not feeling good and so she went and reported that to LVN A. CNA-A then gave report to NA around 6:00 PM and told NA that Resident #1 was not doing good that he didn't really want to eat his meals that day had juice that morning and some breakfast but didn't eat his lunch or evening meal. CNA-A stated NA said ok and that she would check on him. CNA-A came to work on [DATE] at 6:00 AM and NA told her some residents got up, but she didn't tell her anything about Resident #1, CNA-A emphasized I mean nothing about him. CNA-A verified in an interview that she had received training and in-service on making rounds and frequent checks on residents, abuse and neglect, resident rights, and making notifications, after the incident with Resident #1 occurred. During an interview on [DATE] at 5:20 PM with NA revealed she did work on [DATE] from 6PM to 6AM. NA stated she made her last round at 4:00AM and made rounds on the residents she knew needed brief changes and she didn't make visual rounds on Resident #1. NA stated CNA-A came in around 5:00 AM and they didn't make visual or walking rounds only a verbal report and she was unaware if Resident #1 had used his call light while she was on break or lunch break. NA was not aware if LVN B went in Resident #1's room or not that night to check on him. NA stated she was tired that night and she knew Resident #1 wasn't doing well from a few days before when she worked with Resident #1, and Resident #1 would usually use his call light for help during the night. NA noticed the weekend of [DATE] and [DATE] Resident #1 was not doing well, he was just using the call light more and needing more assistance. NA knew in the past Resident #1 would use his call light and tell staff if he thought his blood sugar was dropping, or say he wasn't feeling right like chest was hurting or needing a coke or candy. NA mentioned on any other night she would come to work for her shift and then around 7:,[DATE]:00 PM go see if Resident #1 wanted a snack or a drink, then only go back if Resident #1 pushed the call light or if the nurse told her he was not feeling well. NA verified in an interview that she had received training and in-service on making rounds and frequent checks on residents, abuse and neglect, resident rights, and making notifications, after the incident with Resident #1 occurred. Record review of witness statement form 4825-A from NA on [DATE] at 5:35 PM documented she did not bother Resident #1 that night ([DATE]- [DATE]) because he never pulled his call light. NA wrote she made her last round at 4:30 AM only on her incontinent patients, not on the patients that could do for themselves. Record review of Employee Disciplinary Report Action dated infraction date [DATE] documented the following for employee NA: Employee failed to ensure the following: 1. To ensure the safety and wellbeing of our residents, nursing staff should make a routine resident check on each hall at least every two hours or randomly per shift. 2. Routine resident checks which involved entering the residents room and / or identifying the resident elsewhere on the unit to determine if the resident's needs are being met, identify any change in the resident's condition, identify whether the resident has any concerns, and see if the resident is sleeping, needs toileting assistance, etc. 3. Cameras reviewed [DATE] regarding 6PM-6AM shift; determined that no staff member attempted or entered residents room. During an interview on [DATE] at 2:03 PM with LVN B revealed she worked on [DATE] during the 6PM-6AM shift and she worked on B hall where Resident #1 resided. LVN B stated she arrived for work at 6:00PM and did not do rounds or go in Resident #1's room when she came in for her shift. LVN B received report and was told Resident #1 was running a slight fever and had been placed on oxygen the night before for low O2Sats. LVN B stated did a medication pass for B hall between 7:00 - 9:00 PM. LVN B stated she did go do a medication pass for Resident #1 between 7:00 -9:00 PM. LVN B verified the time frame of 7:00PM - 9:00 PM several times as that is when she entered Resident #1's room. LVN B stated that was the only time she went in Resident #1's room that shift. LVN B, first stated Resident #1 was sitting in his recliner and then later stated he was standing at the table with his iPad and hand held magnifying glass in his hand. LVN B verified she has been trained and in-serviced by the facility to go do rounds every two or three hours on residents. LVN B reported Resident #1 would usually call on the call light if he needed something. LVN B do not recall Resident #1's call light going off any that night. LVN B verified in an interview that she had received training and in-service on making rounds and frequent checks on residents, abuse and neglect, resident rights, and making notifications, after the incident with Resident #1 occurred. Observation on [DATE] at 2:25 PM of the camera footage from [DATE] 6:00 PM -10:00 PM was reviewed with Maintenance Supervisor. These times were reviewed after verifying with LVN B that is when she went in Resident #1's room for medication pass. The video footage revealed LVN B did not enter Resident #1's room at all during the time frame she provided or at any other time during the 6PM-6AM shift. During an interview on [DATE] at 2:45 PM with Maintenance Supervisor revealed he was asked by Administrator to review the camera footage for the 6PM-6AM shift for [DATE] going on to [DATE]. He was asked to review B Hall and to review any activity for Resident #1. Maintenance Supervisor first started to review from 12:00 AM-6:00 AM and there was not very much activity in B Hall so he went on and looked at the entire shift for 6:00 PM-6:00 AM. Maintenance Supervisor stated he did see the staff going down B Hall and in rooms, but none of the staff entered Resident #1's room and Resident #1 did not come out of his room. He did see NA and CNA B going in rooms in B Hall but never in Resident #1's room. He did see LVN B one time in B hall and she went in three rooms but none of the rooms were Resident #1's room. Maintenance Supervisor stated he watched the entire 12-hour shift from 6PM-6AM two times to verify that staff never entered Resident #1's room. He then overheard the DON and Assistant Director of Nursing (ADON) say that maybe medication for Resident #1 was given earlier so he rewound the video and found that the last staff that entered Resident #1's room was around 5:45 PM from the day shift on [DATE]. During an interview on [DATE] at 2:00 PM with Administrator revealed he was informed that LVN A found Resident #1 unresponsive while making early morning rounds on [DATE]. Administrator received a text message from ADON around 7:00 AM on [DATE] making him aware that Resident #1 was expired. Administrator stated we started an investigation to see when Resident #1 was last checked on and the information we were receiving was he was last checked on [DATE] around 5:45 PM before change of shift. We were finding out that the 6PM-6AM shift might not have entered his room or provided care for him. Administrator stated, he asked Maintenance Supervisor to check the camera footage and see if the footage showed the 6PM-6AM staff assigned to B Hall entered Resident's #1 room. Administrator stated the Maintenance Supervisor reviewed the footage twice and stated the footage showed staff on 6PM-6AM never entered Resident #1's room. Administrator stated DON interviewed LVN B who worked 6PM-6AM and LVN B stated she went in Resident #1's room to do a medication pass between 7:00 PM and 9:00 PM. Administrator stated he asked Maintenance Supervisor to show him the camera footage for that time frame and LVN B was in the hall with her medication cart but never entered Resident #1's room. Administrator revealed NA assigned B Hall and when interviewed she stated Resident #1 was independent and that the CNA's would not go in and check on him unless he used the call light because he would get upset. Administrator knew that on [DATE] Resident #1started to run a low fever and have body aches and nausea. Administrator stated the Nurse Practitioner (NP) had been to see Resident #1 on [DATE] and did an assessment on him on that day. Administrator stated, his expectations for staff is to come in get report and go do rounds on the residents, then to make rounds every two hours or as needed if before two hours. Administrator verified the facility immediately started in-servicing and training staff on making rounds and frequent checks on residents, abuse and neglect, resident rights, and making notifications, after the incident with Resident #1 occurred. During an interview on [DATE] at 10:55 AM with DON revealed, her expectations on staff making rounds is every two hours and our nursing job description states that. DON stated, she found about Resident #1 on a text message from ADON saying Resident #1 had passed away. DON stated she arrived at the facility on [DATE] and staff was reviewing the camera footage for the 6PM-6AM shift on [DATE]. DON stated she has seen bits and pieces of the footage but not all of the footage for the entire 12-hour shift. DON had been told by Administrator that the camera footage had shown LVN B and NA did not enter Resident #1's room and they were assigned his hall B hall. DON stated she did review some of the camera footage and she did see LVN B on B hall with her treatment cart and looked like she was on her cell phone and then saw LVN B take her cart right past Resident #1's room. LVN B did not enter Resident #1's room during the 8:00 PM-9:00 PM hour. DON and ADON spoke with LVN B and let her know the camera footage revealed she did not enter the room or do any treatments with Resident #1 and LVN B did not seem surprised and she only asked (am I the only one being suspended). DON stated Resident #1 is a diabetic, on [MEDICAL TREATMENT], has heart issues, legally blind and hard of hearing but could hear with hearing aids if close to him and speaking very loudly. DON stated she knew Resident #1 was receiving insulin, and not having blood sugar checks or insulin for 12 hours it could have been very bad for Resident #1. DON verified the facility immediately started in-servicing and training staff on making rounds and frequent checks on residents, abuse and neglect, resident rights, and making notifications, after the incident with Resident #1 occurred. During an interview on [DATE] at 12:15 PM with ADON revealed she spoke with NA and asked if she went in Resident #1's room on [DATE] from 6PM-6AM shift. She stated NA told her she did not go in Resident #1's room the entire shift. ADON verified the facility immediately started in-servicing and training staff on making rounds and frequent checks on residents, abuse and neglect, resident rights, and making notifications, after the incident with Resident #1 occurred. During an interview [DATE] at 1:36 PM with Medical Director revealed per policy staff should be checking on residents every two hours or as needed. He stated he didn't really understand all this because Resident #1 was quick on pushing the call light button when something was wrong, and staff should have known something was wrong by the absence of him not pushing the button. He stated that what happen to Resident #1 must have happened quickly. He stated for the staff to not check on Resident #1 was substandard care. Observation made on [DATE] at 3:30 PM staff making rounds going in and out of resident's rooms and verifying location and resident's needs. Record review of the facility's policy Routine Resident Checks dated revised [DATE] documented: Policy Statement Staff shall make routine resident checks to help maintain resident's safety and wellbeing Policy Interpretation and Implementation 1. To ensure the safety and wellbeing of our residents, nursing staff shall make a routine resident check on each resident on each hall at least every two hours per shift; or randomly thereafter. 2. Routine resident checks involve entering the residents room and/or identifying the resident elsewhere on the unit to determine if the resident's needs are being met, identify any change in the resident's condition, identify if the resident has any concerns, and see if the resident is sleeping, needs toileting assistance, etc. 3. The person conducting the routine check shall report promptly to the nurse supervisor/charge nurse any changes in the resident's condition and medical needs. 4. The nursing supervisor/charge nurse shall keep documentation related to these routine checks, including the time, identify od the person making checks, and any outcomes of each check. (Note CNA's may also record this information and provide it to the nurse supervisor/charge nurse. It was determined these failures placed Resident #1 in an Immediate Jeopardy (IJ) situation from [DATE] through [DATE]. The facility took the following action to correct the non-compliance from [DATE] through [DATE]: The following facility documents were reviewed: In-serviced the facility staff on Resident Routine Checks every two hours or more frequent if needed dated [DATE]. In-serviced staff on appropriate arrival and departure times from work: 15 minutes prior to shift and 15 minutes after shift, clocking in and out, making rounds every two hours on all residents, dated [DATE]. In-serviced the facility staff on Verbal/Physical/Sexual/Neglect Abuse Policy and Protocol dated [DATE]. In-serviced facility staff on Resident Rights [DATE]. The facility interviewed staff and obtained witness statements & made notifications to family and physician dated [DATE].

Based on observation, interview, and record review, the facility failed to ensure residents received care and treatment, consistent with professional standards of practice, to promote healing of existing pressure ulcers and prevent further development of pressure ulcers, for 3 Residents (Resident #2, #19 and #36 ) of 3 residents reviewed for pressure ulcers. 1) Resident #36 had an existing Stage IV pressure ulcer which showed no improvement and worsened over 6 months. a. The facility failed to provide Resident #36 weekly assessment of the wound, provide adequate treatment, or notify the physician when the wound failed to show signs of healing for an existing pressure stage IV pressure sore. b. The facility failed to provide a plan of care to address the resident's refusal of care for pressure ulcers or update plan of care when current treatments are not working. 2) Resident # 19 had a SDTI (Suspected Deep Tissue Injury) pressure injury under a callous formation to the right heel. a. Facility staff failed to provide weekly assessment of the wound, provide adequate treatment, or notify the physician when wound failed to show signs of healing. b.The facility failed to provide a plan of care to address the resident's refusal care for pressure ulcers. 3) Resident #2 had a Stage IV pressure ulcer to the right buttocks. The facility did not follow physician orders [REDACTED]. Facility staff failed to transcribe new orders requiring daily wound care and continued to provide wound care only 3 days a week. On 2/26/19 at 1:57 PM in Immediate Jeopardy (IJ) was identified. While the IJ was removed on 2/27/19 at 11:50 AM, the facility remained out of compliance at a scope of pattern and severity of actual harm due to facilitiy's plan to monitor the plan of removal for effectiveness and train staff. Failure to provide weekly assessment to existing wounds could affect the plan of care to determine any necessary changes in treatment in order to promote healing of the wound. Failure to consult with the physician when wounds are not healing and worsening could cause the continued worsening of pressure ulcers. Failure to provide a plan of care for behavioral issues related to care or update the plan of care to address the worsening of the wound could affect the residents wound from healing. Failure to follow physician's orders [REDACTED]. These failures could lead to further worsening of the wound, infection, or death. On 2/26/19 at 1:57 PM in Immediate Jeopardy (IJ) was identified. While the IJ was removed on 2/27/19 at 11:50 AM, the facility remained out of compliance at a scope of pattern and severity of actual harm due to facility's plan to monitor the plan of removal for effectiveness and train staff. This failure could result in harm, infection, or death to these residents. The findings included: Resident # 36 Record review of Resident #36's admission record revealed a [AGE] year old male who admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. level between unspecified hip and knee, initial encounter. Record review of quarterly MDS(minimum data set) dated 12/26/18 for Resident #36 documented the following: Section E-Behavior E- 0800-Rejection of care-presence and frequency 2. Behavior of this type occurred 4 to 6 days, but less than daily was coded. Section C-Cognitive Patterns C0500-Summary score = 15. This indicates no cognitive impairment. Record review of comprehensive care plan for Resident #36 documented the following: Focus: The resident has potential for pressure ulcer development related to history of ulcers, immobility. Resident currently has stage IV to coccyx. Date initiated 8/21/18 and revised on 1/8/19. Goal: The resident's pressure ulcer will show signs of healing and remain free from infection by/through the goal date. Date initiated 8/21/18 and revised on 10/23/18. Target date 1/10/19. Interventions: 2. Weekly skin assessment by nurse to ensure no new areas of breakdown, rash, etc. Notify MD of any abnormal findings. Date initiated 8/21/18. 7. Assess/record/monitor wound healing weekly. Measure length, width and depth when possible. Assess and document status of wound perimeter, wound bed and healing process. Report improvements and declines to the MD. Date initiated 8/21/18. Record review of Weekly Skin Documentation dated 8/7/18 for Resident #36 documented the following: 1. Date of evaluation-8/7/18 2. Site: sacral area. Length = 6 cm, width = 4 cm, depth = 10 cm. This was staged as a stage IV. 8. Additional notes-will get approval to send him to wound clinic. Dressing changed after shower. Cleanse with wound wash and pat dry with sterile gauze, applied [MEDICATION NAME] cream, packed with alginate wound dressing and covered with [MEDICATION NAME] and tape. Further record review revealed no evidence of the resident going to a wound care clinic. Observation on 2/20/18 9:55 AM revealed Resident #36 was out of his room. The bottom sheet was threadbare towards the head of the bed and there was no air mattress over overlay used for pressure relief on the bed. The center privacy curtain was approximately 3 feet too short to encircle the entire bed. Interview on 2/20/19 at 3:22 PM with LVN #1 revealed the following when asked to describe Resident #36. She stated he refuses showers. He does his own [MEDICAL CONDITION] care. He refuses ADLs (activities of daily living). She stated he hits the girls when they are taking him to the shower. He was admitted with a pressure ulcer to his coccyx. She stated most the time he won't let us treat it. Interview on 2/21/19 at 9:55 AM, ADON was asked to notify this surveyor when wound care was to be performed on Resident #36 . She stated the resident had refused wound care. This surveyor walked back to the room along with the ADON to speak with Resident #36. He readily agreed to allow this surveyor to watch wound care and asked if we could do it after lunch. Observation on 2/21/19 at 4:00 PM revealed RN #2 providing wound care to Resident #36. Observed there was no air mattress, overlay or specialty pressure relieving mattress on the bed. Calcium alginate squares (used to create a gel and keep wound from drying out) were opened and placed on the clean pad. Santyl (used to remove dead tissue from the wound) ointment was squeezed into a plastic medicine cup. One package containing a long cotton-tipped applicator was opened and the applicator was placed on the clean pad. RN #2 then measured the wound as 15 X 19 cm. She did not measure the depth at this time. There was gray tissue covering 50-70% of the wound and most of the wound edges and it was noted there was a lot of undermining (wound extends under the skin) under the edges of the entire wound. RN #2 took the cotton-tipped applicator and using the woodened stick end measured the depth of the wound at 4 cm. She turned the applicator over and using the cotton-tipped portion, dipped the tip into the Santyl ointment from the medication cup. With a back-and-forth scrubbing motion, she applied Santyl ointment to part of the wound. She returned the dirty applicator tip back into the Santyl from the medication cup and applied more Santyl to the wound. She repeated this procedure 2 additional times. Interview on 2/21/19 at 4:33 PM with RN #2 revealed she understood she was supposed to use the cotton-tipped applicator to roll the Santyl into the wound and not reuse the cotton-tipped applicator. She stated she was nervous. Interview on 2/21/19 at 4:34 PM with DON confirmed when applying an ointment to wound using the cotton-tipped applicator, the accepted standard of practice is to roll the medication onto the wound. He stated you're not to reuse the same cotton-tipped applicator. He stated this could cause cross-contamination and is not acceptable standard practice. He stated he did not do competencies (observations used to monitor for acceptable standards of care like wound care) with staff since he started working at the facility in October. He stated he would look for the old competencies. Record review of the physician order [REDACTED].#36 documented the following: 1. Cleanse with wound cleanser, apply Santyl and calcium alginate. Cover with [MEDICATION NAME] and use transparent film tape, daily. Diagnoses: [REDACTED]. Date ordered 10/19/18 and discontinued on 2/20/19. 2. Coccyx: cleanse with wound cleanser, apply Santyl and calcium alginate. Cover with [MEDICATION NAME] and secure with tape daily. Date ordered 2/22/19. 3.Refer to Physician #3 for wound care. Date ordered 2/25/19. Record review of TAR (treatment administration record) for the month of (MONTH) 2019 documented the following: 1. Coccyx: cleanse with wound cleanser, apply Santyl and calcium alginate. Cover with [MEDICATION NAME] and use transparent film tape daily. Date ordered 10/19/18 and discontinued on 2/20/19. TAR indicates treatment was provided on the following dates: 2/6/19 through 2/12/19, 2/17/19 and 2/19/19. The TAR was coded as treatment refused by Resident #36 on the following dates: 2/1/19 through 2/4/19, 2/13/19, 2/14/19, 2/15/19, 2/16/19, 2/18/19. The TAR was coded as treatment not received on 2/5/19 related to vitals outside of parameters for administration. The TAR indicated treatment was not provided for 10 of 19 days in February. Record review of progress notes for Resident #36 documented 3 entries on 2/13/19 regarding refusal of wound care. 2/13/19 at 8:00 AM -resident states he doesn't want to shower or do wound care today. Reeducated about the importance of daily hygiene and wound care. Still refuses at this time. This note was signed by RN #1. 2/13/19 at 10:00 AM-resident still refusing shower or wound care at this time. Will ask again after lunch. This note was signed by RN #1. 2/13/19 at 3:51 PM-resident still refusing to shower or allow wound care today. States he will do it 1st thing in the morning. This note was signed by RN #1. Interview on 2/20/19 at 11:59 AM with LVN #2 confirmed she was the wound care/charge nurse. She stated she only gets about 4 hours a week to do wound care documentation because she has been pulled to the floor to be a charge nurse. She stated right now each nurse does their own wound care. She stated staff is to make the physician aware of the wound and obtain orders. LVN #2 stated she does wound rounds weekly with the DON. She stated the DON does all the wound staging while she does the measurements. She stated they are to notify the physician whenever a resident refuses wound care treatment. She stated any time a physician is notified is to be documented in the progress notes. She stated the MDS coordinator does the care plans and she does not coordinate with the MDS nurse regarding resident refusing treatment or interventions. Interview on 2/20/19 at 2:20 PM with LVN #5 revealed that if a resident refuses treatment she is to notify the physician and document in the progress notes. She stated she does not normally take care of Resident #36 therefore she is unaware of any treatment refusal. She stated the facility does have a wound care nurse, but because of staffing issues, the wound care nurse has been pulled to the floor as a charge nurse. LVN #5 stated she does her own wound care, measurements, orders and staging of wounds. Interview on 2/20/19 at 2:38 PM with DON confirmed staff is to notify the physician if a resident is refusing medication, treatment, or any other care. He confirmed there was no documentation physician was notified regarding Resident #36 refusing 10 wound care treatments of 19 treatments scheduled for the month of (MONTH) in the progress notes. He confirmed the physician was not notified according to the notes. Interview on 2/27/19 11:21 AM with LVN #9 if a resident refuses care she was to notify the medical doctor and ask another nurse to attempt the treatment, medication or care. Interview on 2/27/19 11:23 AM with RN #1 confirmed anytime a resident refuses care, medication, or treatment he should document it in the progress notes. He stated he should have reported the repeated wound care refusals for Resident #36 to Physician #1. He confirmed he did not report the refusal of wound care to Physician #1. He stated Resident #36 did have an air mattress on his bed for a few months after he arrived at the facility. He stated Resident #36 did not like the air mattress and would sleep on the other bed. He stated no other air mattresses or overlays were tried. Interview on 2/27/19 at 12:02 PM with LVN #2 revealed that if a resident refuses care she tries to approach them later. She stated she is to let the DON and physician know the resident refused care, medication, or treatment. She stated she should document the refusal and did not do this for Resident #36. She stated Resident #36 did have an air mattress on his bed until approximately a week ago. She stated she was not sure why the air mattress is not on the bed today. Interview on 2/20/19 at 3:36 PM with LVN #8 revealed the care plans are designed for the nursing staff. When asked what interventions were in place to address the refusal of wound care, she stated measuring the wound and reporting it to the physician . When asked to explain how measuring the wound and reporting it to the physician is addressing Resident #36's refusal of care, LVN #8 stated we have to put that in, some nurses will not call the doctor. When asked again to explain how any of the interventions in the comprehensive care plan regarding potential for pressure ulcers addresses the resident's refusal of care, she stated all of them do. Interview on 2/25/19 at 10:24 AM with DON revealed the last time he saw Resident #36 's wound was approximately one week ago. He stated he thought it needed to be debrided because there was only approximately 25% granulated tissue (good tissue ) and 75% with eschar (dead or devitalized tissue ). He confirmed staff is to complete a wound care assessment and skin assessment weekly. He stated Resident #36 does refuse both often. He confirmed the last wound care assessment for Resident #36 was completed on 2/10/19 and there is no documentation regarding the refusal of other weekly wound or skin assessment. The DON confirmed there were no interventions on the care plan to address Resident #36's continued refusal of wound care. He stated there was an air mattress on the bed at one time, but the resident did not like it and he punctured it. He stated they returned the mattress to the DME (durable medical equipment) company on 1/31/19. Interview on 2/25/19 at 10:24 AM with DON stated he was unable to find competencies on the nursing staff. He also provided a document confirming the air mattress was returned to the DME on 1/31/19. Record review of comprehensive care plan for Resident #36 documented the following: Focus: The resident is resistant to care as evidenced by refuses wound care, showers related to adjustment to nursing home, [MEDICAL CONDITION]. Date initiated 8/8/18 and revised on 8/21/18. Goal: The resident will cooperate with care through next review date. Date initiated 8/8/18 and revised on 10/23/18. Target date is 1/10/19. Interventions: 1. Allow the resident to make decisions about treatment regimen, to provide sense of control. 4. If resident resists with ADLs, reassure resident, leave and return 5 - 10 minutes later try again. 5. Praise the resident when behavior is appropriate. 6. Provide resident with opportunities for choice during care provision. 7. If possible, negotiate a time for ADL so that the resident participates in the decision-making process. Return at the agreed upon time. All interventions were initiated on 8/8/18. There were no interventions regarding wound care, or updated interventions except for intervention number 3. Record review of electronic medical record and paper chart for Resident #36 revealed no further documentation to address behavior of refusing wound care. This was confirmed and verified by the DON. Interview on 2/25/19 at 3:14 PM with Care Plan Coordinator revealed I understand we have a problem, we will get interventions in place. She stated they would start sitting in morning meetings and getting interventions into place. Interview on 2/26/19 at 5:27 PM with DON confirmed the comprehensive care plan in place upon our entrance into the facility regarding refusal of care did not address Resident #36's refusal of wound care, rather it focused on refusal of ADLs. He verified the care plan interventions had not been updated since 8/8/18. Record review of Psychiatric Hospital #1 transfer documentation and notes documented the following: Resident #36 was admitted to Psychiatric Hospital #1 on 6/1/18. History and physical dated 6/2/18 at 9:28 AM for Resident #36 documented the following: Chief complaint: history and physical and medical consult History of present illness: decompensated This is a [AGE] year-old male with psychiatric history of [MEDICAL CONDITION] disorder admitted to Psychiatric Hospital #1, geri psych unit on 6/1/18. The patient is easily agitated and verbally aggressive. Per available medical record, past medical history includes [MEDICAL CONDITION] [MEDICAL CONDITIONS] status, [MEDICAL CONDITION] reflux disease, stage IV pressure ulcer of sacral. Past surgical history includes a left BKA ([MEDICAL CONDITION]). Denies any physical complaints today. Patient has a long history of [MEDICAL CONDITION] disorder with previous psychiatric admits. Patient has multiple medical issues and is paralyzed from the waist down due to gunshot wound as teenager Record review of Clinical Suite Report Detail dated 7/13/18 for Resident #36 documented the following: He is followed by Physician #4 for healing stage IV pressure ulcer to sacral aspect that has steadily improved with offloading and daily [MEDICATION NAME] with normal saline moist packing. He is off any systemic antibiotics at this time and denies any fever, chills, nausea, vomiting, shortness of breath or chest pain. There was no documentation regarding wound measurements in any of the documentation received from Psychiatric Hospital #1. Record review of electronic documentation and paper chart for Resident #36 documented the initial Wound Weekly Observation Tool was not conducted until 11/8/18, 61 days after resident was admitted to this facility. B. Observations/data 1. Location = coccyx 3. Type = pressure 4. Pressure ulcer stage, original = stage IV pressure ulcer stage, current = stage IV 5. Visible tissue-[MEDICATION NAME](pink) tissue present, granulation (beefy red) tissue present, slough(yellow, tan, white, stringy) tissue present, moist. Describe the extent of necrosis and/or slough in the wound bed = 25% 7. Odor = yes, foul odor 8. Wound length in centimeters = 18, wound width in centimeters = 11, wound depth in centimeters = 5 C. Treatment 2. Current treatment plan- Santyl with calcium alginate. Cover with [MEDICATION NAME] and secure with transparent tape. Record review of 2nd Weekly Wound Observation Tool dated 12/12/18, which was 35 days after last documented wound assessment documented the following: B. Observations/data 1. Location = buttock 3. Type = pressure 4. Pressure ulcer stage, original = stage IV pressure ulcer stage, current = stage IV 5. Visible tissue-[MEDICATION NAME](pink) tissue present, moist. Describe the extent of necrosis and/or slough in the wound bed = 0% 7. Odor = no 8. Wound length in centimeters = 15.5, wound width in centimeters = 15, wound depth in centimeters = 1 C. Treatment 2. Current treatment plan- Santyl with calcium alginate. Cover with [MEDICATION NAME] and secure with transparent tape. Record review of 3rd and final Weekly Wound Observation Tool dated 2/8/19 documented the following: B. Observations/data 1. Location = coccyx 3. Type = pressure 4. Pressure ulcer stage, original = stage IV pressure ulcer stage, current = stage IV 5. Visible tissue-[MEDICATION NAME](pink) tissue present, slough tissue present (yellow, tan, white, stringy), moist. Describe the extent of necrosis and/or slough in the wound bed = 0% 7. Odor = no 8. Wound length in centimeters = 18, wound width in centimeters = 10.5, wound depth in centimeters = 2 C. Treatment 2. Current treatment hydrogel with calcium alginate. Cover with foam and secure with tape. Based on facility assessment and measurements, Resident #36 has had a change in wound size as follows: 12/12/18 = length-15.5 cm, width-15.0 cm, depth-1 cm 2/21/18 = length-15.0 cm, width-19 cm, depth-4 cm Width has increased in size by 4 cm or 27% and depth has increased by 300%. There were only 3 Weekly Wound Observation Tools and assessments conducted for Resident #36. The weekly wound observation was conducted on 11/8/18, 12/12/18, and 2/8/19. Interview on 2/25/19 at 3:39 PM with DON confirmed the Weekly Wound Observation Tools and electronic documentation contain errors in type of tissue present and location of wound. He stated he did not know why there was no documentation for weekly wound observation until 2 months after Resident #36 's admission to the facility. He stated based on the information and his observation, the wound has worsened. Record review of Skin Sheet Tracking Record provided by the facility documented the following for Resident #36: Date: 11/8/18-wound is measured at 18 x 11 cm. there is no depth listed. It is assessed with [REDACTED]. Date: 2/14/19-wound is measured at 16 X 12 X2 centimeters. It is assessed with [REDACTED]. Resident #36 is listed as refused measurements on 6 of 17 skin sheet tracking records from 8/31/18 through 2/14/19. Resident #36 is not listed on 6 of 17 skin sheet tracking records from 8/31/18 through 2/14/19. Resident #36 has 5 documented wound measurements out of 17 skin sheet tracking records from 8/31/18 through 2/14/19. Interview on 2/25/19 at 3:39 PM with DON confirmed the weekly skin sheet tracking record was not done weekly because the wound care nurse had been pulled to the floor as charge nurse. He stated he does not know why Resident #36 was not listed on the weekly skin sheet tracking record until 11/8/18 because the resident has not had any hospital admissions. Interview on 2/22/19 at 1:47 PM with Physician #1 revealed he is aware Resident #36 has been refusing wound care. He stated the last time he saw the wound was yesterday but was only able to see a small portion because the resident did not want him to remove the entire dressing. He stated what he did see appeared to be slough and there was an odor. He stated the last time he saw the total wound was a few weeks ago in his office. Physician #1 stated the wound had slough and granulating tissue. He stated he was aware the wound was worsening, and he was concerned about getting Resident #36's pain under control. He confirmed he no longer documents separately from the facility's electronic documentation program. He stated there are no paper notes for this resident, everything is in the computer. He stated he relies on what the staff tells him regarding the wound because he cannot take the dressing off each day. Physician #1 stated they would work on updating the care plan to address Resident #36's behavior when asked what the plan was to address Resident #36's refusal of care and worsening wound. He stated his current plan was to put the resident on antibiotics and bring him to the hospital for sharp debridement. He stated he may admit the resident for a few days to get some IV antibiotics. He stated he would do this when he returned from his vacation on 3/6/19. Interview on 2/27/19 at 10:00 AM with DON revealed Resident #36 was currently at Wound Clinic #1. He stated he had a referral to Physician #3 for assessment and treatment. Record review of Physician #3's initial assessment and orders for Resident #36 documented the following: 1. Cleanse wound with normal saline and blot with 4X4 gauze. Apply APG/alginate topicals as per order. Cover with primary and secondary dressings as ordered and as needed for soiling, loosening, or bleeding. Report significant changes in appearance, I. E. [DIAGNOSES REDACTED], [MEDICAL CONDITION], drainage, odor, bleeding or a fever greater than 100°F. Perform wound care every Monday, Wednesday, and Friday. Date order 2/27/19. Observation on 2/27/19 at 10:30 AM revealed Resident #36 was self-propelling in the hallway in his wheelchair after returning from his appointment. Record review of electronic medical records and orders for Resident #36 at 12:45 PM revealed new orders received from Physician #3 had not been entered into the computer system. Resident #19 Record review of Resident #19's admission record revealed an [AGE] year old female who admitted to the facility on [DATE] and a readmission date of [DATE] with the following Diagnoses: [REDACTED]. Record review of quarterly MDS dated [DATE] for Resident #19 documented the following: Section C-Cognitive Patterns C0500-Summary score = 12. This indicates minimal cognitive impairment. Section E-Behavior E- 0800-Rejection of care-presence and frequency Did the resident reject evaluation or care (e.g., bloodwork, taking medications, ADL assistance) that is necessary to achieve the resident's goals for health and well-being? Do not include behaviors that have already been addressed(e.g., by discussion or care planning with the resident or family) and/or determined to be consistent with resident values, preferences, or goals. 0. Behavior not exhibited was coded Section M-Skin Conditions M010-Risk of pressure ulcers Is this resident at risk of developing pressure ulcers? 1. Yes is coded M1200-Skin and ulcer treatments No interventions were coded. Observation on 2/19/19 at 10:39 AM revealed the door open to the room and Resident #19 asleep in bed, right foot exposed. Skin is dry and flaky. Strong smell of urine odor in room. There is a wheelchair at the bedside and the bed is in low position. Observation on 2/20/19 at 9:00 AM during medication observation in hallway C, a strong pungent odor was noted in the hallway. This surveyor looked for the source of this odor and noted Resident #19 sitting at the side of the bed. There was a 3X3 ' area on the floor under Resident #19's feet where multiple drops of wet purulent ( blood mixed with pus ) drainage had splattered to the floor. When Resident #19 lifted her feet up into the bed, there was dark purulent drainage dripping from the wound on her right heel. There was a strong, acidic pungent odor coming from the room. Interview on 2/20/19 at 9:10 AM with LVN #7 revealed she had not performed wound care at this time for Resident #19. She stated she saw the blood on the floor, but she needed to start an IV on another resident who had lost consciousness. Instructed her to notify this surveyor prior to her performing wound care so the wound and care could be observed. She stated she would. Record review of medication review Report dated (MONTH) 2019 for Resident #19 revealed there were no active orders for wound care to the right heel or left ball of foot. The was a discontinued order documented as follows: 1. Apply skin prep to right posterior heel and left great plantar metatarsal head daily. [DIAGNOSES REDACTED]. Date ordered 5/26/18 and discontinued on 2/10/19. Record review of weekly skin documentation dated 2/20/19 at 3:33 AM for Resident #19 documented the following: 1. Weekly skin documentation: date-2/20/19 skin: is intact 4. Skin is: warm, dry. 5. Skin turgor: good 6. Special equipment in use: no interventions were documented There was no documentation regarding the wound to Resident #19's right heel. Interview on 2/20/19 at 10:35 AM with DON revealed the facility found this wound yesterday (2/19/19). He stated he did not know why there were no orders received and did not know why the skin assessment conducted 12 hours later showed no skin issues. He stated they would not be a weekly wound assessment because the callous is not a wound. DON confirmed there was a strong odor coming from this wound. Interview on 2/20/19 at 10:39 AM with LVN #7 revealed Resident #19 was being sent to the doctor's office for evaluation (2/20/19)of the wound on the right heel and the left ball of foot. She stated she did her assessment earlier but did not see the wound. LVN #7 stated Resident #19 has refused wound care for the last few days. She stated this wound has been there at least a few weeks. She confirmed she did not document the resident had refused care and did not notify the physician. LVN #7 confirmed there was a strong odor coming from the resident's wound. She stated she does not remember an order for [REDACTED]. Interview on 2/20/19 at 10:45 AM with Resident #19 revealed I knew my heel was open. She stated she had pain and winced and pulled her foot away when LVN #7 applied a dressing to the right heel. She stated her left foot did not hurt. Interview on 2/20/19 at 11:59 AM with LVN #2 revealed she did see the wound to the right heel for Resident #19 yesterday. She stated she saw her foot sticking out from under the covers and noted her right heel was dark. She stated she assessed the wound and measured it and notified FNP #1. She stated she was given orders at that time to transfer Resident #19 to the clinic today. She confirmed she did not document this assessment or measurements anywhere and did not write the order but did verbally pass it along to the night shift nurse. She stated when she did the assessment on 2/9/19, she noted her feet were purple but there was no wound, only a callous on her left foot. She stated the callous on the left foot was blanchable ( skin returned to normal color after pressure is applied and released). She stated the DTI was closed and she did not notice any other issues. She stated they were applying skin prep but discontinued it because the resident continued to refuse the care. LVN #2 stated they were offloading ( elevating the heels on pillows or other devices to keep the heels from resting directly onto the bed) the heels with pillows, but the resident didn't like the pillows under her feet and removed them herself. She stated she was aware Resident #19 had a [DIAGNOSES REDACTED]. LVN #2 stated she started working at the facility in (MONTH) (YEAR) and Resident #19 rejected care since she has worked at the facility. She stated she does not do the care plans and has never coordinated interventions with the care plans. She stated she notified the DON when interventions were not working. She stated she does no (TRUNCATED)

Based on interview and record review, the facility failed to ensure the residents had the right to be free from neglect from falls related to transportation safety for 1 of 2 residents (Resident #18, a closed record) reviewed for neglect related to falls in that: The facility failed to ensure Resident #18 (a closed record) was secured in a seat belt during transport in the facility van and sustained a laceration to the right temple when he fell out of his wheel chair onto the floor of the van. An Immediate Jeopardy (IJ) was identified on 05/24/17. While the IJ was removed on (5/25/17) the facility remained out of compliance at a scope of a pattern and a severity of no actual harm with potential for more than minimal harm due to facility needing more time to monitor the plan of removal for effectiveness. This failure affected 1 of 2 residents (Resident #18, a closed record) being transported in the facility van and had the potential to affect the other 40 residents residing in the facility who utilized the facility van/bus for transportation by placing them at increased risk for injuries such as fractures, severe lacerations, or death. Findings included: Resident #18, a closed record: There were no observations of resident #'s 18, (a closed record) as he had discharged to a sister facility about three hours away. Record review of closed record Resident #18's medical record revealed he was a [AGE] year-old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of the receiving facility's Accident/Accident Report for closed record Resident #18 by facility RN documented on 5/4/17 in the description, Called to facility by LVN to assess Resident #18. Report received about resident arriving by facility van with injury from resident falling out of wheelchair. Upon my arrival, resident sitting in wheelchair in dining room. Had a laceration to right temple, 3 centimeters wide, 5 centimeters deep and 5 long with fresh bleeding. Right eye lid with bruising, alert, answered questions. Wound cleansed with wound cleaner, dressing applied, which resident immediately took off. Reapplied bandage, resident removed again. Resident sent to (hospital emergency room via ambulance. Record review of the (hospital emergency room ) records dated 5/4/17 documented the following: Motor Vehicle crash - minor. Patient (Resident #18) Chief complaint from Nursing Triage Note: Chief Complaint: Face Laceration. History of Present Illness: The patient presents following motor vehicle collision. The onset was just prior to arrival. The Collision was EMS stated the patients were in a van being transferred from one nursing home to another nursing home. When the van and suddenly stop >sic<. The patient did not have his restraints on. He came out of the wheelchair striking the right side of his forehead and face in front of him causing a laceration. The patient was the passenger. There were safety mechanisms including unknown. Location: right forehead. Type of injury: laceration. The degree of pain is minimal. The degree of bleeding is minimal. Risk factors consists of a history of [MEDICAL CONDITION] the left side of the brain. Therapy today: emergency medical services. Associated symptoms: none. During a telephone interview with CNA #6 on 5/9/17 at 4:17 p.m. when asked about closed record, Resident #18's van transportation trip to another facility, she said she was the driver and was transporting closed record, Resident #18 and another discharged Resident #19 to a sister facility about three hours away on 5/4/17. She said the facility's newer bus was in the shop and they had to take the old facility van. She said Monitor #1 was the escort for the trip. When asked how closed record, Resident #18 was sitting in the van, she said the resident was in his wheelchair, which was located directly behind the driver's seat with no seat belt over the resident's wheel chair. She said there was no seat belt attached from the van wall to the floor, like there was in the newer facility bus. She said she tried to get Resident #18 to transfer out of his wheelchair into a regular bench seat with a seatbelt, but he refused to sit next to Resident #19, the other passenger, a resident who was also being transported to the other facility. When asked how she secured the resident for safety, she said she and Monitor #1 used blue tie down straps looped through the frame of the wheelchair and secured the straps to the round hooks in the floor. When asked what she thought she should have done since closed record, Resident #18 refused to be transported safely, she said she should have gone and reported it to the facility's administration and let them decide what to do about the issue. When asked what happened at the time of closed record, Resident #18's accident, she said they were already in the receiving facility town, just a block away from the receiving facility when she said she had to stop at a red light. She said Monitor #1 told her Resident #18 had fallen out of his wheel chair and his head was bleeding. She had to turn left to get to the facility which was less than a block away. She said she could not pull over to the side of the road safely and Monitor #1 pointed that the receiving facility was within site, so she decided not stop and drove to the back of the facility, which was fenced and gated. She said the Monitor #1 said he had been to the facility previously and knew the code to the gate, but when he tried, it did not work. She said they waited 20 minutes before anyone answered the buzzer to the gate. When asked what she did about Resident #18's head, she said she had a package of wet wipes and used the wipes and held pressure to his head. She said a nurse from the receiving facility came out and said they were not expecting them that day and the nurse would have to go get, the Administrator #2. Administrator #2 came out to the van and said to unload the patients from the van and he would call the physician. She said she went in and counted the residents' narcotics before she left the facility. She said Administrator #2 called back to former facility and spoke with Administrator and she told Administrator #2 to send both residents to the (hospital emergency room , not located in the facility's town) for emergency attention. EMS personnel took both residents to the hospital ER. During an interview and observation of the facility's old van on 5/11/17 at 9:00 a.m. with Maintenance Supervisor, Surveyor observed the van had a seat belt attached to the van wall which ran to the floor. When asked about the van's safety seat belts, he said he had recently after the accident of 5/4/17, installed a seat belt mechanism with it attached to the van wall and floor and it was not in the van at the time of Resident # 18's accident. When asked why the van did not have a seat belt for the wheelchair, he said he did not know it was required and that after the accident that was the first time he was aware the van needed one. During an interview on 5/11/17 at 9:05 a.m. Monitor #1 verified he was the escort for closed record, Resident # 18's transfer on 5/4/17. When asked about the safety equipment seat belts in the old van prior to the transport of Resident #18, he said the facility's old van did not have a seat belt for securing wheelchairs prior to the transport of Resident #18. When asked how he secured the resident, he said Resident # 18 refused to transfer into a bench seat with a seat belt, so he and CNA #6 took blue safety straps and tied them through the frame of the wheelchair and secured them to the floor through hooks. When asked about Resident # 18's fall, he said when the driver came to a slow gradual stop at a red light in the receiving destination town, he turned around and saw that the resident had fallen out of his wheelchair and hit his head on the door facing of the van and was bleeding from the head. He said they were very near the receiving facility and he told the driver to just proceed to the facility. When asked what happened at arrival to the facility, he said they had to wait more than 20 minutes for anyone to answer the gate and then there was some question about whether the facility would accept the residents because the facility was not expecting the residents that day. During an interview with the DON on 5/11/17 at 8:58 a.m. when asked if she knew the facility's old van did not have seat belts, she said, No. During an interview on 5/11/17 at 9:13 a.m. with Activity Director when asked if she transported residents on the van, she answered, Yes, I used to do resident transportation. When asked what she knew of on the old facility van that was not operational, she answered, I knew there was no seat belt for strapping down wheelchairs. When the van driver, CNA #6, was hired, I told her to at least use a gait belt around a wheel chair with resident and strap it through the wheelchair to prevent a resident from falling out of the wheelchair. During an interview on 5/11/17 at 2:19 p.m. with the Administrator, when asked about the facility's policy for transportation, she said after reviewing the old policy, she knew it was not acceptable and she had drafted a new policy. She said she had instructed the Maintenance Supervisor to install a new seat belt in the old van. Record Review of the facility's Abuse Prohibition Policy and Procedure, with a revision date of 12/20/13, documented the following: Policy: It is the policy of this home to prohibit abuse and neglect in any form, and to report in accordance with the law any incident in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person. Any allegation of abuse MUST be reported to the Administrator or Regional Director immediately. Definitions .Neglect: The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness Record review of the facility's policy, which was current at the time of Resident #18's accident, reflected a policy on Orientation - Transportation dated 3/2011 and revised 3/2012 documented the following: Policy: It is the policy of this home to ensure Orientation is provided to transportation personnel. Procedure: 1. Prior to providing transportation to any resident in community van/bus they will be completely trained on transportation requirements. 2. If personnel fail any area on the checklist they will not be allowed to perform transportation until 100% competency is obtained. 3. All drivers will be in serviced in the following areas: General areas covered: a. General Practice b. Driver's Duties c. Driving d. Wheelchair lift e. Wheelchair and Occupant Securement. An IJ was identified on 05/24/17 and the Administrator was notified at 10:32 a.m. A plan of removal (POR) for the IJ was submitted on 05/24/17 at 5:06 p.m. and was accepted on 05/25/17 at 9:00 a.m. The POR included in part: Plan of Removal (IJ Reason) (Facility) May 24, 2017 ~ In-serviced CNA and drivers on proper loading, securing, and unloading a resident for transport. - Completed 05/24/17 ~ Facility has in-serviced all drivers regarding transporting residents and not to transport a resident if they are at risk or refuse to wear seatbelt. - Completed 05/05/17 ~ Maintenance supervisor repaired the van with a seatbelt bolted to the vehicle for wheelchair transports. Completed 05/15/17 (<sic>should reflect 05/05/17) ~ The van driver who was driving the van at the time of the incident was suspended immediately, then terminated. Suspended on 05/04/17. Termination on 05/11/17. ~ The maintenance supervisor was given a final disciplinary action for failure to complete safety checks and ensure vehicles were safe and mechanically sound for transport. Disciplinary action on 05/04/17. ~ At a minimum of yearly, facility maintenance director will conduct yearly competencies on all transportation drivers. Current 05/24/17 and on-going. ~ No employee, who have not been checked off on the skills competency, will not be allowed to perform the duties of loading, securing, and unloading residents for transport. Current 05/04/17 and on-going. ~ Weekly safety checks to be performed by maintenance supervisor weekly. Current and on-going. ~Pre-trip checklist to be implemented today (05/24/17) and on-going. ~ In-service new staff on new Vehicle Safety Program that was implemented 05/24/17 and will be on-going for all new hires that work transportation. ~ The Maintenance director failed to perform routine safety checks on facility van. ~ Facility van driver failed to ask for assistance when the resident refused to transfer to the seat that had a seatbelt and failed to notify Administrator or DON. Signed by Administrator 05/24/17 Additional information provided after IJ was called included the following: 1.) Preventative Maintenance checklist for Auto/Pickup/Van Inspection dated 05/08/17 by Maintenance Supervisor; No identified issues noted. 2.) Record review of 05/08/17 Random Inspection of Wheelchair Securement for two facility van drivers. No identified issues noted. 3.) Record review of 05/24/17 Random Inspection of Wheelchair Securement for one facility van drivers; No identified issues noted. 4.) In-service training report on 05/09/17 at 8:54 a.m. for Van Safety; No identified issues noted. 5.) Record review of the updated May 2017 Vehicle Safety Program: No identified issues noted. 6.) Record review of in-service training was completed on 05/24/17 at 3:45 p.m.by the Maintenance Supervisor for eight additional staff concerning Wheelchair Securement; No identified issues noted. On 05/24/17 at 12:22 p.m. - 4:00 p.m., 3 van drivers, one escort for transportation, and 2 CNA's were interviewed about transportation procedures of securing a wheelchair resident and all answered with correct responses, no issues noted. On 05/24/17 at 3:00 p.m. DON was interviewed regarding policy and said put all residents in seat belts and w/c (wheelchairs) have to have tie downs from floor to w/c frame plus a seatbelt. An escort will go with the driver. The person who loads resident should double check security of resident's seatbelt and floor tie downs prior to leaving with the resident. Regarding what would you expect to happen in this situation - the DON said it would be possible for an accident to occur if resident did not wear a seatbelt and have w/c secured to floor with tie downs. Regarding staff training of transportation of w/c residents - the DON said transportation drivers of van/bus have been trained, but not CNA's. Regarding the IJ situation and how it occurred, - the DON said the resident was not secured in a w/c seatbelt attached to the floor and safety tie down straps were not secure. The CNA transport driver did not report to the Administration that resident refused to be safely secured in the bench seat belt. The facility transportation policy was not to transport the resident. Regarding resources available to the facility, - the DON said the Maintenance Supervisor was able to in-service staff, and transportation drivers and CNAs who load residents in the van. The Medical Director will discuss at next QA (Quality Assurance) meeting. On 05/24/17 at 2:15 p.m. Administrator was interviewed regarding policy and said all w/c residents must be in seatbelts and use 4 point restraint safety straps attached to floor securing w/c. Regarding evaluating policies and procedures ensuring effectiveness of facility processes, the Administrator said all transportation drivers must have a valid driver's license. They are in-serviced at hire and competency skills check off list completed. In-services are conducted by Maintenance Supervisor in charge of transportation. Regarding staff training of transportation of w/c residents, the Administrator said transportation drivers have all been in-services and escort has also been trained. Regarding what the Administrator would expect staff to do if a resident refused a seatbelt, she said the transportation driver should alert the Administration the resident refused to transport and not transport resident. Regarding how the IJ came about, the Administrator said the driver did not report to Administration that resident refused to transfer to a bench seat with a seatbelt. Regarding the Administrator's awareness of the situation, she said she was not made aware of the situation, as she was out of the building coming back from the admitting facility. Regarding an investigation and implementation of corrective measures, the Administrator said she put into place a new policy and in-serviced the transportation drivers on transporting w/c residents with a seatbelt and 4 point floor restraints for safety. She had a seatbelt installed in the old van and purchased new safety strap tie downs. Regarding what resources were available to her and the facility. She said the policies and procedures had been updated, the Medical Director was made aware and discussion will take place at next QA meeting and the sister facilities made aware of need for transportation assistance. While the IJ was removed on 05/25/17 at 9:00 a.m. the facility remained out of compliance at a scope of a pattern and a severity of no actual harm with potential for more than minimal harm due to facility needing more time to monitor the plan of removal for effectiveness. Record review of the 5/9/17 facility provided list of residents who utilized facility van/bus transportation documented there were 40 residents listed.

Based on interview and record review, it was determined that the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property in that: The facility failed to ensure Resident # 18, a closed record, was secured in a seat belt during transport in the facility van and sustained a laceration to the right temple when he fell out of his wheel chair. onto the floor of the van. An Immediate Jeopardy (IJ) was identified on 05/24/17. While the IJ was removed on (5/25/17) the facility remained out of compliance at a scope of a pattern and a severity of no actual harm with potential for more than minimal harm due to facility needing more time to monitor the plan of removal for effectiveness. This failure affected 1 of 2 residents (Resident #18), a closed record being transported in the facility van and had the potential to affect the other 40 residents residing in the facility who utilized the facility van/bus for transportation by placing them at increased risk for injuries such as fractures, severe lacerations, or death. Findings included: Record Review of the facility's Abuse Prohibition Policy and Procedure, with a revision date of 12/20/13, documented the following: Policy: It is the policy of this home to prohibit abuse and neglect in any form, and to report in accordance with the law any incident in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person. Any allegation of abuse MUST be reported to the Administrator or Regional Director immediately. Definitions .Neglect: The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness Record review of the facility's policy on Orientation - Transportation dated 3/2011 and revised 3/2012 documented the following: Policy: It is the policy of this home to ensure Orientation is provided to transportation personnel. Procedure: 1. Prior to providing transportation to any resident in community van/bus they will be completely trained on transportation requirements. 2. If personnel fail any area on the checklist they will not be allowed to perform transportation until 100% competency is obtained. 3. All drivers will be in serviced in the following areas: General areas covered: a. General Practice b. Driver's Duties c. Driving d. Wheelchair lift e. Wheelchair and Occupant Securement. Resident #18, a closed record There were no observations of resident #18, a closed record, as he had discharged to a sister facility about three hours away. Record review of closed record, Resident #18's medical record revealed he was a [AGE] year-old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of the receiving facility's Accident/Accident Report for Resident #18 by facility RN documented on 5/4/17 in the description, Called to facility by LVN to assess Resident #18's Report received about resident arriving by facility van with injury from resident falling out of wheelchair. Upon my arrival, resident sitting in wheelchair in dining room. Had a laceration to right temple, 3 centimeters wide, 5 centimeters deep and 5 long with fresh bleeding. Right eye lid with bruising, alert, answered questions. Wound cleansed with wound cleaner, dressing applied, which resident immediately took off. Reapplied bandage, resident removed again. Resident sent to (hospital emergency room via ambulance. Record review of the (hospital emergency room ) records dated 5/4/17 documented the following: Motor Vehicle crash - minor. Patient (Resident #18) Chief complaint from Nursing Triage Note: Chief Complaint: Face Laceration. History of Present Illness: The patient presents following motor vehicle collision. The onset was just prior to arrival. The Collision was EMS stated the patients were in a van being transferred from one nursing home to another nursing home. When the van and suddenly stop >sic<. The patient did not have his restraints on. He came out of the wheelchair striking the right side of his forehead and face in front of him causing a laceration. The patient was the passenger. There were safety mechanisms including unknown. Location: right forehead. Type of injury: laceration. The degree of pain is minimal. The degree of bleeding is minimal. Risk factors consists of a history of [MEDICAL CONDITION] the left side of the brain. Therapy today: emergency medical services. Associated symptoms: none. During a telephone interview with CNA #6 on 5/9/17 at 4:17 p.m. when asked about Resident # 18's van transportation trip to another facility, she said she was the driver and was transporting Resident #18 and discharged Resident #19 to a sister facility about three hours away on 5/4/17. She said the facility's newer bus was in the shop and they had to take the old facility van. She said Monitor #1 was the escort for the trip. When asked how Resident #18 was sitting in the van, she said the resident was in his wheelchair, which was located directly behind the driver's seat with no seat belt over the resident's wheel chair. She said there was no seat belt attached from the van wall to the floor, like there was in the newer facility bus. She said she tried to get Resident #18 to transfer out of his wheelchair into a regular bench seat with a seatbelt, but he refused to sit next to Resident #19, the other passenger, a resident who was also being transported to the other facility. When asked how she secured the resident for safety, she said she and Monitor #1 used blue tie down straps looped through the frame of the wheelchair and secured the straps to the round hooks in the floor. When asked what she thought she should have done since Resident #18 refused to be transported safely, she said she should have gone and reported it to the facility's administration and let them decide what to do about the issue. When asked what happened at the time of Resident #18's accident, she said they were already in the receiving facility town, just a block away from the receiving facility when she said she had to stop at a red light. She said Monitor #1 told her Resident #18 had fallen out of his wheel chair and his head was bleeding. She had to turn left to get to the facility which was less than a block away. She said she could not pull over to the side of the road safely and Monitor #1 pointed that the receiving facility was within site, so she decided not stop and drove to the back of the facility, which was fenced and gated. She said the Monitor #1 said he had been to the facility previously and knew the code to the gate, but when he tried, it did not work. She said they waited 20 minutes before anyone answered the buzzer to the gate. When asked what she did about Resident #18's head, she said she had a package of wet wipes and used the wipes and held pressure to his head. She said a nurse from the receiving facility came out and said they were not expecting them that day and the nurse would have to go get, the Administrator #2. Administrator #2 came out to the van and said to unload the patients from the van and he would call the physician. She said she went in and counted the residents' narcotics before she left the facility. She said Administrator #2 called back to former facility and spoke with Administrator and she told Administrator #2 to send both residents to the (hospital emergency room , not located in the facility's town) for emergency attention. EMS personnel took both residents to the hospital ER. During an interview and observation of the facility's old van on 5/11/17 at 9:00 a.m. with Maintenance Supervisor, Surveyor observed the van had a seat belt attached to the van wall which ran to the floor. When asked about the van's safety seat belts, he said he had recently after the accident of 5/4/17, installed a seat belt mechanism with it attached to the van wall and floor and it was not in the van at the time of Resident # 18's accident. When asked why the van did not have a seat belt for the wheelchair, he said he did not know it was required and that after the accident that was the first time he was aware the van needed one. During an interview on 5/11/17 at 9:05 a.m. Monitor #1 verified he was the escort for Resident # 18's transfer on 5/4/17. When asked about the safety equipment seat belts in the old van prior to the transport of Resident #18, he said the facility's old van did not have a seat belt for securing wheelchairs prior to the transport of Resident #18. When asked how he secured the resident, he said Resident # 18 refused to transfer into a bench seat with a seat belt, so he and CNA #6 took blue safety straps and tied them through the frame of the wheelchair and secured them to the floor through hooks. When asked about Resident # 18's fall, he said when the driver came to a slow gradual stop at a red light in the receiving destination town, he turned around and saw that the resident had fallen out of his wheelchair and hit his head on the door facing of the van and was bleeding from the head. He said they were very near the receiving facility and he told the driver to just proceed to the facility. When asked what happened at arrival to the facility, he said they had to wait more than 20 minutes for anyone to answer the gate and then there was some question about whether the facility would accept the residents because the facility was not expecting the residents that day. During an interview with the DON on 5/11/17 at 8:58 a.m. when asked if she knew the facility's old van did not have seat belts, she said, No. During an interview on 5/11/17 at 9:13 a.m. with Activity Director when asked if she transported residents on the van, she answered, Yes, I used to do resident transportation. When asked what she knew of on the old facility van that was not operational, she answered, I knew there was no seat belt for strapping down wheelchairs. When the van driver, CNA #6, was hired, I told her to at least use a gait belt around a wheel chair with resident and strap it through the wheelchair to prevent a resident from falling out of the wheelchair. During an interview on 5/11/17 at 2:19 p.m. with the Administrator, when asked about the facility's policy for transportation, she said after reviewing the old policy, she knew it was not acceptable and she had drafted a new policy. She said she had instructed the Maintenance Supervisor to install a new seat belt in the old van. Record review of the 5/9/17 facility provided list of residents who utilized facility van/bus transportation documented there were 40 residents listed. An IJ was identified on 05/24/17 and the Administrator was notified at 10:32 a.m. A plan of removal (POR) for the IJ was submitted on 05/24/17 at 5:06 p.m. and was accepted on 05/25/17 at 9:00 a.m. The POR included in part: Plan of Removal (IJ Reason) (Facility) May 24, 2017 ~ In-serviced CNA and drivers on proper loading, securing, and unloading a resident for transport. - Completed 05/24/17 ~ Facility has in-serviced all drivers regarding transporting residents and not to transport a resident if they are at risk or refuse to wear seatbelt. - Completed 05/05/17 ~ Maintenance supervisor repaired the van with a seatbelt bolted to the vehicle for wheelchair transports. Completed 05/15/17. (<sic>should reflect 05/05/17) ~ The van driver who was driving the van at the time of the incident was suspended immediately, then terminated. Suspended on 05/04/17. Termination on 05/11/17. ~ The maintenance supervisor was given a final disciplinary action for failure to complete safety checks and ensure vehicles were safe and mechanically sound for transport. Disciplinary action on 05/04/17. ~ At a minimum of yearly, facility maintenance director will conduct yearly competencies on all transportation drivers. Current 05/24/17 and on-going. ~ No employee, who have not been checked off on the skills competency, will not be allowed to perform the duties of loading, securing, and unloading residents for transport. Current 05/04/17 and on-going. ~ Weekly safety checks to be performed by maintenance supervisor weekly. Current and on-going. ~Pre-trip checklist to be implemented today (05/24/17) and on-going. ~ In-service new staff on new Vehicle Safety Program that was implemented 05/24/17 and will be on-going for all new hires that work transportation. ~ The Maintenance director failed to perform routine safety checks on facility van. ~ Facility van driver failed to ask for assistance when the resident refused to transfer to the seat that had a seatbelt and failed to notify Administrator or DON. Signed by Administrator 05/24/17 Additional information provided after IJ was called included the following: 1.) Preventative Maintenance checklist for Auto/Pickup/Van Inspection dated 05/08/17 by Maintenance Supervisor; No identified issues noted. 2.) Record review of 05/08/17 Random Inspection of Wheelchair Securement for two facility van drivers. No identified issues noted. 3.) Record review of 05/24/17 Random Inspection of Wheelchair Securement for one facility van drivers; No identified issues noted. 4.) In-service training report on 05/09/17 at 8:54 a.m. for Van Safety; No identified issues noted. 5.) Record review of the updated May 2017 Vehicle Safety Program: No identified issues noted. 6.) Record review of in-service training was completed on 05/24/17 at 3:45 p.m.by the Maintenance Supervisor for eight additional staff concerning Wheelchair Securement; No identified issues noted. On 05/24/17 at 12:22 p.m. - 4:00 p.m., 3 van drivers, one escort for transportation, and 2 CNA's were interviewed about transportation procedures of securing a wheelchair resident and all answered with correct responses, no issues noted. On 05/24/17 at 3:00 p.m. DON was interviewed regarding policy and said put all residents in seat belts and w/c (wheelchairs) have to have tie downs from floor to w/c frame plus a seatbelt. An escort will go with the driver. The person who loads resident should double check security of resident's seatbelt and floor tie downs prior to leaving with the resident. Regarding what would you expect to happen in this situation - the DON said it would be possible for an accident to occur if resident did not wear a seatbelt and have w/c secured to floor with tie downs. Regarding staff training of transportation of w/c residents - the DON said transportation drivers of van/bus have been trained, but not CNA's. Regarding the IJ situation and how it occurred, - the DON said the resident was not secured in a w/c seatbelt attached to the floor and safety tie down straps were not secure. The CNA transport driver did not report to the Administration that resident refused to be safely secured in the bench seat belt. The facility transportation policy was not to transport the resident. Regarding resources available to the facility, - the DON said the Maintenance Supervisor was able to in-service staff, and transportation drivers and CNAs who load residents in the van. The Medical Director will discuss at next QA (Quality Assurance) meeting. On 05/24/17 at 2:15 p.m. Administrator was interviewed regarding policy and said all w/c residents must be in seatbelts and use 4 point restraint safety straps attached to floor securing w/c. Regarding evaluating policies and procedures ensuring effectiveness of facility processes, the Administrator said all transportation drivers must have a valid driver's license. They are in-serviced at hire and competency skills check off list completed. In-service are conducted by Maintenance Supervisor in charge of transportation. Regarding staff training of transportation of w/c residents, the Administrator said transportation drivers have all been in-services and escort has also been trained. Regarding what the Administrator would expect staff to do if a resident refused a seatbelt, she said the transportation driver should alert the Administration the resident refused to transport and not transport resident. Regarding how the IJ came about, the Administrator said the driver did not report to Administration that resident refused to transfer to a bench seat with a seatbelt. Regarding the Administrator's awareness of the situation, she said she was not made aware of the situation, as she was out of the building coming back from the admitting facility. Regarding an investigation and implementation of corrective measures, the Administrator said she put into place a new policy and in-serviced the transportation drivers on transporting w/c residents with a seatbelt and 4 point floor restraints for safety. She had a seatbelt installed in the old van and purchased new safety strap tie downs. Regarding what resources were available to her and the facility. She said the policies and procedures had been updated, the Medical Director was made aware and discussion will take place at next QA meeting and the sister facilities made aware of need for transportation assistance. While the IJ was removed on 05/25/17 at 9:00 a.m. the facility remained out of compliance at a scope of a pattern and a severity of no actual harm with potential for more than minimal harm due to facility needing more time to monitor the plan of removal for effectiveness. Record review of the 5/9/17 facility provided list of residents who utilized facility van/bus transportation documented there were 40 residents listed.

Based on interview and record review, the facility failed to ensure the residents received adequate supervision and assistance devices to prevent accidents during transportation from the facility; closed record Resident #18. The facility failed to ensure closed record Resident #18 was secured in a seat belt during transport in the facility van and sustained a laceration to the right temple when he fell out of his wheel chair onto the floor of the van. An Immediate Jeopardy (IJ) was identified on 05/24/17. While the IJ was removed on (5/25/17) the facility remained out of compliance at a scope of a pattern and a severity of no actual harm with potential for more than minimal harm due to facility needing more time to monitor the plan of removal for effectiveness. This failure affected 1 of 2 residents (closed record Resident #18) being transported in the facility van and had the potential to affect the other 40 residents residing in the facility who utilized the facility van/bus for transportation by placing them at increased risk for injuries such as fractures, severe lacerations, or death. Findings included: Resident #18, a closed record: There were no observations of resident #18, as he had discharged to a sister facility about three hours away. Record review of closed record Resident #18's medical record revealed he was a [AGE] year-old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of the receiving facility's Accident/Accident Report for Resident #18 by facility RN documented on 5/4/17 in the description, Called to facility by LVN to assess Resident #18's Report received about resident arriving by facility van with injury from resident falling out of wheelchair. Upon my arrival, resident sitting in wheelchair in dining room. Had a laceration to right temple, 3 centimeters wide, 5 centimeters deep and 5 long with fresh bleeding. Right eye lid with bruising, alert, answered questions. Wound cleansed with wound cleaner, dressing applied, which resident immediately took off. Reapplied bandage, resident removed again. Resident sent to (hospital emergency room via ambulance. Record review of the (hospital emergency room ) records dated 5/4/17 documented the following: Motor Vehicle crash - minor. Patient (Resident #18) Chief complaint from Nursing Triage Note: Chief Complaint: Face Laceration. History of Present Illness: The patient presents following motor vehicle collision. The onset was just prior to arrival. The Collision was EMS stated the patients were in a van being transferred from one nursing home to another nursing home. When the van and suddenly stop >sic<. The patient did not have his restraints on. He came out of the wheelchair striking the right side of his forehead and face in front of him causing a laceration. The patient was the passenger. There were safety mechanisms including unknown. Location: right forehead. Type of injury: laceration. The degree of pain is minimal. The degree of bleeding is minimal. Risk factors consists of a history of large CVA involving the left side of the brain. Therapy today: emergency medical services. Associated symptoms: none. During a telephone interview with CNA #6 on 5/9/17 at 4:17 p.m. when asked about closed record, Resident #18's van transportation trip to another facility, she said she was the driver and was transporting Resident #18 and discharged Resident #19 to a sister facility about three hours away on 5/4/17. She said the facility's newer bus was in the shop and they had to take the old facility van. She said Monitor #1 was the escort for the trip. When asked how Resident #18 was sitting in the van, she said the resident was in his wheelchair, which was located directly behind the driver's seat with no seat belt over the resident's wheel chair. She said there was no seat belt attached from the van wall to the floor, like there was in the newer facility bus. She said she tried to get Resident #18 to transfer out of his wheelchair into a regular bench seat with a seatbelt, but he refused to sit next to Resident #19, the other passenger, a resident who was also being transported to the other facility. When asked how she secured the resident for safety, she said she and Monitor #1 used blue tie down straps looped through the frame of the wheelchair and secured the straps to the round hooks in the floor. When asked what she thought she should have done since Resident #18 refused to be transported safely, she said she should have gone and reported it to the facility's administration and let them decide what to do about the issue. When asked what happened at the time of Resident #18's accident, she said they were already in the receiving facility town, just a block away from the receiving facility when she said she had to stop at a red light. She said Monitor #1 told her Resident #18 had fallen out of his wheel chair and his head was bleeding. She had to turn left to get to the facility which was less than a block away. She said she could not pull over to the side of the road safely and Monitor #1 pointed that the receiving facility was within site, so she decided not stop and drove to the back of the facility, which was fenced and gated. She said the Monitor #1 said he had been to the facility previously and knew the code to the gate, but when he tried, it did not work. She said they waited 20 minutes before anyone answered the buzzer to the gate. When asked what she did about Resident #18's head, she said she had a package of wet wipes and used the wipes and held pressure to his head. She said a nurse from the receiving facility came out and said they were not expecting them that day and the nurse would have to go get, the Administrator #2. Administrator #2 came out to the van and said to unload the patients from the van and he would call the physician. She said she went in and counted the residents' narcotics before she left the facility. She said Administrator #2 called back to former facility and spoke with Administrator and she told Administrator #2 to send both residents to the (hospital emergency room , not located in the facility's town) for emergency attention. EMS personnel took both residents to the hospital ER. During an interview and observation of the facility's old van on 5/11/17 at 9:00 a.m. with Maintenance Supervisor, Surveyor observed the van had a seat belt attached to the van wall which ran to the floor. When asked about the van's safety seat belts, he said he had recently after the accident of 5/4/17, installed a seat belt mechanism with it attached to the van wall and floor and it was not in the van at the time of Resident #18's accident. When asked why the van did not have a seat belt for the wheelchair, he said he did not know it was required and that after the accident that was the first time he was aware the van needed one. During an interview on 5/11/17 at 9:05 a.m. Monitor #1 verified he was the escort for closed record Resident #18's transfer on 5/4/17. When asked about the safety equipment seat belts in the old van prior to the transport of Resident #18, he said the facility's old van did not have a seat belt for securing wheelchairs prior to the transport of Resident #18. When asked how he secured the resident, he said Resident # 18 refused to transfer into a bench seat with a seat belt, so he and CNA #6 took blue safety straps and tied them through the frame of the wheelchair and secured them to the floor through hooks. When asked about Resident # 18's fall, he said when the driver came to a slow gradual stop at a red light in the receiving destination town, he turned around and saw that the resident had fallen out of his wheelchair and hit his head on the door facing of the van and was bleeding from the head. He said they were very near the receiving facility and he told the driver to just proceed to the facility. When asked what happened at arrival to the facility, he said they had to wait more than 20 minutes for anyone to answer the gate and then there was some question about whether the facility would accept the residents because the facility was not expecting the residents that day. During an interview with the DON on 5/11/17 at 8:58 a.m. when asked if she knew the facility's old van did not have seat belts, she said, No. During an interview on 5/11/17 at 9:13 a.m. with Activity Director when asked if she transported residents on the van, she answered, Yes, I used to do resident transportation. When asked what she knew of on the old facility van that was not operational, she answered, I knew there was no seat belt for strapping down wheelchairs. When the van driver, CNA #6, was hired, I told her to at least use a gait belt around a wheel chair with resident and strap it through the wheelchair to prevent a resident from falling out of the wheelchair. During an interview on 5/11/17 at 2:19 p.m. with the Administrator, when asked about the facility's policy for transportation, she said after reviewing the old policy, she knew it was not acceptable and she had drafted a new policy. She said she had instructed the Maintenance Supervisor to install a new seat belt in the old van. Record Review of the facility's Abuse Prohibition Policy and Procedure, with a revision date of 12/20/13, documented the following: Policy: It is the policy of this home to prohibit abuse and neglect in any form, and to report in accordance with the law any incident in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person. Any allegation of abuse MUST be reported to the Administrator or Regional Director immediately. Definitions .Neglect: The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness Record review of the facility's policy, which was current at the time of Resident #18's accident, reflected a policy on Orientation - Transportation dated 3/2011 and revised 3/2012 documented the following: Policy: It is the policy of this home to ensure Orientation is provided to transportation personnel. Procedure: 1. Prior to providing transportation to any resident in community van/bus they will be completely trained on transportation requirements. 2. If personnel fail any area on the checklist they will not be allowed to perform transportation until 100% competency is obtained. 3. All drivers will be in serviced in the following areas: General areas covered: a. General Practice b. Driver's Duties c. Driving d. Wheelchair lift e. Wheelchair and Occupant Securement. An IJ was identified on 05/24/17 and the Administrator was notified at 10:32 a.m. A plan of removal (POR) for the IJ was submitted on 05/24/17 at 5:06 p.m. and was accepted on 05/25/17 at 9:00 a.m. The POR included in part: Plan of Removal (IJ Reason) (Facility) May 24, 2017 ~ In-serviced CNA and drivers on proper loading, securing, and unloading a resident for transport. - Completed 05/24/17 ~ Facility has in-serviced all drivers regarding transporting residents and not to transport a resident if they are at risk or refuse to wear seatbelt. - Completed 05/05/17 ~ Maintenance supervisor repaired the van with a seatbelt bolted to the vehicle for wheelchair transports. Completed 05/15/17 (<sic>should reflect 05/05/17) ~ The van driver who was driving the van at the time of the incident was suspended immediately, then terminated. Suspended on 05/04/17. Termination on 05/11/17. ~ The maintenance supervisor was given a final disciplinary action for failure to complete safety checks and ensure vehicles were safe and mechanically sound for transport. Disciplinary action on 05/04/17. ~ At a minimum of yearly, facility maintenance director will conduct yearly competencies on all transportation drivers. Current 05/24/17 and on-going. ~ No employee, who have not been checked off on the skills competency, will not be allowed to perform the duties of loading, securing, and unloading residents for transport. Current 05/04/17 and on-going. ~ Weekly safety checks to be performed by maintenance supervisor weekly. Current and on-going. ~Pre-trip checklist to be implemented today (05/24/17) and on-going. ~ In-service new staff on new Vehicle Safety Program that was implemented 05/24/17 and will be on-going for all new hires that work transportation. ~ The Maintenance director failed to perform routine safety checks on facility van. ~ Facility van driver failed to ask for assistance when the resident refused to transfer to the seat that had a seatbelt and failed to notify Administrator or DON. Signed by Administrator 05/24/17 Additional information provided after IJ was called included the following: 1.) Preventative Maintenance checklist for Auto/Pickup/Van Inspection dated 05/08/17 by Maintenance Supervisor; No identified issues noted. 2.) Record review of 05/08/17 Random Inspection of Wheelchair Securement for two facility van drivers. No identified issues noted. 3.) Record review of 05/24/17 Random Inspection of Wheelchair Securement for one facility van drivers; No identified issues noted. 4.) In-service training report on 05/09/17 at 8:54 a.m. for Van Safety; No identified issues noted. 5.) Record review of the updated May 2017 Vehicle Safety Program: No identified issues noted. 6.) Record review of in-service training was completed on 05/24/17 at 3:45 p.m. the Maintenance Supervisor for eight additional staff concerning Wheelchair Securement; No identified issues noted. On 05/24/17 at 12:22 p.m. - 4:00 p.m., 3 van drivers, one escort for transportation, and 2 CNA's were interviewed about transportation procedures of securing a wheelchair resident and all answered with correct responses, no issues noted. On 05/24/17 at 3:00 p.m. DON was interviewed regarding policy and said put all residents in seat belts and w/c (wheelchairs) have to have tie downs from floor to w/c frame plus a seatbelt. An escort will go with the driver. The person who loads resident should double check security of resident's seatbelt and floor tie downs prior to leaving with the resident. Regarding what would you expect to happen in this situation - the DON said it would be possible for an accident to occur if resident did not wear a seatbelt and have w/c secured to floor with tie downs. Regarding staff training of transportation of w/c residents - the DON said transportation drivers of van/bus have been trained, but not CNA's. Regarding the IJ situation and how it occurred, - the DON said the resident was not secured in a w/c seatbelt attached to the floor and safety tie down straps were not secure. The CNA transport driver did not report to the Administration that resident refused to be safely secured in the bench seat belt. The facility transportation policy was not to transport the resident. Regarding resources available to the facility, - the DON said the Maintenance Supervisor was able to in-service staff, and transportation drivers and CNAs who load residents in the van. The Medical Director will discuss at next QA (Quality Assurance) meeting. On 05/24/17 at 2:15 p.m. Administrator was interviewed regarding policy and said all w/c residents must be in seatbelts and use 4 point restraint safety straps attached to floor securing w/c. Regarding evaluating policies and procedures ensuring effectiveness of facility processes, the Administrator said all transportation drivers must have a valid driver's license. They are in-serviced at hire and competency skills check off list completed. In-services are conducted by Maintenance Supervisor in charge of transportation. Regarding staff training of transportation of w/c residents, the Administrator said transportation drivers have all been in-services and escort has also been trained. Regarding what the Administrator would expect staff to do if a resident refused a seatbelt, she said the transportation driver should alert the Administration the resident refused to transport and not transport resident. Regarding how the IJ came about, the Administrator said the driver did not report to Administration that resident refused to transfer to a bench seat with a seatbelt. Regarding the Administrator's awareness of the situation, she said she was not made aware of the situation, as she was out of the building coming back from the admitting facility. Regarding an investigation and implementation of corrective measures, the Administrator said she put into place a new policy and in-serviced the transportation drivers on transporting w/c residents with a seatbelt and 4 point floor restraints for safety. She had a seatbelt installed in the old van and purchased new safety strap tie downs. Regarding what resources were available to her and the facility. She said the policies and procedures had been updated, the Medical Director was made aware and discussion will take place at next QA meeting and the sister facilities made aware of need for transportation assistance. While the IJ was removed on 05/25/17 at 9:00 a.m. the facility remained out of compliance at a scope of a pattern and a severity of no actual harm with potential for more than minimal harm due to facility needing more time to monitor the plan of removal for effectiveness. Record review of the 5/9/17 facility provided list of residents who utilized facility van/bus transportation documented there were 40 residents listed.

Based on observations, interviews and record reviews, the facility failed implement its policies and procedures that prohibit neglect of residents. The facility staff failed to provide supervision to prevent 1 of 5 sampled residents (Resident #2) with exit seeking behaviors, from being unsupervised, thus exiting the facility and fleeing to another city. Resident #2, who had a history of [REDACTED]. Monitor Tech #3 failed to supervise for approximately 12 minutes, the surveillance monitors and did not observe resident #2 carrying items from her window to the fence and going over the fence. Resident #2 was missing from 12:59 PM on 5/3/12 to 1:50 PM on 5/4/12 (24 hours and 51 minutes). Resident #2 had traveled from the facility to her residence in Lubbock which was approximately 45 miles. This led to the identification of an Immediate Jeopardy (IJ) on 5/4/12 at 5:50 PM. The IJ was removed on 5/5/12 at 5:30 PM after all staff was in-serviced and a second Monitor Tech was assigned to monitoring the outside of the facility. The facility remained out of compliance at a pattern with the potential for more than minimal harm due to the facility's need to monitor and evaluate the effectiveness of the corrective actions for exit seeking residents. The facility identified 11 residents (including resident #2) at high risk for elopement, who exhibited a behavior of exit seeking. Failure to provide supervision for the remaining 10 residents could result in allowing the residents to leave the facility resulting in serious injury. The evidence is as follows: Resident #2's clinical record documented the resident was admitted to the secured facility on 1/18/12 due to a court order for placement. Resident #2's admission face sheet dated 1/18/12 documented [DIAGNOSES REDACTED]. The resident ' s records contained two emergency detentions dated 4/2/2012 and 4/14/12 for transfer to a psychiatric facility for evaluation due to attempts to elope. The clinical records (nurses' notes and physician's orders [REDACTED]. The clinical records and care plan dated 4/19/12 revealed resident #2 was on every 15 minute checks and a high risk for elopement. A court order dated 1/17/12 documented a temporary appointment for a guardian for resident #2 and placement in a secured facility. The court order dated 2/13/12 placed resident #2 under the care of the guardian. The order dated 1/17/12 deemed resident #2 was to be placed in a safe area, for her safety and welfare. Resident #2 had been deemed incompetent and was a danger to herself and others. Resident #2 had a history of [REDACTED]. The order documented resident #2 was incapable of and does not understand the consequences of her drinking and driving. The order documented the resident's mother had a car for her to use; therefore, she was an immediate threat to herself and the driving public. The order documented resident #2's mother had left town and felt it to be in her best interest for the resident be placed in a residential facility where she can be monitored 24 hours, given medication, and prohibited from drinking. The order dated 1/17/12 found it necessary to commit resident #2 to a residential facility, namely Tumbleweed Care Center (APEX Secure Care of Brownfield) and the Lubbock County Sheriff's Office transport her to the facility for her safety and the safety of those around her. During observations on 5/4/12 at 1:40 PM, the facility had a locked gate with a buzzer on the outside to alert staff of a visitor and a locked front door with an alarm. The facility was enclosed by an 8'4 " high iron fence. During an interview on 5/4/12 at 1:45 PM with the administrator said the facility was in lockdown (none of the residents are allowed outside unless supervised by staff) due to resident #2's elopement on 5/3/12 at 12:57 PM. The administrator said he had reported the incident of elopement for resident #2 to the Texas Department of Aging and Disability Services and was investigating. He said resident #2 had broken her window and stacked a shower chair, drawers and a suitcase in order to climb over the fence and elope. The administrator said facility staff was notified of resident #2's elopement by resident #1 who witnessed resident #2 climb over the fence. The administrator said Monitor Tech #3 was sitting at the nurses' station in front of the cameras/monitors. He stated the nurse on duty called a "code orange " for a missing resident. The administrator said he had viewed the video during resident #2's elopement and Monitor Tech #3 had to be "sleeping with his eyes open". The administrator said it took resident #2, two minutes and 47 seconds to get over the fence. The administrator said he terminated Monitor Tech #3 for not staying focused and not watching the monitors at the time of resident #2's elopement. The administrator said he had not in-serviced staff and had only terminated Monitor Tech #3. During an interview on 5/4/12 at 5:10 PM, the administrator said the Monitor Tech job was to watch the cameras in order to supervise residents at risk for elopement. He stated the Monitor Tech should keep their eyes on the cameras at all times unless relieved to make hourly rounds or breaks. During an interview on 5/4/12 at 2 PM, the Director of Nurses (DON) said the local police were notified of resident #2's elopement on 5/3/12 at 12:57 PM. The DON said she had instructed Monitor Tech #3 he better keep his eyes on the residents before she left for lunch on 5/3/12. The DON said Monitor Tech #3 was looking down at the time and may have been texting or sleeping when she walked by the nurses' station to go to lunch. The DON said resident #2 had a credit card and a cell phone. The DON said the guardian informed her on 5/3/12 at 1:47 PM, a friend of resident #2 had called him to report resident #2 had escaped, got a ride with a random couple and was going to her residence in Lubbock. The DON said resident #2 was sighted at her residence in Lubbock by the guardian on 5/3/12 around 6 PM and managed to get away from the guardian. The DON said there were reported sightings (Dollar store and bank) of resident #2 all morning long on 5/4/12. The DON said resident # 2 was located in the back of a cab at her residence in Lubbock by law enforcement on 5/4/10 around 1:50 PM. She said resident #2 had been drinking alcohol. The DON said the guardian informed the facility they would have to keep resident #2 because he could not find anyone to accept her. The DON stated resident #2 had two emergency detentions (4/2/12 and 4/14/12) for transfers to a psychiatric facility for April 2012 due to attempts to elope and had returned to the facility. During an interview on 5/7/12 at 2:40 PM, LVN #4 said he was working on the day resident #2 left the facility. LVN #4 said resident #2 was on every 15 minute checks and listed as a high risk for elopements. LVN #4 said he had been at the nurses ' station and observed resident #2 numerous times. He said Monitor Tech #3 was sitting in front of the cameras when he left the desk to fax reports to the physician on 5/3/12 around 12:40 PM. LVN #4 said he had seen resident #2 come out of her room and look down the hall at this time. LVN #4 said resident #2 had placed a sign on her door that she was resting. LVN #4 said he was aware of resident #2's elopement when resident #1 alerted staff resident #2 had climbed the fence. During an interview on 5/7/12 at 2:55 PM, RN #1 said she was working in the dining room on 5/3/12 around 1 PM. RN #1 said she was assisting a resident from the dining room when resident #1 informed her he had seen resident #2 go over the fence. She said a "code orange "was announced and a head count of the residents was conducted by staff. RN #1 said she went down "D" hall and outside. RN #1 said resident #2 had stacked things next to the fence. RN #1 said staff is assigned certain things to do when a resident was missing and a "code orange" was announced. RN #1 said the police arrived with a dog and went to resident #2's room for an article of clothing. RN #1 said resident #2 did not act any differently. RN #1 said it was a daily occurrence for resident #2 to allege she was being held against her will. RN #1 said resident #2 would call 911 (police), lawyers, judges and anyone she could think of in attempts to get released from the facility. During an interview on 5/4/12 at 5 PM, the assistant administrator said he reviewed the surveillance videos and Monitor Tech #3 was not watching the cameras. He said monitor tech #3 was looking towards the front door for 10-15 minutes, talking to residents and staff and was not watching the cameras. The assistant administrator said the Monitor Tech had been instructed to keep their eyes on the cameras and make sure the doors are locked. The assistant administrator said Monitor Tech are to make hourly rounds outside and use maintenance staff and not nurse aides to relieve them during rounds and breaks. During an interview on 5/4/12 at 3:10 PM, Monitor Tech #3 said his job was to watch the cameras and lock the doors after the smokers returned inside the facility after lunch. Monitor Tech #3 said he was told by the administrator to watch resident #2 on 5/3/12 around 11 AM. He said resident #2 would try to leave the facility all the time. Monitor Tech #2 said resident #2 had her own cell phone and would call police, lawyers and guardian in attempts to get out of the facility. He said he was busy watching the cameras for the smokers and another resident who was in the front of the facility during the elopement. Resident #2 was observed sitting outside the fence of the facility on 5/4/12 at 4:20 PM in the custody of local and county law enforcement. The resident did not appear to have any injuries. On 5/4/12 at 4:30 PM, resident #2 said she had climbed the fence and paid a married couple $25 to $30 to take her home (residence in Lubbock). Resident #2 refused to tell the surveyor the names of the couple. Resident #2 said she went home and then to a motel. Resident #2 said that while she was out of the facility, she had gone shopping and ate at her favorite restaurant. Resident #2 was insisting that she did not belong in the facility and was being held against her will. When resident #2 understood the local police were going to be transferring her to the jail, resident #2 wanted to stay at the facility. Resident #2 was not readmitted to the facility. The local police left the facility premise with resident #2 in their custody and was going to be transported to a psychiatric facility when the judge completed the emergency detention process. Google maps search on 5/16/12 at www.http//classic mapquest.com documented the mileage from the facility's address to resident #2's residence in Lubbock was approximately 45.76 miles. Surveillance Video Review Observation - Review of the facility ' s surveillance video for camera #8 documented the actions of Monitor Tech #3 prior to and during resident #2 ' s elopement on 5/3/12 from 12:42 PM to-12:59 PM. The facility had 19 operational cameras located inside and outside which were video fed simultaneously to the two large monitors located at the nurses ' station The facility's surveillance video recordings reviewed for 4 of the cameras dated on 5/3/12 beginning at 12:42 PM documented the administrator left the facility. At 12:44:10 PM resident #2 was at the nurses' station talking to Monitor Tech #3. He was not watching the cameras/monitors (There are two large monitors at the nurses' station which provide camera surveillance which are recorded). At 12:44:20 resident #2 left the nurses' station. At 12:45:02 PM Monitor Tech #3 was observed talking with other residents and not watching the cameras/monitors. At 12:46:24 PM Monitor Tech #3 was not watching the cameras/monitors and resident #2 pushed the screen out of her window. Resident #2 went out the window and carried a drawer and suitcase to the fence. Monitor Tech #3 was looking away from the cameras/monitors. At 12:47:00 resident #2 was observed to stack items next to the fence and attempted to climb over the fence. The monitor tech was not watching the cameras/monitors. At 12:47:31 resident #2 went back into her room via the window and Monitor Tech #3 was not watching the cameras/monitors. At 12:48:10 PM resident #2 went out her window with a white chair (shower chair) which she carried to the fence. Monitor Tech #3 was not watching the cameras/monitors. At 12:48:40 resident #2 was stacking the chair next to the fence. At 12:49:09 resident #2 went back through the window into her room. At 12:49:45 resident #2 went out her window and carried another item to the fence. Resident #1 walked past resident #2 by the fence. At 12:50:20 resident #2 attempted to climb over the fence, but the stacked items fell . Resident #2 restacked the items and returned to her window at 12:50:41 and Monitor Tech #3 was not looking at the cameras/monitors. At 12:52:23 resident #2 walked by the nurses' station. At 12:53:26 resident #2 walked by nurses' station to the front yard area. Resident #2 was observed to stay in the front yard area until 12:54:29 and returned inside the facility. At 12:54:51 resident #2 walked past the nurses' station. At 12:55:23 resident #2 was at the nurses' station. At 12:56:59 resident #2 climbed out her window and restacked items by the fence. At this time the Monitor Tech #3 was looking away from the cameras/monitors. At 12:57:53 resident #2 was unable to climb over the fence and restacked the items. Monitor Tech #3 was not looking at the cameras/monitors. At 12:58:57 resident #2 was over the fence and ran north at 12:59:21. Resident #1 was standing inside the fence watching resident #2. At 13:00:45 Resident #1 was standing at the nurses' station and no one spoke to him. He speaks to another resident. At 13:10:02 resident #1 was telling RN #1 something and all staff took off running to exits. At 13:10:54 resident #1 took staff to the fence and showed staff items stacked next to the fence. The surveillance video recorded resident #2 made 5 trips out her window to the fence. Facility ' s Policy The facility's policies documented the following: The Abuse Prevention Program policy dated revised December 2006, documented: "Neglect is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish or mental illness." It documented signs and symptoms of neglect included "inadequate provision of care," and leaving someone unattended who needs supervision" Review of facility's policies titled "Wandering Residents," revised December 2007 documented: "The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk of elopement. The staff will identify residents who were at risk for harm because of unsafe wandering (including elopement). The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering. The resident's care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety will be included in the resident's care plan. Nursing staff will document circumstances related to unsafe actions, including wandering, by a resident. Staff will institute a detailed monitoring plan for residents who are assessed to have a high risk of elopement or other unsafe behavior. Staff will notify the Administrator and Director of Nurses immediately and will institute appropriate measures, including searching for any resident who is discovered to be missing from the unit on facility. On 5/4/12 at 5:50 PM the Administrator and DON were notified An Immediate Jeopardy (IJ) was identified .The IJ was called due to no other action had been taken by the facility to prevent elopements except to terminate Monitor Tech #3. IMMEDIATE PLAN OF REMOVAL On 5/5/12 at 4:36 PM the facility's plan of action was accepted. Review of the plan documented the following: 1. Two monitor technicians will be on duty at all times. This will begin effective at 1330 hours (1:30 PM) on May 5, 24 hours a day/365 days a year. One monitor tech will make rounds outside while the second monitor tech will monitor the camera systems. After two hours they will switch responsibilities. To monitor the effectiveness of this program, the Assistant Administrator, Director of Nurses, and the Administrator have the capabilities of putting the entire camera system on their cell phones to monitor effectiveness. Periodic monitoring will be done by all three of the senior staff. The board of directors already has these cameras on their cell phones. The facility will continue to research more effective methods of resident protection improvement. In the event of inclement weather, the outside rotation will be provided appropriate weather gear (rain coat, parka, etc.). Extreme heat does present a problem. As such, water stations (at least 4) will be present at various locations throughout the exterior of the facility. Based on the existing magnetic lock system at Apex Secure Care, it will be necessary for the monitor tech to come through the facility to go to the next monitoring area, thus providing some relief from the heat. 2. The monitor techs will operate 2-way radios to check in and report any unusual sightings or activities that can be monitored at all times on the camera system. Implementation is immediate, May 5. The 2-way radios are already in the facility. 3. No monitor tech will be disturbed by carrying on conversations with staff or residents. Only the senior charge nurse, Assistant Administrator, Director of Nurses, and the Administrator will coordinate with the monitor tech. Implementation is immediate, May 5. 4. On shift change, both the on-coming and out-going monitor techs will do either walking rounds or internal reports for specific resident issues such as who is exit-seeking. Implementation is May 7 at 0700 hours. The senior charge nurse will be responsible for ensuring the monitors are watched during the transition time. Also, the exterior monitor checks with walking rounds will prevent any other problems. This plan will be monitored by the QAAC (Quality Assurance and Assessment Committee) on a monthly basis for effectiveness or sooner if necessary. 5. Each morning, Monday through Friday, at morning stand-up, the Assistant Administrator will bring security issues to be addressed. An occasional Saturday, when all the department heads are in the home, will also have a brief standup. Implementation is May 5 at 10:30 AM. 6. Every staff member will be in-serviced regarding this plan of correction and what it means to each of them. Implementation is May 5, 1500 hours (3 PM). The QAAC will monitor each shift to determine effectiveness of all the information on a monthly basis or sooner if necessary. 7. Code Orange - Elopement policy and procedures will be reviewed by all staff members, regardless of position, on a monthly basis. Implementation is immediately, May 5 at 1030 hours (10:30 AM). The QAAC will monitor monthly the effectiveness of this plan, or sooner if necessary. 8. At the current time, Apex Secure Care Brownfield maintains an at risk for elopement list of all residents at risk for elopement. In addition, any new residents that come into the facility, or residents that have been in the hospital for more than five days, are placed on this listing for a period of 14 days, starting with the day of admission or readmission. At the end of 14 days, if the resident is still considered a risk factor, that resident will remain on the list for a period of 30 days, at which time he or she will be re-evaluated by the QAAC for removal. To ensure that this information is disseminated to every staff member, at the start of each business day, the Elopement listing will be updated by the Director of Nurses, printed out, given to each department manager to brief their employees, as well as the senior charge nurse assigned to the floor each day, Monday through Friday. The department managers and senior charge nurses are responsible to ensure that each staff member, regardless of new or current, are aware who is on the list and who has been taken off for whatever reason. Further, the Human Resources manager will update the Elopement book with a current Face Sheet and current picture of every new resident to the facility. This is the current policy and procedure in place at Apex Secure Care, updated to include all of the above information as of May 5. 9. Effective immediately, 1030 hours (10:30 AM) on May 5, all residents are placed on every-30 minute monitoring program replacing the every hour process. 10. The primary responsibility of both monitor tech (staff) positions is to ensure safety and security of each and every resident placed into our trust and care. Safety-wise, the monitor techs are to view and report any kind of issue that may be harm to any resident able to go outside between the temperatures of 40 degrees F., and 90 degrees F., which is the facility policy for weather temperatures. Also, each and every monitor tech is responsible for the safety, security and well-being of all residents in the facility, especially with possible intruders. The monitor tech that makes rounds outside will ensure no resident can escape out of the windows or over the fencing. If something transpires, the monitor tech that spots an incident will radio that incident to the other monitor tech to investigate and immediately report back to the Senior Charge Nurse, who in turn will notify the Asst. Administrator, DON, and Administrator for further action to be taken. Observations, record reviews and interviews conducted on 5/5/12 revealed the following steps were taken by the facility to remove the Immediate Jeopardy. Observations on 5/5/12 at 12:15 PM revealed the facility was still in lockdown and no residents were observed outside. Observations by the surveyor on 5/5/12 (12:25 PM, 1:30 PM, 1:45 PM, 1:55 PM, 2:45, and 3:14 PM, 3:25 PM) confirmed Monitor Tech #1 was monitoring the cameras (monitors) at various times. Observations on 5/5/12 at 3:15 PM confirmed Monitor Tech #1 was monitoring the camera feeds and Monitor Tech #2 was observed on camera making rounds outside the facility. The Monitor Tech #1 and #2 had walkie talkies to communicate with each other. On 5/5/12 at 4:33 PM the Administrator said a second monitoring staff was on duty at 6 AM on 5/5/12 to make rounds outside and switch off with each other every two hours. On 5/5/12 at 4:35 PM, Monitor Tech #1 said he was to keep his eyes on the cameras (monitors) at all times. He said if he observes a resident trying to elope, he was to alert the outside Monitor Tech and notify the charge nurse of the possible elopement. He said none of the residents are allowed outside without supervision of staff. Monitor Tech #1 stated he was to notify his partner if he did not recognize a car near the facility. Monitor Tech #1 said he would be relieved for breaks by his partner or maintenance staff. On 5/15/12 at 4:45 PM Monitor Tech #2 confirmed the same information as Monitor Tech #1. Monitor Tech #2 said you make rounds outside for two hours and then switch places with the other Monitor Tech. Monitor Tech #2 stated they were informed to remove anything they found next to the fence and alert administration or the other Monitor Tech via the walkie talkie. Monitor Tech #2 said, if a resident was trying to get out, you keep your eyes on the resident and alert staff. He said if a resident eloped a "code orange" was called by staff. Monitor Tech #2 said the in-service stressed the importance of resident elopement and prevention. Interviews were conducted with CNA #6 (5 PM), CNA #7 (5:10 PM), LVN #5 (4:50 PM), CNA #2 (4:40 PM) and RN #2 (4:45 PM). They confirmed the in-service meeting covered the facility's actions plan and "code orange" for elopement. Staff said the charge nurse was the only one to communicate with the Monitor Tech and other staff is not allowed to distract the Monitor Tech. The aides are to be on time and make rounds and have to visually see a resident every 30 minutes, and high risk for elopement resident are every 15 minutes. The staff was knowledgeable of what to do when a "code orange" was called regarding a missing resident and what to do when they took their breaks. Staff said a list of high risk residents for elopements was posted at the time clock and at the nurses' station daily. Record review documented all staff (all departments) was in-serviced on 5/5/12 beginning at 10 AM. Four of the staff who was unable to attend was in-serviced via telephone. This in-service was documented. The in-service revealed the facility's action plan, "code orange " for missing/elopement of residents and importance of knowing where the residents were discussed. Confidential interviews with two alert residents confirmed a resident council meeting was conducted with the residents on 5/5/12 at 11 AM. They indicated the meeting was regarding the lockdown and resident elopement. The residents indicated the Monitor Tech was presently watching the cameras/monitors. Removal of the Immediate Jeopardy On 5/5/12 at 5:30 PM, the Administration was notified the Immediate Jeopardy had been removed due to observations, staff and resident interviews confirmed the staff was knowledgeable of the facility's plan of action and "code orange" and Monitor Tech were observed watching the cameras/monitors and monitoring the premise. The facility remained out of compliance at pattern and potential for more than minimal harm due to evaluation of the action plan and monitoring of staff to ensure they were appropriately supervising residents with exit seeking behavior. Resident Census The facility had a census of 88 residents in the secured facility. A list of residents at high risk for elopement documented there were 11 residents including resident #2 who was at high risk to elope.

Based on observations, interviews and record reviews, the facility failed implement its written policies and procedures that prohibit neglect of residents. The facility failed to provide supervision to prevent 1 of 5 sampled residents (Resident #2) with exit seeking behaviors, from being unsupervised, thus exiting the facility and fleeing to another city. Resident #2, who had a history of [REDACTED]. Monitor Tech #3 failed to supervise for approximately 12 minutes, the surveillance monitors and did not observe resident #2 carrying items from her window to the fence and going over the fence. Resident #2 was missing from 12:59 PM on 5/3/12 to 1:50 PM on 5/4/12 (24 hours and 51 minutes). Resident #2 had traveled from the facility to her residence in Lubbock which was approximately 45 miles. This led to the identification of an Immediate Jeopardy (IJ) on 5/4/12 at 5:50 PM. The IJ was removed on 5/5/12 at 5:30 PM after all staff was in-serviced and a second Monitor Tech was assigned to monitoring the outside of the facility. The facility remained out of compliance at a pattern with the potential for more than minimal harm due to the facility's need to monitor and evaluate the effectiveness of the corrective actions for exit seeking residents. The facility identified 11 residents (including resident #2) at high risk for elopement, who exhibited a behavior of exit seeking. Failure to provide supervision for the remaining 10 residents could result in allowing the residents to leave the facility resulting in serious injury. One of 27 sampled personnel records documented 1 employee was not eligible to be employed at the facility because the individual was listed on the Nurse Aide Registry. This practice placed the 88 residents at risk for interaction with an individual listed on the Registry for abuse, neglect or exploitation. The evidence is as follows: Facility ' s Policy The facility's policies documented the following: The Abuse Prevention Program policy dated revised December 2006, documented: "Neglect is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish or mental illness." It documented signs and symptoms of neglect included "inadequate provision of care," and leaving someone unattended who needs supervision". Review of facility's policies titled "Wandering Residents," revised December 2007 documented: "The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk of elopement. The staff will identify residents who were at risk for harm because of unsafe wandering (including elopement). The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering. The resident's care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety will be included in the resident's care plan. Nursing staff will document circumstances related to unsafe actions, including wandering, by a resident. Staff will institute a detailed monitoring plan for residents who are assessed to have a high risk of elopement or other unsafe behavior. Staff will notify the Administrator and Director of Nurses immediately and will institute appropriate measures, including searching for any resident who is discovered to be missing from the unit on facility. Resident #2's clinical record documented the resident was admitted to the secured facility on 1/18/12 due to a court order for placement. Resident #2's admission face sheet dated 1/18/12 documented [DIAGNOSES REDACTED]. The resident ' s records contained two emergency detentions dated 4/2/2012 and 4/14/12 for transfer to a psychiatric facility for evaluation due to attempts to elope. The clinical records (nurses' notes and physician's orders [REDACTED]. The clinical records and care plan dated 4/19/12 revealed resident #2 was on every 15 minute checks and a high risk for elopement. A court order dated 1/17/12 documented a temporary appointment for a guardian for resident #2 and placement in a secured facility. The court order dated 2/13/12 placed resident #2 under the care of the guardian. The order dated 1/17/12 deemed resident #2 was to be placed in a safe area, for her safety and welfare. Resident #2 had been deemed incompetent and was a danger to herself and others. Resident #2 had a history of [REDACTED]. The order documented resident #2 was incapable of and does not understand the consequences of her drinking and driving. The order documented the resident's mother had a car for her to use; therefore, she was an immediate threat to herself and the driving public. The order documented resident #2's mother had left town and felt it to be in her best interest for the resident be placed in a residential facility where she can be monitored 24 hours, given medication, and prohibited from drinking. The order dated 1/17/12 found it necessary to commit resident #2 to a residential facility, namely Tumbleweed Care Center (APEX Secure Care of Brownfield) and the Lubbock County Sheriff's Office transport her to the facility for her safety and the safety of those around her. During observations on 5/4/12 at 1:40 PM, the facility had a locked gate with a buzzer on the outside to alert staff of a visitor and a locked front door with an alarm. The facility was enclosed by an 8'4 " high iron fence. During an interview on 5/4/12 at 1:45 PM with the administrator said the facility was in lockdown (none of the residents are allowed outside unless supervised by staff) due to resident #2's elopement on 5/3/12 at 12:57 PM. The administrator said he had reported the incident of elopement for resident #2 to the Texas Department of Aging and Disability Services and was investigating. He said resident #2 had broken her window and stacked a shower chair, drawers and a suitcase in order to climb over the fence and elope. The administrator said facility staff was notified of resident #2's elopement by resident #1 who witnessed resident #2 climb over the fence. The administrator said Monitor Tech #3 was sitting at the nurses' station in front of the cameras/monitors. He stated the nurse on duty called a "code orange " for a missing resident. The administrator said he had viewed the video during resident #2's elopement and Monitor Tech #3 had to be "sleeping with his eyes open". The administrator said it took resident #2, two minutes and 47 seconds to get over the fence. The administrator said he terminated Monitor Tech #3 for not staying focused and not watching the monitors at the time of resident #2's elopement. The administrator said he had not in-serviced staff and had only terminated Monitor Tech #3. During an interview on 5/4/12 at 5:10 PM, the administrator said the Monitor Tech job was to watch the cameras in order to supervise residents at risk for elopement. He stated the Monitor Tech should keep their eyes on the cameras at all times unless relieved to make hourly rounds or breaks. During an interview on 5/4/12 at 2 PM, the Director of Nurses (DON) said the local police were notified of resident #2's elopement on 5/3/12 at 12:57 PM. The DON said she had instructed Monitor Tech #3 he better keep his eyes on the residents before she left for lunch on 5/3/12. The DON said Monitor Tech #3 was looking down at the time and may have been texting or sleeping when she walked by the nurses' station to go to lunch. The DON said resident #2 had a credit card and a cell phone. The DON said the guardian informed her on 5/3/12 at 1:47 PM, a friend of resident #2 had called him to report resident #2 had escaped, got a ride with a random couple and was going to her residence in Lubbock. The DON said resident #2 was sighted at her residence in Lubbock by the guardian on 5/3/12 around 6 PM and managed to get away from the guardian. The DON said there were reported sightings (Dollar store and bank) of resident #2 all morning long on 5/4/12. The DON said resident # 2 was located in the back of a cab at her residence in Lubbock by law enforcement on 5/4/10 around 1:50 PM. She said resident #2 had been drinking alcohol. The DON said the guardian informed the facility they would have to keep resident #2 because he could not find anyone to accept her. The DON stated resident #2 had two emergency detentions (4/2/12 and 4/14/12) for transfers to a psychiatric facility for April 2012 due to attempts to elope and had returned to the facility. During an interview on 5/7/12 at 2:40 PM, LVN #4 said he was working on the day resident #2 left the facility. LVN #4 said resident #2 was on every 15 minute checks and listed as a high risk for elopements. LVN #4 said he had been at the nurses ' station and observed resident #2 numerous times. He said Monitor Tech #3 was sitting in front of the cameras when he left the desk to fax reports to the physician on 5/3/12 around 12:40 PM. LVN #4 said he had seen resident #2 come out of her room and look down the hall at this time. LVN #4 said resident #2 had placed a sign on her door that she was resting. LVN #4 said he was aware of resident #2's elopement when resident #1 alerted staff resident #2 had climbed the fence. During an interview on 5/7/12 at 2:55 PM, RN #1 said she was working in the dining room on 5/3/12 around 1 PM. RN #1 said she was assisting a resident from the dining room when resident #1 informed her he had seen resident #2 go over the fence. She said a "code orange "was announced and a head count of the residents was conducted by staff. RN #1 said she went down "D" hall and outside. RN #1 said resident #2 had stacked things next to the fence. RN #1 said staff is assigned certain things to do when a resident was missing and a "code orange" was announced. RN #1 said the police arrived with a dog and went to resident #2's room for an article of clothing. RN #1 said resident #2 did not act any differently. RN #1 said it was a daily occurrence for resident #2 to allege she was being held against her will. RN #1 said resident #2 would call 911 (police), lawyers, judges and anyone she could think of in attempts to get released from the facility. During an interview on 5/4/12 at 5 PM, the assistant administrator said he reviewed the surveillance videos and Monitor Tech #3 was not watching the cameras. He said monitor tech #3 was looking towards the front door for 10-15 minutes, talking to residents and staff and was not watching the cameras. The assistant administrator said the Monitor Tech had been instructed to keep their eyes on the cameras and make sure the doors are locked. The assistant administrator said Monitor Tech are to make hourly rounds outside and use maintenance staff and not nurse aides to relieve them during rounds and breaks. During an interview on 5/4/12 at 3:10 PM, Monitor Tech #3 said his job was to watch the cameras and lock the doors after the smokers returned inside the facility after lunch. Monitor Tech #3 said he was told by the administrator to watch resident #2 on 5/3/12 around 11 AM. He said resident #2 would try to leave the facility all the time. Monitor Tech #2 said resident #2 had her own cell phone and would call police, lawyers and guardian in attempts to get out of the facility. He said he was busy watching the cameras for the smokers and another resident who was in the front of the facility during the elopement. Resident #2 was observed sitting outside the fence of the facility on 5/4/12 at 4:20 PM in the custody of local and county law enforcement. The resident did not appear to have any injuries. On 5/4/12 at 4:30 PM, resident #2 said she had climbed the fence and paid a married couple $25 to $30 to take her home (residence in Lubbock). Resident #2 refused to tell the surveyor the names of the couple. Resident #2 said she went home and then to a motel. Resident #2 said that while she was out of the facility, she had gone shopping and ate at her favorite restaurant. Resident #2 was insisting that she did not belong in the facility and was being held against her will. When resident #2 understood the local police were going to be transferring her to the jail, resident #2 wanted to stay at the facility. Resident #2 was not readmitted to the facility. The local police left the facility premise with resident #2 in their custody and was going to be transported to a psychiatric facility when the judge completed the emergency detention process. Google maps search on 5/16/12 at www.http//classic mapquest.com documented the mileage from the facility's address to resident #2's residence in Lubbock was approximately 45.76 miles. Surveillance Video Review Review of the facility ' s surveillance video for camera #8 documented the actions of Monitor Tech #3 prior to and during resident #2 ' s elopement on 5/3/12 from 12:42 PM to-12:59 PM. The facility had 19 operational cameras located inside and outside which were video fed simultaneously to the two large monitors located at the nurses ' station The facility's surveillance video recordings reviewed for 4 of the cameras dated on 5/3/12 beginning at 12:42 PM documented the administrator left the facility. At 12:44:10 PM resident #2 was at the nurses' station talking to Monitor Tech #3. He was not watching the cameras/monitors (There are two large monitors at the nurses' station which provide camera surveillance which are recorded). At 12:44:20 resident #2 left the nurses' station. At 12:45:02 PM Monitor Tech #3 was observed talking with other residents and not watching the cameras/monitors. At 12:46:24 PM Monitor Tech #3 was not watching the cameras/monitors and resident #2 pushed the screen out of her window. Resident #2 went out the window and carried a drawer and suitcase to the fence. Monitor Tech #3 was looking away from the cameras/monitors. At 12:47:00 resident #2 was observed to stack items next to the fence and attempted to climb over the fence. The monitor tech was not watching the cameras/monitors. At 12:47:31 resident #2 went back into her room via the window and Monitor Tech #3 was not watching the cameras/monitors. At 12:48:10 PM resident #2 went out her window with a white chair (shower chair) which she carried to the fence. Monitor Tech #3 was not watching the cameras/monitors. At 12:48:40 resident #2 was stacking the chair next to the fence. At 12:49:09 resident #2 went back through the window into her room. At 12:49:45 resident #2 went out her window and carried another item to the fence. Resident #1 walked past resident #2 by the fence. At 12:50:20 resident #2 attempted to climb over the fence, but the stacked items fell . Resident #2 restacked the items and returned to her window at 12:50:41 and Monitor Tech #3 was not looking at the cameras/monitors. At 12:52:23 resident #2 walked by the nurses' station. At 12:53:26 resident #2 walked by nurses' station to the front yard area. Resident #2 was observed to stay in the front yard area until 12:54:29 and returned inside the facility. At 12:54:51 resident #2 walked past the nurses' station. At 12:55:23 resident #2 was at the nurses' station. At 12:56:59 resident #2 climbed out her window and restacked items by the fence. At this time the Monitor Tech #3 was looking away from the cameras/monitors. At 12:57:53 resident #2 was unable to climb over the fence and restacked the items. Monitor Tech #3 was not looking at the cameras/monitors. At 12:58:57 resident #2 was over the fence and ran north at 12:59:21. Resident #1 was standing inside the fence watching resident #2. At 13:00:45 Resident #1 was standing at the nurses' station and no one spoke to him. He speaks to another resident. At 13:10:02 resident #1 was telling RN #1 something and all staff took off running to exits. At 13:10:54 resident #1 took staff to the fence and showed staff items stacked next to the fence. The surveillance video recorded resident #2 made 5 trips out her window to the fence. On 5/4/12 at 5:50 PM the Administrator and DON were notified An Immediate Jeopardy (IJ) was identified .The IJ was called due to no other action had been taken by the facility to prevent elopements except to terminate Monitor Tech #3. IMMEDIATE PLAN OF REMOVAL On 5/5/12 at 4:36 PM the facility's plan of action was accepted. Review of the plan documented the following: 1. Two monitor technicians will be on duty at all times. This will begin effective at 1330 hours (1:30 PM) on May 5, 24 hours a day/365 days a year. One monitor tech will make rounds outside while the second monitor tech will monitor the camera systems. After two hours they will switch responsibilities. To monitor the effectiveness of this program, the Assistant Administrator, Director of Nurses, and the Administrator have the capabilities of putting the entire camera system on their cell phones to monitor effectiveness. Periodic monitoring will be done by all three of the senior staff. The board of directors already has these cameras on their cell phones. The facility will continue to research more effective methods of resident protection improvement. In the event of inclement weather, the outside rotation will be provided appropriate weather gear (rain coat, parka, etc.). Extreme heat does present a problem. As such, water stations (at least 4) will be present at various locations throughout the exterior of the facility. Based on the existing magnetic lock system at Apex Secure Care, it will be necessary for the monitor tech to come through the facility to go to the next monitoring area, thus providing some relief from the heat. 2. The monitor techs will operate 2-way radios to check in and report any unusual sightings or activities that can be monitored at all times on the camera system. Implementation is immediate, May 5. The 2-way radios are already in the facility. 3. No monitor tech will be disturbed by carrying on conversations with staff or residents. Only the senior charge nurse, Assistant Administrator, Director of Nurses, and the Administrator will coordinate with the monitor tech. Implementation is immediate, May 5. 4. On shift change, both the on-coming and out-going monitor techs will do either walking rounds or internal reports for specific resident issues such as who is exit-seeking. Implementation is May 7 at 0700 hours. The senior charge nurse will be responsible for ensuring the monitors are watched during the transition time. Also, the exterior monitor checks with walking rounds will prevent any other problems. This plan will be monitored by the QAAC (Quality Assurance and Assessment Committee) on a monthly basis for effectiveness or sooner if necessary. 5. Each morning, Monday through Friday, at morning stand-up, the Assistant Administrator will bring security issues to be addressed. An occasional Saturday, when all the department heads are in the home, will also have a brief standup. Implementation is May 5 at 10:30 AM. 6. Every staff member will be in-serviced regarding this plan of correction and what it means to each of them. Implementation is May 5, 1500 hours (3 PM). The QAAC will monitor each shift to determine effectiveness of all the information on a monthly basis or sooner if necessary. 7. Code Orange - Elopement policy and procedures will be reviewed by all staff members, regardless of position, on a monthly basis. Implementation is immediately, May 5 at 1030 hours (10:30 AM). The QAAC will monitor monthly the effectiveness of this plan, or sooner if necessary. 8. At the current time, Apex Secure Care Brownfield maintains an at risk for elopement list of all residents at risk for elopement. In addition, any new residents that come into the facility, or residents that have been in the hospital for more than five days, are placed on this listing for a period of 14 days, starting with the day of admission or readmission. At the end of 14 days, if the resident is still considered a risk factor, that resident will remain on the list for a period of 30 days, at which time he or she will be re-evaluated by the QAAC for removal. To ensure that this information is disseminated to every staff member, at the start of each business day, the Elopement listing will be updated by the Director of Nurses, printed out, given to each department manager to brief their employees, as well as the senior charge nurse assigned to the floor each day, Monday through Friday. The department managers and senior charge nurses are responsible to ensure that each staff member, regardless of new or current, are aware who is on the list and who has been taken off for whatever reason. Further, the Human Resources manager will update the Elopement book with a current Face Sheet and current picture of every new resident to the facility. This is the current policy and procedure in place at Apex Secure Care, updated to include all of the above information as of May 5. 9. Effective immediately, 1030 hours (10:30 AM) on May 5, all residents are placed on every-30 minute monitoring program replacing the every hour process. 10. The primary responsibility of both monitor tech (staff) positions is to ensure safety and security of each and every resident placed into our trust and care. Safety-wise, the monitor techs are to view and report any kind of issue that may be harm to any resident able to go outside between the temperatures of 40 degrees F., and 90 degrees F., which is the facility policy for weather temperatures. Also, each and every monitor tech is responsible for the safety, security and well-being of all residents in the facility, especially with possible intruders. The monitor tech that makes rounds outside will ensure no resident can escape out of the windows or over the fencing. If something transpires, the monitor tech that spots an incident will radio that incident to the other monitor tech to investigate and immediately report back to the Senior Charge Nurse, who in turn will notify the Asst. Administrator, DON, and Administrator for further action to be taken. Observations, record reviews and interviews conducted on 5/5/12 revealed the following steps were taken by the facility to remove the Immediate Jeopardy. Observations on 5/5/12 at 12:15 PM revealed the facility was still in lockdown and no residents were observed outside. Observations by the surveyor on 5/5/12 (12:25 PM, 1:30 PM, 1:45 PM, 1:55 PM, 2:45, and 3:14 PM, 3:25 PM) confirmed Monitor Tech #1 was monitoring the cameras (monitors) at various times. Observations on 5/5/12 at 3:15 PM confirmed Monitor Tech #1 was monitoring the camera feeds and Monitor Tech #2 was observed on camera making rounds outside the facility. The Monitor Tech #1 and #2 had walkie talkies to communicate with each other. On 5/5/12 at 4:33 PM the Administrator said a second monitoring staff was on duty at 6 AM on 5/5/12 to make rounds outside and switch off with each other every two hours. On 5/5/12 at 4:35 PM, Monitor Tech #1 said he was to keep his eyes on the cameras (monitors) at all times. He said if he observes a resident trying to elope, he was to alert the outside Monitor Tech and notify the charge nurse of the possible elopement. He said none of the residents are allowed outside without supervision of staff. Monitor Tech #1 stated he was to notify his partner if he did not recognize a car near the facility. Monitor Tech #1 said he would be relieved for breaks by his partner or maintenance staff. On 5/15/12 at 4:45 PM Monitor Tech #2 confirmed the same information as Monitor Tech #1. Monitor Tech #2 said you make rounds outside for two hours and then switch places with the other Monitor Tech. Monitor Tech #2 stated they were informed to remove anything they found next to the fence and alert administration or the other Monitor Tech via the walkie talkie. Monitor Tech #2 said, if a resident was trying to get out, you keep your eyes on the resident and alert staff. He said if a resident eloped a "code orange" was called by staff. Monitor Tech #2 said the in-service stressed the importance of resident elopement and prevention. Interviews were conducted with CNA #6 (5 PM), CNA #7 (5:10 PM), LVN #5 (4:50 PM), CNA #2 (4:40 PM) and RN #2 (4:45 PM). They confirmed the in-service meeting covered the facility's actions plan and "code orange" for elopement. Staff said the charge nurse was the only one to communicate with the Monitor Tech and other staff is not allowed to distract the Monitor Tech. The aides are to be on time and make rounds and have to visually see a resident every 30 minutes, and high risk for elopement resident are every 15 minutes. The staff was knowledgeable of what to do when a "code orange" was called regarding a missing resident and what to do when they took their breaks. Staff said a list of high risk residents for elopements was posted at the time clock and at the nurses' station daily. Record review documented all staff (all departments) was in-serviced on 5/5/12 beginning at 10 AM. Four of the staff who was unable to attend was in-serviced via telephone. This in-service was documented. The in-service revealed the facility's action plan, "code orange " for missing/elopement of residents and importance of knowing where the residents were discussed. Confidential interviews with two alert residents confirmed a resident council meeting was conducted with the residents on 5/5/12 at 11 AM. They indicated the meeting was regarding the lockdown and resident elopement. The residents indicated the Monitor Tech was presently watching the cameras/monitors. Removal of the Immediate Jeopardy On 5/5/12 at 5:30 PM, the Administration was notified the Immediate Jeopardy had been removed due to observations, staff and resident interviews confirmed the staff was knowledgeable of the facility's plan of action and "code orange" and Monitor Tech were observed watching the cameras/monitors and monitoring the premise. The facility remained out of compliance at pattern and potential for more than minimal harm due to evaluation of the action plan and monitoring of staff to ensure they were appropriately supervising residents with exit seeking behavior. Resident Census The facility had a census of 88 residents in the secured facility. A list of residents at high risk for elopement documented there were 11 residents including resident #2 who was at high risk to elope.

Based on observations, interviews and record reviews, the facility failed to ensure that each resident receives adequate supervision to preven accidents. The facility staff failed to provide supervision to prevent 1 of 5 sampled residents (Resident #2) with exit seeking behaviors, from being unsupervised, thus exiting the facility and fleeing to another city. Resident #2, who had a history of [REDACTED]. Monitor Tech #3 failed to supervise for approximately 12 minutes, the surveillance monitors and did not observe resident #2 carrying items from her window to the fence and going over the fence. Resident #2 was missing from 12:59 PM on 5/3/12 to 1:50 PM on 5/4/12 (24 hours and 51 minutes). Resident #2 had traveled from the facility to her residence in Lubbock which was approximately 45 miles. This led to the identification of an Immediate Jeopardy (IJ) on 5/4/12 at 5:50 PM. The IJ was removed on 5/5/12 at 5:30 PM after all staff was in-serviced and a second Monitor Tech was assigned to monitoring the outside of the facility. The facility remained out of compliance at a pattern with the potential for more than minimal harm due to the facility's need to monitor and evaluate the effectiveness of the corrective actions for exit seeking residents. The facility identified 11 residents (including resident #2) at high risk for elopement, who exhibited a behavior of exit seeking. Failure to provide supervision for the remaining 10 residents could result in allowing the residents to leave the facility resulting in serious injury. Non- Immediate Jeopardy: Based on observation, interview, and record review, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible, and each resident receives adequate supervision and assistance devices to prevent accidents. Two residents (#9 and #12) did not receive the required care; Resident #9 was being transferred with assistance x1, instead of the care planned instructions for assistance x2. The facility failed to attach a personal safety alarm consistently to resident #12 which was a component of the supervision to prevent the resident from sustaining a fall. This failure could place the 15 residents that were identified as a two person assist for transfers and the two residents that have a personal safety device (TABS Alarm) at risk for unnecessary injury. The evidence is as follows: Resident #2's clinical record documented the resident was admitted to the secured facility on 1/18/12 due to a court order for placement. Resident #2's admission face sheet dated 1/18/12 documented [DIAGNOSES REDACTED]. The resident ' s records contained two emergency detentions dated 4/2/2012 and 4/14/12 for transfer to a psychiatric facility for evaluation due to attempts to elope. The clinical records (nurses' notes and physician's orders [REDACTED]. The clinical records and care plan dated 4/19/12 revealed resident #2 was on every 15 minute checks and a high risk for elopement. A court order dated 1/17/12 documented a temporary appointment for a guardian for resident #2 and placement in a secured facility. The court order dated 2/13/12 placed resident #2 under the care of the guardian. The order dated 1/17/12 deemed resident #2 was to be placed in a safe area, for her safety and welfare. Resident #2 had been deemed incompetent and was a danger to herself and others. Resident #2 had a history of [REDACTED]. The order documented resident #2 was incapable of and does not understand the consequences of her drinking and driving. The order documented the resident's mother had a car for her to use; therefore, she was an immediate threat to herself and the driving public. The order documented resident #2's mother had left town and felt it to be in her best interest for the resident be placed in a residential facility where she can be monitored 24 hours, given medication, and prohibited from drinking. The order dated 1/17/12 found it necessary to commit resident #2 to a residential facility, namely Tumbleweed Care Center (APEX Secure Care of Brownfield) and the Lubbock County Sheriff's Office transport her to the facility for her safety and the safety of those around her. During observations on 5/4/12 at 1:40 PM, the facility had a locked gate with a buzzer on the outside to alert staff of a visitor and a locked front door with an alarm. The facility was enclosed by an 8'4 " high iron fence. During an interview on 5/4/12 at 1:45 PM with the administrator said the facility was in lockdown (none of the residents are allowed outside unless supervised by staff) due to resident #2's elopement on 5/3/12 at 12:57 PM. The administrator said he had reported the incident of elopement for resident #2 to the Texas Department of Aging and Disability Services and was investigating. He said resident #2 had broken her window and stacked a shower chair, drawers and a suitcase in order to climb over the fence and elope. The administrator said facility staff was notified of resident #2's elopement by resident #1 who witnessed resident #2 climb over the fence. The administrator said Monitor Tech #3 was sitting at the nurses' station in front of the cameras/monitors. He stated the nurse on duty called a "code orange " for a missing resident. The administrator said he had viewed the video during resident #2's elopement and Monitor Tech #3 had to be "sleeping with his eyes open". The administrator said it took resident #2, two minutes and 47 seconds to get over the fence. The administrator said he terminated Monitor Tech #3 for not staying focused and not watching the monitors at the time of resident #2's elopement. The administrator said he had not in-serviced staff and had only terminated Monitor Tech #3. During an interview on 5/4/12 at 5:10 PM, the administrator said the Monitor Tech job was to watch the cameras in order to supervise residents at risk for elopement. He stated the Monitor Tech should keep their eyes on the cameras at all times unless relieved to make hourly rounds or breaks. During an interview on 5/4/12 at 2 PM, the Director of Nurses (DON) said the local police were notified of resident #2's elopement on 5/3/12 at 12:57 PM. The DON said she had instructed Monitor Tech #3 he better keep his eyes on the residents before she left for lunch on 5/3/12. The DON said Monitor Tech #3 was looking down at the time and may have been texting or sleeping when she walked by the nurses' station to go to lunch. The DON said resident #2 had a credit card and a cell phone. The DON said the guardian informed her on 5/3/12 at 1:47 PM, a friend of resident #2 had called him to report resident #2 had escaped, got a ride with a random couple and was going to her residence in Lubbock. The DON said resident #2 was sighted at her residence in Lubbock by the guardian on 5/3/12 around 6 PM and managed to get away from the guardian. The DON said there were reported sightings (Dollar store and bank) of resident #2 all morning long on 5/4/12. The DON said resident # 2 was located in the back of a cab at her residence in Lubbock by law enforcement on 5/4/10 around 1:50 PM. She said resident #2 had been drinking alcohol. The DON said the guardian informed the facility they would have to keep resident #2 because he could not find anyone to accept her. The DON stated resident #2 had two emergency detentions (4/2/12 and 4/14/12) for transfers to a psychiatric facility for April 2012 due to attempts to elope and had returned to the facility. During an interview on 5/7/12 at 2:40 PM, LVN #4 said he was working on the day resident #2 left the facility. LVN #4 said resident #2 was on every 15 minute checks and listed as a high risk for elopements. LVN #4 said he had been at the nurses ' station and observed resident #2 numerous times. He said Monitor Tech #3 was sitting in front of the cameras when he left the desk to fax reports to the physician on 5/3/12 around 12:40 PM. LVN #4 said he had seen resident #2 come out of her room and look down the hall at this time. LVN #4 said resident #2 had placed a sign on her door that she was resting. LVN #4 said he was aware of resident #2's elopement when resident #1 alerted staff resident #2 had climbed the fence. During an interview on 5/7/12 at 2:55 PM, RN #1 said she was working in the dining room on 5/3/12 around 1 PM. RN #1 said she was assisting a resident from the dining room when resident #1 informed her he had seen resident #2 go over the fence. She said a "code orange "was announced and a head count of the residents was conducted by staff. RN #1 said she went down "D" hall and outside. RN #1 said resident #2 had stacked things next to the fence. RN #1 said staff is assigned certain things to do when a resident was missing and a "code orange" was announced. RN #1 said the police arrived with a dog and went to resident #2's room for an article of clothing. RN #1 said resident #2 did not act any differently. RN #1 said it was a daily occurrence for resident #2 to allege she was being held against her will. RN #1 said resident #2 would call 911 (police), lawyers, judges and anyone she could think of in attempts to get released from the facility. During an interview on 5/4/12 at 5 PM, the assistant administrator said he reviewed the surveillance videos and Monitor Tech #3 was not watching the cameras. He said monitor tech #3 was looking towards the front door for 10-15 minutes, talking to residents and staff and was not watching the cameras. The assistant administrator said the Monitor Tech had been instructed to keep their eyes on the cameras and make sure the doors are locked. The assistant administrator said Monitor Tech are to make hourly rounds outside and use maintenance staff and not nurse aides to relieve them during rounds and breaks. During an interview on 5/4/12 at 3:10 PM, Monitor Tech #3 said his job was to watch the cameras and lock the doors after the smokers returned inside the facility after lunch. Monitor Tech #3 said he was told by the administrator to watch resident #2 on 5/3/12 around 11 AM. He said resident #2 would try to leave the facility all the time. Monitor Tech #2 said resident #2 had her own cell phone and would call police, lawyers and guardian in attempts to get out of the facility. He said he was busy watching the cameras for the smokers and another resident who was in the front of the facility during the elopement. Resident #2 was observed sitting outside the fence of the facility on 5/4/12 at 4:20 PM in the custody of local and county law enforcement. The resident did not appear to have any injuries. On 5/4/12 at 4:30 PM, resident #2 said she had climbed the fence and paid a married couple $25 to $30 to take her home (residence in Lubbock). Resident #2 refused to tell the surveyor the names of the couple. Resident #2 said she went home and then to a motel. Resident #2 said that while she was out of the facility, she had gone shopping and ate at her favorite restaurant. Resident #2 was insisting that she did not belong in the facility and was being held against her will. When resident #2 understood the local police were going to be transferring her to the jail, resident #2 wanted to stay at the facility. Resident #2 was not readmitted to the facility. The local police left the facility premise with resident #2 in their custody and was going to be transported to a psychiatric facility when the judge completed the emergency detention process. Google maps search on 5/16/12 at www.http//classic mapquest.com documented the mileage from the facility's address to resident #2's residence in Lubbock was approximately 45.76 miles. Surveillance Video Review Review of the facility ' s surveillance video for camera #8 documented the actions of Monitor Tech #3 prior to and during resident #2 ' s elopement on 5/3/12 from 12:42 PM to-12:59 PM. The facility had 19 operational cameras located inside and outside which were video fed simultaneously to the two large monitors located at the nurses ' station The facility's surveillance video recordings reviewed for 4 of the cameras dated on 5/3/12 beginning at 12:42 PM documented the administrator left the facility. At 12:44:10 PM resident #2 was at the nurses' station talking to Monitor Tech #3. He was not watching the cameras/monitors (There are two large monitors at the nurses' station which provide camera surveillance which are recorded). At 12:44:20 resident #2 left the nurses' station. At 12:45:02 PM Monitor Tech #3 was observed talking with other residents and not watching the cameras/monitors. At 12:46:24 PM Monitor Tech #3 was not watching the cameras/monitors and resident #2 pushed the screen out of her window. Resident #2 went out the window and carried a drawer and suitcase to the fence. Monitor Tech #3 was looking away from the cameras/monitors. At 12:47:00 resident #2 was observed to stack items next to the fence and attempted to climb over the fence. The monitor tech was not watching the cameras/monitors. At 12:47:31 resident #2 went back into her room via the window and Monitor Tech #3 was not watching the cameras/monitors. At 12:48:10 PM resident #2 went out her window with a white chair (shower chair) which she carried to the fence. Monitor Tech #3 was not watching the cameras/monitors. At 12:48:40 resident #2 was stacking the chair next to the fence. At 12:49:09 resident #2 went back through the window into her room. At 12:49:45 resident #2 went out her window and carried another item to the fence. Resident #1 walked past resident #2 by the fence. At 12:50:20 resident #2 attempted to climb over the fence, but the stacked items fell . Resident #2 restacked the items and returned to her window at 12:50:41 and Monitor Tech #3 was not looking at the cameras/monitors. At 12:52:23 resident #2 walked by the nurses' station. At 12:53:26 resident #2 walked by nurses' station to the front yard area. Resident #2 was observed to stay in the front yard area until 12:54:29 and returned inside the facility. At 12:54:51 resident #2 walked past the nurses' station. At 12:55:23 resident #2 was at the nurses' station. At 12:56:59 resident #2 climbed out her window and restacked items by the fence. At this time the Monitor Tech #3 was looking away from the cameras/monitors. At 12:57:53 resident #2 was unable to climb over the fence and restacked the items. Monitor Tech #3 was not looking at the cameras/monitors. At 12:58:57 resident #2 was over the fence and ran north at 12:59:21. Resident #1 was standing inside the fence watching resident #2. At 13:00:45 Resident #1 was standing at the nurses' station and no one spoke to him. He speaks to another resident. At 13:10:02 resident #1 was telling RN #1 something and all staff took off running to exits. At 13:10:54 resident #1 took staff to the fence and showed staff items stacked next to the fence. The surveillance video recorded resident #2 made 5 trips out her window to the fence. Facility ' s Policy The facility's policies documented the following: The Abuse Prevention Program policy dated revised December 2006, documented: "Neglect is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish or mental illness." It documented signs and symptoms of neglect included "inadequate provision of care," and leaving someone unattended who needs supervision" Review of facility's policies titled "Wandering Residents," revised December 2007 documented: "The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk of elopement. The staff will identify residents who were at risk for harm because of unsafe wandering (including elopement). The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering. The resident's care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety will be included in the resident's care plan. Nursing staff will document circumstances related to unsafe actions, including wandering, by a resident. Staff will institute a detailed monitoring plan for residents who are assessed to have a high risk of elopement or other unsafe behavior. Staff will notify the Administrator and Director of Nurses immediately and will institute appropriate measures, including searching for any resident who is discovered to be missing from the unit on facility. On 5/4/12 at 5:50 PM the Administrator and DON were notified An Immediate Jeopardy (IJ) was identified .The IJ was called due to no other action had been taken by the facility to prevent elopements except to terminate Monitor Tech #3. IMMEDIATE PLAN OF REMOVAL On 5/5/12 at 4:36 PM the facility's plan of action was accepted. Review of the plan documented the following: 1. Two monitor technicians will be on duty at all times. This will begin effective at 1330 hours (1:30 PM) on May 5, 24 hours a day/365 days a year. One monitor tech will make rounds outside while the second monitor tech will monitor the camera systems. After two hours they will switch responsibilities. To monitor the effectiveness of this program, the Assistant Administrator, Director of Nurses, and the Administrator have the capabilities of putting the entire camera system on their cell phones to monitor effectiveness. Periodic monitoring will be done by all three of the senior staff. The board of directors already has these cameras on their cell phones. The facility will continue to research more effective methods of resident protection improvement. In the event of inclement weather, the outside rotation will be provided appropriate weather gear (rain coat, parka, etc.). Extreme heat does present a problem. As such, water stations (at least 4) will be present at various locations throughout the exterior of the facility. Based on the existing magnetic lock system at Apex Secure Care, it will be necessary for the monitor tech to come through the facility to go to the next monitoring area, thus providing some relief from the heat. 2. The monitor techs will operate 2-way radios to check in and report any unusual sightings or activities that can be monitored at all times on the camera system. Implementation is immediate, May 5. The 2-way radios are already in the facility. 3. No monitor tech will be disturbed by carrying on conversations with staff or residents. Only the senior charge nurse, Assistant Administrator, Director of Nurses, and the Administrator will coordinate with the monitor tech. Implementation is immediate, May 5. 4. On shift change, both the on-coming and out-going monitor techs will do either walking rounds or internal reports for specific resident issues such as who is exit-seeking. Implementation is May 7 at 0700 hours. The senior charge nurse will be responsible for ensuring the monitors are watched during the transition time. Also, the exterior monitor checks with walking rounds will prevent any other problems. This plan will be monitored by the QAAC (Quality Assurance and Assessment Committee) on a monthly basis for effectiveness or sooner if necessary. 5. Each morning, Monday through Friday, at morning stand-up, the Assistant Administrator will bring security issues to be addressed. An occasional Saturday, when all the department heads are in the home, will also have a brief standup. Implementation is May 5 at 10:30 AM. 6. Every staff member will be in-serviced regarding this plan of correction and what it means to each of them. Implementation is May 5, 1500 hours (3 PM). The QAAC will monitor each shift to determine effectiveness of all the information on a monthly basis or sooner if necessary. 7. Code Orange - Elopement policy and procedures will be reviewed by all staff members, regardless of position, on a monthly basis. Implementation is immediately, May 5 at 1030 hours (10:30 AM). The QAAC will monitor monthly the effectiveness of this plan, or sooner if necessary. 8. At the current time, Apex Secure Care Brownfield maintains an at risk for elopement list of all residents at risk for elopement. In addition, any new residents that come into the facility, or residents that have been in the hospital for more than five days, are placed on this listing for a period of 14 days, starting with the day of admission or readmission. At the end of 14 days, if the resident is still considered a risk factor, that resident will remain on the list for a period of 30 days, at which time he or she will be re-evaluated by the QAAC for removal. To ensure that this information is disseminated to every staff member, at the start of each business day, the Elopement listing will be updated by the Director of Nurses, printed out, given to each department manager to brief their employees, as well as the senior charge nurse assigned to the floor each day, Monday through Friday. The department managers and senior charge nurses are responsible to ensure that each staff member, regardless of new or current, are aware who is on the list and who has been taken off for whatever reason. Further, the Human Resources manager will update the Elopement book with a current Face Sheet and current picture of every new resident to the facility. This is the current policy and procedure in place at Apex Secure Care, updated to include all of the above information as of May 5. 9. Effective immediately, 1030 hours (10:30 AM) on May 5, all residents are placed on every-30 minute monitoring program replacing the every hour process. 10. The primary responsibility of both monitor tech (staff) positions is to ensure safety and security of each and every resident placed into our trust and care. Safety-wise, the monitor techs are to view and report any kind of issue that may be harm to any resident able to go outside between the temperatures of 40 degrees F., and 90 degrees F., which is the facility policy for weather temperatures. Also, each and every monitor tech is responsible for the safety, security and well-being of all residents in the facility, especially with possible intruders. The monitor tech that makes rounds outside will ensure no resident can escape out of the windows or over the fencing. If something transpires, the monitor tech that spots an incident will radio that incident to the other monitor tech to investigate and immediately report back to the Senior Charge Nurse, who in turn will notify the Asst. Administrator, DON, and Administrator for further action to be taken. Observations, record reviews and interviews conducted on 5/5/12 revealed the following steps were taken by the facility to remove the Immediate Jeopardy. Observations on 5/5/12 at 12:15 PM revealed the facility was still in lockdown and no residents were observed outside. Observations by the surveyor on 5/5/12 (12:25 PM, 1:30 PM, 1:45 PM, 1:55 PM, 2:45, and 3:14 PM, 3:25 PM) confirmed Monitor Tech #1 was monitoring the cameras (monitors) at various times. Observations on 5/5/12 at 3:15 PM confirmed Monitor Tech #1 was monitoring the camera feeds and Monitor Tech #2 was observed on camera making rounds outside the facility. The Monitor Tech #1 and #2 had walkie talkies to communicate with each other. On 5/5/12 at 4:33 PM the Administrator said a second monitoring staff was on duty at 6 AM on 5/5/12 to make rounds outside and switch off with each other every two hours. On 5/5/12 at 4:35 PM, Monitor Tech #1 said he was to keep his eyes on the cameras (monitors) at all times. He said if he observes a resident trying to elope, he was to alert the outside Monitor Tech and notify the charge nurse of the possible elopement. He said none of the residents are allowed outside without supervision of staff. Monitor Tech #1 stated he was to notify his partner if he did not recognize a car near the facility. Monitor Tech #1 said he would be relieved for breaks by his partner or maintenance staff. On 5/15/12 at 4:45 PM Monitor Tech #2 confirmed the same information as Monitor Tech #1. Monitor Tech #2 said you make rounds outside for two hours and then switch places with the other Monitor Tech. Monitor Tech #2 stated they were informed to remove anything they found next to the fence and alert administration or the other Monitor Tech via the walkie talkie. Monitor Tech #2 said, if a resident was trying to get out, you keep your eyes on the resident and alert staff. He said if a resident eloped a "code orange" was called by staff. Monitor Tech #2 said the in-service stressed the importance of resident elopement and prevention. Interviews were conducted with CNA #6 (5 PM), CNA #7 (5:10 PM), LVN #5 (4:50 PM), CNA #2 (4:40 PM) and RN #2 (4:45 PM). They confirmed the in-service meeting covered the facility's actions plan and "code orange" for elopement. Staff said the charge nurse was the only one to communicate with the Monitor Tech and other staff is not allowed to distract the Monitor Tech. The aides are to be on time and make rounds and have to visually see a resident every 30 minutes, and high risk for elopement resident are every 15 minutes. The staff was knowledgeable of what to do when a "code orange" was called regarding a missing resident and what to do when they took their breaks. Staff said a list of high risk residents for elopements was posted at the time clock and at the nurses' station daily. Record review documented all staff (all departments) was in-serviced on 5/5/12 beginning at 10 AM. Four of the staff who was unable to attend was in-serviced via telephone. This in-service was documented. The in-service revealed the facility's action plan, "code orange " for missing/elopement of residents and importance of knowing where the residents were discussed. Confidential interviews with two alert residents confirmed a resident council meeting was conducted with the residents on 5/5/12 at 11 AM. They indicated the meeting was regarding the lockdown and resident elopement. The residents indicated the Monitor Tech was presently watching the cameras/monitors. Removal of the Immediate Jeopardy On 5/5/12 at 5:30 PM, the Administration was notified the Immediate Jeopardy had been removed due to observations, staff and resident interviews confirmed the staff was knowledgeable of the facility's plan of action and "code orange" and Monitor Tech were observed watching the cameras/monitors and monitoring the premise. The facility remained out of compliance at pattern and potential for more than minimal harm due to evaluation of the action plan and monitoring of staff to ensure they were appropriately supervising residents with exit seeking behavior. Resident Census The facility had a census of 88 residents in the secured facility. A list of residents at high risk for elopement documented there were 11 residents including resident #2 who was at high risk to elope. Non- Immediate Jeopardy Findings: 1. During initial rounds on 5/7/12 at 10:15 a.m. RN #3 indicated that resident #9 was incontinent, had a suprapubic catheter, transfer x1 person, is in a wheelchair, and is assisted with eating. 2. Resident #9 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. 3. Record review of Resident #9's Admission MDS (Minimum Data Set) dated 4/29/12 indicates resident #9 is alert and oriented, is total dependence of two persons physical assistance for bed mobility, transfers, toilet use, and bathing. Resident #9 requires extensive assistance of one person physical assistance for dressing and personal hygiene, and requires limited assistance of one person physical assistance for eating. Resident #9 is able to wheel self around facility in her wheelchair. Resident #9 has a functional limitation in range of motion in both upper and lower extremities. Resident #9 has a suprapubic catheter and is continent of bowel. The MDS indicates resident #9 has pain on occasion and has pain medication on an as needed basis. 4. Review of Incident/Accident Report dated 5/6/12 indicates CNA #2 was transferring resident #9 from the bed to the wheelchair, and that resident #9 slipped out of the wheelchair causing a scratch and bruise to resident #9's left arm. The report indicated that antibiotic ointment was applied to the scratch on resident #9's left arm. 5. Review of the witness statement dated 5/6/12 at 10:50 is signed by CNA #1 and reveals that CNA #2 was transferring resident #9 to her wheelchair when she slid to the floor causing the scratch and bruise to the left arm. CNA #2 stated that CNA #1 and CNA #8 were there to help her get resident #9 up. CNA #2 also indicated in her statement that they were shorthanded and that the resident refused to see a nurse and just wanted to go smoke. 6. During an interview on 5/8/12 at 3:00 p.m., the DON said resident #9 is a two person lift, and then said, "Some can transfer her by themselves." The DON reported she did not recommend one person doing it, because resident #9 is dead weight and no one should be lifting her by their selves, because it is too dangerous for her and staff. The DON indicated that CNA #3 was assigned to resident #9 on this day. 7. During an interview with CNA #3 on 5/8/12 at 3:05 p.m. she indicated that she does transfer resident #9 by herself, because she is bigger, but stated that the resident really needed to be transferred by two persons because the resident is heavy. 8. LVN #3 reported in an interview on 5/8/12 at 3:55 p.m. that she didn't know if resident #9 was a two-person lift or not. At that time LVN #2 stated, "That reminds me I have to do an in-service for staff," regarding Resident #9. 9. During an interview with resident #9 on 5/8/12 at 3:35 p.m., she indicated that CNA #3 had transferred her by herself earlier today from the bed side commode to the wheelchair. At 3:56 p.m. CNA #4 and CNA #5 entered resident's room. The surveyor asked them how they know how much assistance a resident needs when admitted to the facility. CNA #4 indicated they get a report from the nurse and reported that she also does the weights when somebody is admitted , so she knew that resident #9 was a two-person assist for transfers. CNA #5 stated she knew that the resident was a two-person transfer, but that she had done it by herself at times because the resident had told her to. 10. On 5/9/12 at 10:43 a.m. the DON relayed to surveyor that resident #9's mom wanted to be called and talk to the surveyor. During a phone interview with resident #9's mom on 5/9/12 at 10:45 a.m. she indicated that the resident is a two- person transfer, she stated, "sometimes we had to have 3 people to transfer her, because when she starts to go down there is no way to stop it." 11. Resident #9's chart did not document any Nurse's Notes for the time frame surrounding the incident on 5/6/12. The Fall Risk assessment dated [DATE] indicates the resident scored a 16 indicating high risk for falls. The Braden Scale assessment dated [DATE] indicates the resident is chairfast, and is completely immobile. The ADL Functional/Restorative Assessment and Progress report dated 5/8/12 indicates the resident is assist x2 for transfers, bed mobility, and positioning. 12. Review of the Monthly ADL Record for May 2012 reveals that staff were using one person assists to transfer resident #9 on the A.M. shift on the days of 5/2/12, 5/3/12, and 5/7/12. 13. Review of the Admission MDS dated [DATE] indicates resident #9 is total assist of two for transfers, as does the Care Plan dated for 5/8/12. 14. Review of Resident #12's physician's orders [REDACTED]. 15. Observation of resident #12 on 5/7/12 at 3:00 p.m. showed TAB Alarm was not connected to him. 16. On 5/8/12 at 3:40 p.m. the TAB Alarm was not connected to resident #12 as ordered. The surveyor notified CNA #9, who in turn connected the personal alarm to the resident immediately. 17. During an observation of resident #12 on 5

Based on interviews and record reviews, it was determined that for 2 of 6 sampled residents (Residents #1 and #3), who exhibited a behavior of exit seeking behaviors, the facility failed to prohibit incidents of neglect when they - 1) Failed to ensure staff were made aware Resident #3, a new admission, had a current history of wandering and exit seeking. 2) Failed to ensure staff provided Resident #3 an appropriate level of supervision to prevent him from exiting the facility and going into a fenced yard during an arctic cold front with snow on the sidewalks and ground. 3) Failure to ensure staff provided Resident #1 an appropriate level of supervision to prevent him from eloping and being found approximately 128 miles from the facility. Resident #3, who had resided in the facility less than 12 hours, exited the facility at approximately 4:15 a.m. and remained outside in a wind chill factor of -10 to -13F. During the timeframe he was outside, the night shift charge nurse failed to conduct observation rounds every two hours and at shift change, the night shift charge nurse and day shift charge nurse failed to conduct walking shift change observation rounds. As a result, at approximately 8:00 a.m., staff realized Resident #3 was missing and found him lying face down on the snow. He was unresponsive with no pulse, his body cold and stiff, and an abrasion on his forehead and knuckles. He was transferred to a local hospital where his death was pronounced as due to acute hypothermia. Resident #1, who had a history of [REDACTED]. Failure to supervise Resident #1 placed him at risk of physical harm or death. This led to the identification of an Immediate Jeopardy on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity of actual harm and a scope of pattern due to not all employees had been in-serviced regarding supervision of exiting seeking residents and monitoring of staff to ensure they were providing an appropriately level of supervision for residents with exit seeking behavior. The facility identified 5 residents as exhibiting a behavior of exit seeking, 2 residents as having a history of elopement, 7 residents at high risk to elope, and 18 residents as expressing a desire to leave. All 18 residents were placed at risk of harm due to staff failure to provide an appropriate level supervision to prevent incidents of exiting the facility unsupervised. The evidence is as follows: I. RESIDENT #3 During an interview with the Administrator, DON and MD "A" , on [DATE] at 12:50 p.m., the Administrator said that on that morning ([DATE]) at approximately 8:00 a.m., Resident #3 was found unresponsive lying outside on the snow covered ground. The Administrator said their exterior cameras revealed Resident #3 had been outside since 4:00 a.m. MD "A" said at 9:22 a.m., he pronounced Resident #3's death at the local hospital. The Administrator said Resident #3 had admitted to their facility the prior evening around 9:30 p.m., along with 7 other residents from a nursing facility that was closing. The DON said she had assessed Resident #3 at the facility he discharged from. The DON said Resident #3 had resided in a secured (locked) unit and exhibited a behavior of wandering. The Administrator said they admitted Resident #3 because they could provide him a secured environment. When asked if they used exit door alarms, he said, "No," the facility grounds were secured by fences with locked gates. The Administrator added that due to an incident of Resident #1 eloping from the facility the prior weekend (1-,[DATE]-11), nurses had been in-serviced on [DATE] to conduct shift change walking rounds when giving report and to observe the residents during report. At that time, review of the documented in-service, dated [DATE], revealed the DON conducted the in-service with 7 nurses. The form documented the DON instructed the nurses to make walking rounds every 2 hours to observe each resident and to conduct walking rounds when given report. The DON explained "given report" meant giving report during shift change. Observations of the facility with the Administrator on [DATE], starting at 1:30 p.m., revealed the following: - The shape of the facility resembled a bicycle wheel. The center (rotunda area) housed the nurses' station which was in view of the six resident room halls and entry/TV/lobby area. The nurses' station had a monitor for viewing the real-time events captured by 8 exterior cameras. Five of the six resident room halls were used to house residents: Halls B, C, D, E and F. - The exterior grounds had four fenced areas: 1) Main Entrance with a coded gate entrance, 2) From Hall A to Hall C, 3) Patio off the dining room, and 4) From Hall D to Hall F. Each resident room hall extended out in a "V" shape. The Administrator pointed out where 8 cameras were mounted at each exit door. The Administrator said each camera captured activity in the area of the exit door and the open yard area, not within the "V" shape. The Administrator also said Resident #3 was found in the area of a gray storage building between Halls D and Hall E. Two storage buildings were located within the area: a gray wooden structure and a metal structure. The gray structure was nearest the sidewalk that ran the length of the yard between the three resident room halls. It was noted that snow covered the ground up to the Investigator's ankles. During subsequent interviews with LVN "H" and RN "G", they revealed Resident #3 was found lying face down on the snow behind the storage buildings, not near the sidewalk by the gray storage building, which was an area not view of the Hall D or Hall E cameras. The interviews occurred on [DATE] at 5:20 p.m. and [DATE] at 12:57 p.m., respectively. Observations of the video from the Hall D and Hall E cameras for the morning of [DATE], revealed Resident #3 was outside unsupervised in the area of Hall D and Hall E from 4:12 a.m. to 4:14 a.m., then 4:25 a.m. to 4:27 a.m., then 4:45 a.m. to 4:49 a.m., then 4:53 a.m. to 5:15 a.m. At 5:15 a.m., he went into the "blind spot" between Hall D and Hall E, but never left the area until staff discovered him at around 8:15 a.m. and carried him into the facility at 8:16 a.m. It was also noted that during the above times, Resident #3 fell 7 times. The following was observed: - At 4:12 a.m., Resident #3 went out the Hall E door and onto the fenced yard. He walked upright with a bundle of what appeared to be clothing in his arms. He walked on the sidewalk from Hall E exit toward Hall D. He walked through a snow drift on the Hall E side of a gray storage building near the sidewalk and then veered off the sidewalk as he passed a gray storage building on the Hall D side of the storage building. He then walked through the snow covered ground with snow up above his ankles. - At 4:45 a.m., Resident #3 came in view of the Hall E camera from the direction of Hall F. He appeared to have a garment dangling from his right hand. As he passed the entry to Hall E, he fell , bracing his fall with his hands. - At 4:53 a.m., Resident #3 re-entered the view of the Hall E camera from the direction of Hall F. He walked near the fence through the snow, then slowly walked out onto sidewalk. He appeared to wobble as he walked. He then fell to hands and knees at a snow drift, which crossed the sidewalk path. - At 4:58 a.m., he started to stand, but fell to his left side on the snow covered ground. - At 5:01 a.m., after attempting to gathering the items he dropped, he stood, but then fell forward on his hands and knees onto the sidewalk by the snow drift. He then stands and walks a few paces, then turns and retrieves the bundle he had gathered on the ground and walks toward Hall D. - At 5:02 a.m., he wobbles as he slowly walks through the snow near the Hall D exit and then into a "blind spot" between Hall D and the storage buildings. - At 5:07 a.m., Resident #3 was again in view of the Hall E camera standing upright carrying a bundle. With a slow gait, he came to the snow drift on the sidewalk and fell face down. - At 5:08 a.m., he stood and stumbled to the fence and then grabbed the fence as if to stable himself. He then turn and attempted to retrieve his bundle, and fell . At that time, it appeared he struck his head on the snow covered ground. - At 5:11 a.m., he stood and started to walk, but again fell . He then stood again and with an unsteady gait, he walked a few paces to the fence and leaned against the fence. - At 5:14 a.m., Resident #3 had his bundle and walked with an unsteady gait, while leaning slightly forward, and went around the storage building. He then walked through the snow covered ground up to the Hall D exit door, but then turned and walked out of view of the Hall D and Hall E cameras, which would be the area to the sides and behind the storage buildings. - Starting at 8:02 a.m., staff began exiting Hall D. - At 8:16 a.m., five plus staff came in view of the Hall D camera pulling blanket around from the direction of the backside of the two storage buildings, which left an indentation in the snow and dirt. They stopped outside Hall D, then they all lifted the blanket with what appeared to contain Resident #3's body and entered Hall D. At that same time, a video camera of the main entry area showed EMS personnel arriving and then exiting the facility with Resident #3 on a stretcher at 8:27 a.m. A temperature log for [DATE], received from the National Weather Service, revealed that for the city where the nursing facility was located, the temperatures were as follows: - From 4:00 a.m. to 7:15 a.m., the temperature was 6 F with wind gust ranging from 13 to 18 mph and sustained winds of 11 to 14 mph. - From 7:20 a.m. to 7:55 a.m., the temperature was 5 F with wind gust ranging from 15 to 18 mph with sustained winds of 12 to 13 mph. - At 8:00 a.m., the temperature was 4 F with wind gust of 15 mph with a sustained wind of 12 mph. The National Oceanic and Atmospheric Administration's (NOAA) Wind Chill Chart, effective [DATE], documented the following: - At a temperature of 5F and a wind speed of 10 mph, the ambient temperature is -10F. - At a temperature of 5F and a wind speed of 15 mph, the ambient temperature is -13F. The CDC (Center of Disease Control) documented the following in a pamphlet titled " Extreme Cold, A Prevention Guide to Promote Your Personal Health and Safety " and obtained online at <http://www.bt.cdc.gove/disasters/winter/> (no date) - - Whenever temperatures drop decidedly below normal and as wind speed increases, heat can leave the body more rapidly. - Elderly individuals are at greater risk of hypothermia because they often make less body heat due to a slower metabolism and less physical activity. - Hypothermia or abnormally low body temperature is most likely at very cold temperatures and can occur at 40F. - If the body temperature falls below 95F, the situation is a medical emergency. - Even if the victim appears dead, CPR should be provided. In some cases, hypothermia victims who appear to be dead can be successfully resuscitated. Review of Resident #3's clinical record revealed the following: - The Admission Face Sheet documented he admitted to the facility on [DATE] at 2130 (9:30 p.m.) at the age of 71. It also noted his [DIAGNOSES REDACTED]. - There was no documented pre-admission assessment or admission assessment. During an interview with the DON on [DATE] at 2:37 p.m., she said she did not complete a written pre-admission assessment; she only observed him and reviewed his clinical record at the prior facility. Review of Resident #3's clinical record from the prior facility revealed the following: - He had a DNR (Texas Standard Out-of-Hospital Do-Not-Resuscitate Order). - A quarterly Minimum Data Set (MDS) Resident Assessment, dated [DATE], documented he had severe cognitive impairment, exhibited a behavior of wandering, which was not easily altered, and he resided on an Alzheimer's/dementia special care unit. - The Care Plan with a print date of [DATE], documented he resided on a locked unit and he was at high risk for elopement. - The nurse's notes, dated [DATE] for the 6:00 p.m. to 6:00 a.m. shift, documented an incident of elopement, which occurred at approximately 2:00 a.m. Further review of Resident #3's current clinical record revealed the following: - The nurse's notes, dated [DATE], completed by RN "C", documented Resident #3's time of admission as 2030 (8:30 p.m.), not 9:30 p.m. as noted on the Admission Face Sheet. It noted he was confused, had a history of [REDACTED]. Monitored for elopement precautions." - There was no evidence contained within the record to indicate Resident #3 was monitored as noted in the above nurses' note written by RN "C" or to indicate the two nurses on duty the night of 2-,[DATE]-11 (RN "C" and LVN "D") implemented the facility's required every two hour observation rounds as per the in-serviced conducted by the DON on [DATE]. - The next nurse's notes entry was not until the following morning ([DATE]). At 8:00 a.m., RN "B" noted Resident #3 was found outside Hall E, behind a storage building. It noted he was in a prone position (face down), unresponsive and his skin was cold to touch. It noted when he was turned over and assessed, he had stiffness with no purposeful body movements, his eyes open with pupils full blown (dilated) and nonreactive. It also noted he had no palpable pulse and no spontaneous breath sounds. It noted he arrived from another facility the prior night and that they had no medical or personal information regarding Resident #3. It noted they initiated CPR. - RN "B" nurse's note for [DATE] at 8:15 a.m., noted emergency medical services (EMS) was called. It also noted Resident #3 had a 6 cm (2.36 inches) abrasion to his forehead and his pants were down to his knees. RN "B" noted at 8:18 a.m., EMS personnel arrived and took over his care. RN "B" noted at 8:30 a.m., Resident #3 was transferred to a local hospital. - The record contained no additional information regarding the status of Resident #3. Review of Resident #3's local hospital closed record documented the following: - The EMS Pre-Hospital Patient Care Report, dated [DATE], documented they arrived at the nursing facility at 8:20 a.m. and Resident #3 was receiving CPR from two nursing facility employees. It documented he was unconscious, unresponsive and in [MEDICAL CONDITION]. It noted he had a temperature of 69F and his skin was "extremely" cold, stiff and blackened on his hands and feet. It noted he had an abrasion type [MEDICATION NAME] wound across his forehead and abrasions to the knuckles of both hands. It noted they took over the CPR and used a defibrillator twice prior to transporting him to the local hospital and once while in route, but he remained in V-fib. (According to the American Heart Association, V-fib (ventricular fibrillation) is a serious medical condition in which the heart's electrical activity becomes disordered and can result in collapse and sudden cardiac death within minutes unless medical help is provided immediately. Website: http://www.americanheart.org). - The Emergency Department Triage form documented he arrived at 8:51 a.m. and continued to remain unresponsive with fixed/dilated pupils and no gag reflex. It also noted the abrasion to his forehead measured 5 cm in length (1.97 inches) with no hematoma noted. It noted that at 8:51 a.m., he had a temperature of 68.7F and at 9:22 a.m. (time death pronounced) his temperature was 77.2F. - The emergency room Note, completed by MD "A", dated [DATE], noted Resident #3 was given [MEDICATION NAME] upon arrival and two rounds of [MEDICATION NAME]. (Note: The 12th Edition of the Geriatric Dosage Handbook, copyright 2007 by Lexi-Comp Inc., pages 76, noted [MEDICATION NAME] may be used for [MEDICAL CONDITION] with persistent irregular heart rate when defibrillation, CPR, and vasopressor administration have failed. On page 502, it noted [MEDICATION NAME] may be used to stimulate the heart when the individual is in asystole (without heart beat).) MD "A" also noted that with re-warming and resuscitation efforts, they brought Resident #3's core body temperature up to 80F, but he remained unresponsive and in asystole. He noted they inserted a Foley catheter, but no urine was obtained. He noted Resident #3 was pronounced dead at 9:22 a.m. with the cause of death noted as acute hypothermia. He then noted: "appears patient has passed away due to a fall he sustained while outside after leaving his room at the facility to the yard where apparently he fell hitting his head. Patient may have suffered a snycopal episode and while being out in the cold weather he suffered from severe hypothermia as the temperature was only 5 to 6 degrees F this morning." Review of the computer-generated timesheets for [DATE] and [DATE] revealed the following: - On [DATE] from 11:00 p.m. to [DATE] at 6:00 a.m., there were 4 staff on duty: 2 nurses (RN "C" and LVN "D") and 2 nurse aides (CNA "E" and CNA "F"). RN "C" remained on duty until 7:32 a.m. and LVN "D" remained on duty until 7:48 a.m. - On [DATE], there were 2 nurses, 7 certified nurse aides, 1 resident aide, and 1 medication aide assigned to the day shift (6:00 a.m. to 6:00 p.m.). The two charge nurses were RN "G" (arrived at 6:05 a.m.) and LVN "H" (arrived at 6:22 a.m.). One aide had worked the night shift and six aides arrived between 5:03 a.m. and 6:29 a.m. During an interview with the Administrator on [DATE] at 2:10 p.m., he said on [DATE] at approximately 4:00 p.m., he was notified the facility Resident #3 discharged from was closing. He said he sent his DON and ADON "K" to the facility. He said at approximately 9:30 p.m., two vehicles arrived with 8 residents to admit from the facility that was closing. He said at that time, he had 10 staff on duty to assist with admitting the residents and getting them settled into their new rooms. He said they had already scheduled 2 nurses and 3 nurse aides to work from 11:00 p.m. to 6:00 a.m., but one aide called in and did not come to work. He said they called multiple staff, but not one was available to work. When asked if he considered the use of agency staff, he said he had already left and they did not discuss that option. When asked what time he left, he said around 10:00 p.m. He said when he left the facility, there were still additional staff in the facility, but at 11:00 p.m., only 2 nurses and 2 nurse aides would remain on duty to care for the current residents and 8 new admissions. He added that RN "C" knew the residents since he had worked at the other facility the prior week. During an interview with the DON on [DATE] at 3:30 p.m., she said she and ADON "K" along with two additional staff went to the nursing facility that was closing on [DATE] and determined 8 residents could be admitted to their facility that evening. She said they arrived at their facility at approximately 9:30 p.m. She said she was aware they would only have 2 nurses and 2 nurse aides on duty from [DATE] at 11:00 p.m. to [DATE] at 6:00 a.m. She said they called "everyone," but no one was available. She said they did not consider the use of agency staff. She said RN "C", who had worked at the other nursing facility for approximately one week, had told her "he had it covered," so she left at approximately 10:30 p.m. During an interview with the Administrator of Resident #3's prior facility on [DATE] at 11:25 a.m., he said when Resident #3 resided at his nursing facility, he routinely set off fire alarms and knew this would release the exit doors and gates. He said when a fire alarms went off, staff immediately went to the secured unit to look for Resident #3. He said he was aware the current facility did not have an actual secured unit, but he thought the fenced grounds would provide Resident #3 an area to wander in. He said he "assumed" staff would monitor their videos of the exterior cameras and the staff would monitor Resident #3 to prevent him from going out in the extremely cold weather. During an interview with RN "C" on [DATE] at 12:55 p.m., he confirmed he worked the night shift on 2-,[DATE]-11 when they admitted 8 new residents around 9:30 p.m. He said he had worked with the new residents the prior week at the facility they were discharging from. He said he was aware Resident #3 had resided on a secured unit. He added that he was not Resident #3's charge nurse the night he admitted , although, he had assisted with his care. He said Resident #3 remained in his room until 2:30 a.m. to 3:00 a.m. and then went and sat in the TV/lobby area with his coat and cap on, plus he carried a bundle of clothes. He said he saw Resident #3 around 5:00 a.m. and at no time did he see him exit the facility. He added that usually the night shift had 2 nurses and 3 nurse aides, but on that night, one aide called in sick. He said they did not have a sufficient number of staff to meet the individual needs of the residents due to the admission of 8 new residents. When asked if he had received training or had access to a policy related to adverse weather conditions, he said he was aware of no policy and he had received no training regarding weather extremes and monitoring of residents during cold weather. During an interview with LVN "D" on [DATE] at 4:03 p.m., she confirmed she worked the night shift on 2-,[DATE]-11 and was the charge nurse for Halls B, C and half of Hall D. She said on the evening of [DATE], between 8:00 p.m. and 9:00 p.m., they admitted 8 new residents from a facility that was closing. She said Resident #3 was one of the residents. She said Resident #3 was assigned a room on Hall B. She said she was not told he exhibited a behavior of wandering or exit seeking, although, she was aware he had wandered about their facility throughout the night. She said during the night, Resident #3 stepped out the Hall F exit door, but he turned around and came back in the facility (time unknown). She said she also saw him in the facility around 5:00 a.m. to 5:30 a.m. LVN "D" also said she had recently been in-serviced regarding ensuring they conduct shift change walking rounds and rounds every two hours. She said that night (2-,[DATE]-11), she did not make rounds every two hours due to helping the two nurse aides provide care for the residents. She further said she did not make the shift change walking rounds with the on-coming nurse. She concluded by noting that on the night of 2-,[DATE]-11, they did not have an adequate number of staff to meet the individual needs of the residents. She said no additional staff had been assigned to assist them even though they had 8 new residents, plus, the 12 to 15 current residents who were usually up at night. During an interview with CNA "E" on [DATE] at 11:35 p.m., she confirmed she worked the night shift on 2-,[DATE]-11. She said when the 8 new residents arrived, they were told their names and then told to assist them to their room. She said she was not told Resident #3 had a behavior of wandering or exit seeking. She said she did not recall seeing Resident #3 up wandering until around 2:30 a.m. to 3:00 a.m. She said he was dressed and carrying a bundle of clothes. She said during the night (time unknown), she heard LVN "D" tell LVN "C" that she thought she saw someone outside. She said they had assumed it was Resident #15, but he was in bed asleep. She said no one went outside to see if a resident was outside in the cold. She said they did not make rounds during the night to observe each resident, because they did not have enough staff to provide care and make the observations rounds. She said when she and the other nurse aide provided care for the residents, they "jumped" from hall to hall. During an interview with LVN "H" on [DATE] at 5:20 p.m., she confirmed she worked the day shift (6:00 a.m. to 6:00 p.m.) on [DATE]. She said she arrived late, around 6:15 a.m., due to the weather. She said she was assigned as charge nurse for Halls B, C and one-half of Hall D. She said when she arrived, she and the off-going nurse (LVN "D") did not make walking rounds together. She said LVN "D" told her "everything was fine". She said after completing other tasks, she she went to the dining room and noted Resident #3 was not in the dining room. She said she then went to his room and discovered he was not in his room. She said when she could not locate him, she notified the other staff and they began looking for him. She said RN "G" found Resident #3 outside between Halls D and E. She said when she arrived, she saw Resident #3 lying face down in the snow behind two storage buildings between Halls D and E. She said he had a coat and cap on, but his jeans were down around his knees, and he was wearing only one tan corduroy house shoe. She said when they rolled him over, she noted his eyes and mouth were open and he was cold to touch. She said with the help of other staff, they carried him to a room on Hall D and she and RN "G" initiated CPR. She said EMS personnel arrived shortly thereafter and took over. She added that she was aware of the no weather related facility policy that provided guidance regarding cold temperatures and what measures to take to reduce the risk of residents developing hypothermia. She further said she had worked late the night of [DATE] and had been present when the 8 new residents arrived. She said when she left she recalled Resident #3 being in bed. She said when she left she was aware the night shift would only have 2 nurses and 2 nurse aides after 11:00 p.m. with no additional staff arriving to assist with the residents. During an interview with RN "G" on [DATE] at 12:57 p.m., she confirmed she worked the day shift on [DATE]. She said she was the charge nurse for one-half of Hall D, plus Halls E and F. She said when LVN "H" told her she could not find Resident #3, she began assisting with looking for him. She said she went out on the grounds of the facility and found Resident #3 lying face down behind two storage buildings located between Halls D and E. She said his pants were down around his knees and ice crystals had formed on his hips. She said when staff arrived, they rolled him over. She said he was "stiff as a board" and "frozen to death". She said his eyes and mouth were open and he had an abrasion on his forehead. She said while she waited for staff assistance, she called 911 with her cell phone. She said staff assisted with carrying Resident #3 to a room on Hall D and she and LVN "G" initiated CPR until EMS personnel arrived and took over. She said she was aware of no policy related to inclement weather. III. FACILITY POLICIES Review of the facility's policy titled "Wandering Residents," revised [DATE], documented: "Every effort will be made to prevent wandering episodes while maintaining the least restrictive environment for residents who are at risk of elopement. It documented that if a "resident repeatedly wanders off the unit, a monitoring schedule will be implemented to ensure resident safety. The resident's care plan will be documented as the implementation of the monitoring schedule." Review of the facility's policy titled "Abuse Prevention Program," revised [DATE], documented: "Neglect is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish or mental illness." It documented signs and symptoms of neglect included "inadequate provision of care," and 'leaving someone unattended who needs supervision" There was no policy policy presented related to procedures for supervising residents during inclement weather. On [DATE], the Administrator presented a policy developed on [DATE], titled "Policy and Procedure for Inclement Weather Conditions", effective date [DATE]. Review of the policy revealed it documented the following: - "If temperatures in winter months drops to 40F or below, residents will be redirected to a safe area. If the resident refused to cooperate, resident will be redirected for safety until resident agrees to relocate to a safer area. Residents will be permitted to go outside into the courtyard areas under the direct supervision of a staff member not to exceed 5 to 10 minute intervals and will be dressed in proper attire with several layers of protective clothing, season appropriate. Individuals considered to be wanderers or high risk will be observed by the nursing staff and accounted for every 30 minutes and signed off that they have seen the individual. All paved areas will be kept free of snow and salt will be applied." - It further noted their sources for temperature variations included MD "A", Wind Chill Temperature Index by the National Weather Service. During an interview with MD "A" on [DATE] at 4:00 p.m., he confirmed he assisted with formulating the inclement weather policy. III. RESIDENT #1 Review of Resident #1's nurses' notes, completed by LVN "C", revealed on Sunday, [DATE], at 1:00 a.m., Resident #1 was discovered missing. It noted Resident #1 was not located until 2:10 p.m. when police notified the facility he was found in Aspermont, Texas, a town two hours away from the facility. An on-line mileage calculator with MapQuest (http://classic.mapquest.com/) documented the distance from the facility to the town of Aspermont was 127.94 miles. Further review of Resident #1's nurse's notes, dated [DATE], documented police returned Resident #1 to the facility at 6:30 p.m. It noted he was assessed to have no injuries. The notes further documented that when staff first realized he was missing (on Sunday, [DATE], at 1:00 a.m.), staff had observed his bed was made and his closet was empty of his clothes. It noted the local police were notified at 1:15 a.m. It noted calls were made to staff from the day shift (6:00 a.m. to 6:00 p.m.), which revealed the following: - CNA "I" told them that on Saturday, [DATE], around 5:30 p.m., she had answered the activated call light for his room and he was not in his room at that time. - CNA "F" told them she last saw Resident #1 during the noon meal on Saturday, [DATE]. Review of the Incident/Accident (I/A) Reports for [DATE] through the 3rd of February 2011 and additional review of Resident #1's nurses' notes revealed prior to the above incident, there had been two additional incidents of elopement. - An I/A Report documented on [DATE], he was found one block from the facility. - His nurse's notes, dated [DATE], documented at 1315 (1:15 p.m.), Resident #1 was found on the Tahoka highway by a housekeeper who was returning to work. It noted staff used the facility's van to return him to the facility. It noted he told staff he walked out behind a visitor. It noted he was assessed to have no injuries. It noted he was placed on 15 minute monitoring. Additional review of Resident #1's clinical record revealed the following: - The Admission Face Sheet documented Resident #1 admitted to the facility on [DATE], was [AGE] years-of-age and had a State appointed guardian. - A History and Physical, [DATE], documented his [DIAGNOSES REDACTED]. - The February 2011 Physician's Recapitulation Order documented Resident #1 received routine medications for the treatment of [REDACTED]. - A quarterly MDS Resident Assessment, dated [DATE], documented his mental status was stable, he had no [MEDICAL CONDITION], but his behaviors included [MEDICAL CONDITION] and a behavior related to either hitting/scratching, packing, rummaging, or making disruptive sounds, but no evidence of wandering. It further noted he was independently ambulatory and stood 72 inches (6 feet, 2 inches) tall and weighed 217 pounds. - The care plan, dated [DATE], documented he was at high risk of elopement and that he would be monitored every one hour - There was no evidence of the one-hour monitoring contained within his clinical record for [DATE] through [DATE]. - An Elopement Risk Assessment form, completed on [DATE], 1

Based on interviews and record reviews, it was determined the facility failed to implement their written policy for neglect prevention when for 2 of 6 sampled residents (Residents #1 and #3), who exhibited a behavior of exit seeking behaviors, the facility - 1) Failed to ensure staff were made aware Resident #3, a new admission, had a current history of wandering and exit seeking. 2) Failed to ensure staff provided Resident #3 an appropriate level of supervision to prevent him from exiting the facility and going into a fenced yard during an arctic cold front with snow on the sidewalks and ground. 3) Failure to ensure staff provided Resident #1 an appropriate level of supervision to prevent him from eloping and being found approximately 128 miles from the facility. Resident #3, who had resided in the facility less than 12 hours, exited the facility at approximately 4:15 a.m. and remained outside in a wind chill factor of -10 to -13F. During the timeframe he was outside, the night shift charge nurse failed to conduct observation rounds every two hours and at shift change, the night shift charge nurse and day shift charge nurse failed to conduct walking shift change observation rounds. As a result, at approximately 8:00 a.m., staff realized Resident #3 was missing and found him lying face down on the snow. He was unresponsive with no pulse, his body cold and stiff, and an abrasion on his forehead and knuckles. He was transferred to a local hospital where his death was pronounced as due to acute hypothermia. Resident #1, who had a history of [REDACTED]. Failure to supervise Resident #1 placed him at risk of physical harm or death. This led to the identification of an Immediate Jeopardy on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity of actual harm and a scope of pattern due to not all employees had been in-serviced regarding supervision of exiting seeking residents and monitoring of staff to ensure they were providing an appropriately level of supervision for residents with exit seeking behavior. The facility identified 5 residents as exhibiting a behavior of exit seeking, 2 residents as having a history of elopement, 7 residents at high risk to elope, and 18 residents as expressing a desire to leave. All 18 residents were placed at risk of harm due to staff failure to provide an appropriate level supervision to prevent incidents of exiting the facility unsupervised. The evidence is as follows: I. POLICY Review of facility policy titled "Abuse Prevention Program," revised [DATE], documented: "Neglect is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish or mental illness." It documented signs and symptoms of neglect included "inadequate provision of care," and leaving someone unattended who needs supervision" Review of facility's policies titled "Wandering Residents," revised [DATE], documented: "Every effort will be made to prevent wandering episodes while maintaining the least restrictive environment for residents who are at risk of elopement. It documented that if a "resident repeatedly wanders off the unit, a monitoring schedule will be implemented to ensure resident safety. The resident's care plan will be documented as the implementation of the monitoring schedule." II. RESIDENT #3 During an interview with the Administrator, DON and MD "A" , on [DATE] at 12:50 p.m., the Administrator said that on that morning ([DATE]) at approximately 8:00 a.m., Resident #3 was found unresponsive lying outside on the snow covered ground. The Administrator said their exterior cameras revealed Resident #3 had been outside since 4:00 a.m. MD "A" said at 9:22 a.m., he pronounced Resident #3's death at the local hospital. The Administrator said Resident #3 had admitted to their facility the prior evening around 9:30 p.m., along with 7 other residents from a nursing facility that was closing. The DON said she had assessed Resident #3 at the facility he discharged from. The DON said Resident #3 had resided in a secured (locked) unit and exhibited a behavior of wandering. The Administrator said they admitted Resident #3 because they could provide him a secured environment. When asked if they used exit door alarms, he said, "No," the facility grounds were secured by fences with locked gates. The Administrator added that due to an incident of Resident #1 eloping from the facility the prior weekend (1-,[DATE]-11), nurses had been in-serviced on [DATE] to conduct shift change walking rounds when giving report and to observe the residents during report. At that time, review of the documented in-service, dated [DATE], revealed the DON conducted the in-service with 7 nurses. The form documented the DON instructed the nurses to make walking rounds every 2 hours to observe each resident and to conduct walking rounds when given report. The DON explained "given report" meant giving report during shift change. Observations of the facility with the Administrator on [DATE], starting at 1:30 p.m., revealed the following: - The shape of the facility resembled a bicycle wheel. The center (rotunda area) housed the nurses' station which was in view of the six resident room halls and entry/TV/lobby area. The nurses' station had a monitor for viewing the real-time events captured by 8 exterior cameras. Five of the six resident room halls were used to house residents: Halls B, C, D, E and F. - The exterior grounds had four fenced areas: 1) Main Entrance with a coded gate entrance, 2) From Hall A to Hall C, 3) Patio off the dining room, and 4) From Hall D to Hall F. Each resident room hall extended out in a "V" shape. The Administrator pointed out where 8 cameras were mounted at each exit door. The Administrator said each camera captured activity in the area of the exit door and the open yard area, not within the "V" shape. The Administrator also said Resident #3 was found in the area of a gray storage building between Halls D and Hall E. Two storage buildings were located within the area: a gray wooden structure and a metal structure. The gray structure was nearest the sidewalk that ran the length of the yard between the three resident room halls. It was noted that snow covered the ground up to the Investigator's ankles. During subsequent interviews with LVN "H" and RN "G", they revealed Resident #3 was found lying face down on the snow behind the storage buildings, not near the sidewalk by the gray storage building, which was an area not view of the Hall D or Hall E cameras. The interviews occurred on [DATE] at 5:20 p.m. and [DATE] at 12:57 p.m., respectively. Observations of the video from the Hall D and Hall E cameras for the morning of [DATE], revealed Resident #3 was outside unsupervised in the area of Hall D and Hall E from 4:12 a.m. to 4:14 a.m., then 4:25 a.m. to 4:27 a.m., then 4:45 a.m. to 4:49 a.m., then 4:53 a.m. to 5:15 a.m. At 5:15 a.m., he went into the "blind spot" between Hall D and Hall E, but never left the area until staff discovered him at around 8:15 a.m. and carried him into the facility at 8:16 a.m. It was also noted that during the above times, Resident #3 fell 7 times. The following was observed: - At 4:12 a.m., Resident #3 went out the Hall E door and onto the fenced yard. He walked upright with a bundle of what appeared to be clothing in his arms. He walked on the sidewalk from Hall E exit toward Hall D. He walked through a snow drift on the Hall E side of a gray storage building near the sidewalk and then veered off the sidewalk as he passed a gray storage building on the Hall D side of the storage building. He then walked through the snow covered ground with snow up above his ankles. - At 4:45 a.m., Resident #3 came in view of the Hall E camera from the direction of Hall F. He appeared to have a garment dangling from his right hand. As he passed the entry to Hall E, he fell , bracing his fall with his hands. - At 4:53 a.m., Resident #3 re-entered the view of the Hall E camera from the direction of Hall F. He walked near the fence through the snow, then slowly walked out onto sidewalk. He appeared to wobble as he walked. He then fell to hands and knees at a snow drift, which crossed the sidewalk path. - At 4:58 a.m., he started to stand, but fell to his left side on the snow covered ground. - At 5:01 a.m., after attempting to gathering the items he dropped, he stood, but then fell forward on his hands and knees onto the sidewalk by the snow drift. He then stands and walks a few paces, then turns and retrieves the bundle he had gathered on the ground and walks toward Hall D. - At 5:02 a.m., he wobbles as he slowly walks through the snow near the Hall D exit and then into a "blind spot" between Hall D and the storage buildings. - At 5:07 a.m., Resident #3 was again in view of the Hall E camera standing upright carrying a bundle. With a slow gait, he came to the snow drift on the sidewalk and fell face down. - At 5:08 a.m., he stood and stumbled to the fence and then grabbed the fence as if to stable himself. He then turn and attempted to retrieve his bundle, and fell . At that time, it appeared he struck his head on the snow covered ground. - At 5:11 a.m., he stood and started to walk, but again fell . He then stood again and with an unsteady gait, he walked a few paces to the fence and leaned against the fence. - At 5:14 a.m., Resident #3 had his bundle and walked with an unsteady gait, while leaning slightly forward, and went around the storage building. He then walked through the snow covered ground up to the Hall D exit door, but then turned and walked out of view of the Hall D and Hall E cameras, which would be the area to the sides and behind the storage buildings. - Starting at 8:02 a.m., staff began exiting Hall D. - At 8:16 a.m., five plus staff came in view of the Hall D camera pulling blanket around from the direction of the backside of the two storage buildings, which left an indentation in the snow and dirt. They stopped outside Hall D, then they all lifted the blanket with what appeared to contain Resident #3's body and entered Hall D. At that same time, a video camera of the main entry area showed EMS personnel arriving and then exiting the facility with Resident #3 on a stretcher at 8:27 a.m. A temperature log for [DATE], received from the National Weather Service, revealed that for the city where the nursing facility was located, the temperatures were as follows: - From 4:00 a.m. to 7:15 a.m., the temperature was 6 F with wind gust ranging from 13 to 18 mph and sustained winds of 11 to 14 mph. - From 7:20 a.m. to 7:55 a.m., the temperature was 5 F with wind gust ranging from 15 to 18 mph with sustained winds of 12 to 13 mph. - At 8:00 a.m., the temperature was 4 F with wind gust of 15 mph with a sustained wind of 12 mph. The National Oceanic and Atmospheric Administration's (NOAA) Wind Chill Chart, effective [DATE], documented the following: - At a temperature of 5F and a wind speed of 10 mph, the ambient temperature is -10F. - At a temperature of 5F and a wind speed of 15 mph, the ambient temperature is -13F. The CDC (Center of Disease Control) documented the following in a pamphlet titled " Extreme Cold, A Prevention Guide to Promote Your Personal Health and Safety " and obtained online at <http://www.bt.cdc.gove/disasters/winter/> (no date) - - Whenever temperatures drop decidedly below normal and as wind speed increases, heat can leave the body more rapidly. - Elderly individuals are at greater risk of hypothermia because they often make less body heat due to a slower metabolism and less physical activity. - Hypothermia or abnormally low body temperature is most likely at very cold temperatures and can occur at 40F. - If the body temperature falls below 95F, the situation is a medical emergency. - Even if the victim appears dead, CPR should be provided. In some cases, hypothermia victims who appear to be dead can be successfully resuscitated. Review of Resident #3's clinical record revealed the following: - The Admission Face Sheet documented he admitted to the facility on [DATE] at 2130 (9:30 p.m.) at the age of 71. It also noted his [DIAGNOSES REDACTED]. - There was no documented pre-admission assessment or admission assessment. During an interview with the DON on [DATE] at 2:37 p.m., she said she did not complete a written pre-admission assessment; she only observed him and reviewed his clinical record at the prior facility. Review of Resident #3's clinical record from the prior facility revealed the following: - He had a DNR (Texas Standard Out-of-Hospital Do-Not-Resuscitate Order). - A quarterly Minimum Data Set (MDS) Resident Assessment, dated [DATE], documented he had severe cognitive impairment, exhibited a behavior of wandering, which was not easily altered, and he resided on an Alzheimer's/dementia special care unit. - The Care Plan with a print date of [DATE], documented he resided on a locked unit and he was at high risk for elopement. - The nurse's notes, dated [DATE] for the 6:00 p.m. to 6:00 a.m. shift, documented an incident of elopement, which occurred at approximately 2:00 a.m. Further review of Resident #3's current clinical record revealed the following: - The nurse's notes, dated [DATE], completed by RN "C", documented Resident #3's time of admission as 2030 (8:30 p.m.), not 9:30 p.m. as noted on the Admission Face Sheet. It noted he was confused, had a history of [REDACTED]. Monitored for elopement precautions." - There was no evidence contained within the record to indicate Resident #3 was monitored as noted in the above nurses' note written by RN "C" or to indicate the two nurses on duty the night of 2-,[DATE]-11 (RN "C" and LVN "D") implemented the facility's required every two hour observation rounds as per the in-serviced conducted by the DON on [DATE]. - The next nurse's notes entry was not until the following morning ([DATE]). At 8:00 a.m., RN "B" noted Resident #3 was found outside Hall E, behind a storage building. It noted he was in a prone position (face down), unresponsive and his skin was cold to touch. It noted when he was turned over and assessed, he had stiffness with no purposeful body movements, his eyes open with pupils full blown (dilated) and nonreactive. It also noted he had no palpable pulse and no spontaneous breath sounds. It noted he arrived from another facility the prior night and that they had no medical or personal information regarding Resident #3. It noted they initiated CPR. - RN "B" nurse's note for [DATE] at 8:15 a.m., noted emergency medical services (EMS) was called. It also noted Resident #3 had a 6 cm (2.36 inches) abrasion to his forehead and his pants were down to his knees. RN "B" noted at 8:18 a.m., EMS personnel arrived and took over his care. RN "B" noted at 8:30 a.m., Resident #3 was transferred to a local hospital. - The record contained no additional information regarding the status of Resident #3. Review of Resident #3's local hospital closed record documented the following: - The EMS Pre-Hospital Patient Care Report, dated [DATE], documented they arrived at the nursing facility at 8:20 a.m. and Resident #3 was receiving CPR from two nursing facility employees. It documented he was unconscious, unresponsive and in [MEDICAL CONDITION]. It noted he had a temperature of 69F and his skin was "extremely" cold, stiff and blackened on his hands and feet. It noted he had an abrasion type [MEDICATION NAME] wound across his forehead and abrasions to the knuckles of both hands. It noted they took over the CPR and used a defibrillator twice prior to transporting him to the local hospital and once while in route, but he remained in V-fib. (According to the American Heart Association, V-fib (ventricular fibrillation) is a serious medical condition in which the heart's electrical activity becomes disordered and can result in collapse and sudden cardiac death within minutes unless medical help is provided immediately. Website: http://www.americanheart.org). - The Emergency Department Triage form documented he arrived at 8:51 a.m. and continued to remain unresponsive with fixed/dilated pupils and no gag reflex. It also noted the abrasion to his forehead measured 5 cm in length (1.97 inches) with no hematoma noted. It noted that at 8:51 a.m., he had a temperature of 68.7F and at 9:22 a.m. (time death pronounced) his temperature was 77.2F. - The emergency room Note, completed by MD "A", dated [DATE], noted Resident #3 was given [MEDICATION NAME] upon arrival and two rounds of [MEDICATION NAME]. (Note: The 12th Edition of the Geriatric Dosage Handbook, copyright 2007 by Lexi-Comp Inc., pages 76, noted [MEDICATION NAME] may be used for [MEDICAL CONDITION] with persistent irregular heart rate when defibrillation, CPR, and vasopressor administration have failed. On page 502, it noted [MEDICATION NAME] may be used to stimulate the heart when the individual is in asystole (without heart beat).) MD "A" also noted that with re-warming and resuscitation efforts, they brought Resident #3's core body temperature up to 80F, but he remained unresponsive and in asystole. He noted they inserted a Foley catheter, but no urine was obtained. He noted Resident #3 was pronounced dead at 9:22 a.m. with the cause of death noted as acute hypothermia. He then noted: "appears patient has passed away due to a fall he sustained while outside after leaving his room at the facility to the yard where apparently he fell hitting his head. Patient may have suffered a snycopal episode and while being out in the cold weather he suffered from severe hypothermia as the temperature was only 5 to 6 degrees F this morning." Review of the computer-generated timesheets for [DATE] and [DATE] revealed the following: - On [DATE] from 11:00 p.m. to [DATE] at 6:00 a.m., there were 4 staff on duty: 2 nurses (RN "C" and LVN "D") and 2 nurse aides (CNA "E" and CNA "F"). RN "C" remained on duty until 7:32 a.m. and LVN "D" remained on duty until 7:48 a.m. - On [DATE], there were 2 nurses, 7 certified nurse aides, 1 resident aide, and 1 medication aide assigned to the day shift (6:00 a.m. to 6:00 p.m.). The two charge nurses were RN "G" (arrived at 6:05 a.m.) and LVN "H" (arrived at 6:22 a.m.). One aide had worked the night shift and six aides arrived between 5:03 a.m. and 6:29 a.m. During an interview with the Administrator on [DATE] at 2:10 p.m., he said on [DATE] at approximately 4:00 p.m., he was notified the facility Resident #3 discharged from was closing. He said he sent his DON and ADON "K" to the facility. He said at approximately 9:30 p.m., two vehicles arrived with 8 residents to admit from the facility that was closing. He said at that time, he had 10 staff on duty to assist with admitting the residents and getting them settled into their new rooms. He said they had already scheduled 2 nurses and 3 nurse aides to work from 11:00 p.m. to 6:00 a.m., but one aide called in and did not come to work. He said they called multiple staff, but not one was available to work. When asked if he considered the use of agency staff, he said he had already left and they did not discuss that option. When asked what time he left, he said around 10:00 p.m. He said when he left the facility, there were still additional staff in the facility, but at 11:00 p.m., only 2 nurses and 2 nurse aides would remain on duty to care for the current residents and 8 new admissions. He added that RN "C" knew the residents since he had worked at the other facility the prior week. During an interview with the DON on [DATE] at 3:30 p.m., she said she and ADON "K" along with two additional staff went to the nursing facility that was closing on [DATE] and determined 8 residents could be admitted to their facility that evening. She said they arrived at their facility at approximately 9:30 p.m. She said she was aware they would only have 2 nurses and 2 nurse aides on duty from [DATE] at 11:00 p.m. to [DATE] at 6:00 a.m. She said they called "everyone," but no one was available. She said they did not consider the use of agency staff. She said RN "C", who had worked at the other nursing facility for approximately one week, had told her "he had it covered," so she left at approximately 10:30 p.m. During an interview with the Administrator of Resident #3's prior facility on [DATE] at 11:25 a.m., he said when Resident #3 resided at his nursing facility, he routinely set off fire alarms and knew this would release the exit doors and gates. He said when a fire alarms went off, staff immediately went to the secured unit to look for Resident #3. He said he was aware the current facility did not have an actual secured unit, but he thought the fenced grounds would provide Resident #3 an area to wander in. He said he "assumed" staff would monitor their videos of the exterior cameras and the staff would monitor Resident #3 to prevent him from going out in the extremely cold weather. During an interview with RN "C" on [DATE] at 12:55 p.m., he confirmed he worked the night shift on 2-,[DATE]-11 when they admitted 8 new residents around 9:30 p.m. He said he had worked with the new residents the prior week at the facility they were discharging from. He said he was aware Resident #3 had resided on a secured unit. He added that he was not Resident #3's charge nurse the night he admitted , although, he had assisted with his care. He said Resident #3 remained in his room until 2:30 a.m. to 3:00 a.m. and then went and sat in the TV/lobby area with his coat and cap on, plus he carried a bundle of clothes. He said he saw Resident #3 around 5:00 a.m. and at no time did he see him exit the facility. He added that usually the night shift had 2 nurses and 3 nurse aides, but on that night, one aide called in sick. He said they did not have a sufficient number of staff to meet the individual needs of the residents due to the admission of 8 new residents. When asked if he had received training or had access to a policy related to adverse weather conditions, he said he was aware of no policy and he had received no training regarding weather extremes and monitoring of residents during cold weather. During an interview with LVN "D" on [DATE] at 4:03 p.m., she confirmed she worked the night shift on 2-,[DATE]-11 and was the charge nurse for Halls B, C and half of Hall D. She said on the evening of [DATE], between 8:00 p.m. and 9:00 p.m., they admitted 8 new residents from a facility that was closing. She said Resident #3 was one of the residents. She said Resident #3 was assigned a room on Hall B. She said she was not told he exhibited a behavior of wandering or exit seeking, although, she was aware he had wandered about their facility throughout the night. She said during the night, Resident #3 stepped out the Hall F exit door, but he turned around and came back in the facility (time unknown). She said she also saw him in the facility around 5:00 a.m. to 5:30 a.m. LVN "D" also said she had recently been in-serviced regarding ensuring they conduct shift change walking rounds and rounds every two hours. She said that night (2-,[DATE]-11), she did not make rounds every two hours due to helping the two nurse aides provide care for the residents. She further said she did not make the shift change walking rounds with the on-coming nurse. She concluded by noting that on the night of 2-,[DATE]-11, they did not have an adequate number of staff to meet the individual needs of the residents. She said no additional staff had been assigned to assist them even though they had 8 new residents, plus, the 12 to 15 current residents who were usually up at night. During an interview with CNA "E" on [DATE] at 11:35 p.m., she confirmed she worked the night shift on 2-,[DATE]-11. She said when the 8 new residents arrived, they were told their names and then told to assist them to their room. She said she was not told Resident #3 had a behavior of wandering or exit seeking. She said she did not recall seeing Resident #3 up wandering until around 2:30 a.m. to 3:00 a.m. She said he was dressed and carrying a bundle of clothes. She said during the night (time unknown), she heard LVN "D" tell LVN "C" that she thought she saw someone outside. She said they had assumed it was Resident #15, but he was in bed asleep. She said no one went outside to see if a resident was outside in the cold. She said they did not make rounds during the night to observe each resident, because they did not have enough staff to provide care and make the observations rounds. She said when she and the other nurse aide provided care for the residents, they "jumped" from hall to hall. During an interview with LVN "H" on [DATE] at 5:20 p.m., she confirmed she worked the day shift (6:00 a.m. to 6:00 p.m.) on [DATE]. She said she arrived late, around 6:15 a.m., due to the weather. She said she was assigned as charge nurse for Halls B, C and one-half of Hall D. She said when she arrived, she and the off-going nurse (LVN "D") did not make walking rounds together. She said LVN "D" told her "everything was fine". She said after completing other tasks, she she went to the dining room and noted Resident #3 was not in the dining room. She said she then went to his room and discovered he was not in his room. She said when she could not locate him, she notified the other staff and they began looking for him. She said RN "G" found Resident #3 outside between Halls D and E. She said when she arrived, she saw Resident #3 lying face down in the snow behind two storage buildings between Halls D and E. She said he had a coat and cap on, but his jeans were down around his knees, and he was wearing only one tan corduroy house shoe. She said when they rolled him over, she noted his eyes and mouth were open and he was cold to touch. She said with the help of other staff, they carried him to a room on Hall D and she and RN "G" initiated CPR. She said EMS personnel arrived shortly thereafter and took over. She added that she was aware of the no weather related facility policy that provided guidance regarding cold temperatures and what measures to take to reduce the risk of residents developing hypothermia. She further said she had worked late the night of [DATE] and had been present when the 8 new residents arrived. She said when she left she recalled Resident #3 being in bed. She said when she left she was aware the night shift would only have 2 nurses and 2 nurse aides after 11:00 p.m. with no additional staff arriving to assist with the residents. During an interview with RN "G" on [DATE] at 12:57 p.m., she confirmed she worked the day shift on [DATE]. She said she was the charge nurse for one-half of Hall D, plus Halls E and F. She said when LVN "H" told her she could not find Resident #3, she began assisting with looking for him. She said she went out on the grounds of the facility and found Resident #3 lying face down behind two storage buildings located between Halls D and E. She said his pants were down around his knees and ice crystals had formed on his hips. She said when staff arrived, they rolled him over. She said he was "stiff as a board" and "frozen to death". She said his eyes and mouth were open and he had an abrasion on his forehead. She said while she waited for staff assistance, she called 911 with her cell phone. She said staff assisted with carrying Resident #3 to a room on Hall D and she and LVN "G" initiated CPR until EMS personnel arrived and took over. She said she was aware of no policy related to inclement weather. III. RESIDENT #1 Review of Resident #1's nurses' notes, completed by LVN "C", revealed on Sunday, [DATE], at 1:00 a.m., Resident #1 was discovered missing. It noted Resident #1 was not located until 2:10 p.m. when police notified the facility he was found in Aspermont, Texas, a town two hours away from the facility. An on-line mileage calculator with MapQuest (http://classic.mapquest.com/) documented the distance from the facility to the town of Aspermont was 127.94 miles. Further review of Resident #1's nurse's notes, dated [DATE], documented police returned Resident #1 to the facility at 6:30 p.m. It noted he was assessed to have no injuries. The notes further documented that when staff first realized he was missing (on Sunday, [DATE], at 1:00 a.m.), staff had observed his bed was made and his closet was empty of his clothes. It noted the local police were notified at 1:15 a.m. It noted calls were made to staff from the day shift (6:00 a.m. to 6:00 p.m.), which revealed the following: - CNA "I" told them that on Saturday, [DATE], around 5:30 p.m., she had answered the activated call light for his room and he was not in his room at that time. - CNA "F" told them she last saw Resident #1 during the noon meal on Saturday, [DATE]. Review of the Incident/Accident (I/A) Reports for [DATE] through the 3rd of February 2011 and additional review of Resident #1's nurses' notes revealed prior to the above incident, there had been two additional incidents of elopement. - An I/A Report documented on [DATE], he was found one block from the facility. - His nurse's notes, dated [DATE], documented at 1315 (1:15 p.m.), Resident #1 was found on the Tahoka highway by a housekeeper who was returning to work. It noted staff used the facility's van to return him to the facility. It noted he told staff he walked out behind a visitor. It noted he was assessed to have no injuries. It noted he was placed on 15 minute monitoring. Additional review of Resident #1's clinical record revealed the following: - The Admission Face Sheet documented Resident #1 admitted to the facility on [DATE], was [AGE] years-of-age and had a State appointed guardian. - A History and Physical, [DATE], documented his [DIAGNOSES REDACTED]. - The February 2011 Physician's Recapitulation Order documented Resident #1 received routine medications for the treatment of [REDACTED]. - A quarterly MDS Resident Assessment, dated [DATE], documented his mental status was stable, he had no [MEDICAL CONDITION], but his behaviors included [MEDICAL CONDITION] and a behavior related to either hitting/scratching, packing, rummaging, or making disruptive sounds, but no evidence of wandering. It further noted he was independently ambulatory and stood 72 inches (6 feet, 2 inches) tall and weighed 217 pounds. - The care plan, dated [DATE], documented he was at high risk of elopement and that he would be monitored every one hour - There was no evidence of the one-hour monitoring contained within his clinical record for [DATE] through [DATE]. - An Elopement Risk Assessment form, completed on [DATE], [DATE], [DATE] and [DATE], documented he had cognitive impairment with poor decision-making skills and at least one [DIAGNOSES REDACTED]. The assessments for [DATE], [DATE] and [DATE] documented he was not accepting placement in the nursing facility; he openly expressed a desire to go home, he packed his belongings to go home or stayed near an exit door; and he left the facility without supervision and without informing staff. The interventions included placement on a secured unit, frequent monitoring - check every hour and as needed, and staff staying aware of his wandering risk. During an interview with the Administrator, DON and MD "A", on [DATE] at 12:50 p.m., the Administrator said the facility was a secured unit based on fact they had a coded gate entrance and three locked fenced areas around the facility to prevent residents from leaving the facility grounds. Therefore, the Elopement Risk Assessment form's documented intervention of placement on a secured unit, did not provide a change to reduce the risk of further incidents of eloping from the facility. During an interview with Resident #1 on [DATE] at 7:27 a.m., he was observed in his room, seated at the side of his bed. He confirmed he had recently left the facility.

Based on interviews and record reviews, it was determined the facility failed to utilize resources effectively and efficiently when - 1) The Administrator failed to ensure all nursing staff were trained regarding their policy related to residents who exhibited a behavior of wandering. 2) DON failed to ensure new nursing staff were trained regarding monitoring of residents per an in-service training, dated [DATE]. 3) LVN "D" failed to conduct the assigned observation rounds every two hours and at shift change. Resident #3, who had resided in the facility less than 12 hours, exited the facility at approximately 4:15 a.m. and remained outside in a wind chill factor of -10 to -13F. During the timeframe he was outside, the night shift charge nurse failed to conduct observation rounds every two hours and at shift change, the night shift charge nurse and day shift charge nurse failed to conduct walking shift change observation rounds. As a result, at approximately 8:00 a.m., staff realized Resident #3 was missing and found him lying face down on the snow. He was unresponsive with no pulse, his body cold and stiff, and an abrasion on his forehead and knuckles. He was transferred to a local hospital where his death was pronounced as due to acute hypothermia. Resident #1, who had a history of [REDACTED]. Failure to supervise Resident #1 placed him at risk of physical harm or death. This led to the identification of an Immediate Jeopardy on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity of actual harm and a scope of pattern due to not all employees had been in-serviced regarding supervision of exiting seeking residents and monitoring of staff to ensure they were providing an appropriately level of supervision for residents with exit seeking behavior. The facility identified 5 residents as exhibiting a behavior of exit seeking, 2 residents as having a history of elopement, 7 residents at high risk to elope, and 18 residents as expressing a desire to leave. All 18 residents were placed at risk of harm due to staff failure to provide an appropriate level supervision to prevent incidents of exiting the facility unsupervised. The facility employed 13 nurses, 3 medication aides and 27 nurse aides. The evidence is as follows: I. RESIDENT #3 During an interview with the Administrator, DON and MD "A" , on [DATE] at 12:50 p.m., the Administrator said that on that morning ([DATE]) at approximately 8:00 a.m., Resident #3 was found unresponsive lying outside on the snow covered ground. The Administrator said their exterior cameras revealed Resident #3 had been outside since 4:00 a.m. MD "A" said at 9:22 a.m., he pronounced Resident #3's death at the local hospital. The Administrator said Resident #3 had admitted to their facility the prior evening around 9:30 p.m., along with 7 other residents from a nursing facility that was closing. The DON said she had assessed Resident #3 at the facility he discharged from. The DON said Resident #3 had resided in a secured (locked) unit and exhibited a behavior of wandering. The Administrator said they admitted Resident #3 because they could provide him a secured environment. When asked if they used exit door alarms, he said, "No," the facility grounds were secured by fences with locked gates. The Administrator added that due to an incident of Resident #1 eloping from the facility the prior weekend (1-,[DATE]-11), nurses had been in-serviced on [DATE] to conduct shift change walking rounds when giving report and to observe the residents during report. At that time, review of the documented in-service, dated [DATE], revealed the DON conducted the in-service with 7 nurses. The form documented the DON instructed the nurses to make walking rounds every 2 hours to observe each resident and to conduct walking rounds when given report. The DON explained "given report" meant giving report during shift change. Observations of the facility with the Administrator on [DATE], starting at 1:30 p.m., revealed the following: - The shape of the facility resembled a bicycle wheel. The center (rotunda area) housed the nurses' station which was in view of the six resident room halls and entry/TV/lobby area. The nurses' station had a monitor for viewing the real-time events captured by 8 exterior cameras. Five of the six resident room halls were used to house residents: Halls B, C, D, E and F. - The exterior grounds had four fenced areas: 1) Main Entrance with a coded gate entrance, 2) From Hall A to Hall C, 3) Patio off the dining room, and 4) From Hall D to Hall F. Each resident room hall extended out in a "V" shape. The Administrator pointed out where 8 cameras were mounted at each exit door. The Administrator said each camera captured activity in the area of the exit door and the open yard area, not within the "V" shape. The Administrator also said Resident #3 was found in the area of a gray storage building between Halls D and Hall E. Two storage buildings were located within the area: a gray wooden structure and a metal structure. The gray structure was nearest the sidewalk that ran the length of the yard between the three resident room halls. It was noted that snow covered the ground up to the Investigator's ankles. During subsequent interviews with LVN "H" and RN "G", they revealed Resident #3 was found lying face down on the snow behind the storage buildings, not near the sidewalk by the gray storage building, which was an area not view of the Hall D or Hall E cameras. The interviews occurred on [DATE] at 5:20 p.m. and [DATE] at 12:57 p.m., respectively. Observations of the video from the Hall D and Hall E cameras for the morning of [DATE], revealed Resident #3 was outside unsupervised in the area of Hall D and Hall E from 4:12 a.m. to 4:14 a.m., then 4:25 a.m. to 4:27 a.m., then 4:45 a.m. to 4:49 a.m., then 4:53 a.m. to 5:15 a.m. At 5:15 a.m., he went into the "blind spot" between Hall D and Hall E, but never left the area until staff discovered him at around 8:15 a.m. and carried him into the facility at 8:16 a.m. It was also noted that during the above times, Resident #3 fell 7 times. The following was observed: - At 4:12 a.m., Resident #3 went out the Hall E door and onto the fenced yard. He walked upright with a bundle of what appeared to be clothing in his arms. He walked on the sidewalk from Hall E exit toward Hall D. He walked through a snow drift on the Hall E side of a gray storage building near the sidewalk and then veered off the sidewalk as he passed a gray storage building on the Hall D side of the storage building. He then walked through the snow covered ground with snow up above his ankles. - At 4:45 a.m., Resident #3 came in view of the Hall E camera from the direction of Hall F. He appeared to have a garment dangling from his right hand. As he passed the entry to Hall E, he fell , bracing his fall with his hands. - At 4:53 a.m., Resident #3 re-entered the view of the Hall E camera from the direction of Hall F. He walked near the fence through the snow, then slowly walked out onto sidewalk. He appeared to wobble as he walked. He then fell to hands and knees at a snow drift, which crossed the sidewalk path. - At 4:58 a.m., he started to stand, but fell to his left side on the snow covered ground. - At 5:01 a.m., after attempting to gathering the items he dropped, he stood, but then fell forward on his hands and knees onto the sidewalk by the snow drift. He then stands and walks a few paces, then turns and retrieves the bundle he had gathered on the ground and walks toward Hall D. - At 5:02 a.m., he wobbles as he slowly walks through the snow near the Hall D exit and then into a "blind spot" between Hall D and the storage buildings. - At 5:07 a.m., Resident #3 was again in view of the Hall E camera standing upright carrying a bundle. With a slow gait, he came to the snow drift on the sidewalk and fell face down. - At 5:08 a.m., he stood and stumbled to the fence and then grabbed the fence as if to stable himself. He then turn and attempted to retrieve his bundle, and fell . At that time, it appeared he struck his head on the snow covered ground. - At 5:11 a.m., he stood and started to walk, but again fell . He then stood again and with an unsteady gait, he walked a few paces to the fence and leaned against the fence. - At 5:14 a.m., Resident #3 had his bundle and walked with an unsteady gait, while leaning slightly forward, and went around the storage building. He then walked through the snow covered ground up to the Hall D exit door, but then turned and walked out of view of the Hall D and Hall E cameras, which would be the area to the sides and behind the storage buildings. - Starting at 8:02 a.m., staff began exiting Hall D. - At 8:16 a.m., five plus staff came in view of the Hall D camera pulling blanket around from the direction of the backside of the two storage buildings, which left an indentation in the snow and dirt. They stopped outside Hall D, then they all lifted the blanket with what appeared to contain Resident #3's body and entered Hall D. At that same time, a video camera of the main entry area showed EMS personnel arriving and then exiting the facility with Resident #3 on a stretcher at 8:27 a.m. A temperature log for [DATE], received from the National Weather Service, revealed that for the city where the nursing facility was located, the temperatures were as follows: - From 4:00 a.m. to 7:15 a.m., the temperature was 6 F with wind gust ranging from 13 to 18 mph and sustained winds of 11 to 14 mph. - From 7:20 a.m. to 7:55 a.m., the temperature was 5 F with wind gust ranging from 15 to 18 mph with sustained winds of 12 to 13 mph. - At 8:00 a.m., the temperature was 4 F with wind gust of 15 mph with a sustained wind of 12 mph. The National Oceanic and Atmospheric Administration's (NOAA) Wind Chill Chart, effective [DATE], documented the following: - At a temperature of 5F and a wind speed of 10 mph, the ambient temperature is -10F. - At a temperature of 5F and a wind speed of 15 mph, the ambient temperature is -13F. The CDC (Center of Disease Control) documented the following in a pamphlet titled " Extreme Cold, A Prevention Guide to Promote Your Personal Health and Safety " and obtained online at <http://www.bt.cdc.gove/disasters/winter/> (no date) - - Whenever temperatures drop decidedly below normal and as wind speed increases, heat can leave the body more rapidly. - Elderly individuals are at greater risk of hypothermia because they often make less body heat due to a slower metabolism and less physical activity. - Hypothermia or abnormally low body temperature is most likely at very cold temperatures and can occur at 40F. - If the body temperature falls below 95F, the situation is a medical emergency. - Even if the victim appears dead, CPR should be provided. In some cases, hypothermia victims who appear to be dead can be successfully resuscitated. Review of Resident #3's clinical record revealed the following: - The Admission Face Sheet documented he admitted to the facility on [DATE] at 2130 (9:30 p.m.) at the age of 71. It also noted his [DIAGNOSES REDACTED]. - There was no documented pre-admission assessment or admission assessment. During an interview with the DON on [DATE] at 2:37 p.m., she said she did not complete a written pre-admission assessment; she only observed him and reviewed his clinical record at the prior facility. Review of Resident #3's clinical record from the prior facility revealed the following: - He had a DNR (Texas Standard Out-of-Hospital Do-Not-Resuscitate Order). - A quarterly Minimum Data Set (MDS) Resident Assessment, dated [DATE], documented he had severe cognitive impairment, exhibited a behavior of wandering, which was not easily altered, and he resided on an Alzheimer's/dementia special care unit. - The Care Plan with a print date of [DATE], documented he resided on a locked unit and he was at high risk for elopement. - The nurse's notes, dated [DATE] for the 6:00 p.m. to 6:00 a.m. shift, documented an incident of elopement, which occurred at approximately 2:00 a.m. Further review of Resident #3's current clinical record revealed the following: - The nurse's notes, dated [DATE], completed by RN "C", documented Resident #3's time of admission as 2030 (8:30 p.m.), not 9:30 p.m. as noted on the Admission Face Sheet. It noted he was confused, had a history of [REDACTED]. Monitored for elopement precautions." - There was no evidence contained within the record to indicate Resident #3 was monitored as noted in the above nurses' note written by RN "C" or to indicate the two nurses on duty the night of 2-,[DATE]-11 (RN "C" and LVN "D") implemented the facility's required every two hour observation rounds as per the in-serviced conducted by the DON on [DATE]. - The next nurse's notes entry was not until the following morning ([DATE]). At 8:00 a.m., RN "B" noted Resident #3 was found outside Hall E, behind a storage building. It noted he was in a prone position (face down), unresponsive and his skin was cold to touch. It noted when he was turned over and assessed, he had stiffness with no purposeful body movements, his eyes open with pupils full blown (dilated) and nonreactive. It also noted he had no palpable pulse and no spontaneous breath sounds. It noted he arrived from another facility the prior night and that they had no medical or personal information regarding Resident #3. It noted they initiated CPR. - RN "B" nurse's note for [DATE] at 8:15 a.m., noted emergency medical services (EMS) was called. It also noted Resident #3 had a 6 cm (2.36 inches) abrasion to his forehead and his pants were down to his knees. RN "B" noted at 8:18 a.m., EMS personnel arrived and took over his care. RN "B" noted at 8:30 a.m., Resident #3 was transferred to a local hospital. - The record contained no additional information regarding the status of Resident #3. Review of Resident #3's local hospital closed record documented the following: - The EMS Pre-Hospital Patient Care Report, dated [DATE], documented they arrived at the nursing facility at 8:20 a.m. and Resident #3 was receiving CPR from two nursing facility employees. It documented he was unconscious, unresponsive and in [MEDICAL CONDITION]. It noted he had a temperature of 69F and his skin was "extremely" cold, stiff and blackened on his hands and feet. It noted he had an abrasion type [MEDICATION NAME] wound across his forehead and abrasions to the knuckles of both hands. It noted they took over the CPR and used a defibrillator twice prior to transporting him to the local hospital and once while in route, but he remained in V-fib. (According to the American Heart Association, V-fib (ventricular fibrillation) is a serious medical condition in which the heart's electrical activity becomes disordered and can result in collapse and sudden cardiac death within minutes unless medical help is provided immediately. Website: http://www.americanheart.org). - The Emergency Department Triage form documented he arrived at 8:51 a.m. and continued to remain unresponsive with fixed/dilated pupils and no gag reflex. It also noted the abrasion to his forehead measured 5 cm in length (1.97 inches) with no hematoma noted. It noted that at 8:51 a.m., he had a temperature of 68.7F and at 9:22 a.m. (time death pronounced) his temperature was 77.2F. - The emergency room Note, completed by MD "A", dated [DATE], noted Resident #3 was given [MEDICATION NAME] upon arrival and two rounds of [MEDICATION NAME]. (Note: The 12th Edition of the Geriatric Dosage Handbook, copyright 2007 by Lexi-Comp Inc., pages 76, noted [MEDICATION NAME] may be used for [MEDICAL CONDITION] with persistent irregular heart rate when defibrillation, CPR, and vasopressor administration have failed. On page 502, it noted [MEDICATION NAME] may be used to stimulate the heart when the individual is in asystole (without heart beat).) MD "A" also noted that with re-warming and resuscitation efforts, they brought Resident #3's core body temperature up to 80F, but he remained unresponsive and in asystole. He noted they inserted a Foley catheter, but no urine was obtained. He noted Resident #3 was pronounced dead at 9:22 a.m. with the cause of death noted as acute hypothermia. He then noted: "appears patient has passed away due to a fall he sustained while outside after leaving his room at the facility to the yard where apparently he fell hitting his head. Patient may have suffered a snycopal episode and while being out in the cold weather he suffered from severe hypothermia as the temperature was only 5 to 6 degrees F this morning." Review of the computer-generated timesheets for [DATE] and [DATE] revealed the following: - On [DATE] from 11:00 p.m. to [DATE] at 6:00 a.m., there were 4 staff on duty: 2 nurses (RN "C" and LVN "D") and 2 nurse aides (CNA "E" and CNA "F"). RN "C" remained on duty until 7:32 a.m. and LVN "D" remained on duty until 7:48 a.m. - On [DATE], there were 2 nurses, 7 certified nurse aides, 1 resident aide, and 1 medication aide assigned to the day shift (6:00 a.m. to 6:00 p.m.). The two charge nurses were RN "G" (arrived at 6:05 a.m.) and LVN "H" (arrived at 6:22 a.m.). One aide had worked the night shift and six aides arrived between 5:03 a.m. and 6:29 a.m. During an interview with the Administrator on [DATE] at 2:10 p.m., he said on [DATE] at approximately 4:00 p.m., he was notified the facility Resident #3 discharged from was closing. He said he sent his DON and ADON "K" to the facility. He said at approximately 9:30 p.m., two vehicles arrived with 8 residents to admit from the facility that was closing. He said at that time, he had 10 staff on duty to assist with admitting the residents and getting them settled into their new rooms. He said they had already scheduled 2 nurses and 3 nurse aides to work from 11:00 p.m. to 6:00 a.m., but one aide called in and did not come to work. He said they called multiple staff, but not one was available to work. When asked if he considered the use of agency staff, he said he had already left and they did not discuss that option. When asked what time he left, he said around 10:00 p.m. He said when he left the facility, there were still additional staff in the facility, but at 11:00 p.m., only 2 nurses and 2 nurse aides would remain on duty to care for the current residents and 8 new admissions. He added that RN "C" knew the residents since he had worked at the other facility the prior week. During an interview with the DON on [DATE] at 3:30 p.m., she said she and ADON "K" along with two additional staff went to the nursing facility that was closing on [DATE] and determined 8 residents could be admitted to their facility that evening. She said they arrived at their facility at approximately 9:30 p.m. She said she was aware they would only have 2 nurses and 2 nurse aides on duty from [DATE] at 11:00 p.m. to [DATE] at 6:00 a.m. She said they called "everyone," but no one was available. She said they did not consider the use of agency staff. She said RN "C", who had worked at the other nursing facility for approximately one week, had told her "he had it covered," so she left at approximately 10:30 p.m. During an interview with the Administrator of Resident #3's prior facility on [DATE] at 11:25 a.m., he said when Resident #3 resided at his nursing facility, he routinely set off fire alarms and knew this would release the exit doors and gates. He said when a fire alarms went off, staff immediately went to the secured unit to look for Resident #3. He said he was aware the current facility did not have an actual secured unit, but he thought the fenced grounds would provide Resident #3 an area to wander in. He said he "assumed" staff would monitor their videos of the exterior cameras and the staff would monitor Resident #3 to prevent him from going out in the extremely cold weather. During an interview with RN "C" on [DATE] at 12:55 p.m., he confirmed he worked the night shift on 2-,[DATE]-11 when they admitted 8 new residents around 9:30 p.m. He said he had worked with the new residents the prior week at the facility they were discharging from. He said he was aware Resident #3 had resided on a secured unit. He added that he was not Resident #3's charge nurse the night he admitted , although, he had assisted with his care. He said Resident #3 remained in his room until 2:30 a.m. to 3:00 a.m. and then went and sat in the TV/lobby area with his coat and cap on, plus he carried a bundle of clothes. He said he saw Resident #3 around 5:00 a.m. and at no time did he see him exit the facility. He added that usually the night shift had 2 nurses and 3 nurse aides, but on that night, one aide called in sick. He said they did not have a sufficient number of staff to meet the individual needs of the residents due to the admission of 8 new residents. When asked if he had received training or had access to a policy related to adverse weather conditions, he said he was aware of no policy and he had received no training regarding weather extremes and monitoring of residents during cold weather. During an interview with LVN "D" on [DATE] at 4:03 p.m., she confirmed she worked the night shift on 2-,[DATE]-11 and was the charge nurse for Halls B, C and half of Hall D. She said on the evening of [DATE], between 8:00 p.m. and 9:00 p.m., they admitted 8 new residents from a facility that was closing. She said Resident #3 was one of the residents. She said Resident #3 was assigned a room on Hall B. She said she was not told he exhibited a behavior of wandering or exit seeking, although, she was aware he had wandered about their facility throughout the night. She said during the night, Resident #3 stepped out the Hall F exit door, but he turned around and came back in the facility (time unknown). She said she also saw him in the facility around 5:00 a.m. to 5:30 a.m. LVN "D" also said she had recently been in-serviced regarding ensuring they conduct shift change walking rounds and rounds every two hours. She said that night (2-,[DATE]-11), she did not make rounds every two hours due to helping the two nurse aides provide care for the residents. She further said she did not make the shift change walking rounds with the on-coming nurse. She concluded by noting that on the night of 2-,[DATE]-11, they did not have an adequate number of staff to meet the individual needs of the residents. She said no additional staff had been assigned to assist them even though they had 8 new residents, plus, the 12 to 15 current residents who were usually up at night. During an interview with CNA "E" on [DATE] at 11:35 p.m., she confirmed she worked the night shift on 2-,[DATE]-11. She said when the 8 new residents arrived, they were told their names and then told to assist them to their room. She said she was not told Resident #3 had a behavior of wandering or exit seeking. She said she did not recall seeing Resident #3 up wandering until around 2:30 a.m. to 3:00 a.m. She said he was dressed and carrying a bundle of clothes. She said during the night (time unknown), she heard LVN "D" tell LVN "C" that she thought she saw someone outside. She said they had assumed it was Resident #15, but he was in bed asleep. She said no one went outside to see if a resident was outside in the cold. She said they did not make rounds during the night to observe each resident, because they did not have enough staff to provide care and make the observations rounds. She said when she and the other nurse aide provided care for the residents, they "jumped" from hall to hall. During an interview with LVN "H" on [DATE] at 5:20 p.m., she confirmed she worked the day shift (6:00 a.m. to 6:00 p.m.) on [DATE]. She said she arrived late, around 6:15 a.m., due to the weather. She said she was assigned as charge nurse for Halls B, C and one-half of Hall D. She said when she arrived, she and the off-going nurse (LVN "D") did not make walking rounds together. She said LVN "D" told her "everything was fine". She said after completing other tasks, she she went to the dining room and noted Resident #3 was not in the dining room. She said she then went to his room and discovered he was not in his room. She said when she could not locate him, she notified the other staff and they began looking for him. She said RN "G" found Resident #3 outside between Halls D and E. She said when she arrived, she saw Resident #3 lying face down in the snow behind two storage buildings between Halls D and E. She said he had a coat and cap on, but his jeans were down around his knees, and he was wearing only one tan corduroy house shoe. She said when they rolled him over, she noted his eyes and mouth were open and he was cold to touch. She said with the help of other staff, they carried him to a room on Hall D and she and RN "G" initiated CPR. She said EMS personnel arrived shortly thereafter and took over. She added that she was aware of the no weather related facility policy that provided guidance regarding cold temperatures and what measures to take to reduce the risk of residents developing hypothermia. She further said she had worked late the night of [DATE] and had been present when the 8 new residents arrived. She said when she left she recalled Resident #3 being in bed. She said when she left she was aware the night shift would only have 2 nurses and 2 nurse aides after 11:00 p.m. with no additional staff arriving to assist with the residents. During an interview with RN "G" on [DATE] at 12:57 p.m., she confirmed she worked the day shift on [DATE]. She said she was the charge nurse for one-half of Hall D, plus Halls E and F. She said when LVN "H" told her she could not find Resident #3, she began assisting with looking for him. She said she went out on the grounds of the facility and found Resident #3 lying face down behind two storage buildings located between Halls D and E. She said his pants were down around his knees and ice crystals had formed on his hips. She said when staff arrived, they rolled him over. She said he was "stiff as a board" and "frozen to death". She said his eyes and mouth were open and he had an abrasion on his forehead. She said while she waited for staff assistance, she called 911 with her cell phone. She said staff assisted with carrying Resident #3 to a room on Hall D and she and LVN "G" initiated CPR until EMS personnel arrived and took over. She said she was aware of no policy related to inclement weather. III. FACILITY POLICIES Review of the facility's policy titled "Wandering Residents," revised [DATE], documented: "Every effort will be made to prevent wandering episodes while maintaining the least restrictive environment for residents who are at risk of elopement. It documented that if a "resident repeatedly wanders off the unit, a monitoring schedule will be implemented to ensure resident safety. The resident's care plan will be documented as the implementation of the monitoring schedule." III. RESIDENT #1 Review of Resident #1's nurses' notes, completed by LVN "C", revealed on Sunday, [DATE], at 1:00 a.m., Resident #1 was discovered missing. It noted Resident #1 was not located until 2:10 p.m. when police notified the facility he was found in Aspermont, Texas, a town two hours away from the facility. An on-line mileage calculator with MapQuest (http://classic.mapquest.com/) documented the distance from the facility to the town of Aspermont was 127.94 miles. Further review of Resident #1's nurse's notes, dated [DATE], documented police returned Resident #1 to the facility at 6:30 p.m. It noted he was assessed to have no injuries. The notes further documented that when staff first realized he was missing (on Sunday, [DATE], at 1:00 a.m.), staff had observed his bed was made and his closet was empty of his clothes. It noted the local police were notified at 1:15 a.m. It noted calls were made to staff from the day shift (6:00 a.m. to 6:00 p.m.), which revealed the following: - CNA "I" told them that on Saturday, [DATE], around 5:30 p.m., she had answered the activated call light for his room and he was not in his room at that time. - CNA "F" told them she last saw Resident #1 during the noon meal on Saturday, [DATE]. Review of the Incident/Accident (I/A) Reports for [DATE] through the 3rd of February 2011 and additional review of Resident #1's nurses' notes revealed prior to the above incident, there had been two additional incidents of elopement. - An I/A Report documented on [DATE], he was found one block from the facility. - His nurse's notes, dated [DATE], documented at 1315 (1:15 p.m.), Resident #1 was found on the Tahoka highway by a housekeeper who was returning to work. It noted staff used the facility's van to return him to the facility. It noted he told staff he walked out behind a visitor. It noted he was assessed to have no injuries. It noted he was placed on 15 minute monitoring. Additional review of Resident #1's clinical record revealed the following: - The Admission Face Sheet documented Resident #1 admitted to the facility on [DATE], was [AGE] years-of-age and had a State appointed guardian. - A History and Physical, [DATE], documented his [DIAGNOSES REDACTED]. - The February 2011 Physician's Recapitulation Order documented Resident #1 received routine medications for the treatment of [REDACTED]. - A quarterly MDS Resident Assessment, dated [DATE], documented his mental status was stable, he had no [MEDICAL CONDITION], but his behaviors included [MEDICAL CONDITION] and a behavior related to either hitting/scratching, packing, rummaging, or making disruptive sounds, but no evidence of wandering. It further noted he was independently ambulatory and stood 72 inches (6 feet, 2 inches) tall and weighed 217 pounds. - The care plan, dated [DATE], documented he was at high risk of elopement and that he would be monitored every one hour - There was no evidence of the one-hour monitoring contained within his clinical record for [DATE] through [DATE]. - An Elopement Risk Assessment form, completed on [DATE], [DATE], [DATE] and [DATE], documented he had cognitive impairment with poor decision-making skills and at least one [DIAGNOSES REDACTED]. The assessments for [DATE], [DATE] and [DATE] documented he was not accepting placement in the nursing facility; he openly expressed a desire to go home, he packed his belongings to go home or stayed near an exit door; and he left the facility without supervision and without informing staff. The interventions included placement on a secured unit, frequent monitoring - check every hour and as needed, and staff staying aware of his wandering risk. During an interview with the Administrator, DON and MD "A", on [DATE] at 12:50 p.m., the Administrator said the facility was a secured unit based on fact they had a coded gate entrance and three locked fenced areas around the facility to prevent residents from leaving the facility grounds. Therefore, the Elopement Risk Assessment form's documented intervention of placement on a secured unit, did not provide a change to reduce the risk of further incidents of eloping from the facility. During an interview with Resident #1 on [DATE] at 7:27 a.m., he was observed in his room, seated at the side of his bed. He confirmed he had recently left the facility. He said the front gate (with a coded security system) was open and a man provided him transportation to a town named Aspermont, Texas. During an interview with RN "B", on [DATE] at 12:57 a.m., she confirmed she was on duty on Saturday ([DATE]) and Sunday ([DATE]) during the timeframe Resident #1 eloped from the facility. She said at the time staff discovered Resident #1 was missing on [DATE], he had been cleared of the prior incident ([DATE]) and no specific monitoring was occurring. She said on Saturday ([DATE]), she last

Based on interviews and record reviews, it was determined that for 2 of 6 sampled residents, who exhibited a behavior of wandering with exit seeking behaviors, the facility - 1) Failed to provide Resident #3 an appropriate level of supervision to prevent him from exiting the facility and going into a fenced yard during an arctic cold front with snow on the sidewalks and ground. 2) Failure to provide Resident #1 an appropriate level of supervision to prevent him from eloping and being found approximately 128 miles from the facility. Resident #3, who had resided in the facility less than 12 hours, exited the facility at approximately 4:15 a.m. and remained outside in a wind chill factor of -10 to -13F. During the timeframe he was outside, the night shift charge nurse failed to conduct observation rounds every two hours and at shift change, the night shift charge nurse and day shift charge nurse failed to conduct walking shift change observation rounds. As a result, at approximately 8:00 a.m., staff realized Resident #3 was missing and found him lying face down on the snow. He was unresponsive with no pulse, his body cold and stiff, and an abrasion on his forehead and knuckles. He was transferred to a local hospital where his death was pronounced as due to acute hypothermia. Resident #1, who had a history of [REDACTED]. Failure to supervise Resident #1 placed him at risk of physical harm or death. This led to the identification of an Immediate Jeopardy on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity of actual harm and a scope of pattern due to not all employees had been in-serviced regarding supervision of exiting seeking residents and monitoring of staff to ensure they were providing an appropriately level of supervision for residents with exit seeking behavior. The facility identified 5 residents as exhibiting a behavior of exit seeking, 2 residents as having a history of elopement, 7 residents at high risk to elope, and 18 residents as expressing a desire to leave. All 18 residents were placed at risk of harm due to staff failure to provide an appropriate level supervision to prevent incidents of exiting the facility unsupervised. The evidence is as follows: I. RESIDENT #3 During an interview with the Administrator, DON and MD "A" , on [DATE] at 12:50 p.m., the Administrator said that on that morning ([DATE]) at approximately 8:00 a.m., Resident #3 was found unresponsive lying outside on the snow covered ground. The Administrator said their exterior cameras revealed Resident #3 had been outside since 4:00 a.m. MD "A" said at 9:22 a.m., he pronounced Resident #3's death at the local hospital. The Administrator said Resident #3 had admitted to their facility the prior evening around 9:30 p.m., along with 7 other residents from a nursing facility that was closing. The DON said she had assessed Resident #3 at the facility he discharged from. The DON said Resident #3 had resided in a secured (locked) unit and exhibited a behavior of wandering. The Administrator said they admitted Resident #3 because they could provide him a secured environment. When asked if they used exit door alarms, he said, "No," the facility grounds were secured by fences with locked gates. The Administrator added that due to an incident of Resident #1 eloping from the facility the prior weekend (1-,[DATE]-11), nurses had been in-serviced on [DATE] to conduct shift change walking rounds when giving report and to observe the residents during report. At that time, review of the documented in-service, dated [DATE], revealed the DON conducted the in-service with 7 nurses. The form documented the DON instructed the nurses to make walking rounds every 2 hours to observe each resident and to conduct walking rounds when given report. The DON explained "given report" meant giving report during shift change. Observations of the facility with the Administrator on [DATE], starting at 1:30 p.m., revealed the following: - The shape of the facility resembled a bicycle wheel. The center (rotunda area) housed the nurses' station which was in view of the six resident room halls and entry/TV/lobby area. The nurses' station had a monitor for viewing the real-time events captured by 8 exterior cameras. Five of the six resident room halls were used to house residents: Halls B, C, D, E and F. - The exterior grounds had four fenced areas: 1) Main Entrance with a coded gate entrance, 2) From Hall A to Hall C, 3) Patio off the dining room, and 4) From Hall D to Hall F. Each resident room hall extended out in a "V" shape. The Administrator pointed out where 8 cameras were mounted at each exit door. The Administrator said each camera captured activity in the area of the exit door and the open yard area, not within the "V" shape. The Administrator also said Resident #3 was found in the area of a gray storage building between Halls D and Hall E. Two storage buildings were located within the area: a gray wooden structure and a metal structure. The gray structure was nearest the sidewalk that ran the length of the yard between the three resident room halls. It was noted that snow covered the ground up to the Investigator's ankles. During subsequent interviews with LVN "H" and RN "G", they revealed Resident #3 was found lying face down on the snow behind the storage buildings, not near the sidewalk by the gray storage building, which was an area not view of the Hall D or Hall E cameras. The interviews occurred on [DATE] at 5:20 p.m. and [DATE] at 12:57 p.m., respectively. Observations of the video from the Hall D and Hall E cameras for the morning of [DATE], revealed Resident #3 was outside unsupervised in the area of Hall D and Hall E from 4:12 a.m. to 4:14 a.m., then 4:25 a.m. to 4:27 a.m., then 4:45 a.m. to 4:49 a.m., then 4:53 a.m. to 5:15 a.m. At 5:15 a.m., he went into the "blind spot" between Hall D and Hall E, but never left the area until staff discovered him at around 8:15 a.m. and carried him into the facility at 8:16 a.m. It was also noted that during the above times, Resident #3 fell 7 times. The following was observed: - At 4:12 a.m., Resident #3 went out the Hall E door and onto the fenced yard. He walked upright with a bundle of what appeared to be clothing in his arms. He walked on the sidewalk from Hall E exit toward Hall D. He walked through a snow drift on the Hall E side of a gray storage building near the sidewalk and then veered off the sidewalk as he passed a gray storage building on the Hall D side of the storage building. He then walked through the snow covered ground with snow up above his ankles. - At 4:45 a.m., Resident #3 came in view of the Hall E camera from the direction of Hall F. He appeared to have a garment dangling from his right hand. As he passed the entry to Hall E, he fell , bracing his fall with his hands. - At 4:53 a.m., Resident #3 re-entered the view of the Hall E camera from the direction of Hall F. He walked near the fence through the snow, then slowly walked out onto sidewalk. He appeared to wobble as he walked. He then fell to hands and knees at a snow drift, which crossed the sidewalk path. - At 4:58 a.m., he started to stand, but fell to his left side on the snow covered ground. - At 5:01 a.m., after attempting to gathering the items he dropped, he stood, but then fell forward on his hands and knees onto the sidewalk by the snow drift. He then stands and walks a few paces, then turns and retrieves the bundle he had gathered on the ground and walks toward Hall D. - At 5:02 a.m., he wobbles as he slowly walks through the snow near the Hall D exit and then into a "blind spot" between Hall D and the storage buildings. - At 5:07 a.m., Resident #3 was again in view of the Hall E camera standing upright carrying a bundle. With a slow gait, he came to the snow drift on the sidewalk and fell face down. - At 5:08 a.m., he stood and stumbled to the fence and then grabbed the fence as if to stable himself. He then turn and attempted to retrieve his bundle, and fell . At that time, it appeared he struck his head on the snow covered ground. - At 5:11 a.m., he stood and started to walk, but again fell . He then stood again and with an unsteady gait, he walked a few paces to the fence and leaned against the fence. - At 5:14 a.m., Resident #3 had his bundle and walked with an unsteady gait, while leaning slightly forward, and went around the storage building. He then walked through the snow covered ground up to the Hall D exit door, but then turned and walked out of view of the Hall D and Hall E cameras, which would be the area to the sides and behind the storage buildings. - Starting at 8:02 a.m., staff began exiting Hall D. - At 8:16 a.m., five plus staff came in view of the Hall D camera pulling blanket around from the direction of the backside of the two storage buildings, which left an indentation in the snow and dirt. They stopped outside Hall D, then they all lifted the blanket with what appeared to contain Resident #3's body and entered Hall D. At that same time, a video camera of the main entry area showed EMS personnel arriving and then exiting the facility with Resident #3 on a stretcher at 8:27 a.m. A temperature log for [DATE], received from the National Weather Service, revealed that for the city where the nursing facility was located, the temperatures were as follows: - From 4:00 a.m. to 7:15 a.m., the temperature was 6 F with wind gust ranging from 13 to 18 mph and sustained winds of 11 to 14 mph. - From 7:20 a.m. to 7:55 a.m., the temperature was 5 F with wind gust ranging from 15 to 18 mph with sustained winds of 12 to 13 mph. - At 8:00 a.m., the temperature was 4 F with wind gust of 15 mph with a sustained wind of 12 mph. The National Oceanic and Atmospheric Administration's (NOAA) Wind Chill Chart, effective [DATE], documented the following: - At a temperature of 5F and a wind speed of 10 mph, the ambient temperature is -10F. - At a temperature of 5F and a wind speed of 15 mph, the ambient temperature is -13F. The CDC (Center of Disease Control) documented the following in a pamphlet titled " Extreme Cold, A Prevention Guide to Promote Your Personal Health and Safety " and obtained online at <http://www.bt.cdc.gove/disasters/winter/> (no date) - - Whenever temperatures drop decidedly below normal and as wind speed increases, heat can leave the body more rapidly. - Elderly individuals are at greater risk of hypothermia because they often make less body heat due to a slower metabolism and less physical activity. - Hypothermia or abnormally low body temperature is most likely at very cold temperatures and can occur at 40F. - If the body temperature falls below 95F, the situation is a medical emergency. - Even if the victim appears dead, CPR should be provided. In some cases, hypothermia victims who appear to be dead can be successfully resuscitated. Review of Resident #3's clinical record revealed the following: - The Admission Face Sheet documented he admitted to the facility on [DATE] at 2130 (9:30 p.m.) at the age of 71. It also noted his [DIAGNOSES REDACTED]. - There was no documented pre-admission assessment or admission assessment. During an interview with the DON on [DATE] at 2:37 p.m., she said she did not complete a written pre-admission assessment; she only observed him and reviewed his clinical record at the prior facility. Review of Resident #3's clinical record from the prior facility revealed the following: - He had a DNR (Texas Standard Out-of-Hospital Do-Not-Resuscitate Order). - A quarterly Minimum Data Set (MDS) Resident Assessment, dated [DATE], documented he had severe cognitive impairment, exhibited a behavior of wandering, which was not easily altered, and he resided on an Alzheimer's/dementia special care unit. - The Care Plan with a print date of [DATE], documented he resided on a locked unit and he was at high risk for elopement. - The nurse's notes, dated [DATE] for the 6:00 p.m. to 6:00 a.m. shift, documented an incident of elopement, which occurred at approximately 2:00 a.m. Further review of Resident #3's current clinical record revealed the following: - The nurse's notes, dated [DATE], completed by RN "C", documented Resident #3's time of admission as 2030 (8:30 p.m.), not 9:30 p.m. as noted on the Admission Face Sheet. It noted he was confused, had a history of [REDACTED]. Monitored for elopement precautions." - There was no evidence contained within the record to indicate Resident #3 was monitored as noted in the above nurses' note written by RN "C" or to indicate the two nurses on duty the night of 2-,[DATE]-11 (RN "C" and LVN "D") implemented the facility's required every two hour observation rounds as per the in-serviced conducted by the DON on [DATE]. - The next nurse's notes entry was not until the following morning ([DATE]). At 8:00 a.m., RN "B" noted Resident #3 was found outside Hall E, behind a storage building. It noted he was in a prone position (face down), unresponsive and his skin was cold to touch. It noted when he was turned over and assessed, he had stiffness with no purposeful body movements, his eyes open with pupils full blown (dilated) and nonreactive. It also noted he had no palpable pulse and no spontaneous breath sounds. It noted he arrived from another facility the prior night and that they had no medical or personal information regarding Resident #3. It noted they initiated CPR. - RN "B" nurse's note for [DATE] at 8:15 a.m., noted emergency medical services (EMS) was called. It also noted Resident #3 had a 6 cm (2.36 inches) abrasion to his forehead and his pants were down to his knees. RN "B" noted at 8:18 a.m., EMS personnel arrived and took over his care. RN "B" noted at 8:30 a.m., Resident #3 was transferred to a local hospital. - The record contained no additional information regarding the status of Resident #3. Review of Resident #3's local hospital closed record documented the following: - The EMS Pre-Hospital Patient Care Report, dated [DATE], documented they arrived at the nursing facility at 8:20 a.m. and Resident #3 was receiving CPR from two nursing facility employees. It documented he was unconscious, unresponsive and in cardiac arrest. It noted he had a temperature of 69F and his skin was "extremely" cold, stiff and blackened on his hands and feet. It noted he had an abrasion type blunt wound across his forehead and abrasions to the knuckles of both hands. It noted they took over the CPR and used a defibrillator twice prior to transporting him to the local hospital and once while in route, but he remained in V-fib. (According to the American Heart Association, V-fib (ventricular fibrillation) is a serious medical condition in which the heart's electrical activity becomes disordered and can result in collapse and sudden cardiac death within minutes unless medical help is provided immediately. Website: http://www.americanheart.org). - The Emergency Department Triage form documented he arrived at 8:51 a.m. and continued to remain unresponsive with fixed/dilated pupils and no gag reflex. It also noted the abrasion to his forehead measured 5 cm in length (1.97 inches) with no hematoma noted. It noted that at 8:51 a.m., he had a temperature of 68.7F and at 9:22 a.m. (time death pronounced) his temperature was 77.2F. - The emergency room Note, completed by MD "A", dated [DATE], noted Resident #3 was given Amiodarone upon arrival and two rounds of Epinephrine. (Note: The 12th Edition of the Geriatric Dosage Handbook, copyright 2007 by Lexi-Comp Inc., pages 76, noted Amiodarone may be used for cardiac arrest with persistent irregular heart rate when defibrillation, CPR, and vasopressor administration have failed. On page 502, it noted Epinephrine may be used to stimulate the heart when the individual is in asystole (without heart beat).) MD "A" also noted that with re-warming and resuscitation efforts, they brought Resident #3's core body temperature up to 80F, but he remained unresponsive and in asystole. He noted they inserted a Foley catheter, but no urine was obtained. He noted Resident #3 was pronounced dead at 9:22 a.m. with the cause of death noted as acute hypothermia. He then noted: "appears patient has passed away due to a fall he sustained while outside after leaving his room at the facility to the yard where apparently he fell hitting his head. Patient may have suffered a snycopal episode and while being out in the cold weather he suffered from severe hypothermia as the temperature was only 5 to 6 degrees F this morning." Review of the computer-generated timesheets for [DATE] and [DATE] revealed the following: - On [DATE] from 11:00 p.m. to [DATE] at 6:00 a.m., there were 4 staff on duty: 2 nurses (RN "C" and LVN "D") and 2 nurse aides (CNA "E" and CNA "F"). RN "C" remained on duty until 7:32 a.m. and LVN "D" remained on duty until 7:48 a.m. - On [DATE], there were 2 nurses, 7 certified nurse aides, 1 resident aide, and 1 medication aide assigned to the day shift (6:00 a.m. to 6:00 p.m.). The two charge nurses were RN "G" (arrived at 6:05 a.m.) and LVN "H" (arrived at 6:22 a.m.). One aide had worked the night shift and six aides arrived between 5:03 a.m. and 6:29 a.m. During an interview with the Administrator on [DATE] at 2:10 p.m., he said on [DATE] at approximately 4:00 p.m., he was notified the facility Resident #3 discharged from was closing. He said he sent his DON and ADON "K" to the facility. He said at approximately 9:30 p.m., two vehicles arrived with 8 residents to admit from the facility that was closing. He said at that time, he had 10 staff on duty to assist with admitting the residents and getting them settled into their new rooms. He said they had already scheduled 2 nurses and 3 nurse aides to work from 11:00 p.m. to 6:00 a.m., but one aide called in and did not come to work. He said they called multiple staff, but not one was available to work. When asked if he considered the use of agency staff, he said he had already left and they did not discuss that option. When asked what time he left, he said around 10:00 p.m. He said when he left the facility, there were still additional staff in the facility, but at 11:00 p.m., only 2 nurses and 2 nurse aides would remain on duty to care for the current residents and 8 new admissions. He added that RN "C" knew the residents since he had worked at the other facility the prior week. During an interview with the DON on [DATE] at 3:30 p.m., she said she and ADON "K" along with two additional staff went to the nursing facility that was closing on [DATE] and determined 8 residents could be admitted to their facility that evening. She said they arrived at their facility at approximately 9:30 p.m. She said she was aware they would only have 2 nurses and 2 nurse aides on duty from [DATE] at 11:00 p.m. to [DATE] at 6:00 a.m. She said they called "everyone," but no one was available. She said they did not consider the use of agency staff. She said RN "C", who had worked at the other nursing facility for approximately one week, had told her "he had it covered," so she left at approximately 10:30 p.m. During an interview with the Administrator of Resident #3's prior facility on [DATE] at 11:25 a.m., he said when Resident #3 resided at his nursing facility, he routinely set off fire alarms and knew this would release the exit doors and gates. He said when a fire alarms went off, staff immediately went to the secured unit to look for Resident #3. He said he was aware the current facility did not have an actual secured unit, but he thought the fenced grounds would provide Resident #3 an area to wander in. He said he "assumed" staff would monitor their videos of the exterior cameras and the staff would monitor Resident #3 to prevent him from going out in the extremely cold weather. During an interview with RN "C" on [DATE] at 12:55 p.m., he confirmed he worked the night shift on 2-,[DATE]-11 when they admitted 8 new residents around 9:30 p.m. He said he had worked with the new residents the prior week at the facility they were discharging from. He said he was aware Resident #3 had resided on a secured unit. He added that he was not Resident #3's charge nurse the night he admitted , although, he had assisted with his care. He said Resident #3 remained in his room until 2:30 a.m. to 3:00 a.m. and then went and sat in the TV/lobby area with his coat and cap on, plus he carried a bundle of clothes. He said he saw Resident #3 around 5:00 a.m. and at no time did he see him exit the facility. He added that usually the night shift had 2 nurses and 3 nurse aides, but on that night, one aide called in sick. He said they did not have a sufficient number of staff to meet the individual needs of the residents due to the admission of 8 new residents. When asked if he had received training or had access to a policy related to adverse weather conditions, he said he was aware of no policy and he had received no training regarding weather extremes and monitoring of residents during cold weather. During an interview with LVN "D" on [DATE] at 4:03 p.m., she confirmed she worked the night shift on 2-,[DATE]-11 and was the charge nurse for Halls B, C and half of Hall D. She said on the evening of [DATE], between 8:00 p.m. and 9:00 p.m., they admitted 8 new residents from a facility that was closing. She said Resident #3 was one of the residents. She said Resident #3 was assigned a room on Hall B. She said she was not told he exhibited a behavior of wandering or exit seeking, although, she was aware he had wandered about their facility throughout the night. She said during the night, Resident #3 stepped out the Hall F exit door, but he turned around and came back in the facility (time unknown). She said she also saw him in the facility around 5:00 a.m. to 5:30 a.m. LVN "D" also said she had recently been in-serviced regarding ensuring they conduct shift change walking rounds and rounds every two hours. She said that night (2-,[DATE]-11), she did not make rounds every two hours due to helping the two nurse aides provide care for the residents. She further said she did not make the shift change walking rounds with the on-coming nurse. She concluded by noting that on the night of 2-,[DATE]-11, they did not have an adequate number of staff to meet the individual needs of the residents. She said no additional staff had been assigned to assist them even though they had 8 new residents, plus, the 12 to 15 current residents who were usually up at night. During an interview with CNA "E" on [DATE] at 11:35 p.m., she confirmed she worked the night shift on 2-,[DATE]-11. She said when the 8 new residents arrived, they were told their names and then told to assist them to their room. She said she was not told Resident #3 had a behavior of wandering or exit seeking. She said she did not recall seeing Resident #3 up wandering until around 2:30 a.m. to 3:00 a.m. She said he was dressed and carrying a bundle of clothes. She said during the night (time unknown), she heard LVN "D" tell LVN "C" that she thought she saw someone outside. She said they had assumed it was Resident #15, but he was in bed asleep. She said no one went outside to see if a resident was outside in the cold. She said they did not make rounds during the night to observe each resident, because they did not have enough staff to provide care and make the observations rounds. She said when she and the other nurse aide provided care for the residents, they "jumped" from hall to hall. During an interview with LVN "H" on [DATE] at 5:20 p.m., she confirmed she worked the day shift (6:00 a.m. to 6:00 p.m.) on [DATE]. She said she arrived late, around 6:15 a.m., due to the weather. She said she was assigned as charge nurse for Halls B, C and one-half of Hall D. She said when she arrived, she and the off-going nurse (LVN "D") did not make walking rounds together. She said LVN "D" told her "everything was fine". She said after completing other tasks, she she went to the dining room and noted Resident #3 was not in the dining room. She said she then went to his room and discovered he was not in his room. She said when she could not locate him, she notified the other staff and they began looking for him. She said RN "G" found Resident #3 outside between Halls D and E. She said when she arrived, she saw Resident #3 lying face down in the snow behind two storage buildings between Halls D and E. She said he had a coat and cap on, but his jeans were down around his knees, and he was wearing only one tan corduroy house shoe. She said when they rolled him over, she noted his eyes and mouth were open and he was cold to touch. She said with the help of other staff, they carried him to a room on Hall D and she and RN "G" initiated CPR. She said EMS personnel arrived shortly thereafter and took over. She added that she was aware of the no weather related facility policy that provided guidance regarding cold temperatures and what measures to take to reduce the risk of residents developing hypothermia. She further said she had worked late the night of [DATE] and had been present when the 8 new residents arrived. She said when she left she recalled Resident #3 being in bed. She said when she left she was aware the night shift would only have 2 nurses and 2 nurse aides after 11:00 p.m. with no additional staff arriving to assist with the residents. During an interview with RN "G" on [DATE] at 12:57 p.m., she confirmed she worked the day shift on [DATE]. She said she was the charge nurse for one-half of Hall D, plus Halls E and F. She said when LVN "H" told her she could not find Resident #3, she began assisting with looking for him. She said she went out on the grounds of the facility and found Resident #3 lying face down behind two storage buildings located between Halls D and E. She said his pants were down around his knees and ice crystals had formed on his hips. She said when staff arrived, they rolled him over. She said he was "stiff as a board" and "frozen to death". She said his eyes and mouth were open and he had an abrasion on his forehead. She said while she waited for staff assistance, she called 911 with her cell phone. She said staff assisted with carrying Resident #3 to a room on Hall D and she and LVN "G" initiated CPR until EMS personnel arrived and took over. She said she was aware of no policy related to inclement weather. III. RESIDENT #1 Review of Resident #1's nurses' notes, completed by LVN "C", revealed on Sunday, [DATE], at 1:00 a.m., Resident #1 was discovered missing. It noted Resident #1 was not located until 2:10 p.m. when police notified the facility he was found in Aspermont, Texas, a town two hours away from the facility. An on-line mileage calculator with MapQuest (http://classic.mapquest.com/) documented the distance from the facility to the town of Aspermont was 127.94 miles. Further review of Resident #1's nurse's notes, dated [DATE], documented police returned Resident #1 to the facility at 6:30 p.m. It noted he was assessed to have no injuries. The notes further documented that when staff first realized he was missing (on Sunday, [DATE], at 1:00 a.m.), staff had observed his bed was made and his closet was empty of his clothes. It noted the local police were notified at 1:15 a.m. It noted calls were made to staff from the day shift (6:00 a.m. to 6:00 p.m.), which revealed the following: - CNA "I" told them that on Saturday, [DATE], around 5:30 p.m., she had answered the activated call light for his room and he was not in his room at that time. - CNA "F" told them she last saw Resident #1 during the noon meal on Saturday, [DATE]. Review of the Incident/Accident (I/A) Reports for [DATE] through the 3rd of February 2011 and additional review of Resident #1's nurses' notes revealed prior to the above incident, there had been two additional incidents of elopement. - An I/A Report documented on [DATE], he was found one block from the facility. - His nurse's notes, dated [DATE], documented at 1315 (1:15 p.m.), Resident #1 was found on the Tahoka highway by a housekeeper who was returning to work. It noted staff used the facility's van to return him to the facility. It noted he told staff he walked out behind a visitor. It noted he was assessed to have no injuries. It noted he was placed on 15 minute monitoring. Additional review of Resident #1's clinical record revealed the following: - The Admission Face Sheet documented Resident #1 admitted to the facility on [DATE], was [AGE] years-of-age and had a State appointed guardian. - A History and Physical, [DATE], documented his [DIAGNOSES REDACTED]. - The February 2011 Physician's Recapitulation Order documented Resident #1 received routine medications for the treatment of [REDACTED]. - A quarterly MDS Resident Assessment, dated [DATE], documented his mental status was stable, he had no delirium, but his behaviors included delusions and a behavior related to either hitting/scratching, packing, rummaging, or making disruptive sounds, but no evidence of wandering. It further noted he was independently ambulatory and stood 72 inches (6 feet, 2 inches) tall and weighed 217 pounds. - The care plan, dated [DATE], documented he was at high risk of elopement and that he would be monitored every one hour - There was no evidence of the one-hour monitoring contained within his clinical record for [DATE] through [DATE]. - An Elopement Risk Assessment form, completed on [DATE], [DATE], [DATE] and [DATE], documented he had cognitive impairment with poor decision-making skills and at least one [DIAGNOSES REDACTED]. The assessments for [DATE], [DATE] and [DATE] documented he was not accepting placement in the nursing facility; he openly expressed a desire to go home, he packed his belongings to go home or stayed near an exit door; and he left the facility without supervision and without informing staff. The interventions included placement on a secured unit, frequent monitoring - check every hour and as needed, and staff staying aware of his wandering risk. During an interview with the Administrator, DON and MD "A", on [DATE] at 12:50 p.m., the Administrator said the facility was a secured unit based on fact they had a coded gate entrance and three locked fenced areas around the facility to prevent residents from leaving the facility grounds. Therefore, the Elopement Risk Assessment form's documented intervention of placement on a secured unit, did not provide a change to reduce the risk of further incidents of eloping from the facility. During an interview with Resident #1 on [DATE] at 7:27 a.m., he was observed in his room, seated at the side of his bed. He confirmed he had recently left the facility. He said the front gate (with a coded security system) was open and a man provided him transportation to a town named Aspermont, Texas. During an interview with RN "B", on [DATE] at 12:57 a.m., she confirmed she was on duty on Saturday ([DATE]) and Sunday ([DATE]) during the timeframe Resident #1 eloped from the facility. She said at the time staff discovered Resident #1 was missing on [DATE], he had been cleared of the prior incident ([DATE]) and no specific monitoring was occurring. She said on Saturday ([DATE]), she last recalled observing Resident #1 around noon when she delivered his meal tray in the dining room. She added that although, she did not see Resident #1 during the evening meal, when she recorded the evening meal intake, staff told her he consumed 100% of his meal. She said when she left Saturday ([DATE]) at 6 p.m., she did not recall seeing him. She said after Resident #1 was returned to the facility on [DATE], they initially provided one-on-one level of supervision, then they went to checks every 15 minutes, then every 30 minute checks. She added