Every finding on record at Avir at Mansfield

Based on observation, interview and record review, the facility failed to ensure the menu was followed for 1 of 2 lunch meals (lunch on 08/05/26) observed.The facility failed to ensure meal tickets were accurate and matched what Residents were served for the lunch meal on 08/05/26. The facility failed to document the vegetable substitution for the lunch meal on 08/05/26. These failures could place residents at risk for a decrease in quality of life.Findings included: Interview on 08/04/26 at 12:00 PM, Resident #33 stated they do not even serve what was on the menu. He stated it will say one thing and it will be something not even like it. Observation and record review on 08/05/26 at 12:12 PM in the dining room, revealed lunch meal that appeared to be chicken, zucchini and rice. Three residents had been served and their meal tickets reflected Lunch 08/05/26 smothered pork roast, seasoned greens, blackeyed peas, cornbread, margarine, bread pudding w/caramel sauce, beverage. The lunch menu posted near the dining room reflected cilantro lime chicken, rice pilaf, squash and red peppers, dinner roll, margarine, mango chunks, and beverage. Observation on 08/05/26 at approximately 12:15 PM, in the dining room, a nursing staff member returned a plate and told kitchen staff the plate does not match the ticket. Interview on 08/05/26 at 12:46 PM, the Dietary Manager stated he printed the meal tickets yesterday and thought he had the right day. He stated he was responsible for checking the meal tickets for accuracy and said the dietary aide and cook also checked meal tickets to ensure they matched the menu. He said it was important for meal tickets to be accurate for residents with allergies. He stated nursing also was responsible for checking meal tickets before residents were served. In a follow up interview on 08/06/26 at 1:27 PM, the Dietary Manager stated they do not substitute menu items very often and it happened maybe every 3-4 weeks. He stated when there was a change, they told the CNAs and he thought they do not get the message to the Residents. He stated residents could be disappointed if their meal ticket did not match the menu or what was served. Interview on 08/06/26 at 12:57 PM, LVN F stated for the past few weeks meal tickets had been different than what the plate was. She stated when that happened, she would address it with the cook and then the manager. She stated it could upset residents if they think they are going to get something then they do not. She stated the risk to residents was they could choke if the diet or consistency was wrong. Interview on 08/06/26 at 1:58 PM, Dietary Aide E stated she did not notice the meal tickets had the wrong meal until somebody [nursing staff] said something. She said herself, the cook and Dietary Manager were responsible for checking the tickets. She stated the risk to residents was they could get confused. Interview on 08/06/26 at 4:51 PM the DON stated the meal ticket had to match what was being served. She said if it does not then staff were not to move forward until it was corrected. She stated it could affect residents because it could be the wrong order or diet. The Administrator stated it affected residents in two ways, one being satisfaction and the other was for different diet types or allergies. He stated the plate should match the ticket. Record review of the facility policy Meal Identification and Preference Cards/Tickets dated 2023, reflected the following: A meal identification and food preferences card (meal ID card/ticket) will be used to properly identify each individual's needs including food and beverage preferences. The meal ID card card/ticket.may be printed daily from a database and disposed of after meals.Meals delivered to the dining rooms, wings/neighborhoods:.4. The director of food and nutrition services or designee will be responsible for keeping computerized meal ID cards/tickets up to date and for printing them prior to each meal.

Based on interview and record review, the facility failed to provide food that accommodated resident food preferences for five of five residents interviewed in a confidential group meeting, and one resident (Resident #31) of eight residents reviewed for food preferences. The facility failed to provide residents with preferred alternate foods of hot dogs, corn dogs, and cheeseburgers. This failure could affect the residents who are provided daily meals by the facility, by placing them at risk for not enjoying meals, and weight loss. Findings included: Review of Resident #31's Face Sheet, dated 08/06/26, reflected he was a [AGE] year-old male, admitted on [DATE], and having diagnoses of type 2 diabetes (resistance to insulin causing blood sugar to be too high, and strongly related to obesity and poor diet), vitamin deficiency, and chronic kidney disease. He was his own responsible party. Review of Resident #31's quarterly MDS, dated [DATE], reflected he was able to understand others, and was able to be understood by others. His BIMS score was 13, indicating intact cognition. He had no behavioral problems or psychosis. Resident #31 had one-sided impairment of his lower body, and was able to use a wheelchair to move throughout the facility. He required only set-up or clean-up assistance for eating. The document reflected Resident #31 required no special nutritional approaches (ie. feeding tube, IV, therapeutic or mechanically altered.) Review of Resident #31's order summary, dated 08/06/26, reflected a diet order for a regular texture, regular consistency, regular diet, with no salt on the tray. Review of Resident #31's care plans, dated 01/12/26, reflected the following:- He was on a regular, low concentrated sweets, with no salt on the tray diet, and thin liquids.- He was independent for meeting emotional, intellectual, physical and social needs in regard to activities.- He was diabetic and received insulin injections. An interview on 08/04/26 at 12:00 P.M. with Resident #31 revealed he was very unhappy with the food in the facility. He showed a picture of a past meal, and said the dietary department served them things that nobody would want to eat sometimes. Resident #31 said the Dietary Manager had taken some of the favorite resident alternates off the menu. He said at one time he had been able to get a hot dog, corn dog, or cheeseburger as an alternate meal when he did not like the meal, but they took those items away from them. He said it had been that way for a long time, but he was not exactly sure how long. Resident #31 said the residents were told the CDC said the hot dogs and corn dogs were a choking hazard. He said the residents were all adults and should be able to eat those things, and he thought it was ridiculous they were not allowed to. He said he thought they took the cheeseburgers away because they were not healthy, and they wanted to give them cheaper, processed chicken patties. A confidential group interview with five residents, on 08/05/26 at 10:00 AM, revealed all were unhappy with food at the facility, and all started to talk at once when asked about it. They were all displeased with the Dietary Manager removing the hot dogs, corn dogs, and cheeseburgers from the alternate menu. One resident said they complained about it a lot when they took them off, but that was some time ago (unknown how long ago it was) and after a while they felt like there was no point in asking any more. Because of this, the resident said they had not asked about it since the new company took over (October), and because it was the same Dietary Manager, they did not feel like he would change anything. Another resident said they were told they could not have corn dogs because the stick presented a danger, and the dietary workers would not tell her why they couldn't just pull the stick out before serving them. One resident said they thought the cheeseburgers were taken off the menu because when nobody liked the meal they were serving, they all wanted them and it cost too much. An interview on 08/06/26 with the Dietary Manager revealed hot dogs and corn dogs were taken off the menu because there was a memo that they were a choking hazard. He said he did not have the memo, and did not remember where it originated, but it came from their former corporation. He said the burgers were also taken off the menu by the old company, he thought over a year ago, because they were too expensive. He said he had not received complaints about those things recently, and he thought it was because they got tired of hearing him say he could not give them those things. He said it was not his decision to remove those items, and it came from the previous company, and he would love to give them those things, but believed he was not allowed. He said he had not asked about it since the new company took over. He said he was told by the previous company that it was a federal thing, from the CDC or something so he was led to believe it had to be that way. He said it did not make sense to him, because the day the company sent the memo out, they were serving the residents bratwurst, and he didn't see the difference between that and hot dogs. He said their policy about food preferences was that he talked with each resident and went over their choices with them. He said they had seven things listed on the alternative menu, which were always available. The Dietary Manager said it was important for the residents to have food they liked to eat, so they did not lose weight, and because food had everything to do with their rights and their dignity. He said he did have to be strict about their diet though, for example if they were not supposed to have sausage and wanted that, he had to stick with the diet. An interview on 08/06/26 at 1:55 P.M. with the DON revealed she was only aware of food complaints that were from Resident Council, and did not hear much about food in between meetings. She said she remembered the former Administrator and Dietary had talked about cheeseburgers, and she thought they were taken off because when they were an alternate 90% of the residents wanted them, but she was not involved in that decision. She said she did not know why the hot dogs and corn dogs were taken off, and only vaguely remembered it being mentioned in a morning meeting, and the former Administrator handled it. She said nobody had choked on a hot dog, and she was not aware of the CDC saying nursing home residents could not have them. She said the sticks in corn dogs were not a problem, and she could not think of any reason they would be. The DON said there was no reason to be extra concerned about a resident on a regular texture diet being in danger eating a hot dog, and if she had known it was a concern, she could have fixed that a long time ago, but nobody said a word about it to her. An interview on 08/06/26 at 4:32 P.M. with the Administrator revealed he was not aware of the complaints about food before the survey, and he was looking into the issue with the hot dogs. He said there was no reason the residents could not be getting cheeseburgers. He said they practiced patient-centered care, and if someone wanted a chef salad, for example, there was no reason they could not make one for them. He said they had a right to have food they wanted to eat. He said it was not a budgetary issue, because they had a good food budget, and if the Dietary Manager went over sometimes, he was able to defend that, because it was for a good cause. He said Meals are so important and that half of their residents were focused on when do I smoke? and the other half were focused on when do I eat? because that was the thing they looked forward to. Review of the list of the always available menu items posted at the dining room entrance on 08/05/26 at 9:49 AM reflected the following items were available: grilled cheese, charbroiled or fried chicken sandwich, turkey and cheese sandwich, soup, fried burrito with picante sauce, chicken nuggets (with fries upon request.) Review of Resident Council minutes for May, June, and July of 2026 reflected only the complaint in was that eggs were not cooked long enough in July. Review of the Food and Nutrition Services policy, revised October 2017, 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: 1. The multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident's nutritional needs, food likes, dislikes and eating habits, as well as physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization. (.) 4. Reasonable efforts will be made to accommodate resident choices and preferences.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure all items were properly covered and labeled in the walk-in fridge. The facility failed to dispose of opened items in the dry storage and keep items in the dry storage area clean. These failures could place residents at risk of foodborne illness.Findings included:Observation and interview on 08/04/26 at 8:43 AM, in the dry storage area revealed an opened bag of pancake mix covered with plastic wrap that was dated 10/30/25. No expiration date was found on the bag of pancake mix. A large container of chocolate syrup had chocolate dripping from the lid and the top of the bottle onto the sides and was stored on the top shelf. In the walk-in refrigerator a large metal container of a red gelatin dessert was uncovered and not labeled. The Dietary Manager stated he thought the pancake mix could last forever since it was powdered. He said whoever opened an item was responsible for labeling and dating that item. He stated they also label items to know when to discard them. The Dietary Manager stated it was important to keep the dry storage area clean to keep bugs and roaches away. He said the gelatin in the fridge should have been labeled and dated. The Dietary Manager stated the risk to residents was contamination. Interview on 08/06/26 at 1:58 PM, Dietary Aide E stated she had prepared the gelatin on 08/04/26 and it should have been covered and dated. She stated it was important to label and date items to know when it was made and cover items so nothing would get in them. She stated the risk if not done was residents could get sick. Interview on 08/06/26 at 4:33 PM, the Administrator stated his expectation was for food items to be covered, labeled and dated, and if not residents could be at risk of contamination and food borne illness. Record review of the facility Policy & Procedure Manual.Chapter 4: Sanitation and Infection Control, undated, reflected 4. Food Storage.a. Stored food is handled to prevent contamination and growth of pathogenic organisms.Food should be protected from contamination (dust, flies, rodents, and other vermin).All time and temperature control for safety (TCS) foods (including leftovers) should be labeled, covered and dated when stored.When a food package is opened, the food item should be marked to indicate the open date. This date is used to determine when to discard the food.Canned and dry foods without expiration dates should be used within six months of delivery or according to the manufacturer's guidelines.

Based on interview and record review, the facility failed to ensure that all allegations involving abuse, neglect, and misappropriation were reported immediately, but no later than 2 hours after the allegation was made to the State Survey Agency for 1 of 6 residents (Resident #9) reviewed for abuse and neglect.The facility did not report to the State Survey Agency (HHSC) a resident-to-resident altercation. Resident #9 and Resident #75 were in an argument and Resident #75 hit Resident #9 on the face on 07/06/2026. This failure could place residents at risk of abuse, and physical and psychosocial harm. Findings included:Record review of Resident #9's Quarterly MDS, dated [DATE], reflected a [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with diagnoses that included hypertension (high blood pressure) and hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction (stroke) affecting left non-dominant side. Resident #9's BIMS score was 12 indicating moderate cognitive impairment. Record review of Resident #9's care plan, dated 03/09/2026, reflected the resident has a behavior problem agitation at times. Record review of Resident #9's progress note dated 7/6/26 written by the DON reflected [Resident #9] was outside in the courtyard and another resident, [Resident #75], asked [Resident #9] for a cigarette. [Resident #9] said no. [Resident #75] became very agitated and started screaming at [Resident #9] and then [Resident #9] started yelling back at [Resident #75], calling each other names. The argument escalated and according to another resident as witness (Resident #26), [Resident #75] started physically lashing out at [Resident #9] with her arms and hands. According to the witness, the hits did not land physically because [Resident #9] was able to move away, however was extremely upset and difficult to redirect. Placed staff with [Resident #75] 1:1 and met with [Resident #9] in my office with NP, [NP's Name] present. Explained to [Resident #9] that his safety is priority and that we have someone sitting with [Resident #75]. [Resident #9's family member], [Name], came in the facility and myself, [Resident #9's family member], [Resident #9], and [Name], The Administrator met in [Administrator's] office. Explained everything that occurred to [Resident #9's family member]. She stated, 'thank you so much for everything that you all do.' Record review of Resident #75's Quarterly MDS, dated [DATE], reflected a [AGE] year-old female who admitted on [DATE] with diagnoses that included non-Alzheimer's Dementia (loss of memory and decline in mental ability not with Alzheimer's not being the cause) and schizophrenia (serious mental illness that may include hallucinations, delusions, and trouble thinking clearly). Resident #75's BIMS score was 12 indicating moderate cognitive impairment. Further review of the MDS revealed Resident #75 had no physical, verbal, or other behaviors exhibited towards others. Record review of Resident #75's care plan, dated 01/14/26 and revised on 07/08/26, reflected, The resident is/has potential to be physically aggressive r/t Poor impulse control with an intervention that included At first sign of aggression separate resident from other residents immediately. Record review of Resident #75's progress note, dated 07/06/26, written by the DON reflected, Resident was outside in the courtyard area and asked another resident, [Resident #9] for a cigarette. [Resident #9] told her no. [Resident #75] became very upset and started yelling and physically lashing out at [Resident #9] with her hands. Another resident, [Resident #26] witnessed the altercation and stated it appeared she did not make physical contact with [Resident #9] before [Resident #9] came back inside the door, which is where I saw him coming inside. Implemented 1:1 with [Resident #75] immediately with a staff member and had [Resident #9] come into my office to get his statement. Record review of Resident #75's progress note, dated 07/06/26, written by the DON, reflected [Resident #75] continued to yell and difficult to redirect. Screaming at staff and calling staff names. NP [Name] present and ordered 0.5 mg haldol X1 IM now. Due to past situations in which [Resident #75] is difficult to redirect, and becomes aggressive, [NP Name] ordered for [Resident #75] to be discharged to a secure unit. Will work on transfer. Record review of Resident #75's progress note, dated 07/06/26, written by the DON, reflected Resident started screaming and yelling again, unable to redirect or calm resident. When asked what is wrong, resident states 'I don't know.' Called [Name] NP and received another order for haldol 0.5mg IM now. Charge nurse [Name] giving now. Will be transferring to sister facility this evening with secure unit. Resident 1:1 until transfer. Record review of Resident #75's progress note, dated 07/07/26, written by the DON, reflected, [Resident #75] has been 1:1 with another staff member since the altercation yesterday. Report has been called to [Name of Nursing Facility] by charge nurse [Name]. Resident's belongings have all been packed up, and resident is transferring to [Name of Nursing Facility] by our transporter, [Name]. CNA that has been 1:1 with [Resident #75] since 6am is accompanying resident and van driver to [Name of Nursing Facility]. Resident is calm at time of transfer. Interview on 08/05/26 at 1:24 PM, Resident #9 stated he was on the patio outside and was coming inside when Resident #75 had asked him for a cigarette and he told her no. He stated Resident #75 asked him for a light and he said no, then Resident #75 hit him in the face. Resident #9 said Resident #75's hand was open and caught the bridge of his nose. Resident #9 said he was not hurt. He stated he felt safe now that she was gone, and staff did one to one with Resident #75 until she left. Interview on 08/05/26 at 2:16 PM, Resident #26 stated he saw Resident #75 ask Resident #9 for a cigarette, then a soda and chips and Resident #9 told her no. Resident #26 stated Resident #75 swung and hit Resident #9 twice. He stated staff did one to one with Resident #75 afterwards and they would not let Resident #75 go out by herself. Interview on 08/05/26 at 4:04 PM, the DON stated Resident #9 and Resident #75 were coming in the door from the courtyard and were arguing, yelling and screaming. She stated Resident #9 told her that Resident #75 tried to hit him in the face after Resident #9 told Resident #75 he did not have a cigarette to give her. The DON stated Resident #26 was a witness and told her Resident #75 did try to hit Resident #9, but there was no physical contact. The DON stated they put Resident #75 on one to one with a staff member. When asked if the incident should have been reported, the DON stated it was not physical but was verbal and stated patients do argue. She stated when they look at actual verbal abuse, they have to look at every scenario and if they think it was verbal abuse, they notified corporate, went over everything and determined if it was reportable. The DON stated verbal abuse was using racial slurs, making another resident feel extremely uncomfortable and if a resident reported to them it made them feel unsafe. The DON stated Resident #9 told her he did not feel unsafe. Interview on 08/05/26 at 4:37 PM, the Administrator stated he was aware of the incident between Resident #9 and Resident #75. He stated he talked with Resident #9 who was angry about the incident but was okay as long as they kept Resident #75 away from him. He stated Resident #9 did not have any marks on his face and they put Resident #75 on one to one until she left. The Administrator stated he used the Provider Letter to determine what to report and said there was no injury. He said there were certain criteria if there was not an injury and he followed the yes no question tree on the provider letter. He stated he checked back with Resident #9 and there were no lasting repercussions of the incident. The Administrator did not answer when asked if this incident was considered reportable. In a follow up interview on 08/06/26 at 4:51 pm with the DON, she stated it was important to report abuse allegations to HHSC and it could affect residents if not reported because the allegation would not be investigated. Record review of TULIP (online system for licensing, credentialing and reporting) did not reflect any facility reported incident for this incident. Record review of the facility policy, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating reflected in part: .1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law and HHSC reporting guidelines. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies:a.The state licensing/certification agency responsible for surveying/licensing the facility;b.The local/state ombudsman;c. The residents representative;.e. Law enforcement officials;f. The resident's attending physician; and g. The facility medical director.

Based on observations, interviews and record reviews [SP5.1]the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 (Residents #12, and # 23) of 23 residents reviewed for ADL care. The facility failed to ensure Residents #12 and #23 received appropriate nail care to prevent fingernails and toenails from being overgrown. This failure could place residents at risk or injury or infections. Record review of Resident #12's quarterly MDSs, dated 06/25/26, reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included a stroke affecting his ability to speak and swallow, feeding tube placement, and pressure ulcers. His BIMS score was not calculated due to his medical conditions. His Functional Abilities assessment indicated he was totally dependent on staff for his ADLs. Record review of Resident #12's care plan, dated 07/10/26, reflected he had a communication deficit, and had an ADL self-care deficit related to his stroke. Observation on 08/04/26 at 10:37 AM revealed Resident #12 was in bed, both arms and hands were severely contracted. Several fingernails on both hands were observed to be overgrown, no obvious skin breakdown to the palms was noted. Strong foul odor was noted to be coming from the left hand. Observation and interview on 08/05/26 at 9:00 AM LVN-A stated Resident #12 did not tolerate anything touching the palms of his hands, he would contract his hands even more. LVN A was able to straighten the resident's fingers slightly, allowing observation of his palms. There were indentations caused by the resident's fingernails, but no skin breakdown noted. Resident #12's right thumbnail, 2nd and 4th fingernails were measured with a disposable paper ruler and were approx. 1/4 inch long. His left thumbnail, 3rd and 4th fingernails were also approx. 1/4 inch long. Measurements were hampered by his hand contractures. LVN A stated Resident #12 kept his left hand tucked against his chin, and he drooled excessively, leading to the left hand being wet frequently, causing the odor emanating from the left hand. LVN A stated the staff were still responsible for the resident's ADLs, even though he had a hospice aide that attended to his ADLs. She stated the risk of Resident #12's fingernails being overgrown could be them causing skin breakdown on his palm and a resulting infection. In an interview on 08/05/26 at 10:15 AM CNA C stated the CNAs were responsible for bathing the residents as well as trimming their fingernails, unless the resident was diabetic or had contractures, then the nurse was supposed to trim the nails. CNA C stated Resident #12 was on hospice and had a hospice aide that came in to provide ADL care to the resident. She stated Resident #12's hand contractures made it very difficult to clean his hands. In an interview on 08/06/26 at 10:45 AM the Director of Rehab stated Resident #12 had several strokes while at the facility, but the stroke in March of 2025 left him in his current condition. She stated the location of that stroke caused the resident's hands to be contracted and resulted in a neurological response when the palm of his hand was touched, he would contract the hand even more. Record review of Resident #23's quarterly MDS assessment, dated 05/25/26 [SP6.1]reflected he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included a stroke affecting the left side of his body, his speech, and his ability to swallow. His BIMS score was 9, indicating he had moderate cognitive impairment. His Functional Abilities assessment indicated he was dependent on staff for his ADLs. Record review of Resident #23's care plan, dated 05/10/26, reflected he had an ADL self-care deficit related to his stroke. He also routinely refused podiatry services. Observation on 08/04/26 at 9:49 AM of Resident #23 revealed several of the resident's toenails on both feet were overgrown. The resident was unable to say when they were trimmed last, stated he did want to see the podiatrist because of foot pain. Resident's toenails were measured with a disposable paper ruler. Resident #23's right 2nd and 3rd toenails were measured to be 1/4 inch long, and his left 3rd through 5th toenails were measured to be 3/8 inch long. In an interview on 08/05/26 at 9:00 AM LVN A stated Resident #23 will often refuse care to his feet because they hurt. She stated the bottoms of his feet were being treated for a fungal infection, leaving them dry and cracked. His pain was controlled with pain medications. She stated the CNAs were not allowed to trim toenails, they were supposed to notify when a resident's toenails needed to be trimmed. LVN-A stated she was not aware Resident #23's toenails were overgrown. She stated staff should still attempt to trim his nails and educate him on the risks if he refused. She stated the risk of having overgrown toenails could be an injury to his legs caused by rubbing the toenail against it, or an ingrown toenail. In an interview and record review on [SP7.1]08/06/26 at 9:43 AM the Social Worker stated the podiatrist visited monthly. There was no need for residents or staff to request to be seen by the podiatrist, he saw all residents during his visit. She was unsure when Resident #23 saw the podiatrist last. The Social Worker checked her files and discovered the resident had been seen by podiatry on 04/17/25, and again on 02/04/26. He was not on the list of residents to be seen in June of 2026. The visit on 02/04/26 had Resident #23 on the list, but no indication if he had been seen by the podiatrist. There was documentation by the names of other residents on the list, but no documentation next to Resident #23's name. In an interview on 08/06/26 at 10:23 AM CNA B stated the CNAs were responsible for trimming fingernails unless the resident was diabetic, then the nurse had to trim them. She stated toenails were also trimmed by the nurses. She stated toenail and fingernail issues were noted during ADL care and then passed on to the nurse. She stated she had notified a nurse about Resident #23's toenails, she did not recall which nurse it was or when she had notified them. In an interview on 08/06/26 at 11:00 AM the DON stated the CNAs were responsible for nail care unless the resident was a diabetic, in which case the nurse was responsible. Toenails were also the responsibility of the nurses, or podiatry. Her expectation was for the CNAs to alert the nurses when nails needed to be trimmed. She also stated her expectation was for the nurses and CNAs to monitor residents receiving hospice aide assistance to ensure ADL care was being provided appropriately. She stated the Infection Preventionist performed fingernail trimming on Resident #12 due to his extreme contractures. The DON stated Resident #12 would probably benefit from having an additional staff member to assist the Infection Preventionist to straighten his fingers as much as possible to allow better access. The DON stated Resident #23 was known to refuse care by podiatry, dentistry, etc. but she did not know if, or how much, education had been done with him about the risks of refusing care. She stated the Infection Preventionist would educate him. She stated the risk of ADL care, including nail trimming, not being performed could lead to the residents developing skin breakdown and resulting infections, as well as dignity issues. In an interview on 08/06/26 at 11:05 AM the Infection Preventionist stated she had trimmed Resident #12's fingernails the previous week, but his nails did grow fast. She stated his contractures made it difficult to provide care, and she agreed with the DON about having an additional person to help straighten his fingers as much as possible to ensure the palms of his hands were being cleaned and his nails were not causing any issues. Review of the facility's policy Activities of Daily Living (ADL) Support, dated February 2025, reflected: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, . including appropriate support and assistance with:a. Hygiene (bathing, dressing, grooming, and oral care).4. If residents with cognitive impairment of dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for one (Resident #26) of three residents reviewed for accidents. The facility failed to ensure the safety of Resident #26 by not placing a smoking apron over his body before he began to smoke during the 2:00 p.m. smoking break on 08/05/26. This failure could place residents at risk for burns.Findings included: Review of Resident #26's admission record, dated 08/06/26, reflected he was a [AGE] year-old male, originally admitted on [DATE], and having diagnoses of quadriplegia (total or partial paralysis of all four limbs and torso) and reduced mobility. He was his own responsible party. Review of Resident #26's quarterly MDS assessment, dated 07/28/26, revealed Resident #26 was able to understand others, be understood by others, and had a BIMS score of 12, indicating moderate cognitive impairment. He had no behavioral issues during the assessment period. Resident #26 had impaired range of motion for both his upper and lower body, and used a wheelchair. He was dependent on staff for his ADLs, but was able to feed himself with substantial assistance (helper does more than half of the effort.) Resident #26 was able to move himself throughout the facility using a motorized wheelchair. Review of Resident #26's Care Plan Report reflected a care plan dated 12/11/25 for I require staff supervision/ adaptations when using tobacco products. The goal, initiated on 12/11/25, and revised on 04/06/26, reflected I will follow tobacco policy of community without injuring myself or others. The interventions included, but were not limited to, the following:- dated 12/11/25 I require assistance with lighting tobacco products (.)- dated 12/11/25 I require the community to keep all tobacco and fire starting materials for safety.- dated 12/11/25 I require the use of an Adaptive Device: Smokers Apron. Review of Resident #26's Smoking Assessment, dated 06/10/26, reflected Resident #26 was able to perform cognitive tasks needed for safe smoking, but had the physical limitation of quadriplegia which required staff assistance or supervision. The document reflected he had no history of burns or holes in clothing from smoking. Resident #26 was noted to need staff supervision per policy, staff storage of smoking materials, and use of a smoking apron when smoking. An interview and observation on 08/05/26 at 1:56 PM with the ADON revealed there were ten residents present in the smoking area, including Resident #26, reclining on his power wheelchair. The ADON stated that there was a schedule and different staff from the assigned department would cover the smoking breaks, depending on who was available at the time. At 2:02 PM Houskeeper D arrived at the smoking area, pulling a wagon, which contained the locked boxes assigned to each resident who smoked, for holding their cigarettes between smoking breaks. She was followed by the Activity Director and CNA B. While some residents were still retrieving their lock boxes while being supervised by Housekeeper D, a female resident (learned later to be Resident #53) carried a single cigarette to Resident #26 (who was not wearing a smoking apron), lit the cigarette, placed it between Resident #26's lips, and returned to her seat. Resident #26 continued to smoke the cigarette until the ashes were approximately an inch long (approximately half of the length of the white paper part of the cigarette, which contains the tobacco.) The ashes were beginning to sag slightly at the end, at which point Resident #26 raised his right hand to the cigarette, removed it from his mouth, and tipped the ashes to his left side, onto the floor. Resident #26's hands were contracted, so that when he removed the cigarette from his mouth, he had to balance it between the bent knuckles of his pointer and middle fingers, instead of gripping it between his fingers as someone without contractures would. Immediately after he did this, the Activity Director placed an apron over him. An interview on 08/05/26 at 2:05 PM with CNA B revealed she knew who needed an apron for smoking, by the limitations the resident had, but they did not have a list. CNA B thought the Activity Director had a list of those residents. An interview and observation on 08/05/26 at 3:05 PM with Resident #26 revealed he was in the dining room in his power chair. He had no holes or burn marks visible on his body or clothing. He said he had always worn an apron before he started smoking, but he thought it was a new staff member supervising, and they forgot for a minute. He said he was kind of hoping they would forget, because he did not like wearing the apron, because it was hot, and kind of heavy. He said he understood why he had to. An interview with Housekeeper D on 08/06/26 at 10:13 AM, using a French-speaking interpreter over the telephone, revealed she understood that security was needed for residents who were disabled and could not safely hold their own cigarettes. She said there was no list, but she knew which residents needed precautions, like the apron, and was trained on how to identify them before she was allowed to supervise smoking breaks. She said that often she observed smoking breaks by herself, but sometimes her supervisor, or another person, would be there to help. When asked why Resident #26 was smoking without an apron, she said that sometimes residents already had cigarettes and could be smoking before she put the apron on them, and sometimes a resident would give another resident a cigarette before she was able to take their own to them. She said the risk of those residents smoking without an apron would be that the ashes could fall on them and burn them. An interview on 08/06/26 at 10:38 AM with the Activity Director revealed she had not observed residents giving each other cigarettes before and did not see Resident #53 give Resident #26 one, and the residents knew better than that. She said normally there was one person supervising, and sometimes two, depending on how large the group of smokers was. She said all the staff who supervised smoking knew which residents needed an apron, and Resident #26 needed one, and needed someone to light his cigarettes. She said she did not know why he was not wearing an apron before she saw him without it and put one on him. She thought maybe the staff were not paying attention, because they knew he had to wear one, and everyone had been trained on that by their supervisors. She said Resident #26 was at risk for dropping ashes on his clothing and burning himself. An interview on 08/06/26 at 4:32 PM with the Administrator revealed his expectations for smoking precautions were that the two people who needed to wear an apron, which included Resident #26, were that they have an apron on before they smoked, and Resident #26 knew that. He said another resident should not have been giving Resident #26 a cigarette. He said he had talked to all of the smokers about the situation, and explained that they could not do that (give each other cigarettes and smoke without following safety precautions), and that it could cause the facility to have to change their entire smoking procedure. He said the risk was that someone could get burned, or catch their clothing on fire, and it was a high risk. An interview on 08/06/26 at 4:51 PM with the DON revealed her expectation was that the staff put an apron on residents who needed them before they started smoking. She said the smokers were regularly assessed, and precautions were put in place to prevent them from burning themselves. She said they did not have a list of residents who needed a smoking apron, because there were only two of them, and the staff were all aware of who those residents were. She said residents were not allowed to give each other cigarettes, or to light them for each other. Only staff were allowed to do that, and the staff were responsible for the safety of the residents. Review of the Supervised Smoking Schedule, dated 10/10/25, reflected a list of smoking break times, with the department responsible for each break. The 2:00 p.m. break was to be supervised by the laundry/housekeeping department. Beneath the schedule was a note reading **ALL SMOKE BREAKS ARE SCHEDULED AND SHOULD BE SUPERVISED WITH REQUIRED MATERIALS IF APPLICABLE (APRONS, ETC>) [sic] RESIDENTS ARE [NAME] [sic] KEEP OR HAVE THEIR OWN CIGARETTES OR ANY OTHER SMOKING PARAPHANELIA. PLEASE REFER TO POLICY IF QUESTIONS. Review of the policy Smoking Policy - Residents dated October 2022, reflected: Policy Statement: This facility shall establish and maintain safe resident smoking practices. Policy Interpretation and Implementation: (.) 7. The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker or smokeless tobacco user, the evaluation will include: (.) b) Method of tobacco consumption (traditional cigarettes; electronic cigarettes; pipe, etc.). (.) d) Ability to smoke safely with or without supervision (per a completed Smoking Assessment). 8. The staff shall consult with the Attending Physician and the Director of Nursing Services to determine if safety restrictions need to be placed on a resident's smoking privileges based on the Smoking Assessment. (.) 10. Any smoking-related and smokeless tobacco use 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. (.) 12. Any resident with restricted smoking or smokeless tobacco privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking or using smokeless tobacco. 13. Residents are not permitted to give smoking articles to other residents.

Based on observation, interview, and record review the facility failed to provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner for 1 of 1 reviewed for resident council meeting. The facility failed to provide a private space for resident council meetings. This failure could place residents, who attended resident council meetings, at risk of not being able to voice concerns [NAME] to lack of privacy. Findings included: Interview on 06/03/2025 at 1:00 PM with Activity Director revealed monthly resident council meetings were held in the facility's dining room because of space needed to accommodate the residents. She stated meetings should be conducted in a private area to allow the residents to express their concerns freely and openly. Observation and interview on 06/04/2025 at 10:00 AM during a confidential resident group meeting with 13 residents revealed the meetings were held in the dining room. The dining room was an open space where staff members would come into the dining room during resident council to get ice. Residents voiced concern for privacy but felt noting was being done. During survey, resident council meeting was held in the facilities therapy gym however due to limited space all residents who wanted to attend were unable to attend. Record review of resident council minutes for 3/2025, 4/2025 and 5/2025 addressed concerns with call light response time and meal portions. No location of resident council meetings. 3/2025 meeting minutes revealed 9 residents attended; 04/2025 meeting minutes revealed 9 residents attended; 05/2025 meeting minutes revealed 10 residents attended. Review of policy titled Resident Council revised February 2021 reflected, The resident council group is provided with space, privacy and support to conduct meetings.

Based on observations, interviews and record reviews, the facility failed to provide a clean and functional environment for 3 of 14 rooms (Residents #5, Resident #36, Resident #1, and Resident #14) reviewed for a sanitary, functional, and homelike environment, as evidenced by: 1. Resident #5's room had an unrepaired wall and noticeably hanging loose paint particles by the head of his bed. 2. The facility failed to ensure Resident #36, Resident #1 and Resident #14's restroom flooring and tiles were repaired, and faucets had both hot and cold running water in the sink. 3. The facility failed to ensure Resident #1 and Resident #14's room did not have a strong urine odor. These failures could place residents at risk for a decreased quality of life. 1. Resident #5 Record review of Resident #5 face sheet dated 06/05/25, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included hemiplegia and hemiparesis following cerebrovascular disease affecting the left side (Partial paralysis of left side due to stroke), major depressive disorder a mental health disorder characterized by persistently depressed mood and loss of interest in activities), wheezing (high pitch sound when breathing caused by inflammation of airways in lungs), dermatitis (itchy inflamed skin), and speech and language problem, and generalized anxiety disorder (this is a mental condition characterized by feeling worried, anxiety, or fear that is strong enough to interfere with one's daily activities. Record review of Resident #5's quarterly MDS assessment, dated 05/24/25, revealed a BIMS score of 9 which indicated moderative impairment. Resident #5 has a range of motion impairment on the left side of her upper and lower extremities and uses a wheelchair for mobility. Resident #5 required substantial/maximum assistance of staff for all ADLs and was always incontinent of bladder and bowel. Observation and interview on 06/03/25 at 11:26 AM revealed the bed for Resident #5 had been moved from the wall a few inches and revealed wall paint that had peeled off and some paint was hanging off the wall and uneven, bumpy texture of wall behind Resident #5's headboard. Resident #5 stated that because the damaged wall was hidden from his viewpoint, it did not bother him. In an interview with Housekeeper H on 06/04/25 at 1:02 PM, she stated she was not aware of the condition of Resident #5's wall prior to observing it today. She said it appeared as if someone had been pushing the bed too close to the wall and the up and down movement of the head of the bed had peeled the pain off the wall. She said that housekeeping would clean the area if it was dirty. She stated everyone was responsible for reporting an item that was broken, including walls that needed fixing. Housekeeper H stated she would report Resident #5's wall to her manager immediately. She said maintenance was responsible for monitoring the conditions of the building, however it was everyone's responsibility to report any maintenance issues. She said the risk to the resident was that the loose and hanging paint could fall on his food or it could fall in his eyes. In an interview with LVN E on 06/05/25 at 1:43 PM, it was revealed she had verbally reported Resident #5's wall condition to the previous maintenance several times. She said they had a lot of maintenance turnover and that could be why it was not fixed. She said the risk to the resident was that it was not a homelike environment. 2. Resident #36 Record review of Resident #36's face sheet, dated 06/05/2025, revealed a [AGE] year-old male who admitted to the facility on [DATE] with an original admission date of 03/05/2021. Resident #36's primary diagnosis was cerebral infarction (stroke). Record review of Resident #36's Quarterly MDS, dated [DATE], revealed a BIMS score of 12, indicating moderate cognitive impairment. Observation on 06/03/2025 at 10:10 am revealed Resident #36's bathroom entry had approximately 5 floor tiles missing, and the faucet had no water when the cold handle was turned. 3. Resident #1 Record review of Resident #1's face sheet, dated 06/05/2025, revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #1's primary diagnosis was epileptic seizures (a brain condition that causes recurring seizures) related to external causes. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 9, indicating moderate cognitive impairment. Resident #14 Record review of Resident #14's face sheet, dated 06/05/2025, revealed a [AGE] year-old man who admitted to the facility on [DATE]. Resident #14's primary diagnosis was dysthymic disorder (a form of depression). Record review of Resident #14's Quarterly MDS, dated [DATE], revealed a BIMS score of 8, indicating moderate cognitive impairment. Observation on 06/03/2025 at 10:07 am revealed Resident #1 and Resident #14 were not in the room. The room smelled like urine and the bathroom had approximately 2 missing floor panels underneath the sink. Observation on 06/03/2025 at 1:29 pm revealed Resident #1 and Resident #14's room had a strong urine odor. Observation on 06/04/2025 at 1:21 pm revealed Resident #1 and Resident #14 room had a strong urine odor. The bathroom sink had no running water when the hot handle was turned on. Interview on 06/05/2025 at 10:37 am, Housekeeper G stated she did notice an odor in Resident #1 and #14's room. She stated she mopped the floor with disinfectant and wringed out the mop. She stated there was not much they could use for the smell. She stated when she noticed something that needed to be repaired in a resident room she would tell her boss, the Maintenance Man or front office. She stated it was important for rooms to be clean and functioning for the residents' sake because it was their home. Interview on 06/05/2025 at 10:47 am, The Housekeeping Supervisor stated Resident #1 and #14's room was pretty hard to clean. She stated they did the best they could and mopped the floor 3-4 times a day. She stated they used the chemicals provided and sometimes the resident would urinate on the floor. Interview on 06/05/2025 at 11:01 am, CNA A stated Resident #1 urinates on his pants, removes his clothes, and puts them in the closet. CNA A stated Resident #1 does not wear briefs and was independent. She stated she noticed an odor in his room in the morning, but after staff picked up the clothes and housekeeping cleaned the room there was no odor. CNA A said she did not notice the bathroom flooring missing or that there was no hot water on in the sink. She stated if something needed repairs she would tell maintenance. CNA A stated it was important for residents to have a clean and functioning environment for their health and comfort. Interview on 06/05/2025 at 11:32 AM, LVN 3 stated she could not deny there was an odor in Residents #1and #14's room. She stated if she noticed a strong urine odor, she would let the doctor know in case the resident had an infection and let housekeeping know to clean the room. LVN 3 stated she did not notice the missing flooring or no hot water in the bathroom. She said if something was not working, she was supposed to let Maintenance know. She stated it was important to make sure residents had a clean environment to prevent infection and because it was their home. Interview on 06/05/2025 at 3:00 pm, the DON stated she was aware of the odor in Resident #1's room. She said staff worked on it nonstop to make sure Resident #1 was clean and dry, linens were clean and dry, and to make sure nothing on the floor was clean. The DON stated Housekeeping was responsible for cleaning the room and nursing was responsible for changing clothing. The DON stated she was not aware of any water issues in Resident #1, #14 and # 36's rooms. The DON stated water was a basic need and residents needed to be able to wash their hands or wash up and staff needed to be able to wash their hands. She stated she expected staff to report any issues to maintenance through TELS, and to tell him verbally if it was urgent. She stated they monitor the environment by making rounds Monday through Friday, and anything noticed they would bring to the morning meeting and notify Maintenance or Housekeeping. Observation and interview on 06/05/2025 at 3:46 pm, the Maintenance Director stated he put a brand new faucet in Resident #1 and #14's room today. The hot and cold water was observed to be working. He stated he did not notice the flooring in that room. Surveyor and Maintenance Director went to Resident #36's room and the Maintenance Director stated there was tile missing on the floor and there was no hot water when he turned on the faucet. He stated he was not aware of the water or missing tiles. He said staff were supposed to call or text him if something needed to be fixed. He stated he had access to TELS work order system on his phone. He said it would not be a homelike, safe, or clean environment resident rooms were not working or needed to be repaired. He stated it was important to have working faucets so residents could wash themselves and for staff to wash their hands. Interview on 06/05/2025 at 4:18 pm, the Administrator stated staff were supposed to put in a work order to let Maintenance know, as well as go tell him if something needed to be repaired. She stated if they could not find him, they were to let someone in management know. She stated Resident #1 would sometimes go to the restroom, but it was hit and miss. She stated the risks would be UTI, dignity, comfort, and depression. Record review of facility work orders, dated 03/01/2025 through 05/31/2025, revealed no work orders for rooms of Residents #5, #36, #1 or #14. Review of the facility policy Homelike Environment, revised February 2021, reflected: Homelike Environment Policy Statement: Residents are provided with a safe, clean, comfortable, and homelike environment ( .) Policy Interpretation and Implementation: 1. Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. 2. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment; ( .) c. inviting colors and décor; d. personalized furniture and room arrangements; e. clean bed and bath linens that are in good condition; f. pleasant, neutral scents; ( .)

Based on observations, interview and record review, the facility failed to ensure that one of one resident (#31) removed oxygen tubing and tank before entering smoking area and smokers extinguish cigarette in designated areas. Staff failed to ensure smoking residents extinguished cigarettes in a safe manner. Staff failed to remove Resident #31's oxygen tubing and tank before entering smoking area. This failure could affect residents by placing them at risk for burns and injuries. Findings included: 1.Review of current, undated admission Record for Resident #31 revealed she was a [AGE] year-old female, re-admitted on [DATE] with diagnosis including acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, encounter for adjustment and management of vascular access device, acute bronchitis and nicotine dependence, cigarettes. Review of Resident #31's Care Plan dated 04/15/2025 revealed the following focus areas: *Problem; Non-compliant with smoking policy r/t hiding leftover cigarette and hides in room. Approach: instructed resident cigarettes must be disposed of appropriately during smoke break and cannot be kept, cannot be saved. Smoking policy has been provided to resident and resident has signed and agreed to policy. *Problem: Resident has oxygen saturation disturbance symptoms related to emphysema/COPD. Approach: administer oxygen as ordered. Observe oxygen precautions. *Problem: I am a smoker, and I must be supervised when smoking. Patient may go to smoke with no oxygen in use in smoking area. Review of Resident #31's Minimum Data Set Interim Payment Assessment Item Set dated 05/28/2025 revealed; BIMs score 11 (moderate impairment). Review of Resident #31's active orders reveal; nasal cannula 9continuous): O2 @ 4l/Min every shift. Review of Resident #31's Safe Smoking Evaluation dated 06/03/2025 revealed, Supervised smoker. Additional comments: Resident removes her oxygen before smoking. Observation on 06/04/2025 at 10:35 AM revealed, Resident # 31 sitting in her wheelchair outside (Nurse station one) exit door smoking a cigarette accompanied by male staff. Observation of resident flicking her ashes onto the ground. Interview on 06/04/2025 at 10:39 am with resident #31 revealed she that was the only place she can smoke, outside the door because she cannot be around people that smoke per her doctor's orders. She stated staff will push her outside and she will take a few puffs from her cigarette and come back inside because she cannot be off her oxygen for too long. Observation and interview on 06/04/2025 at 1:58 pm revealed; CNA I with resident 31 outside in the courtyard. CNA I was observed with O2 tubing in her hand wrapping it up. She then removed the Oxygen tank from the back of the resident's wheelchair. Resident was observed with a cigarette that was not lit. Resident smoked the cigarette and extinguished it on the bottom of her shoe. Resident #31 revealed she told CNA I to take off the tank when they were inside. She stated they (staff) always take it off, but she did not normally take me out. Interview on 06/04/2025 at 2:00 pm with CNA I revealed she takes resident #31 out to smoke at 9, 11, 2pm. She stated she does not know why the resident smoked outside the door she thought she went to an appointment one time, and they told her not to be around others. She stated she knew to take the oxygen tank off the back of the wheelchair before the resident goes outside but the resident was calling her stupid and saying she did not need to take it off. She stated the resident wanted to go outside and get it over with. She said the resident continued to call her stupid. She stated the risk of not removing the oxygen could cause the resident to burn herself. She stated she should have taken the resident back to her room and told the nurse. Interview on 06/05/2025 at 1:43 pm with LVN E revealed; staff know they are supposed to take Resident #31 to smoke, but the tank should not go outside the door. Leave the tank and tubing inside (right inside the door). They know the risk with oxygen you can blow up; it can blow all of us up. LVN E stated she had them take her out more because the resident takes two or three puffs because she cannot breathe. The oxygen tank was right there (by the door) because when she comes back in, she needs the oxygen. Interview on 06/05/2025 at 3:00 pm with DON revealed; staff are educated often to remove oxygen tank before they go outside. We in-service them at least weekly about the risk. The risk was it could catch on fire. She stated she was not aware that the area where Resident # 31 was smoking did not have an ashtray to extinguish the cigarette safely. 2.Observation on 06/03/2025 at 1:04 PM revealed at least 100 cigarette butts scattered around the courtyard's grassy area outside less than 2 feet from kitchen zone 3 exit door and at least 100 cigarette butts and a metal chair located outside the door of nurse station one to the courtyard. No ashtrays were observed by each exit doors. Observation of No Smoking signs posted on each door. Interview on 06/03/2025 at 1:15 PM with Activity Director revealed, residents are not supposed to smoke by the doors only under the covered patio area and extinguish their cigarettes in ashtrays. She stated staff members are assigned to monitor residents during smoke breaks. Interview on 06/03/2025 at 1:25 PM with Maintenance Director revealed, his duties include maintaining the facility grounds. He stated he did not notice the cigarette butts on the ground. Interview on 06/05/2025 at 4:17 pm with Administrator revealed; oxygen should come off the resident before exiting the door. If the resident did not allow the removal of the tank and tubing, then the CNA I should have alerted the nurse. The risk was a fire hazard. She stated there was a designated smoking area for residents to smoke. She stated maintenance was responsible for cleaning the smoking area. Policy review of Resident Smoking Policy dated 2024 revealed; 1. Smoking is prohibited in all areas except the designated smoking area. A Designated Smoking Area Sign will be prominently posted. 4. No smoking signs will be maintained on doors or gates where oxygen is used or stored. 15. All smoking material will be maintained by nursing staff and at no time are to be kept on stored in a resident's room.

Based on observations, interviews, and record reviews, the facility failed to promote and facilitate resident self-determination through support of resident choice for 1 resident (Resident #23) of 24 residents reviewed for resident rights, as evidenced by: The facility failed to ensure Resident #23's right to participate in walking activities were consistent with his interest and choices about aspects of his life in the facility that are significant to the resident. This failure could place residents at risk of limiting the resident's opportunity to exercise their autonomy regarding those things that are important, including interests and preferences. Findings included: Record Review of Resident #23's face sheet, dated 06/04/2025, reflected that the resident was a [AGE] year-old male, admitted on [DATE] with primary diagnosis of other epilepsy, not intractable, with status epilepticus, and other diagnoses of hemiplegia (affecting right dominant side), generalized anxiety disorder, cognitive communication deficit, other abnormalities of gait and mobility, Muscle weakness (generalized), Other lack of coordination, major depressive disorder (recurrent, moderate), expressive language disorder, dementia (in other diseases classified elsewhere), severe, with mood disturbance. Record Review of Resident #23's MDS assessment, dated 03/17/2025, reflected a BIMS of 11 which indicated Resident #23 was cognitively intact. Resident #23 completed all ADLs with supervision and one-person physical assist for bed mobility. Record Review of Resident #23's Physical Therapy Discharge summary dated [DATE] reflected: discharge recommendations: recommend 24 hour supervision.pt has all necessary equipment at this time. Record Review of Resident #23's Psychological Evaluation/Management note dated 05/29/2025 reflected: Nonpharmacologic Interventions: Provide a calm milieu, supportive care, encourage psychotherapy, and social interactions. Record Review of Resident #23's Care Plan dated 03/26/2025 reflected: (Resident) benefits from daily programming based on personal history, interests, and current abilities due to a diagnosis of dementia and other comorbidities, with the goal that the resident will verbalize satisfaction with person centered programming over the next 90 days. Approach/interventions included: He spends much of his time walking around the facility. Understand that behaviors result from changes in the brain and difficulty with communication. I am on an antidepressant due to depression, with the goal that the resident will experience limit episodes of depression over the next 90 days. Approach/interventions included: Encourage resident to attend activities of choice. Observation and interview with Resident #23 on 06/03/2025 at 10:18AM revealed Resident #23 walking down the hallway and into his room. Resident #23 discussed with the surveyor that he did not participate in therapy provided by the facility. He stated he did his own exercise therapy to stay strong. Resident #23 had a goal of walking 100 laps around the facility each day. Observation and interview with Resident #23 on 06/03/2025 at 10:51AM revealed Resident #23 walking a lap in the hallway. During the resident's walk, he showed the surveyor the 2 sets of weights velcro wrapped around his wrists. Resident #23 stated he used wrist weights as a part of his exercise activity to stay strong. The resident discussed wanting to be discharged to go to an assisted living facility. Observation and interview with Resident #23 on 06/03/2025 at 11:03AM revealed Resident #23 approached surveyor visibly upset, indicated by his facial expression. The resident said the gym (the occupational therapy and physical therapy room) took away the wrist weights he was wearing because state was here and pointed to the surveyor. To confirm what the resident communicated, the resident was asked if he normally wears the weights around his wrists while he walks his laps, but because state surveyors are in the facility, they took them away. The resident confirmed this by stating yes and shaking his head. Interview on 06/03/2025 at 1:47PM with PTA revealed she worked with Resident #23 when he was on the physical therapy caseload. The resident discharged himself from therapy because he did not think he needed it. The PTA stated Resident #23 took charge of his physical activity and he had been given permission to use the therapy gym's equipment. She further stated Resident #23 knew he was not supposed to take the (wrist) weights out of the gym and had to be reminded not to take gym equipment. The PTA stated she recently talked with the DOR about alternatives options for the resident to prevent him from taking wrist weights out of the gym. Interview on 06/03/2025 at 1:56PM with the DOR revealed Resident #23 had a medical condition (impairment) due to frontal lobe involvement and it was hard to regulate the resident's agitation. The resident was periodically on therapy's caseload; he would stick with therapy for a couple weeks and then discharge from the therapy plan. The DOR stated the resident liked to come into the therapy gym and it was always open for him to come in and work out if staff were present. The DOR stated Resident #23 liked to be as independent as much as possible, and in the past, the resident wanted to use equipment outside of the gym, but it had to be stopped. She further stated with or without survey, he would have been stopped; therapy did not want the resident to lose the wrist weights. The DOR stated she planned to look into having the resident purchase his own set of wrist weights. Other alternatives include having him participate in group activities. The DOR stated staff have to be very mindful of resident switching gear or having agitation (when interacting with resident and trying to redirect him). Observation and interview on 06/04/2025 at 11:52AM with Resident #23 revealed the resident walking around the facility while not wearing the wrist weights. Resident appeared to still be upset about the wrist weights being taken away. He stated he had not used them since because state was in the facility. At this time, the resident approached LVN 2. The surveyor asked LVN 2 if Resident #23 normally wears wrist weights when walking laps in the facility, she stated he did. LVN 2 stated the resident using the wrist weights has never been a problem. Interview on 06/05/2025 at 11:38 PM with LVN 3 revealed she provided care to Resident #23, and he was independent, unless he was not feeling well or asked staff for something. She explained the resident walked all day and sometimes took breaks, he walked to stay strong. LVN 3 recalled Resident #23 wearing weights on his wrist on 06/03/2025. She said she questioned the resident on why he was wearing the wrist weights and that he became mad. She said that he made many laps around the facility, and she asked him to take a break from the weights; the resident said no and continued walking. LVN 3 explained that when the resident does something he wants to do, you cannot tell him no; he can get upset quickly, and walking helps with the resident's mood. LVN 3 stated the resident had used a wheelchair in the past, but once he was walking, he felt like he was gaining independence. Interview with the DOR on 06/05/25 at 12:18 PM revealed Resident #23 had used the wrist weights while on caseload for therapy exercises like bicep curls. The DOR explained that it was preferred if the resident came into the therapy gym when it was not busy so they can keep an eye on him. She said the PTA said the gym was busy at the time of when Resident #23 had taken the wrist weights on 6/3/2025. The DOR stated that on 6/3/2025, Resident #23 was seen with multiple (2) sets of wrist weights on his wrist and wanted to walk laps around the facility; the resident was asked to leave the weights in the gym. She said that if the resident was walking around and no one needs the weights, he can walk with them. She emphasized him coming back and utilizing the weights at another time, if the gym was busy. The DOR described Resident #23 as goal driven did not follow a specific schedule, but she will talk with the resident about making more of a schedule to avoid types of conversations that would upset him. The DOR stated therapy wanted to provide patient centered care 100%. It's important to give him tools (equipment) to utilize safely, because the equipment was important to him. Interview with the DON on 06/05/2025 at 2:58PM revealed therapy (staff) and the DOR have told the DON that Resident #23 had to be supervised when using the wrist weights and they are to be kept in the therapy gym, so they were not lost or stolen. She further stated she has not seen Resident #23 wearing the wrist weights. The DON stated she had no problem care planning the wrist weights and it had never been an issue before since the resident has not been upset before. It was never a concern to have to come up with an intervention. She stated that it was resident's right to have independence, and if that (using the wrist weights) was what makes him feel better. Interview with the ADM on 06/05/2025 at 4:08PM revealed that the ADM was told the reason therapy wanted Resident #23 to stay in the gym with the wrist weights was for safety; she understood it as he was being monitored. The ADM stated the resident's independence was at risk if he was not able to have access to his wrist weights; it could have an issue with the resident being able to go home, since he wanted to discharge from the facility, and (not allowing the resident to walk with weights) could keep him from improving (his mobility and strength, in which is essential for performing ADL tasks independently). The ADM explained that the resident had a goal in his mind and it was his right to walk laps around the building. The ADM stated interventions to meet Resident #23 needs include providing him with his own wrist weights, to care plan use of wrist weights, and his preference to use in his room or the facility. Record review of the facility's Resident Rights Policy Statement revised February 2021 reflected: Employees shall treat all residents with kindness, respect, and dignity . 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: . e. self-determination; . p. be informed of, and participate in, his or her care planning and treatment .

Based on observation, interview, and record review the facility failed to designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident The designated interdisciplinary team member is responsible for the following: ii) Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the patient and family. (iii) Ensuring that the LTC facility communicates with the hospice medical director, the patient's attending physician, and other practitioners participating in the provision of care to the patient as needed to coordinate the hospice care with the medical care provided by other physicians for two (resident #22 and Resident #44) of four residents reviewed for hospice services. 1.The facility did not designate a member of the facility to obtain Resident #22's current hospice recertification, most current hospice orders, and most recent plan of care since hospice benefits expired on [DATE]. 2.The facility did not have the same physician determination of terminal illness as hospice company did. The facility had a COPD as the primary hospice admission diagnosis while in the hospice binder, the primary hospice admission was Metabolic Encephalopathy (this is a fluid disorder that causes brain alteration and brain function) and vascular dementia (this is a brain condition that progressively destroys memory and other important mental functions) for Resident #22 3.The facility did not designate a member of the facility to obtain Resident #44's current recertification records from hospice, most recent hospice plan of care, most recent hospice physician orders, and most current hospice nursing documentation since benefit period ended on [DATE]. 4.The facility did not designate a member of the facility to verify signing in for hospice RN for Resident #44 since [DATE]. These failures could affect residents by placing them at risk for services and treatments not being coordinated for end-of-life care. Findings included: Resident #22 Record review of Resident #22 admission record dated [DATE], revealed an [AGE] year-old female who was readmitted to the facility on [DATE] with an initial admission of [DATE]. Her primary diagnosis was metabolic encephalopathy (this is a fluid disorder that causes brain alteration and brain function). Her secondary diagnoses included chronic obstructive pulmonary diseases (a lung disease that blocks airflow and makes it difficult to breathe), hypo-osmolality and hyponatremia (low levels of sodium due to fluid imbalance), wheezing (high pitch sound when breathing caused by inflammation of airways in lungs), coughing and plural effusion (this is a buildup of excessive fluid in the spaces between the lungs and chest walls). Resident was her own RP, and she was on hospice. Record review of Resident #22's quarterly MDS assessment, dated [DATE] reflected a BIMS score of 8 which indicated moderative impairment. Resident #22 required substantial/maximum assistance of staff for all ADLs and was always incontinent of bladder and bowel. Resident #22 received hospice services while in the facility, she did not have a left expectancy of less than six months. Further review of MDS did not reflect active diagnoses of dementia. Record review of Resident #22's active physician orders for [DATE] reflected, Resident #22 admitted to hospice on [DATE] with a primary diagnosis of COPD. Her level of hospice care: routine in-patient. Record review of Resident #22's care plan, revision date [DATE] , revealed Resident #22 was admitted to hospice with a primary diagnosis of COPD. Her goal was comfort and dignity to be provided while on hospice through the next review date. Her interventions were to follow hospice orders as written, to inform hospice if any significant changes in residents' status including signs and symptoms of discomfort and will be addressed accordingly. Record review of Resident #22's hospice binder on [DATE] revealed a hospice initial plan of care and physician orders for benefit period [DATE] to [DATE]. Resident #22's terminal hospice admission diagnosis was revealed as ICD-10-CM code G93.41- Metabolic Encephalopathy (this code is used to classify a transient or permanent impairment of brain function resulting from abnormal metabolic process) and vascular dementia. Record review and interview with Resident #22 on [DATE] at 09:44 AM, revealed she was not interviewable. She was her own RP and no other family on her chart. In a phone interview with the hospice RN B on [DATE] at 10:16 AM, revealed he was Resident #22 hospice nurse, and he evaluated her, monitored her paperwork, and assessed her needs weekly. He said Resident #22 also had a hospice aide that came to perform personal hygiene and assist with ADLs, 5 days a week, and as needed. RN B said that he made sure that he communicated with the facility nurses for any changes, and he inquired with the facility nurses for a change in condition and if they needed any new orders or supplies. RN B stated he was sure that Resident #22 had a current and updated hospice care plan and orders because the hospice IDT team just met to do the recertification for Resident #22. He said the IDT was made up of RN's, Social workers, chaplain, and physician. He said he would fax to the facility the current benefit period, hospice plan of care, and orders. He said it was his responsibility to make sure that all hospice documentation in the hospice binder was current as these forms were pertinent to ensuring coordination of care. He stated not having accurate documentation would cause the resident not to have Continuity of care. He said not having accurate diagnoses for services causes a risk of being unable to verify that residents received scheduled care. During an interview with LVN E on [DATE] at 1:43 PM, LVN E said she worked the morning shift Monday to Friday and hospice RN B always verbally communicated with her when he came to see Resident #22 and she would sign his tablet to verify that he came to see the resident. She said she expected the hospice providers to keep resident hospice records current. LVN E said it was especially important to ensure coordination of care with medications and comfort and that the facility had corresponding orders, diagnoses, and plans of care as the hospice for continuation of care. She said it was important for the facility to have current orders for coordination of care. She said she did not know who was assigned by the facility for monitoring the hospice binders and documentation. LVN E said she uses the hospice binder to verify orders and to see if the aide came in to provide care if she did not see her. Resident #44 Record review of Resident #44 face sheet dated [DATE], revealed a [AGE] year-old female who was readmitted to the facility on [DATE] with an initial admission on [DATE]. Her diagnosis includes acute on chronic systolic congestive heart failure (this is a sudden worsening of symptoms in a person with pre-existing heart failure), malignant neoplasm of unspecifies site of left female breast (breast cancer), breast cancer surgery, high blood pressure, and chronic pain. Resident#44 was on hospice. Record review of Resident #44's quarterly MDS assessment, dated [DATE], reflected a BIMS of 13 which indicated Resident #44 was cognitively intact. Resident #44 was occasionally incontinent, and she completed all ADL's independently with no assistance. Resident #44 received hospice services while in the facility; she did not have a left expectancy of less than six months. Record review of Resident #44's active physician orders for [DATE], reflected Resident # 44 was readmitted to hospice on [DATE] with diagnosis of Metastatic breast cancer (cancer that has spread). Her hospice level of hospice care: routine in-patient. Record review of Resident #44's care plan, revised [DATE], revealed Resident #44 was admitted to hospice with a primary diagnosis of Metastatic breast cancer. Her goal was to have an optimal quality of life. The intervention was to notify the hospice of a change in condition. A record review of Resident #44's hospice binder on [DATE] revealed a comprehensive hospice assessment and plan of care updated report that ended on [DATE]. The frequency of skilled nursing visits was once a week. The hospice binder had no evidence of an updated hospice comprehensive assessment and plan of care report to reflect current recertification period, most recent hospice plan of care, and most recent hospice physician orders since [DATE]. The hospice binder also had no evidence to reflect current RN hospice nursing progress notes documentation since [DATE]. Further review of the hospice binder revealed RN last sign in was dated [DATE]. In an interview with Resident #44 on [DATE] at 08:58 AM, she said she was on hospice for breast cancer. She said she had been in hospice since 2023. She said that she did not have an aide in her plan of care as she did not need one. She said that her hospice nurse came weekly to see her, and the hospice case worker came to see her too although she could not recall which date. Resident #44 said she had no concerns with her hospice care. During a phone interview with hospice RN C on [DATE] at 11:04 AM, he said he forgot the updated documentation for Resident #44 when he was in the facility last week. He said he does not look at the hospice book because all documentation, evaluations and medication orders are on his tablet. He said he was responsible for monitoring and updating hospice B's documents so that they were current for all residents admitted to his hospice company. He said the risk of not having current hospice documentation lacked continuation of care between the facility and hospice. In an interview on [DATE] at 11:46 AM with LVN D, it revealed RN C came weekly, and RN C asked for his signature on his tablet for verification of visit. LVN D said he never looked at the hospice binder except when he handed it to the hospice providers. He said the hospice providers always communicate with him if there are changes. He said hospice RNC was especially good because he always asked if they needed to reorder any medications for Resident #44. He said it was important to have a current plan of care because when it was care planned, it was expected to be done. In an interview on [DATE] at 10:58 AM with SW, it was revealed that her responsibility with hospice was to give residents and family information for the different hospice companies that the facility had contracts with. She said after the family chooses the hospice of their choice then she reached out to nursing for the face sheets, diagnosis, and order and sends it to the hospice company. SW said she was not the designated coordinator to make sure that all hospice documentation was the same as the facilities. She said she expected the hospice providers to keep resident hospice records current to ensure coordination of care. During an interview on [DATE] at 03:01 PM, with DON, she said the hospice provider should supply all the admission paperwork when the resident admitted to hospice. DON said the facility had its own orders, and their own plan of care. DON said no one had been assigned as a hospice designated coordinator. She said moving forward they will meet and assign someone who will be responsible for ensuring and monitoring the hospice provider updated the clinical records of each hospice resident. She said not having current and accurate documentation prevents continuity of care. During an interview on the Administrator [DATE] at 4:28 PM, it was revealed she expected the hospice to provide all the required documents at the time of admission to ensure an accurate hand off care ensuring the coordination of care. The Administrator said the nurse completing the admission was responsible for ensuring the documentation was available. The Administrator said the process will be reviewed in the daily meetings to review the admissions, and then again in the weekly standards of care meetings. Review of Hospice A and Hospice B updated documents sent via fax on [DATE] at 12:22 PM for Resident #22 and Resident #44 revealed updated care plans, orders, and current recertification periods. Review of the facility's policy titled, Hospice Program, revised [DATE], did not reflect a designated coordinator. It reflected as follows: .12. Our facility has designated [blank/no name] to coordinate care provided to the resident by our facility staff and the hospice staff. He or she is responsible for the following: b. Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the terminal illness .; d. Obtaining the following information from hospice: .(2) Hospice election form, (3) Physician certification and recertification of the terminal illness specific to each resident .; e. Ensure that our facility staff provide orientation on the policies and procedures of the facility, including resident rights, appropriate forms, and record keeping requirements to hospice staff furnishing care to the residents. 13. Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility (including the responsible provider and discipline assigned to specific tasks) in order to maintain the resident's highest practicable physical, mental and psychosocial well-being.

Based on observation, interview, and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 1 of 3 residents (Resident #1) reviewed for dietary services. The facility failed to ensure Resident #1 received their prescribed diet special instructions finger foods for the lunch meal on 04/09/2025. This failure could place residents at risk for loss of independence and a decreased quality of life. Findings included: Record review of Resident #1's face sheet, dated 04/09/2025, revealed a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included cerebral infarction (stroke), dysphagia (difficulty swallowing), and hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following unspecified cerebrovascular disease (conditions that affect blood flow to the brain) affecting left dominant side. Record review of Resident #1's Annual MDS assessment, dated 02/07/2025, revealed a BIMS score of 8, indicating moderate cognitive impairment. Review of Section K - Swallowing/Nutritional status of the MDS, revealed Resident #1 had coughing or choking during meals or when swallowing medications. Resident #1 did not have weight loss or gain. Resident #1 required a mechanically altered diet and therapeutic diet while a resident. Record review of Resident #1's care plan, dated 02/27/2025 and edited 03/03/2025, revealed Resident #1 was on a regular diet with thin liquids, with low concentrated sweets and Resident #1 will like to have finger good with all meals. Record review of Resident #1's Physician order, start date 04/02/2025, revealed diet type: LCS Diet consistency: Regular; Fluid Consistency: thin liquids Special Instructions: finger foods. Record review of the menu on 04/09/2025 at 11:59 AM revealed the lunch menu was meatballs with spaghetti sauce, spaghetti noodles, capri vegetables, herb butter roll, cheesecake bar. Observation on 04/09/2025 at 12:33 pm, revealed Resident #1 sitting in the dining room in her wheelchair. Resident #1 had a regular tray with spaghetti sauce and meatballs on top of spaghetti noodles, and vegetables next to the noodles. Resident #1 was not feeding herself. Observation on 04/09/2025 at 12:45 pm, revealed Resident #1 not feeding herself and the meal ticked read finger foods. RN A then began to feed Resident #1. Observation and interview on 04/09/2025 at 1:10 pm, RN A stated Resident #1 had eaten 80% of the spaghetti, 100% of the dessert and juice. RN A stated Resident #1 tried to feed herself but if she observed Resident #1 not eating, she would help Resident #1 to eat. When asked what finger foods meant, RN A stated like French Fries, or one she can just pick up and eat. Interview on 04/09/2025 at 1:14 pm, the Dining Services Manager stated Resident #1 was the only resident on the finger foods diet. He stated Resident #1 could eat by herself and staff would cut her food so she could eat with her hand. He said the diet was not a different type of food from the regular diet, but the way it was served so she could feed herself. He said Resident #1 had been on the finger foods diet for about 2.5 to 3 months and would not eat when she was on the mechanical soft diet prior. Interview on 04/09/2025 at 3:39 pm, the DON stated the finger foods diet was something where Resident #1 could pick up and put in her mouth herself easily and gave an example of a sandwich cut up into pieces. The DON stated today's regular lunch meal would not be considered finger food unless the noodles and sauce were separated. She said the kitchen was responsible to follow the diets, and the nurses were responsible to check the diet against the food on the tray. The DON stated the risk was a dignity issue and not a swallowing issue. She stated they did inservice staff on finger foods. Surveyor requested policy and inservice. Interview on 04/09/2025 at 4:10 pm, the DON provided an inservice on diet types and said it was completed on 03/04/2025. Interview on 04/09/2025 at 4:15 pm, [NAME] D stated only Resident #1 was on finger foods and it meant that the food was cut into little pieces so she could eat with her fingers. She stated the meatballs would be considered finger foods and they should have been separated. [NAME] D stated she was inserviced on diet types. Interview on 04/09/2025 at 4:20 pm, the Dining Services Manager stated if the items for lunch were served individually that would be considered finger foods. He stated the kitchen was responsible to cut up her food and they usually always cut up her food but today was an oversight. Interview on 04/09/2025 at 5:24 pm, the Administrator stated there was no risk for any type of choking hazards, but it would be an issue with her independence if Resident #1 was not able to pick up food. She stated her expectation was for staff to follow the diet order. She stated the kitchen would be responsible to ensure the correct diet was served and the nurse would check the tray to match what the tray card said before it was served. Record review of Therapeutic Diet In-Service, undated, revealed in part: The Finger Foods Diet is used to promote self-feeding for those residents who have difficulty using utensils due to cognitive or physical issues. Foods offered are typically in bite size pieces or offered as sandwiches. Soups are pureed and pureed into a cup for drinking. All fruits and vegetables should be bite-sized and drained, ice cream & pudding can be served in ice cream cones, on cookies & graham crackers.

Based on observation, interview, and record review, the facility failed to ensure residents with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (Resident #1) of three residents reviewed for pressure ulcers. 1. The facility failed to ensure there were PRN wound care orders for Resident #1's Stage 4 sacral pressure ulcer per professional standards of care. 2. The facility failed to ensure Resident #1's dressing was replaced when it became dislodged, allowing the wound to become contaminated with feces. This failure could place residents at risk of developing infections to wounds. Findings included: Record review of Resident #1's undated face sheet reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of Stage 4 pressure ulcer of sacrum. Record review of Resident #1's quarterly MDS, dated [DATE], reflected his BIMS score was not calculated due to his medical condition. His Functional Status assessment indicated he required total assistance from staff for all of his ADLs. His Skin Conditions did not reflect any pressure ulcers. Record review of Resident #1's care plan, dated 09/27/24, indicated he had a Stage 4 pressure ulcer to his coccyx that was being treated by the wound care physician. Record review of Resident #1's physicians orders reflected an order, dated 11/19/24, which reflected: Wound Treatment Order: Location: (sacrum and right buttock) Clean with Normal Saline/Wound Cleanser. Apply:(Dilute 1/4 of Dakins solution onto kerlix). Cover with Primary Dressing:(optiform/bordered dressing). Once A Day 06:00 AM - 06:00 PM Observation on 11/23/24 at 11:00 AM of Resident #1 revealed he was on his back in bed, tracheostomy in place, feeding tube in place with feeding infusing, and a urinary catheter draining amber colored urine. The resident was not responsive to verbal stimulation. Observation and interview on 11/23/24 at 11:40 AM with LVN A revealed Resident #1's pressure ulcer did not have dressing in place. The dressing was not present in the resident's brief, and the pressure ulcer was covered with loose bowel movement. LVN A stated she did not know when the dressing had come off. She stated this was her first assessment of the resident this shift. Observation and interview on 11/23/24 at 12:00 PM with the ADON revealed she agreed the dressing for Resident #1's pressure ulcer was not present in the resident's brief. The ADON stated if the dressing had been removed while providing care because it was soiled or dislodged. She stated the nurse should have been notified immediately, so the dressing could be replaced. Interview on 11/23/24 at 12:05 PM with CNA B revealed she had changed Resident #1's brief, with CNA C assisting, between 7:30 AM and 8:00 AM. CNA B stated the dressing was in place at that time. CNA B stated the resident's brief was only wet, not soiled when she changed it. When CNA B was asked if she had reported the wetness to the nurse, since the resident had a urinary catheter, she stated she did not notify LVN A. She stated LVN A had been assisting her with Resident #1. Interview on 11/23/24 at 12:15 PM with CNA C revealed he had not helped CNA B change Resident #1. Follow-up interview on 11/23/24 at 12:18 PM with LVN A revealed she had not assisted CNA B with changing Resident #1. Observation on 11/23/24 at 12:24 PM with LVN A revealed Resident #1's pressure ulcer had been cleansed of bowel movement. The resident's skin did not appear red or irritated, and the wound measured 10 cm x 15 cm x 4.5 cm. LVN A provided Resident #1 with wound care per the physician order. Telephone interview on 11/23/24 at 1:40 PM with the Wound Care Nurse revealed Resident #1 had returned to the facility from an LTAC facility in September 2024. The Wound Care Nurse stated he had gone to the LTAC after having his tracheostomy placed, with the wound to his coccyx. Prior to his hospital admission and treatment at the LTAC, Resident #1 had no wounds. The Wound Care Nurse stated the Wound Physician thought the wound was healing slowly due to the resident's medical conditions. The Wound Care Nurse stated the nurses knew they were responsible for wound care when she was not present in the facility, and they knew to follow the physician's order for the procedure. Record review of the facility's Wound Care policy, dated June 2022, reflected the policy did not address what to do when the dressing had been dislodged or if the wound had been contaminated with bodily fluids.

Based on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment for 6 (Resident's #7, #8, #9, #10, #11, and #12) of 8 residents reviewed for environment sanitation and safety. The facility failed to ensure Resident #7's portable toilet was emptied after use and soiled briefs and wipes were discarded after completing incontinent care. The facility failed to ensure trash was discarded from the adjoined restroom for Resident's #8, #9, #10, and #11 to a biohazard waste location upon incontinent care. The facility failed to ensure hardware from a dis-assembled nightstand draw (exposing loose boards, screws, and metal frame) was removed from Resident's #12's environment. This deficient practice could result infections due to unsanitary environment, injuries, and/or accidents while propelling and ambulating independently in the facility. Findings included: Record review of Resident #7's face sheet, dated 08/16/24, revealed the resident was a [AGE] year-old female with an initial admitted [DATE]. Diagnoses included COPD, hypo-osmolality (low concentration of sodium in the blood), hyponatremia (low concentration of sodium in the blood), functional dyspepsia (reoccurring stomach symptoms), major depression disorder, cough, neuralgia (pain in the nerve) , and neuritis (nerve pain) nausea, anemia (water retention), pain, insomnia, and acute and chronic respiratory failure with hypoxia (inadequate gas exchange by respiratory system.) Record review of resident #7's Quarterly MDS dated [DATE] reflected a BIMS score of 12 indicating she was moderately impaired. Resident required staff assistance for hygiene, toileting, and bathing. The MDS reflected the resident was on oxygen. Record review of resident 7's Care plan dated 05/15/24 reflected resident requires dressing/grooming amount of assist:1 Resident care as per facility protocol . Toileting amount of assist: 1. Record review of Resident #8's face sheet, dated 08/15/24, revealed the resident was a [AGE] year-old male with an initial admitted [DATE]. Diagnoses included Cerebral Palsy (group movement disorder), Cerebellar ataxia (lack of voluntary coordination of muscle), Psoriasis (long lasting non-contagious autoimmune disease), and Intellectual Disability Disorder ( learning disabled) Record review of Resident # 8's quarterly MDS dated [DATE] reflected a BIMS score of 6, indicating he was impaired severely cognitively, required total assistance for ADL, incontinent care. MDS addressed diagnosis. Record review of Resident # 8's quarterly care plan 05/23/24 reflected he was PASSR positive and has a diagnosis of Severe intellectual disability with expected decline in cognitive impairment over a period of time. He has impaired communication, Record review of Resident #9's face sheet, dated 08/16/24, revealed the resident was a [AGE] year-old male with an initial admitted [DATE]. Diagnoses included Polyneuropathy (damaged nerves in two areas), DM 2(unstable blood sugar levels). Record review of Resident # 9's Entry MDS dated [DATE] reflected a BIMS score of 9, indicating he was impaired moderately cognitively, required supervision and touching assistance for toileting. The resident's MDS addressed diagnosis. Record review of Resident # 9's base line care plan 08/14/24 reflected resident observation for needed additional care needs, monitor blood sugars every meal, and offer stacks between meals. Record review of Resident #10's face sheet, dated 08/15/24, revealed the resident was a [AGE] year-old male with an initial admitted [DATE]. Diagnoses included Cerebral infarction (stroke) History of falling, Depression (mood) and Encephalopathy (disease of the brain). Record review of Resident # 10's Entry MDS dated [DATE] reflected a BIMS score of 10, indicating he was impaired moderately cognitively, required total assistance for ADL and hygiene care, incontinent care. MDS addressed diagnosis. Record review of Resident # 10's initial care plan 07/28/24 reflected he was at risk of falling, infections, anti-depressant medication monitoring. Record review of Resident #11's face sheet, dated 08/15/24, revealed the resident was an [AGE] year-old male with an initial admitted [DATE]. Diagnoses included Acute Kidney Failure, Cerebral Infarction (stroke), Major Depressive Disorder (mood). Record review of Resident # 11's Entry MDS dated [DATE] reflected a BIMS score of 9, indicating he was impaired moderately cognitively, required substantial to maximal assistance with toileting. Record review of Resident # 11's initial care plan 07/28/24 reflected he was at risk of falling with last fall on 05/10/24, interventions in place to educate resident to use call light and wait for help. infections, anti-depressant medication monitoring. Record review of Resident #12's face sheet, dated 08/16/24, revealed the resident was a [AGE] year-old male with an initial admitted [DATE]. Diagnoses included Hemiplegia and hemiparesis (paralysis) affecting his left side, Vascular Dementia(dementia caused by a series of strokes), Cognitive communication deficit (difficulty communicating.) Record review of resident #12's MDS dated [DATE] reflected a BIMS score of 9 indicating he was moderately impaired cognitively. Resident required substantial assistance from staff for hygiene, toileting, and bathing. The MDS reflected the resident was on oxygen. Record review of resident 12's Care plan dated 05/15/24 reflected resident has weight loss, in the last 30 days. He has a history of falling, at risk of elopement and wanders due to diagnosis of vascular dementia. He wears a roam alert bracelet. In an observation on 08/15/24 at 10:35 AM of Resident #7's room, there was a portable toilet filled with a liquid yellow substance with the lid raised up. Observed a small trashcan next to the portable toilet, which was filled with soiled incontinent supplies (tissue, wipes, brief, and incontinent pad). No ordor was present in the room. In an observation on 08/15/24 at 2:45 PM, the adjoined bathroom for Residents #8, #9, #10, and #11 the trashcan was observed with soiled incontinent supplies (brief, wipes, and incontinent pad ). No odor was presen in the restroom. In an observation of Resident #8 on 08/15/24 at 10:50 AM revealed he was not interviewable due to a communication deficit. In an interview and observation of Resident #10 on 08/15/24 at 10:55 AM revealed resident lying in bed, and the staff were assisting him with incontinent care. In an interview and observation of Resident #9 on 08/15/24 at 10:58 AM revealed resident walking with a walker, stated the staff does assist him with incontinent care and clean the restroom afterwards. Observed and interviewed Resident #11 on 08/16/24 at 11:30 AM in the dining room engaged with other residents. He confirms that the staff assist with incontinent care. In an observation of Resident's #12's room on 08/16/24 at 10:00 AM and 4:30 PM, there was a nightstand drawer, which was unassembled with sharp metal hardware components (exposing loose boards, screws, and metal frame) left on Resident's #12's bedside table. In an observation and interview with Resident #12, on 08/15/24 at 11:55 AM, revealed him sitting outside his room door in this wheelchair. An interview was attempted; however, he did not respond to detailed questions. He stated he was treated well. In an interview with LVN O on 08/15/24 at 2:55 PM revealed that he did not know that the restroom trashcan was filled with soiled incontinent supplies. LVN O said he monitored the environment and care tasks for CNA's during his shift. He completed rounds every 2 hours and expected the aide to as well. He said that during his rounds he did not check the restroom. In an interview with CNA Z on 08/16/24 at 10:40 AM stated that residents were expected to be assisted by staff during incontinent care. CNA Z said that the portable toilet should be cleaned and emptied immediately after completing the incontinent task to prevent infections. CNA Z said that all of the soiled supplies should be discarded in a plastic bag and removed from the room. She stated that the nurse should be informed that maintenance equipment was left out and accessible to residents. CNA Z stated that residents could injure themselves by interacting with the equipment left behind. CNA Z said she did not observe the items when entering the room during the rounds. CNA Z said all nursing staff were responsible for resident safety and reporting environment hazards to prevent falls, injuries, cuts, abrasion, and resident tapering with sharp materials. She did not observed the drawer in the room. In an interview with CNA R on 08/16/24 at 11:00 AM, she said she was assigned to the room. She did not check the bathroom for sanitation. She conducts frequent patient rounds and assist residents with incontinent care. She stated all supplies should be discarded in a plastic bag and discard in the BW (feces, bowel, urine, manure .) location to prevent cross contamination. She had not assisted a resident during her shift with incontinent care. In an interview with the DON on 08/16/24 at 4:25 PM revealed that she expected all nursing staff to conduct regular environment and patient rounds, and to assess the environment for sanitation and hazards to residents. The staff would be expected to report environmental and maintenance concerns immediately to maintenance and submit work orders. The DON stated she expected the nursing staff to immediately disinfect, sanitize equipment before and after toilet use, assist the resident with hygiene to wash hands, doff gloves, place all biohazard waste, soiled incontinent supplies in a plastic bag, close bag tightly, discard gloves and bag in the biohazard location. The DON stated that the charge nurse, the ADON, and the DON were responsible for monitoring the ADL and toileting environment and sanitation task efficiently to prevent infections and injury hazards to residents and staff. The staff are responsible for conducting resident care and environment rounds. All safety hazards should be reported to the Maintenance Director immediately to prevent injuries to wandering residents. She expects the leadership to be checking, and will be conducting in-services to address the concerns. In an interview with LVN L on 08/16/24 at 4:30 PM, she stated that all nursing staff were responsible for reporting environmental concerns, such as sanitation, hazards, and potential hazards to residents and staff. Incontinent care should be completed immediately after the resident was clean and safe, and discarding in the BW (feces, bowel, urine, manure .) room to prevent infection. The staff are responsible for conducting resident care and environment rounds. All safety hazards should be reported to the Maintenance Director immediately to prevent injuries to wandering residents. LVN did not observed the metal parts on the night stand during rounds. In an interview with Maintenance Director (MD) on 08/16/24 at 5:07 PM, revealed the hardware of the drawer located on Resident #12's bed side table must have been left by the manufacturer or whoever moved the resident out. He agreed that the materials left out were a hazard and he would remove them immediately. He said during staff nursing rounds when hardware and other safety hazards were observed he should be notified immediately and submit a work order. Record review of facility policy dated February 2018 titled bedside commode, offering/removing. The purpose of this procedure is to assist the resident with using a bedside commode. Assemble the equipment and supplies needed. Equipment and Supplies The following equipment and supplies will be necessary when performing this procedure: Portable bedside commode; Bedpan; Disposable bedpan cover or paper towel; Toilet tissue; Wash basin; Soap; Towel; Wash cloth; and Personal protective equipment (e.g., gowns, gloves, mask, etc., as needed). Steps in the Procedure .When the resident calls that he or she has finished, return to the room. Wash your hands. Put on gloves. Fill the wash basin one-half (1/2) full of warm water. Place the wash basin on the bedside stand within easy reach. This water will be used to wash the resident's hands. Help the resident clean him or herself with toilet tissue or warm water and a washcloth Remove gloves and wash your hands. Close the cover on the commode. Apply gloves. Allow the resident to wash his or her hands. (Use wash basin or clean wash cloth. Be sure water in basin is clean.) Take the bedpan into the bathroom. Check the feces or urine for unusual appearance. Measure and record output. Collect specimens as instructed. Empty and clean the bedpan. Wipe down the portable commode. Store it in its designated storage area. Remove gloves. Wash and dry your hands. Clean wash basin and return to designated storage area. Wash and dry your hands.

Based on observations, interviews, 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 kitchen sanitation. The facility failed to ensure the food preparation tables were clean, food was covered and all utensils were removed during meal prep, the lid was on the kitchen trashcan near food prep table and fish, fish was properly thawed, and dry storage containers were cleaned and free of dried food particles. This failure could place residents at risk for food-borne illness. Findings Included: In an observation of the facility's only kitchen on 08/16/24 beginning at 11:30 AM revealed: 1) 1- Large stainless-steel pan of apple cobbler on the prep table uncovered. 2) 1-Large stainless-steel pan of apple cobbler on the prep table uncovered and serving spoon inside the container. 3) 1-8 oz. carton of thickener under the prep table with the cap removed and lying on the bottom shelf. 4) 3-5-gallon clear dry unclean containers under a prep table (dried red, white, brown smudges) next to two hot plate covers. 5) 1-Prep table containing dropped food substance, brown spots, and rust. 6) 1 tall gray kitchen trash can with no lid, placed next to fish which was being thawed in a clear container with water, uncovered on the prep table. In an interview on 08/16/24 at 11:35 AM with the facilities DM revealed that he forgot to place the cap back on the puree food thickener. The DM said he was prepping the cobbler and forgot to cover the pans and remove the spoon when he walked away. The DM said someone returned the trashcan lid after discarding the food. He said the dry storage containers and prep tables should be cleaned when he observed the prep table with food and crumbs. The Dietary Manager stated all prepared foods should be covered when not being prepped by a person and caps returned and stored in a clean area. The Dietary Manager stated all dietary staff were responsible for ensuring foods were cleaned, stored, and prepared correctly and all trashcan lids returned to prevent cross contamination to food being prepped. The Dietary Manager stated not doing these things could cause foodborne illnesses. The Dietary Manager stated it was his responsibility to ensure that safe food and storage practices were completed. It is his expectation for kitchen staff to cover the food when not preparing, clean canisters daily as need, ensure trash can was covered and fish defrosted and covered consistent with food standards. he would begin to in-service dietary staff on food storage, cleaning, and sanitation in the kitchen. He said the failures could result in cross contamination and residents having food borne illnesses from bacteria and environment exposure. In an interview on 08/16/24 at 5:15 PM, the Administrator stated it was the facility's expectation that all foods stored in the kitchen be prepared, stored, and protected from the environment. The ADM said the food serving utensils should not be left in food pans. The ADM said all trash can lids should be covered with a lid to prevent cross contamination. All food prep materials and containers should be cleaned daily and as needed. The Administrator stated she expected the DM to monitor and educate kitchen staff on the safety of preparing, cleaning, and storing food. The Administrator stated not doing these things could cause food related illnesses. The Administrator stated dietary staff would be in-serviced and the Dietary Manager would conduct weekly audits for food storage and temperature logs. In a record review of the facility policy titled Food Preparation and Handling dated 2018 reflected the, Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be prepared and handled according to the state and US Food Codes and HACCP guidelines. Thawing Foods: Thaw meat, poultry, and fish in a refrigerator at 41 F or less. Treat all raw products as though they are contaminated and handle with methods to reduce existing contamination or prevent cross-contamination.

Based on observations, interviews, and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for one (Resident #1 and #7) of 3 resident reviewed for respiratory therapy. 1. The facility failed to ensure Resident #1's NC was stored in a clean bag and dated (bag was spotted with liquid white and brown substance). 2. The facility failed to ensure Resident #7's oxygen concentrator filter was clean and free of dust, crumbs, and white particles, and the humidifier water bottle was not dated. These failures could lead to respiratory infections, poor air quality, and not having their respiratory requirements met. Findings included: Resident #1 Record review of Resident #1's face sheet, dated 08/16/24, revealed the resident was a [AGE] year-old male with an initial admitted [DATE] and a re-admitted [DATE]. The resident's diagnoses included metabolic Encephalopathy (disease of the brain) COPD, emphysema (chronic lung disease that causes SOB), wheezing, (course whistling sound produced in respiratory airways during breathing), shortness of breath (not being able to breath), acute and chronic respiratory failure with hypoxia (inadequate gas exchange by respiratory system.). Record review of Resident #1's quarterly MDS dated [DATE] reflected a BIMS score of 10 indicating he was moderately impaired. The MDS reflected the resident was on oxygen. Record review of Resident #1's Care plan dated 05/15/24 reflected a medical diagnosis of COPD exacerbation (worsening of disease) Edited: 08/15/2024 interventions: assist the client to assume a position of comfort (elevate the head of the bed) as needed auscultate (listen to lung sounds) and breath sounds. Note adventitious breath sounds (wheezes, crackles) .Resident requires oxygen therapy R/T COPD. Edited: 08/15/2024 interventions, administer oxygen at 2-4 L via nasal cannula. Monitor and report signs of hypoxia (cyanosis, tachypnea (breathing rate), SOB, confusion, restlessness, nasal flaring, elevated blood pressure, increased respirations, increased pulse). Monitor/document respiratory status every shift. Observe oxygen precautions. Record review of Resident #1's physician orders dated 08/16/24 reflected nasal canula (continuous): O2 at 3-4 L/min every shift. Record review of Resident #1's progress note dated 08/15/24 at 3:17 PM, by LVN B, reflected Resident is post readmit day 1 today with primary DX: Acute Chronic Respiratory Failure with Hypoxia (area deprived of oxygen and Hypercapnia (abnormal elevated levels of carbon dioxide in the blood.) Resident is alert and oriented x 2 with confusion. Respiration noted even, resident is left BKA. Resident remains on oxygen@4 L via nasal cannula. Record review of Resident #1's August 2024 MAR/TAR dated 08/16/24 reflected Monitor oxygen humidification bottle every shift, Replace or refill as required every shift .change oxygen tubing, canula/Mask once a week. Once a day on Sunday, dated 08/16/24-Open ended) .oxygen concentrator filter: clean concentrator filter weekly. Wash with mild soap and water, dry with towel and replace once a day on Sunday. The TAR from August 2024 did not reflect documentation that the nursing staff had performed these medical tasks ordered by the MD. Observation on 08/16/24 at 10:36 AM revealed Resident #1's NC mask was stored in a plastic bag hanging on the wall with a camouflage hat stored inside. The outside of the bag was spotted with brown dried drippings. The bag was not dated. Observation and interview on 08/16/24 at 10:36 AM with Resident #1 revealed he had his oxygen nasal cannula on at 3 liters. Resident #1 stated he had returned from the hospital on 08/15/24. Resident #1 said staff were entering and checking on him often. Resident #1 said he used the NC mask overnight, and the overnight nurse removed the mask this morning. Observation and interview with the ADON on 08/16/24 at 10:47 AM revealed Resident #1's oxygen mask was located in the soiled plastic that was not dated. The ADON opened the bag and found a camouflage hat inside. The ADON said she would have the nurse change the NC mask, place in plastic bag, and date the bag . The ADON stated the risk of not dating and changing out the tubing, could cause an infection . The ADON said it was the responsibility of the charge nurses to clean oxygen concentrator filters as needed to prevent inadequate oxygen consumption to the resident. Observation and interview with LVN I on 08/16/24 at 10:55 AM revealed Resident #1 received oxygen by NC tubing and mask continuously. LVN I stated he had checked on Resident #1 upon arrival for his shift at 6:00 AM, and every 2 hours thereafter, and the tubing was bagged and dated. He said he did not see the nasal cannula mask, soiled bag, and no date until this observation. He stated he knew he was supposed to check on the resident's oxygen flow rate, tubing flow and date, and storage of tubing. He stated the tubing was not to be in a used plastic bag to prevent environment exposure that could lead to infection. LVN I said he would change the tubing, and store in a dated plastic bag. Observation and interview with LVN I at 11:30 AM revealed the plastic bag undated in the same location with the contents emptied. LVN I observed the soiled bag, and said he forgot to discard the bag. LVN I removed the bag and discarded properly. Resident #7's Record review of Resident #7's face sheet, dated 08/16/24, revealed the resident was a [AGE] year-old female with an initial admitted [DATE]. The resident's diagnoses included Metabolic Encephalopathy (disease of the brain) COPD, and acute and chronic respiratory failure with hypoxia (inadequate gas exchange by respiratory system.) Record review of resident #7's quarterly MDS dated [DATE] reflected a BIMS score of 12 indicating she was moderately impaired. The MDS reflected the resident was on oxygen. Record review of resident #7's Care plan dated 05/15/24 reflected resident requires oxygen therapy r/t COPD edited 07/3024. Interventions included Resident will not exhibit signs of hypoxia (cyanosis, tachypnea, dyspnea, confusion, restlessness, nasal flaring, elevated blood pressure, increased respirations, increased pulse). Approach Start Date: 12/29/2023 Administer oxygen at 4 L via NC. Observe oxygen precautions. Edited: 12/29/2023 Approach Start Date: 12/29/2023 Monitor and report signs of hypoxia (cyanosis, tachypnea, dyspnea, confusion, restlessness, nasal flaring, elevated blood pressure, increased respirations, increased pulse). Approach Monitor lung sounds every shift. Monitor oxygen saturation via pulse oximetry every shift. Record review of Resident #1's physician orders dated 01/10/24 Monitor resident's oxygen saturation every shift. Notify MD with O2 sat less than 90% and transfer to ER . Every Shift Open Ended Treatments; Nasal Cannula (Continuous): O2 @ 4 L/Min Every Shift; Change Nebulizer Mask and tubing weekly .Once A Day on Sunday 10:00 PM - 06:00 AM .Oxygen Concentrator Filter: Clean concentrator filter weekly. Wash with mild soap and water, dry with towel and replace. Once A Day on Sunday 10:00 PM - 06:00 AM. Record review of Resident #7's Progress note dated 08/09/2024 03:02 AM reflected, Resident in bed with no s/s respiratory distress noted. Receiving continuous O2 @ 4 lpm via N/C with 96% O2 sat remains on Lactulose 30 cc PO Q 6 hrs. day 2/3 with no adverse reaction. Record review of Resident #7's August 2024 MAR/TAR dated 01/10/24 reflected Monitor oxygen humidification bottle every shift, Replace or refill as required every shift .change oxygen tubing, canula/Mask once a week. Once a day on Sunday, dated 01/10/24 Open ended .oxygen concentrator filter: clean concentrator filter weekly. Wash with mild soap and water, dry with towel and replace once a day on Sunday 01/10/24 The August 2020 TAR, dated 8/16/24 did not reflect documentation that the nursing staff had performed these medical tasks ordered by the MD. In an observation on 08/16/24 at 11:00 AM, Resident 7's oxygen concentrator filter was filled with gray particles and dust throughout the machine. The machine as powered on and the humidifier water bottle was empty and not dated. In an interview with the DON on 08/16/24 at 4:25 PM revealed her expectation was once the doctor submitted an order for oxygen, the nurse should ensure physician orders were followed. She expected the nursing staff to conduct rounds checking oxygen levels, oxygen flow, tubing dated, and stored in a plastic dated bag when not in use. The DON stated she and the ADON were responsible for monitoring to ensure the orders were followed. The DON stated the tubing and humidifiers on the oxygen concentrators were scheduled to be changed every Sunday night by the night nurse. She stated the nursing staff should be checking for this. The DON stated the empty humidifier could cause the resident some irritation in the nose and the tubing causing dryness, when not being changed. In an interview with LVN L on 08/16/24 at 4:30 PM she stated she was not the nurse for Resident #1, but she was the wound and infection prevention nurse at the facility. She stated the tubing, and humidifiers on the oxygen concentrator were scheduled to be changed every Sunday night by the night nurse. She stated the nursing staff should be checking for this every time they round on the patient. She stated staff were to date the tubing every time it was changed, and the humidifier should be checked frequently to ensure fluids were in it in order to avoid any irritation to the resident's nose. She stated the risk of not changing out the tubing, could cause an infection . In an interview on 08/16/24 at 5:15 PM, the Administrator stated that it was her expectation for staff to monitor and clean resident oxygen machines as needed, date all equipment to prevent potential infections. She expects the ADON and DON to monitor and ensure all clinical tasks were completed as requested and scheduled by the MD. Record review of facility policy titled Oxygen Administration dated October 2010 reflected Steps in the Procedure 12 Check the mask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened. Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through .13. Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated (see Assessment) .14. Periodically re-check water level in humidifying jar .15. Discard used supplies into designated containers .16. Discard personal protective equipment in designated receptacles. Wash and dry your hands .thoroughly .17. Reposition the bed covers. Make the resident comfortable. Documentation: Documentation: After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: 1. The date and time that the procedure was performed. 2. The name and title of the individual who performed the procedure. 6. All assessment data obtained before, during, and after the procedure .7. How the resident tolerated the procedure Reporting: .2. Report other information in accordance with facility policy and professional standards of practice.

Based on observations, interviews, and record review, the facility failed to 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 infections for1 of 1 laundry room and 1 of 6 residents (Resident # 13) reviewed for infection control. The facility failed to handle, store, and process linens and residents clothing to prevent the spread of infection by not preventing cross contamination of staff belongings and resident personal clothing when staff placed their purses, in the same laundry cart with residents personal clothing. The facility failed to have in place a barrier between the clean and dirty areas of the laundry room to prevent the spread of infection. The facility failed to implement appropriate measures for sorting and folding resident laundry on a table that was free of staff personal keys and water cups to prevent cross contamination. The facility failed to ensure MA J wore gloves and performed hand hygiene when opening Resident #13's capsule medication and mixing it into apple sauce. These failures could place residents at risk for infections and cross contamination. The findings included: Record review of Resident #13's face sheet on 04/23/24 reflected a [AGE] year-old man that was admitted to the facility on [DATE]. His diagnoses included disorder of circulation, hip fracture, urinary tract infection, restless, agitation, disorientation, local infection of the skin, heart failure, and dementia (this is a memory problem in making decisions, reasoning, judgment and thought process. Review of Resident #13's orders on 04/23/24 revealed medication; Depakote Sprinkles (divalproex) capsule, delayed release sprinkle; 125 milligrams; amount: 1 capsule; by mouth for [DX: Restlessness and agitation] Three Times A Day; 08:00 AM, 02:00 PM, 08:00 PM. Start date 04/12/24- open ended date. Order description reflected may crush crushable medication, open capsules, and mix with food or jelly. Observation and interview on 04/23/24 at 10:30 AM, revealed MA J took a medication from the medication cart, she took 1 capsule out of the medication bubble card from a medication card, opened it with her bare fingers, and sprinkled the medication in apple sauce. MA J was asked by the state surveyor to look at the medication card which reflected Divalproex Sodium 125 MG Capsule Delayed Release Sprinkle. Pharmacy Directions: Give 1 capsule by mouth three times daily. MA J said that Resident #13 could not take pills whole. She said that she was supposed to wear gloves when opening medications to prevent cross contamination. MA J said she was employed at the facility for 1 month. She stated she forgot to wear gloves, which was a risk of infection to the resident. She said that hand hygiene was important and should be done before and after medication administration. Interview with the DON on 04/25/24 at 6:13 pm, revealed that she expected all staff to perform hand hygiene during the medication pass. She said she expected staff to use hand sanitizer prior to providing medications and in between, before popping the pill, before giving it, and after giving it. She said the facility performs weekly training for QIPP . They do PPE and hand hygiene, and competency checks every week. She said the QIPP program was associated with the hospital. She said they get extra funding for certain areas like infection control for doing a good job, they have monthly meetings, and they go over everything to show improvement. They have been involved in it since maybe 2020. She said the risk of poor hand hygiene was spread of infection . She said gloves should be worn when touching medication to prevent contamination and she expected staff to perform hand hygiene before medication administration and after medication administration. Observation and interview with Laundry Aide A and Laundry Aide B on 04/24/24 at 2:03 PM in the laundry room revealed there were two doors to the area. One door was an exterior door on the left where the dirty laundry was brought into the laundry room for processing. The clean, dry laundry exited the laundry room through a right-side exterior door in clear plastic bags in the large laundry cart with a cover to return to the main facility building. Further observation revealed there was no barrier separating the clean and dirty areas of the laundry room, and the areas were instead defined by a partial wall extending in from the exterior wall and ceiling with pass-through area that was approximately 6 feet wide. A white floor fan was placed near the dryers and chemicals for the washing machines. Observation of laundry room revealed staff members cellphones, personal car keys, water bottles, a red handbag, and a black handbag on a black table that was approximately 20 x 60 inches. Laundry Aide A stated the table was used as a folding table for linens and residents' personal items. One large laundry cart with a blue cover partially opened was observed with clothing on hangers and some in plastic bags. A smaller cart without a cover on it was close to the door near the exit door of the clean area with clothing hanging on hangers and some folded inside the basket of the cart. Laundry Aide B then took the red handbag from the sorting/folding table and placed it inside the laundry cart basket on top of the folded clean resident's items. Laundry Aide A said Laundry Aide B could not understand English therefore she could not answer the questions. Laundry Aide A said that they were expected to put their personal belongings on the floor under the folding table or in the break room. They said they enter with the dirty items on the left and exit with clean items on the right of the laundry room. Laundry Aide A and Laundry Aide B did not state the risk to the residents. During an interview with Laundry Aide C on 04/25/24 at 09:26 AM, it was revealed that Laundry Aide C has been employed at the facility for 1 year. She said she had never seen in place a barrier between the clean and dirty areas of the laundry room. She said the laundry room got hot due to the small space and they used the floor fan to blow cool air into the room. She said she understood after the in-service, that morning, that they were spreading germs between the clean and dirty by using the fan. She stated she had been in-serviced this morning about employees' personal belongings not being in the work areas or placed in the laundry carts to prevent the spread of germs to the residents. She said separating the clean and dirty was important for infection control. Interview and observation with the Housekeeping Supervisor on 04/24 at 02:06 PM and 04/25/24 at 09:04 AM, revealed he was employed at the facility since 2022 but in his current role as Environmental manager for 1 year. He was observed removing the red handbag from a small laundry cart and placing it under the black folding table. He stated that he had told his staff not to put their personal belongings with residents' items because that was a risk for cross contamination. He said that no one had ever informed him about having a barrier between the clean and dirty areas of the laundry room. He said he just followed what the previous laundry manager did. He said he had never looked at the laundry policy. He said all staff should prevent the spread of infection and should follow policy for infection control. He said he expected staff to enter to the left with dirty items and exit to the right with clean items. He said he expected his staff to place their personal belongings in the breakroom or on the floor under the folding table. Interview with the administrator on 04/25/24 at 6:13 PM, revealed she was not aware of the laundry room situation. A policy for laundry rooms and the separation of the clean and dirty areas was requested, but the facility did not provide it before exit 04/25/24. Review of facility policy titled Medication Administration-General Guidelines revision date December 2019 reflected . If breaking tablets is ultimately necessary to administer the proper dose, hands are washed with soap and water or alcohol gel [and examination gloves worn] prior to handling tablets, and examination gloves must be worn to prevent touching of tablets during the process .

Based on interviews and record review, the facility failed to ensure care plans were developed in consultation with the resident and the resident's representative for 4 of 4 residents (Resident #20, Resident #24, Resident #42, Resident #167) reviewed for Comprehensive Care Plan. The facility failed to ensure Resident #20, Resident#24, Resident #42, and Resident 167, and/or the resident's representative were invited to participate in the comprehensive care plan meeting per resident rights guidelines that residents have the right to participate in their planning of care. This failure affected 4 residents and placed 62 residents at risk for a loss of independence, psychosocial well-being, and the opportunity for them to participate in their planning of care. Findings included: Record review of Resident #20's face sheet dated 04/25/2024, revealed a [AGE] year-old female readmitted to the facility on [DATE] with an initial admission to facility on 02/01/2013. Her diagnoses included Aphasia following unspecified cerebrovascular disease (impairment of language caused by stroke), cerebral palsy, unspecified (a congenital disorder of movement, muscle tone, or posture), and other intellectual disabilities (mental retardation). Record review of Resident #20's file revealed documentation that care plan conferences were held with resident's sister the responsible party on the following dates, 04/28/2021, 05/26/2021, 07/21/2021, 10/15/2021, 01/18/2022, 09/21/2022, 09/21/2022, 05/10/2023, 07/19/2023, and the last meeting held on 09/18/2023. There were no further documented care plan conferences held with resident's sister after 09/18/2023. Record review of Resident #24's face sheet dated 04/25/2024, revealed a [AGE] year-old male readmitted to facility on 02/06/2022 with an initial admission to facility on 03/04/2021. His diagnoses included major depressive disorder, recurrent, moderate (feelings of worthlessness, appetite, other disturbances), carcinoma inside of the esophagus (Cancer of the throat)., and other dysphagia (most common symptom of esophageal cancer that prevents food from passing normally through esophagus). Record review of Resident #24's file revealed that care plan conferences were held with the resident and daughter on 09/03/2021, 06/23/2022, 04/19/2023, 07/20/23, and the last meeting held on 09/13/2023. There were no further documented care plan conferences held with the resident and daughter after 09/13/2023. Record review of Resident #42's face sheet dated 04/25/2024, revealed a [AGE] year-old female readmitted to facility on 04/07/2024 with an initial admission to facility on 08/24/2023. Her diagnoses included chronic obstructive pulmonary disease, unspecified (lung disease), essential (primary) hypertension (force of the blood against the artery walls is too high), and generalized anxiety disorder (Mental disorder). Record review of Resident #42's file revealed the initial admission care plan meeting held with the resident and spouse on 08/24/2023. There were no further documented care plan conferences held with the resident and spouse after 08/24/2023. Record review of Resident #167's face sheet dated 04/25/2024, revealed a [AGE] year-old male readmitted to facility on 04/19/2024 with an initial admission to facility on 09/28/2022. His diagnoses included metabolic encephalopathy (chemical imbalance in the blood), neuromuscular dysfunction of bladder, unspecified (bladder that does not fill or empty correctly), and essential (primary) hypertension (force of the blood against the artery walls is too high). Record review of Resident #167's file revealed quarterly care plan meetings with the resident on 04/19/2023, 06/22/2023, and the last held on 08/23/2023. There were no further documented care plan conferences held with the resident after 08/23/2023. Interview on 03/24/2024 at 3:40 PM with the Social Worker stated that the facility has been without a consistent Social Worker on staff. The new Social Worker started in December 2023. The SW was working on setting up the care plan meetings to coincide with the MDS (Minimum Data Set) schedules. The SW invited residents and family members and/or representatives to the care plan meetings that are scheduled quarterly. The care plan meeting provides information related to the daily care of the resident in the facility and focuses on the problems, goals, and interventions to assist the resident in meeting their needs. The care plan summarizes a person's health conditions, specific care needs, and current treatments. Expectations are to invite residents and their family members and/or responsible parties quarterly to the meetings and have them be a part of goals set for the resident. The SW is setting up the calendar to invite the residents and family and/or responsible party to coincide with the quarterly MDS (Minimum Data Set) schedule. On 04/25/2024 at 4:00 PM, requested a policy related to Care Plans. Administrator provided policy. Facility's policy for Resident Participation - Assessment/Care Plans revealed: The resident and his or her representative were encouraged to participate in the resident's assessment and in the development and implementation of the resident's care plan. 1. The resident and his or her legal representative are encouraged to attend and participate in the resident's assessment and in the development of the resident's person-centered care plan. 44894

48520 Based on observations and interviews the facility failed to provide a clean and functional environment for six (Residents #34, #54, #16, #59, #36, and #7) out of 24 residents reviewed for a sanitary, functional, and homelike environment, as evidenced by: 1. Resident #34's room had grimy, stained, dusty floors, a badly scraped chest with missing wood veneer and handle, and grimy, stained floor, and a bent privacy curtain runner. The bathroom, which was shared with Resident #54 in the room next-door had a non-working sink and toilet, and a damaged and badly repaired wall in the bathroom. The bathroom floor was also grimy, stained, and was repaired with noticeably mismatched tiles. Resident #34's door would not close completely, due to the placement of a bed next to the door. 2. Resident #16''s room had gnats, and the unmade bed was saturated with urine. 3. Resident #59's room had a cracked, flaking, translucent film over part of the window, and damaged windowsill and wall below the window. 4. Resident #36's room was only partially painted, having walls with different colors of paint. In addition, the room had damage to the baseboard and walls, and the bathroom was grimy, stained, and had unrepaired damage to the wall under the sink, cracked and peeling caulking, and missing tiles. 5. Resident #7's room had a dusty, grimy, stained floor with cracked tiles, and damaged walls (including damaged and stained areas around her window), areas of different colored paint, and a damaged dresser with a hinged padlock which was unscrewed from one side. These failures could place residents at risk for infection, for feelings of low self-worth due to living in an unclean, visually unappealing, and non-functional environment. Findings: 1. Residents #34 and #54: Review of Resident #34's face sheet, dated 04/25/25, reflected she was a [AGE] year-old female, admitted on [DATE], with diagnoses of paraplegia (lower body paralysis), colostomy, pressure ulcers, mood disorder, bi-polar disorder, post-traumatic stress disorder, anti-social personality disorder, and seizures. Review of Resident #34's Quarterly MDS, dated [DATE], revealed she could understand others, and be understood by others. She had a BIMS score of 14, indicating intact cognition. Resident #34 had impaired range of motion of her lower body, on both sides, and used a wheelchair to move around in the facility. She was dependent on staff for some ADLs but was able to feed herself and do her own oral hygiene. An interview and observation on 04/23/24 at 10:53 AM with Resident #34 revealed her to be fully alert and oriented, and lying in her bed. The floor appeared stained and grimy around the edges, especially near the doorways. She said she was not happy at the facility, and while going over her concerns with the state surveyor, directed the state surveyor to the bathroom. She said that when it rained a lot, the bathroom floor flooded, water came in, and it was disgusting. The state surveyor went in the bathroom and observed that the floor was dark and grimy, with stained tiles overall, but build-up of grime around the edges. The floor had been repaired around the toilet, and the newer tiles highlighted how dirty and stained the older, unmatching tiles were. The door and doorway had staining, and paint chipped off. The walls near the sink were dirty and stained, and had been repaired poorly in the past, leaving the surface uneven, with cracks discoloration, and peeling around the lumpy repaired area. The wall appeared chipped around the edges of the mounted sink. The state surveyor asked the resident about the water in the sink, and the resident said it never drained properly. The state surveyor waited four minutes to see if the sink drained, and no change was visible in the level of the water. The toilet had urine and toilet paper in it, and the resident said it did not flush properly, and sometimes overflowed. She told the state surveyor you have to hold the handle down the whole time, so the state surveyor flushed the toilet, holding the handle down the entire time. The contents swirled, and only about half of the contents flushed, very slowly. The resident said that she was not able to use the bathroom, but her mother visited often, and was disgusted by the bathroom. She said she and her mother had complained numerous times.She said the toilet had overflowed sometimes when her mother used it, and it has poop and stuff in it and was gross. Resident #34 said pointed out that she had no privacy curtain, and said she had not had one since she moved in. The railing for the privacy curtain was bent downward about 1/3 of the length from the end, which she said prevented them from being able to replace it. She said they were supposed to fix it, and she had asked about it before, but it was still broken. The door would not close all the way (opening was approximately 12 as measured by the floor tiles). Resident #34 said when her roommate moved out, they moved the longer bed into the room, and it got in the way of the door closing. An interview and observation on 04/24/24 at 4:33 PM with Resident #34 revealed the bed that had been keeping the door from closing had been moved out. The bedside dresser table had been moved to the corner, and the state surveyor could see it was badly scraped, and had areas of veneer missing, and was missing the handle on the top drawer. The floor where the bed was removed was stained with brown-ish orange areas, and purple stains, as well as a significant amount of dust and debris, which was heavier around and under the bedside dresser table. Resident #34 said the housekeeping typically came into the room and swept or mopped a little, but did not bother to sweep very well. She said, they just pushed the dresser into the dirt. Review of a grievance form, dated 03/21/24, filed by Resident #34's family member, reflected the sink and toilet in Resident #34's (and 54's) room was clogged, and Maintenance unclogged it the same date. Review of Resident #54's Face sheet, dated 04/25/24, reflected she was a [AGE] year-old female, admitted on [DATE], with diagnoses of congestive heart failure, breast cancer, rheumatoid arthritis, depression, chronic pain, and colitis (chronic inflammation of the inner lining of the colon.) Resident #34 was a hospice patient. Review of Resident #54's quarterly MDS, dated [DATE], reflected she could understand others, and be understood by others. She had a BIMS score of 13, indicating she was cognitively intact. She was able to walk independently and required little to no assistance from staff with ADLs. An interview and observation on 04/23/24 at 11:42 AM with Resident #54 revealed the jack-and-[NAME] bathroom she shared with Resident #34 did not work, and the toilet overflowed, which made her afraid to flush it. She said sometimes she could not wash her hands because the sink did not drain , and she did not like it. She wanted them to fix it. 2. Resident #16 Review of Resident #16's face sheet, dated 04/25/24, reflected he was an [AGE] year-old male, admitted on [DATE], with diagnoses of one-sided weakness following stroke, major depressive disorder, kidney failure, and Parkinson's disease (a nervous system disorder). Review of Resident #16's quarterly MDS assessment, dated 02/07/24, reflected he could be understood by others, and was able to understand others. He had a BIMS score of 11, indicating moderate cognitive impairment. He had impaired mobility on both sides of his lower body and used a wheelchair. Review on 04/24/24 at 1:18 PM revealed the windowsill by his bed was broken, with bare, splintered wood exposed for the length of the windowsill. The wall under the windowsill was damaged, with the drywall peeling off between the window and the baseboard for approximately one-third of the length of the window. His window was partially covered with a cracked, peeling, and cloudy film. Interview and Observation on 04/24/24 at 1:30 PM of Resident #16 revealed he was in the dining area in his wheelchair, watching TV. The state surveyor was unable to understand the resident's speech clearly, but he nodded that he was fine, and did not have problems with his room. 3. Resident #59 Review of Resident #59's face sheet, dated 04/25/24 revealed he was a [AGE] year-old man, admitted on [DATE], with diagnoses of stroke and residual effects of stroke, major depressive disorder, and encephalopathy (a condition causing brain dysfunction). Review of Resident #59's quarterly MDS, dated [DATE], reflected he was able to understand others, and be understood by others. He had a BIMS score of nine, indicating moderate cognitive impairment. Observation on 04/24/24 at 1:16 PM of Resident #16's room revealed his bed was unmade and saturated with urine. There were several gnats resting on his bed, which started flying and landing on the bed and other furniture when the state surveyors got near the bed. An observation and interview on 04/24/25 at 2:00 PM with Resident #59 revealed him to be seated in his wheelchair in the dining area, wearing stained, but dry clothing. He said he was fine, and he was dry, and he did not have any problems. He had not noticed any gnats. 3. Resident #36 Review of Resident #36's face sheet dated 02/25/24, revealed a [AGE] year-old female admitted to facility on 12/20/23. Her diagnoses included end stage kidney disease on dialysis Monday, Wednesday, Friday, nasal congestion, seasonal allergies, heart diseases, and unspecific lump in the left breast. Review of Resident #36's quarterly MDS assessment dated [DATE] revealed a BIMS score of 12, indicating moderate cognitive impairment. Resident #36 could be understood by others, and she could understand others. Activities of daily living revealed resident required supervision or touching assistance from the facility staff for toileting. Resident #36 was always continent and on dialysis. Observation and interview with Resident #36 in her room on 04/25/24 at 09:00 AM, revealed grimy greyish and black floors in the room, floor tiles were broken along the edge of the room. Black colored baseboards were loose and gapping from the wall exposing holes in the drywall. The bathroom mirror was not broken but had a missing tile on the right side of the mirror. The sink had a brown/orange stain inside it. The bathroom tiles above the sink and below the sink were missing. A white floor fan was observed connected and on an electric socket that was broken by B bed. The walls in the room were partially painted and unfinished in a grey color on two walls and a tan/gold color by the window wall and an eggshell/cream color by on the fourth wall by A bed. Cracks were observed around the left side of the window seal. Resident said she had been reporting and had filed grievances on her room's state. She said she had been complaining since being admitted to the facility in December 2023. She showed the state surveyor the copies of filed grievances and she said the facility had not resolved her grievance. She said the previous maintenance man started to work on her bathroom and replaced the broken mirror at the time, but he never replaced the tiles around the mirror. She said that she was frustrated by the state of her room and had put it on herself to place some boxes with her personal belongings to block the view of the holes in the walls. She said that she was also frustrated because she has been asking someone to help her put her dresser together for about a month. She said the maintenance persons don't really follow through and will tell her they will come back and fix something, but they never do. Review of grievances reflected a grievance filed on 04/04/24 by Resident #36, regarding a sewage smell coming from the bathroom, bathroom tiles and the mirror coming off the wall, the commode loose and rocking, and the room only half painted. The date the grievance occurred reflected on-going since January (2024). The Grievance Official Follow-Up reflected Over the next two weeks I will get all things fixed. [sic] 4. Resident #7 Record review of resident #7 face-sheet reviewed on 4/23/2024 revealed admission to the facility on [DATE] she was an [AGE] year-old female who admitted with diagnoses of chronic kidney disease, dementia, type 1 diabetes, and end stage renal failure. Record review of Resident #7's MDS reviewed on 4/24/2024 revealed that resident diagnoses included major depressive disorders and cognitive communication deficit. BIMS (Brief interview for Mental Status) score of a 9 indicating that the resident had severe cognitive impairment. Review of functional abilities and goals indicate that the resident requires assistance with day-to-day function ability. Record review of Resident #7 Care Plan dated 2/21/2024 revealed Resident #7 required dialysis r/t Renal failure. Resident received Dialysis three times a week and was at risk for increased SOB , chest pains, blood pressure, itchy skin, nausea/vomiting, and infected access site Observation of Resident #7's room on 4/23/2024 revealed the room had a dusty, grimy, stained floor with cracked tiles, and small bits of black debris near the corners. The wall beneath the window was damaged, with brownish-yellow staining, concentrated near the baseboard. The room was painted incompletely and with different colored paint on the walls. The edges and other parts of walls had not been painted, and in some areas the a paint roller or brush were used visible, as though the paint had been started, and left undone. The wall behind and beside the bed was damaged with badly scraped and stained drywall. The built-in wardrobe was badly scraped, and doors were uneven. The bedside dresser table was badly scraped, with missing veneer, and a hinged padlock which was unscrewed from one side, but still had a lock. The room had a strong urine smell. There were visible holes in the baseboard near the door. Observation of Resident #7 on 04/23/2024 at 2:23 PM revealed she was too tired to be interviewed and said she just wanted to sleep. Observation of Resident #7 on 04/25/24 at 2:23 PM revealed she was sleeping . An interview on 04/25/24 at 3:42 PM with the Environmental Service Director revealed he helped to patchwork when the problems happened. He said he was aware the floors were bad but there was only so much he could do with cleaning them. He said his housekeeping staff and himself deep clean, mop, and dust the residents' rooms . An interview with the maintenance director could not be completed because he left the building without notice on 04/24/24. An interview on 04/25/24 at 6:13 PM with the Administrator revealed the Administrator thought the maintenance man (prior to the one who just left) had not worked in long term care before and did not realize how much upkeep there was. She said she felt that he was more focused on the regulatory aspects than getting things done. She said she started in February of 2024, and some staff blamed her for him leaving because she was asking him to fix things. She said the building was very old, and some of the problems, like the call light system, was due to age. She said the corporation was supportive about making improvements and they had talked about new flooring, but she did not know when that was planned. She said the condition and cleanliness of the building was an infection control and quality of life issue. She said the environment should be homelike and it could affect people clinically. She said that on the first day of the survey (04/23/24) she smelled urine when she walked in the door, but it was not normally that bad, and they had addressed it. She said there were certain rooms where the housekeepers would be sent to clean when she smelled urine, but the building as a whole was not bad. She was not aware of issues with gnats until the surveyors brought it to her attention, but they did have regular pest control, and they normally stopped to check in with her to see if there were issues. She also was not aware of the problem with the privacy curtain in Resident #34's room, and that would have been something maintenance should have addressed. Review of the facility policy Homelike Environment, revised February 2021, reflected: Homelike Environment Policy Statement: Residents are provided with a safe, clean, comfortable, and homelike environment ( .) Policy Interpretation and Implementation: 1. Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. 2. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment; ( .) c. inviting colors and decor; d. personalized furniture and room arrangements; e. clean bed and bath linens that are in good condition; f. pleasant, neutral scents; ( .) Review of the facility policy Maintenance Service, revised November 2021, reflected: 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. ( .) c. Maintaining the heat/cooling system, plumbing fixtures, wiring, etc., in good working order. ( .) f. Establishing priorities in providing repair service. g. Maintaining the paging system in good working order. ( .) 3. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner.

Based on observations, interviews, and record review, the facility failed to ensure each resident received and the facility provided food that was palatable and attractive for two of two meals (lunch meals on 04/23/24 and 04/25/24) reviewed for food and nutrition services. The facility failed to deliver food with an appetizing taste for the lunch meals on 04/23/24 and 04/25/24. The deficient practice could place residents at risk of poor intake of nutrition, weight loss, and a decreased quality of life. Findings included: An interview on 04/23/24 at 10:53 AM with Resident #34 revealed she thought the food had gone downhill in quality since the new DM started, about a month and a half ago, and it was terrible. She also felt the current dietary manager was not very nice and was not accommodating. She told the state surveyor if there was any doubt about the food, to ask the other residents, because everyone hates it. She said they talked about food at every resident council meeting, and everyone she knew was unhappy with it. In an anonymous group interview on 04/24/24 at 1:00 PM six of six residents agreed the food in the facility was of poor quality and flavor, and they did not like it. Observation on 04/23/24 at 12:59 PM revealed the lunch test tray of regular and pureed diets were tasted by four state surveyors. The regular chicken enchiladas, which came with one packet of sour cream, did not have any sauce on them, and the corn tortillas were dry, and leathery, especially on the edges. They were also cracked and broken and unappealing in appearance. They contained diced chicken in a cheese sauce and had very little flavor. The rice had very little flavor. The beans tasted saltier than the other dishes but had very little other discernable flavor. The pureed diet tasted the same as the regular diet. Observation on 04/25/24 at 1:00 PM revealed the lunch test tray for a regular diet was tasted by four state surveyors. The barbequed chicken thigh was acceptable, and the state surveyors felt the potato salad was good. The green beans were overcooked and mushy, had little flavor, were noticeably oily, and had a slimy mouthfeel when chewed. The cake was dry and had a stale flavor. An interview on 04/25/24 at 10:31 AM with the Dietician revealed she had only been contracted with the facility since February 2024. She said she did meet with new residents to check with them about dietary preferences and needs, and residents who triggered for weight loss. She stated she had not spoken with all of the residents yet and had not been made aware of food complaints. She said she had heard the residents were saying the food had improved, but it depended on who she talked to. She said the menu was pre-programmed, and they used standardized recipes which were low in sodium, but they still should have some kind of flavor. She said the Dietary Manager was brand new at the facility and walked into a lot of disorganization and was having a hard time getting acclimated. She said if someone did not like the food, and there were no alternates they liked, there could be a risk of weight loss. An interview on 04/25/24 at 5:02 PM with the Administrator revealed they did not have a policy regarding food palatability. An interview on 04/25/24 at 5:33 PM with the Dietary Manager revealed she had been working at the facility for about two months. She said when she started, she talked to the residents, and they did not like the food. She said the previous cooks were not using recipes. She said it had been hard to get them to try the food since she started, because they did not like it before. She stated she was getting more of them to try it, and they were liking it. She said the enchiladas served on 04/23/24 were premade, from the company they ordered their food from. The box did not come with sauce, and they gave everyone sour cream. She said when they cooked them, they broke up. She said she was not very happy with the way they looked either, and thought it would probably be better to just make them from scratch. She did not know how the cake could taste stale, because they mad it in the kitchen, from a mix from the same company the rest of the food came from. She said she was working with a lot of new dietary staff, training them, and some of them did not know how to follow recipes. She was working on teaching them how to follow recipes, and that they could not just substitute things all the time, that they had to do their jobs even when she was not there. She said she was also telling them to taste the food they cooked, and when she cooked, she tasted it. She said the meals were the only thing some people looked forward to in a nursing home, so they should get some things they liked. She said that some of the things the residents complained about, she could not change, because they had to order from the same company. She said some of the items were not even available for her to order, because of the food plan the facility was on with the food supplier. She said she had asked and was told they had to order what was open for her to order, because they had to get what was in their budget. She said there were also problems with the food order not all coming in, and the guy who supplied the food had come in twice. She said when she placed the order, things were getting kicked out of her list and not coming in. She said they need the items, so she had to go back every time and check to make sure everything on her order went through. She wanted to get food the residents liked, so she said that she asked him what they could get that was better eating, because the residents would not eat some of it. He told her they could only get what showed up for when she placed her orders. She said the last place she worked prepared the food from scratch, and she would like to do that, but they did not have enough staff to do that. She said they did have cases of running out of some alternates, because the residents order them so much. She said the only time they were allowed to change the menu cycle was if they were out of something and had to serve a substitute, so she was not able to make any big changes. She said one problem was that she was not able to get residents to try some of the foods. She said they would argue with her and cuss her out. She had talked with the Administrator about raising the budget, but because the census was low, they could not do that . An interview on 04/25/24 at 6:13 PM with the Administrator revealed the new Dietary Manager had put in her notice. When informed of the state surveyors' impression of the meals, she said she was not aware that the food served during the survey was not good, and that they were always trying to work with the residents on meals and dietary preferences .

Based on interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of five residents reviewed for quality of care in that: The facility failed to ensure nurses across multiple shifts monitored and notified the physician of Resident #1's episodes of hypotension, fever, reduced urine output, and urinary catheter for changes in condition, recognize, and address such changes that required further action. Resident #1 was hospitalized on [DATE] for acute cystitis (inflammation of the bladder) with hematuria (blood in urine): acute illness or injury; generalized weakness; and Sepsis (body ' s extreme response to an infection. It is a life-threatening medical emergency. Sepsis happens when an infection you already have triggers a chain reaction throughout your body. Infections that lead to sepsis most often start in the lung, urinary tract, skin, or gastrointestinal tract. Without timely treatment, sepsis can rapidly lead to tissue damage, organ failure, and death). Resident #1 remained hospitalized during investigation. This failure placed residents with indwelling catheters and changes in conditon at risk of potential CAUTI's and developing complications such as injury to the urinary tract and resulted in Resident #1's admission to the hospital. Findings included: A record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a 62 y.o. male admitted on [DATE]; most recent reentry into the SNF was 04/20/23. Resident #1 had diagnoses of wound infection (other than foot), DM, and paraplegia {paralysis of the legs and lower body, typically caused by spinal injury or disease}. Resident #1's BIMS score was 09, which suggested moderately impaired cognition. Resident #1 rejected evaluation or care that is necessary to achieve the goals for health and well-being 1 to 3 days during the Quarterly MDS review period. Resident #1 required two+ persons physical assist with bed mobility, transfer between surfaces using a mechanical lift, dressing and toilet use. Resident #1 had a functional limitation in range of motion on both sides of lower extremities. Resident #1 admitted with an indwelling catheter and colostomy. Resident #1 was hospitalized on [DATE] for recurrent cystitis (inflammation of the bladder)/CAUTI (a urinary tract infection associated with urinary catheter use) with hematuria (blood in urine). Record Review of Resident #1's physician orders revealed: Start date 06/13/23 [open-ended]: Promethazine tablet; 12.5 mg; 1 tab; Oral. Every 4 hours - PRN Start date 06/18/23 [End Date: 06/18/23]: Basic Metabolic Panel; CBC; Urinalysis; STAT Start date 07/26/22 [open-ended]: Foley Catheter: May obtain urine sample via Foley Catheter Port as needed when a Urine Analysis is ordered. (If Foley Catheter has been in place greater than 14 days, change Foley Catheter before obtaining urine.) As Needed Review of Resident #1's comprehensive care plan last reviewed/revised: 04/27/23, revealed care plan details: PROBLEM (Start date: 01/02/23): Category: Indwelling Catheter; Catheter Care, Edited: 04/27/23 SHORT TERM GOAL (Target date: 11/27/23), Resident will establish an individual bowel and bladder routine Edited: 04/27/23 APPROACH (Start date: 01/02/23): Catheter care per policy, Edited: 01/02/23 Intake and outputs, Edited: 01/02/23 PROBLEM (Start date: 01/02/23): Category: ADLs Functional Status/Rehabilitation Potential; ADL Function/Rehab Potential, Edited: 04/27/23 SHORT TERM GOAL (Target date: 11/27/23), Resident will achieve maximum functional mobility, Edited: 04/27/23 APPROACH (Start date: 01/02/23): Toileting amount of assist total foley and colostomy, Edited: 01/02/23 Record review of Resident #1's June 2023 MAR/TAR reflected the following orders: Foley catheter: Output every shift. Every Shift. [Start date 07/26/22 - Open Ended], revealed the following over a 3-day lookback: 06/15/23 - Shift 1 6:00 AM - 2:00 PM 1100 cc output - Shift 2 2:00 PM - 10:00 PM 800 cc output - Shift 3 10:00 PM - 6:00 AM 600 cc output 06/16/23 - Shift 1 6:00 AM - 2:00 PM 800 cc output - Shift 2 2:00 PM - 10:00 PM 800 cc output - Shift 3 10:00 PM - 6:00 AM 700 cc output 06/17/23 - Shift 1 6:00 AM - 2:00 PM 500 cc output - Shift 2 2:00 PM - 10:00 PM 450 cc output - Shift 3 10:00 PM - 6:00 AM 400 cc output 06/18/23 - Shift 1 6:00 AM - 2:00 PM 450 cc output Review of Resident #1's Vitals Taken During Last 30 Days in the EMR entered by staff, included temperature, pulse, respirations, blood pressure, pain, and urine output. The measurements over a 3-day lookback reflected: Wednesday, 06/14/23: - Shift 1 6:00 AM - 2:00 PM (LVN B) o Temperature: No measurement documented o Pulse (7:45 AM): 76 bpm; (12:33 PM): 70 bpm o Respirations: No measurement documented o Blood Pressure (7:45 AM): 120/66 mmHg; (12:33 PM): 116/68 mmHg o Pain (6:54 AM): 0 of 10; (8:48 AM): 0 of 10 o Urine (1:40 PM): 900 mL - Shift 2 2:00 PM - 10:00 PM (RN D) o Temperature (8:07 PM): 97.4 F o Pulse (8:05 PM): 72 per minute o Respirations (8:07 PM): 17 per minute o Blood Pressure (8:05 PM): 100/56 mmHg o Pain (8:06 PM): 2 of 10 o Urine (7:59 PM): 800 mL - Shift 3 10:00 PM - 6:00 AM (LVN C) o Temperature: No measurement documented o Pulse: No measurement documented o Respirations: No measurement documented o Blood Pressure: No measurement documented o Pain (06/15/23 at 12:23 AM): 0 of 10 o Urine (06/15/23 at 4:31 AM): 700 mL Thursday, 06/15/23: - Shift 1 6:00 AM - 2:00 PM (LVN B) o Temperature: No measurement documented o Pulse (8:57 AM): 71 bpm; (11:24 AM): 66 bpm o Respirations: No measurement documented o Blood Pressure (8:57 AM): 118/73 mmHg; (11:24 AM): 132/63 mmHg o Pain (6:15 AM): 0 of 10; (8:56 AM): 0 of 10 o Urine (1:53 PM): 1100 mL - Shift 2 2:00 PM - 10:00 PM (LVN E) o Temperature (5:56 PM): 97.6 F o Pulse (5:56 PM): 73 bpm; (8:08 PM): 70 bpm o Respirations (5:56 PM): 18 per minute o Blood Pressure (5:56 PM): 122/69 mmHg; (8:08 PM): 116/77 mmHg o Pain (5:54 PM): 0 of 10 o Urine (8:25 PM): 800 mL - Shift 3 10:00 PM - 6:00 AM (LVN C) o Temperature: No measurement documented o Pulse: No measurement documented o Respirations: No measurement documented o Blood Pressure: No measurement documented o Pain (06/16/23 at 12:47 AM): 0 of 10 o Urine (06/16/23 at 4:35 AM): 600 mL Friday, 06/16/23: - Shift 1 6:00 AM - 2:00 PM (LVN B) o Temperature: No measurement documented o Pulse (8:29 AM): 70 bpm; (12:29 PM): 68 bpm o Respirations: No measurement documented o Blood Pressure (8:29 AM): 100/65 mmHg; (12:29 PM): 120/66 mmHg o Pain (06:39 AM): 0 of 10; (8:29 AM): 0 of 10 o Urine (1:41 PM): 800 mL - Shift 2 2:00 PM - 10:00 PM (LVN E) o Temperature (8:34 PM): 97.8 F o Pulse (8:33 PM): 71 per minute o Respirations (8:34 PM): 18 per minute o Blood Pressure (8:33 PM): 114/68 mmHg o Pain (8:31 PM): 0 of 10 o Urine (8:31 PM): 800 mL - Shift 3 10:00 PM - 6:00 AM (LVN C) o Temperature: No measurement documented o Pulse: No measurement documented o Respirations: No measurement documented o Blood Pressure: No measurement documented o Pain (06/17/23 at 12:11 AM): 0 of 10 o Urine (06/17/23 at 4:05 AM): 700 mL Saturday, 06/17/23: - Shift 1 6:00 AM - 2:00 PM (RN D) o Temperature: No measurement documented o Pulse (8:03 AM): 71 bpm; (12:09 PM): 74 bpm o Respirations: No measurement documented o Blood Pressure (8:03 AM): 114/58 mmHg; (12:09 PM): 116/57 mmHg o Pain (8:02 AM): 2 of 10; (8:07 AM): 2 of 10 o Urine (12:11 PM): 500 mL - Shift 2 2:00 PM - 10:00 PM (RN D) o Temperature (8:45 PM): 97.3 F o Pulse (8:45 PM): 76 per minute o Respirations (8:45 PM): 17 per minute o Blood Pressure (8:44 PM): 140/69 mmHg o Pain (8:44 PM): 0 of 10 o Urine (8:46 PM): 450 mL - Shift 3 10:00 PM - 6:00 AM (RN H) o Temperature: No measurement documented o Pulse: No measurement documented o Respirations: No measurement documented o Blood Pressure: No measurement documented o Pain (06/18/23 at 2:07 AM): 0 of 10 o Urine (06/18/23 at 6:42 AM): 400 mL Sunday, 06/18/23: - Shift 1 6:00 AM - 2:00 PM (RN D) o Temperature: No measurement documented o Pulse (9:06 AM): 85 bpm; (12:15 PM): 88 bpm o Respirations: No measurement documented o Blood Pressure (9:06 AM): 121/75 mmHg; (12:15 PM): 107/56 mmHg o Pain (12:14 PM): 0 of 10 o Urine (12:14 PM): 450 mL Record review of progress notes for Resident #1 indicated: - 6/13/23 at 2:12 PM, LVN B entered: Resident c/o feeling nauseated, [NP] notified; new order received as needed for Nausea . - 6/14/23 - 6/16/23: There were no nursing notes entered. - 06/17/23 9:03 PM, RN D entered, Resident running fever of 101 PRN PO Motrin 200 mg, 2 tablets administered and tolerated well. Will evaluate after 45 minutes. Will continue to monitor any change patient condition. - 06/17/23 9:51 PM, RN D entered, Resident fever reduced to 98.5. CN paged Dr's answering personnel and stated [NP] is on call will give a call back. Awaits for the call. - 06/18/23 12:00 AM, RN H entered, Resident resting quietly .V/S [BP] 121/63, [P] 69, [R] 16, [T] 98.2 . no pain or discomfort voiced, PO fluids offered and encouraged but resident refused . - 06/18/23 4:30 AM, RN H entered, V/S [BP] 104/55, [P] 67, [R] 18, [T] 97.9 . no call back from NP yet. - 06/18/23 9:30 AM, RN D entered, Resident received in bed weak looking, took breakfast 25% of meal. Paged on call Dr.'s answering personnel and stated [NP] on call will give a call back. - 06/18/23 9:41 AM, RN D entered, [NP] called back, and new orders received; STAT chest x-ray, U/A, CBC, and BMP. Called . scheduled orders . - 06/18/23 11:27 AM, RN D entered, Blood sample . collected. U/A to be collected tomorrow 06/19/23 at 5 AM. - 06/18/23 3:02 PM, RN D entered, Lab results received [NP] notified and new orders received . DON and RP notified. - 06/18/23 4:11 PM, RN D entered, Resident family in the facility . requested resident to be taken to the hospital despite of receiving orders to start [NAME] from [NP] . The writer [RN D] called 911. Resident taken to [hospital] . A record review of hospital medical records for admitted [DATE] - 04/20/23 indicated Resident #1]presented to the ED from SNF on 04/13/23 and was admitted for primary diagnosis of acute sepsis, septic shock, acute cystitis/CAUTI, Complicated UTI-ruled out, chronic foley; hx recurrent cystitis, and sacral pressure ulcer, stage 4, Osteomyelitis of coccyx-diagnosed prior admission. Resident #1 discharged back to SNF on 04/20/23 with orders to continue IV abx for resolving sepsis, osteomyelitis of coccyx, right foot osteomyelitis, and NPWT. A record review of medical records for a recent hospitalization , admitted [DATE] indicated Resident #1 presented to the ED on 06/18/23 at 4:24 PM by EMS with primary complaint of generalized pain . has foley catheter in place upon arrival with thick, milky, red urine draining . Review of Resident #1 vital signs measured in the ED: 06/18/23 at 4:35 PM: BP-91/52; Pulse-81; Resp-18; Temp-98.3 F 06/18/23 at 5:30 PM: BP-105/50; Pulse-89; Resp-16 06/18/23 at 5:45 PM: BP-106/49 Review of Resident #1 hospital sepsis workup (labs) in the ED indicated {*critical lab values}: WBC 22.0 (high, indicative of infection, Normal Range: 4.5 - 11) RBC 2.53 (low, indicative of blood loss or abnormal kidney function, Normal Range: 4.0 - 5.9) Hgb 8.4 (low, indicative of blood loss or abnormal kidney function, Normal Range: 13.8 - 17.2) Hct 24.7 (low, indicative of blood loss or abnormal kidney function, Normal Range: 41% - 50%) UA with Reflex Culture Color - Dark Red (indicative of blood in urine) Appearance - Turbid (cloudy, opaque, or thick with suspended matter) Blood - Large Leukocyte - Large (white blood cells in the urine - may have UTI) A review of the ED physician notes dated 06/18/23 at 4:56 PM indicated Resident #1 was admitted for acute cystitis (inflammation of the bladder) with hematuria (blood in urine): acute illness or injury; generalized weakness; and Sepsis, due to unspecified organism. Treatment plan indicated replacement of FC, IV antibiotics, and ID consultation in the morning. Resident #1 remained hospitalized during investigation. During an interview on 06/23/23 at 2:31 PM, RP indicated they requested Resident #1 be sent to the hospital on 06/18/23 because, . his foley bag was full of urine mixed with blood. He barely was conscious, and he could not speak. The RP could not describe in measurements how full the drainage bag was of urine or how much blood was noted mixed with the urine. The RP described barely conscious and could not speak as not fully awake or able to hold a conversation. During an interview on 06/23/23 at 4:02 PM, LVN E stated she was familiar with Resident #1 and last worked with Resident #1 on 06/16/23. LVN E described Resident #1 as bedbound, had a FC, colostomy, wound vac, could make needs known, and had recurring infections. LVN E said a change in condition would be a change from the resident's day to day baseline vital signs or behavior - acting confused. LVN E stated early signs of sepsis include a fever, high heart rate, and a low blood pressure. LVN E said that she provided direct care to Resident #1 but did not recall a change in condition, behavior, or vital signs that caused concern. LVN E stated whenever she provided catheter care to a resident she checked the entry site, to ensure it was free from pus, discharge, and drainage and that the tubing was not clogged and drained clear yellow urine. LVN E said CNAs were typically responsible for emptying the FC drainage bag, measured urine, and were to inform the charge nurse of the color, any odor, and the amount. LVN E said that she was not present when Resident #1 went to the hospital on 06/18/23. During an interview on 06/23/23 at 5:31 PM, the DON described Resident #1 as liked to stay in room, was bedbound, had a wound vac to coccyx wound, was admitted with a foley and a colostomy. [Resident #1] was on/off abx for recurring infections and completed IV abx the end of May [2023] and there were no concerns. The DON said that she was informed via phone by staff on Sunday, June 18th that Resident #1 had a fever, labs were drawn that resulted with a high WBC, the MD/NP was notified, and the RP requested to send Resident #1 to ED. The DON stated she was unaware of blood mixed with the urine, the nurse did not inform of concerns about catheter or urine output. The DON said that it is expected when a resident has a change in condition, the nurse assess, notify the DON, call MD/NP, carry out any orders given, and document. The DON said that vital signs should be measured every shift that include temperature, pulse, respirations, blood pressure, pain, and urine output. When asked, the DON could not justify why Resident #1's temperature and respirations were not always checked when vital signs were measured. The DON stated not measuring a resident's temperature or providing appropriate catheter and peri care could lead to or miss early signs of an UTI. The DON stated CNAs and nurses are observed for competency skills during new hire orientation and annually (sometimes sooner if needed). The DON stated it is especially important to monitor the FC urine output because if a resident had little output or no output it could be indicative of a UTI. The DON said that there are batch orders to change FC every 30 days, change drainage bag every 14 days, and provide catheter care. The NP reported on 06/26/23 at 2:42 PM that Resident #1 was seen on 06/16/23 for monthly visit. The NP reported Resident #1 had a history of chronic osteomyelitis (serious infection to the bone) and recurrent sepsis. The NP siad on 06/16/23, Resident #1 appeared chronically ill, foley drained straw-colored urine - that did not present abnormal, was lethargic, slow to respond, and confused. The NP indicated the nurse staff did not report any concerns or a change in condition. The NP reported labs and UA were ordered after a message was received about Resident #1 having a fever . The NP stated when preliminary lab results were recevied, antibiotics were ordered on or about 06/18/23 . The NP said they gave an order to send to hospital per family request on 06/18/23. During an interview on 06/26/23 at 4:53 PM, the ADON stated nurses should assess the catheter and urine output when assessing the resident during their shift. The ADON stated signs and symptoms of a UTI include fever, dark yellow urine, and foul smell. The ADON said that Resident #1 complained of pain to abdomen a day or two before sent to hospital, but that happened whenever experienced complications with TIPS (Transjugular Intrahepatic Portosystemic Shunt - relieves the pressure of blood flowing through the diseased liver and can help stop bleeding and fluid back up) and did not think the discomfort related to an UTI. The ADON stated she worked the day Resident #1 went to ED. The ADON stated preliminary results were received that showed an elevated white blood count . the NP ordered antibiotics . there was cloudy urine with blood noted when the resident was transported to the hospital. During an interview on 06/26/23 at 5:28 PM, RN D said that Resident #1 spiked a fever on Saturday [06/17/23], gave Motrin, was effective, but placed call to MD/NP's answering service to notify them of the fever and left message. RN D said that he placed an outbound call to MD/NP on 06/18/23 around 9:30 AM to follow up on call placed on 6/17/23 and received orders for STAT labs and UA. RN D said that the CNA (could not recall which CNA])emptied the drainage bag when providing peri-care and reported the amount - was not notified if the urine had an odor or was dark in color. RN D said that if a CNA reported abnormal characteristics of urine, it could be a possible UTI. RN D said that a behavior change, confusion, or not making sense were potential symptoms for a UTI, with or without a catheter, and should be reported to the nurse. RN D said that he noticed a little blood in the drainage bag when he went to attempt to obtain the STAT UA on 06/18/23. The CNAs scheduled 06/17/23 - 06/18/23 were unavailable for an interview and calls were not returned. Record review of the facility's Catheter Care, Urinary, revised December 2010, policy and procedure reflected, the purpose is to prevent catheter-associated urinary tract infections. General guidelines indicate observing the resident's urine level for noticeable increases or decreases, maintaining unobstructed urine flow, infection control, observe for complications, and obstruction management.

Based on observation, interview, and record review, the facility failed to immediately inform the physician and the resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status (deterioration in health in either life-threatening conditions) for one (Resident #1) of eleven residents reviewed for physician notification. The facility failed to ensure LVN B notified the physician on 06/10/23 when Resident #1 suffered from heat exhaustion when the temperature reached 95 degrees Fahrenheit. Resident #1 was found unresponsive outside by the patio, which resulted in the resident having a change of condition. LVN A, LVN B, and LVN C were aware that Resident #1 was found outside in the heat and his temperature reached 106 degrees [Fahrenheit], reporting a change of condition from 06/10/23 - 06/12/23. Once the Immediate Jerporady was removed, the facility remained out of complaince at a scope of pattern and severity of actual harm. An IJ was identified on 06/15/23, and while the IJ was removed on 06/17/23, the facility remained out of compliance at a scope of pattern and a severity level of actual harm because all staff had not been trained on change in condition, physician notification, and resident neglect and following facility policy. This failure placed residents at risk of a delay in treatment, and a worsening of their condition or could result in death. Findings included: Record review of Resident #1's face sheet dated 06/17/23 revealed Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included nontraumatic subdural hemorrhage (complication of head trauma), history of falling, nausea with vomiting, adult failure to thrive, altered mental status, unsteadiness on feet, hypertension (high blood pressure), Type 2 diabetes mellitus, hyperlipidemia (high cholesterol), and vascular dementia. Record review of Resident #1's admission MDS assessment, dated 06/02/23 revealed his BIMS score was 07 indicating severe cognitive impairment. His Functional Status for activities of daily living indicated he required limited assistance with one person assist with dressing and toileting. Resident #1 uses a wander/elopement alarm daily. Supervision for personal hygiene. Independent with bed mobility, transfers, walking in and out of the room, walking on and off the unit, and with eating. Record review of Resident #1's care plan, last care conference 05/24/23, revealed care areas 1-3 were revised on 06/16/23: 1. Resident #1 at risk for dehydration (problem started 06/02/23) due to complaints of frequently being cold and dresses in winter like attire. Goal: Resident will be free of signs and symptoms of dehydration/over-exposure to the sun, brought on by heat exposure while dressed in winter like attire. Approach: Encourage Resident #1 to drink cool fluids at least hourly while outside. Explain potential negative outcomes related to wearing winter like clothing while outside in warm weather. Allow him time and opportunity to process this information, ask questions and voice concerns or consent/refusal. If dehydration or over-exposure to the sun, notify the DON, Administrator and Medical Director/Nurse Practitioner. If noted for dehydration, remove Resident #1 from sun exposure, remove outer wear, apply cool towels, take vital signs, and encourage fluids. If Resident #1 is noted as being dressed in winterlike attire and wants to go out for sun exposure, offer alternate attire. Monitor Resident #1 for signs and symptoms of dehydration (dry mouth, extreme thirst, fatigue, dizziness, extreme sweating, or confusion). 2. Resident #1 at risk for wandering/attempting elopement (problem started 06/02/23) related to impaired memory/dementia as evidenced by resident wandering throughout the building often asking where he can go outside. Goal: Resident will remain inside long term care facility. Approach: Resident to have wander guard on at all times. Staff to redirect resident as needed. Staff will check functionality of wander guard daily. Staff will check to ensure wander guard is in place every shift. 3. Resident #1 has impaired cognition (problem started 06/02/23) with expected decline in cognitive impairment over a period of time as a natural progression of the disease process. Goal: Resident will be safe in his environment over the next 90 days. Approach: Reorient resident to person, place and time as needed when confusion is noted. Monitor resident whereabouts in the facility to ensure safe environment. Record review of Resident #1's progress notes dated 06/10/23 at 8:42 PM written by LVN B reflected, At about 1PM while the lunch was been served, resident was found in the courtyard sitting on a chair under the triple digit heat of the sun unresponsive, the attention of the nurses was called by the medication aide who noticed him while she was about to give him his medication his was sweating profusely under his thick jacket, his temp at this time was 106 degrees [Fahrenheit], he was rushed into the building while cold water was been poured on him continuously, he will not open his eyes and both temperature and blood pressure been taking at intervals of 5 mins until when these assessments record was at 97.8 [degrees Fahrenheit] and 133/78 [blood pressure] respectively, he was giving cold water and juice to drink, fed with food tray, then he started responding and talking as he used to, resident was praising God continually, saying God is good repeatedly, Resident Responsible Party cannot be reached as the phone number was declining. Record review of Resident #1's progress notes dated 06/11/23 at 5:50 AM written by LVN C reflected, Resident stayed up for some time refusing to stay in bed. Very weak to walk by himself. Dragging feet and would get frozen nearly falling. Put in wheelchair but is not able to propel self. Incontinent in the hallway times two - trying to sit down in his pee. Resident very upset when this nurse tried to redirect him stating that you think I don't think. Resident cleaned up and given incontinent brief. Eventually fell asleep. Has been sleeping since then. Bed in low position. Vitals taken 97.8 86 18 147/74 97% RA. Record review of Resident #1's progress notes dated 06/12/23 at 2:06 AM written by LVN C reflected, Resident in bed but keeps on getting up. He is kind of confused and has been asking for French Fries. Resident not able to walk with steady gait, has been using wheelchair if he agrees to. Continues using incontinence products. Resident a feeder at the moment, is not able to steadily hold silverware when eating and would need cueing. Staff continue keeping constant checks on resident to maintain safety. Bed in low position and call light within reach. Will continue to monitor. Record review of Resident #1's progress notes dated 06/12/23 at 11:31 AM written by LVN D reflected, Resident alert and oriented to name and present situation. Resident has been ambulatory, with un-steady gait resident was then placed in wheelchair for safety. Neurochecks done within normal limits. Resident extensively assisted with all activities of daily living and transfers. Resident's wander guard in place and functional. Fluids by mouth offered and encouraged. Able to make needs known responds appropriately when spoken to in conversation. Record review of Resident #1's progress notes dated 06/12/23 at 11:49 AM written by LVN D documented Notified Nurse Practitioner in regard to recent heat exposure. New orders received as follows: 1) STAT CBC, BMP (urgent overall blood lab test gives an overall view of your health, lab test that show how well your kidneys work) 2) UA C&S (test that checks for bacteria in urine). Unable to reach Resident's Responsible Party message left on answering machine to return call back to facility when available. Nursing to follow. Record review of Resident #1's progress notes dated 06/12/23 at 1:15 PM written by LVN D reflected, Reported to Director of Nursing of new orders given via Nurse Practitioner, Director of Nursing stated to call emergency medical transportation and send resident out to the emergency room for further evaluation and treatment. Nurse Practitioner made aware of resident's transfer to hospital. 12:10 PM emergency medical services arrives via stretcher accompanied by 2 attendants to transport resident to hospital. 12:20 PM [LVN D] was able to reach [family members] to update her on resident's care and transfer to emergency room . Record review of accident and incident reports dated 03/14/23 - 06/14/23 did not indicate Resident #1 was found unresponsive on 06/10/23 or went to the hospital on 06/12/23. Attempts were made to contact Resident #1's family members by phone on 06/15/23 at 9:16 AM; however, the attempts were not successful. Review of weather temperatures for the city in which the facility was located for 06/10/23 retrieved at www.accuweather.com and https://www.timeanddate.com/weather/usa/[NAME]/historic reflected the high for 06/10/23 was 95 degrees Fahrenheit (35 degrees Celsius). During an interview on 06/15/23 at 9:34 AM with the Nurse Practitioner revealed she was not on-call on June 10, 2023, however, was she on-call on Monday June 12,, 2023. The Nurse Practitioner stated LVN D notified her on 06/12/23 at 10:57 AM that Resident #1 was going to the hospital, he was found outside, on the ground unresponsive. The Nurse Practitioner stated she was not aware of the situation or a significant change of condition until Monday, June 12, 2023, according to the weekend notes, the on-call phone was not contacted about Resident #1's situation. The Nurse Practitioner stated had she been on call or notified about the situation she would have sent Resident #1 to the hospital for further evaluation and or treatment. Being exposed to heat could cause a range of reactions for example Resident #1 was found unresponsive. The Nurse Practitioner stated not sending Resident #1 to the hospital immediately could prevent medical treatment. During an interview on 06/15/23 at 9:52 AM with the Administrator revealed Resident #1 ambulated around the facility without assistance, did wear a wander guard, liked to dress with shoes, socks, pants, long-sleeved shirt, and a hoodie. The Administrator stated on Monday 06/12/23, she was reading through progress notes, and it was noted that on Saturday, 06/10/23, Resident #1 was found unresponsive outside. The Administrator stated LVN A and Medication Aide E brought him inside to cool him down. The Administrator stated Resident #1 had a change of condition so the protocol should have been followed. The Administrator stated the charge nurse on the floor should have competed an assessment, notified the physician or nurse practitioner and 911 to send the resident out to the hospital. The Administrator stated not following protocol could result in residents having a delay in treatment. The Administrator stated it was the responsibility of the nursing staff to contact the physician, director of nursing, and family to alert them of any situation affecting residents. During an interview on 06/15/23 at 10:18 AM with LVN A revealed Resident #1 was usually observed in his room, sitting at the nursing station, or walking around the building. LVN A stated she was sitting at the nursing station documenting, about 1:25 PM when she heard Medication Aide E saying something and walking fast. She stated Medication Aide E then grabbed a wheelchair and headed towards the courtyard and LVN A followed. LVN A stated once the doors opened, she saw Resident #1 sitting in a chair, and she could not tell if Resident #1 was sleeping or not. LVN A stated she could not tell how long Resident #1 had been outside. LVN A stated he was leaned back, head arched back, face towards the sky, and his arms were open branched out to his sides. LVN A stated she knew it was hot outside and noted he had on a big bubble coat and pants. She stated the first thing she did was unzip his coat. LVN A stated Resident #1 did not have on a shirt, and was sweating a lot under the coat. LVN A stated LVN B came out behind her, and she then stated she needed a thermometer, cold towels and to get him inside the building. LVN A stated Resident #1 was really hot, his skin was hot, and his face started to turn red, and he was very weak. LVN A stated once back inside the facility at Resident #1's room she removed wool socks, shoes, joggers, his briefs and administered cold towels to his face and body. LVN A stated chest rubs were being done. She stated Resident #1's eye were closed, he was not moving much because he was very weak, and he was trying to respond but could not. LVN A stated she kept applying fresh wet towels and rubbing his sternum for at least 30 minutes until he finally started to come to. LVN A stated there was several attempts at checking his temperature; once he was alert his temperature reading was 102 degrees Fahrenheit. Resident #1's head of bed was lifted slowly, and they began giving him something to drink (ice water, Gatorade, and juice). Medication Aide E checked his blood pressure to read 157/98, LVN A rechecked his temperature to read 98.3 degrees Fahrenheit, LVN B was saying it was good time to end the cold towels. According to LVN A she said. No, we are not done, let me check his hands and feet (which were still warm), it took a while before his legs were coming to a reasonable temperature. LVN A stated it was the end of the shift, Resident #1 was drinking more, continued to check his vitals which his temperature was 99.4 degrees Fahrenheit and his blood pressure was 136/80. LVN A stated she told LVN B you may want to call the physician and see if they want to send him out for further evaluation. LVN A stated Resident #1 was not her resident, so she left his care in LVN B's hands, and she was not sure if he contacted the doctor. LVN A stated she gave report to the nurse that was replacing her for the next shift. LVN A stated from what she could see at the time he was back at his baseline. LVN A stated it was the responsibility of the charge nurse to contact the physician, Director of Nursing, Administrator, and the family, and not doing so would be harmful to resident care. According to LVN A Resident #1 should have been sent out to the hospital for further evaluation. An attempted phone call interview on 06/15/23 at 11:20 AM with Medication Aide E was unsuccessful. During an interview on 06/15/23 at 11:27 AM with LVN B revealed Resident #1 was ambulatory, liked to walk around the facility and was usually sitting in front of the nursing station. LVN B stated he was the charge nurse for Resident #1 on June 10, 2023. LVN B stated it was a very terrible day for him because he had both nursing and certified nursing aide responsibilities and could not recall when Resident #1 went outside or how long he had been outside. LVN B stated around 1:00 PM Medication Aide E stated she was looking for Resident #1 to administer his medication. LVN B stated Medication Aide E ran into the facility stating Resident #1 was sitting out in the courtyard sweating, and another nurse ran out behind her. LVN B stated he assisted with getting Resident #1 inside to his room, he was observed sweating, skin was hot, and his temperature was high, around 106 degrees Fahrenheit or something like that. According to LVN B staff immediately began interventions with cold water, bed baths and checking vitals every 5 minutes. LVN B stated Resident #1's temperature came down to between 101 - 97.8 degrees Fahrenheit and his blood pressure reading was 133/77. According to LVN B after 15 minutes or so Resident #1 was fine. LVN B stated Resident #1 was administered orange juice to drink and completed his lunch tray. LVN B stated Resident #1 started praising God which was something he would usually do. LVN B stated after an hour Resident #1 got up from bed and requested to go outside and see the sun. LVN B stated, [Resident #1] did not go to the hospital at that time because I just felt he was back to normal, he was fine, and he was his normal self. LVN B stated he did not contact the physician, Director of Nursing, or the Administrator, however attempted to contact [Resident #1's] responsible party and family but had not spoken with anyone. LVN B stated he was so happy that [Resident #1] was ok and was at his baseline. I just entered the progress note. I did not find it necessary to contact the physician or the Director of Nursing. LVN B stated the protocol was to immediately complete an assessment, call the physician if I need, most of the time I don't want to take a chance to call the physician or emergency medical services because they are busy or may take long to call me back. LVN B stated, In this case I should have checked the vitals, called 911, and documented. LVN B stated I should have notified the physician, Director of Nursing, and the Administrator along with the family. According to LVN B it was his responsibility to follow facility policy and alert the medical team of the resident's change of condition. LVN B stated not doing so put [Resident #1] at risk of not having proper medical treatment. During an interview on 06/15/23 at 12:02 PM with LVN D revealed Resident #1 was pleasant, disoriented, required redirection, and usually sat at the nursing station. LVN D stated she encouraged the resident to sit at the nursing station to have eyes on him because he liked to go to the restroom, and he is with unsteady gait and now required assistance. He is usually dressed in sweats, jeans, hoodies, and jackets because he is cold natured. LVN D stated she never saw Resident #1 go outside during her shift, so the it was odd to hear he was outside. LVN D stated she was informed by LVN C in the morning upon her shift beginning at 6:00 AM, on June 12, 2023 that Resident #1 was found outside with an elevated temperature on Saturday, June 10, 2023. Nursing staff brought Resident #1 inside to cool him down with cold compress towels and hydrated him with fluids. LVN D stated she was told by LVN C during the weekend that Resident #1 required assistance with incontinent care and feeding during meals. LVN D stated LVN C also stated Resident #1 was not sent out to the hospital, that she may want to contact the physician. According to LVN D she observed Resident #1 to have signs of weakness, which was a change in condition from the last time she saw him (Friday, June 09, 2023) and considering what happened over the weekend, she needed to notify the physician. LVN D stated she contacted the doctor on June 12, 2023 about 11:30AM, followed up with the Director of Nursing and it was discussed to send him out to the hospital. LVN D stated not sending Resident #1 to the hospital in a timely manner prevented a quicker turn around for care. LVN D stated it was the responsibility of the charge nurse to make the proper calls to the physician and the Director of Nursing. During an interview on 06/15/23 at 12:24 PM with Administrator revealed the facility was continuing to complete the investigation and in-services that started on Monday June 12, 2023, on abuse and neglect, accidents, hazards, and supervision regarding heat illnesses, and staying hydrated during high temperatures and reporting changes. The Administrator stated the facility was continuing to educate residents to come inside when temperatures were high. The Administrator stated staff had been trained to monitor for proper clothing, staying hydrated, and the use of the water cooler on the patio. The facility would also provide Gatorade. The Administrator stated she, and the Director of Nursing are doing frequent checks along with staff outside during smoking times throughout the day to ensure resident are not showing signs and symptoms of heat exhaustion. During an interview on 06/15/23 at 12:40 PM with LVN C revealed when she entered for her shift on June 10, 2023 at 2:30 PM, she observed staff working with Resident #1 after he was found outside; she saw staff trying to give him drinks and food. LVN C stated Medication Aide E explained Resident #1 was found sitting outside in the sun, not under the shade and could not open his eyes. Staff brought him inside for cold water because his temperature was 106 degrees Fahrenheit. According to LVN C when she worked with him later that night, he was very weak and confused. LVN C stated Resident #1 urinated twice on the floor and wanted to sit in it, and he would get upset when he attempted to redirect him. LVN C stated she had to watch him closely because he would try walking but was not steady and unbalanced, he was very weak. LVN C stated at that point she provided him with briefs so that he did not have to attempt going to the restroom and risk falling. LVN C stated he would usually be up walking very slow or sitting at the nursing station however at that time he was too weak. LVN C stated on Sunday, June 11, 2023, Resident #1 was the same, not strong, and was too weak to walk. LVN C stated she monitored him and had frequent vital checks which were within normal limits. LVN C stated she questioned if his temperature read 106 degrees Fahrenheit why wouldn't they send him out to the hospital, and stated if it was me, I would have sent him out. LVN C stated on Sunday his vitals were ok, the only difference with him was that he was weak, briefs was placed on him so he would not attempt to toilet alone. According to LVN C it was the nurse's responsibility to make the call to contact the physician and the Director of Nursing and inform what is going on. LVN C stated she was not sure if that happened but thought when she had seen staff working with him in his room with the wet bed, feeding him and giving him drinks that the physician had been contacted and the nurses were following physician's orders. During an interview on 06/15/23 at 1:36 PM from the hospital case worker revealed Resident #1 was brought in by emergency medical services on June 12, 2023, for evaluation. Resident #1 was usually alert times 2 (Resident #1 was aware of his name and surroundings), however was showing signs of confusion and alert times 1(Resident #1 was aware of his name). Resident #1 presented with warm, dry skin, able to transfer, no fever, no wounds and would be discharged on this day. Case Worker stated Resident #1 was presented with fluids due to acute kidney injury on 06/13/23 until his discharge on 06/15/23. During an interview on 06/15/23 at 2:05 PM with the Director of Nursing revealed when she entered the facility on Monday, 06/12/23, she was notified during a clinical meeting that Resident #1 had an incident. The Director of Nursing stated she was reviewing the notes from the weekend, she started asking questions and it was told to her that Resident #1 was outside, and staff had to bring him inside to get his body temperature down. The Director of Nursing stated, No one had informed her of the incident. The Director of Nursing stated she had the charge nurse contact the physician while she contacted their regional consultant. According to the Director of Nursing it was decided by corporate to send Resident #1 to the hospital. The Director of Nursing stated staff followed up with the hospital later that day and it was revealed there were no critical findings and they were waiting on the doctor to complete an evaluation and then he would discharge. The Director or Nursing stated her expectations were to have immediately notify the physician and have contacted her about Resident #1 having heat exhaustion and found unresponsive. The Director of Nursing stated she would have had the nurse to send Resident #1 out immediately to the hospital for further evaluation. The Director of Nursing stated she started in-services on Monday June 12, 2023, on heat exposure and what to do, signs and symptoms of heat exposure along with a quiz for understanding. The Director of Nursing stated it was the responsibility of the nursing staff to act quickly to notify the physician and then The Director of Nursing if there is a change of condition with residents. The Director of Nursing stated not notifying the physician or The Director of Nursing of the incident could have caused delayed treatment for the resident. The Director of Nursing stated during her investigation with LVN B he stated he did not alert the physician or the Director of Nursing because the resident was brought back inside and got him back to his baseline and he was fine. The Director of Nursing stated LVN B was placed on suspension during the investigation. According to Director of Nursing, the staff has been trained and is aware of how she liked the floor to operate, which was by policy and procedures, and to notify her of any change of condtion. Review of facility policy revised 04/20/23 titled Change in a Resident's Condition or Status reflected: Our facility promptly notified the resident, his or her attending physician, health care provider and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) The nurse will notify the resident's attending physician, health care provider or physician on call when there has been a(an): Accident or incident involving the resident. .D. significant change in the resident's physical/emotional/mental condition. .G. Need to transfer the resident to a hospital/treatment center. A significant change of condition is a major decline or improvement in the resident's status that: A. will not normally resolve itself without intervention by staff . B. impacts more than one area of the president's health status. C. requires interdisciplinary review and/or revision to the care plan; and D. ultimately is based on the judgement of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. On 06/15/23 at 4:00 PM the Administrator was notified of an Immediate Threat had been identified. The facility's Plan of Removal was accepted on 06/16/23 at 9:51 AM. The Plan of Removal reflected the following: .Charge Nurse assigned to [Resident #1] member [sic] identified in the alleged deficient practice was suspended pending investigation. Education: In-services was conducted on the following policies: 1. Abuse/Neglect. (All Staff) 2. Heat and dehydration Signs and symptoms. Accidents, hazards and supervisions. (All Staff) 3. Hydration during warm weather. (All Staff) 4. Reporting to include when to notify the administrator and DON of reportable incidents or other serious incidents. (All Staff) 5. Assess for change of condition, physician/family/POA notification, significant change of condition is a major decline in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard clinical interventions (is not self-limiting) will result in a call to emergency services. Change in Condition will be documented in the progress notes in the electronic medical record. All residents with new progress notes will be reviewed in clinical meeting, daily, x5 days by Director of Nursing and or designee. (Charge Nurses) All current staff will be in-serviced prior to working their next shift, all new staff will be in-serviced regarding the above information prior to working their first shift. Completed by Director of Nurses, Assistant Director of Nurses, and/or designee. Review and identify residents who wander and have an increased risk of exposure to elements. Monitor: 1. Staff assigned to Monitor Courtyard hourly. (staff are aware of their assignment through education, staff responsible for monitoring will vary.) Staff will monitor courtyard for residents who wander; wandering residents have been identified through audit and will be communicated to staff for monitoring. Administrator and or designee will provide oversight of monitoring. This will include the log audit for completion. Administrator and/or designee has created a schedule for courtyard monitoring. The courtyard monitoring log will be reviewed/audited, daily, x5 days. Any concerns noted on the log will result in education and up to disciplinary action for staff assigned/responsible. 2. Staff responsible for monitoring will offer hydration during their assigned monitoring time and as needed. 3. DON/designee to correct any noted concerns and report to the Administrator. 4. Administrator will report, in summary, noted concerns to QAA Committee. Out of Cycle QAPI meeting to discuss concerns and approaches to correct. During observation and interview on 06/16/23 at 10:13 AM with Resident #1 revealed Resident #1 in bed under a blanket. The head of the bed was elevated, and Resident #1 was slumped over leaning to the right side. Resident #1 has his knees bent. According to Resident #1 he did not recall going to the hospital. Resident #1 stated he was having some pain in the right hand and right knee. Resident #1 requested pain medication. Further monitoring on 06/16/23 during re-interviews and interviews consisting of both day and night shifts revealed the following: Interviews on 06/16/23 from 1:00 PM through 06/17/23 10:30 AM with the Business Office Manager, LVN A, LVN B, LVN C, LVN D, Medication Aide E, Medication Aide F, LVN G, LVN H, LVN I, RN J, RN K , CNA L, CNA M, CNA N, CNA O, CNA P, who worked the shifts of 6:00 AM-2:00 PM, 2:00 PM-10:00PM and 6:00 PM-6:00 AM were able to verify education was provided to them; nursing staff were able to accurately summarize abuse and neglect policy, definitions and examples of change of condition and how, who, and when to report changes. The nursing staff revealed signs and symptoms of heat illnesses and what to look for and do if heat exhaustion is identified. The nursing staff expressed understanding of the importance of accidents, hazards, and supervision and how that plays in part to resident safety. During observations on 06/16/23-06/17/23 between 8:00 AM-5:00 PM revealed staff walking outside hourly to monitor residents in the courtyard. Staff were observed engaging with residents, offering water, and completing education about heat exhaustion and wearing proper attire when outside. Record review of the facility plan of correction monitoring tool form revised October 2022 titled Courtyard & Hydration Monitor indicated log started on 06/16/23 at 8:00 AM with slots for signatures, concerns, action taken, date, and a yes (Y) or no (N) for hydration. While the IJ was removed on 06/17/23, the facility remained out of compliance at a scope of pattern and a severity level of actual harm because all staff had not been trained on change in condition, physician notification, and resident neglect and following facility policy.

Based on observation, interview, and record review, the facility failed to ensure the right to be free from neglect was provided for one (Resident #1) of eleven residents reviewed for neglect. The facility failed to ensure Resident #1 was free from neglect when the facility failed to notify the physician when Resident #1 was unresponsive after extreme heat exposure and failed to provide Resident #1 with timely hospitalization following the incident. An IJ was identified on 06/15/23, and while the IJ was removed on 06/17/23, the facility remained out of compliance at a scope of pattern and a severity level of actual harm because all staff had not been trained on change in condition, physician notification, and resident neglect and following facility policy. This failure placed residents at risk of not having supervision or their needs adequately met. Findings included: Record review of Resident #1's face sheet dated 06/17/23 revealed Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included nontraumatic subdural hemorrhage (complication of head trauma), history of falling, nausea with vomiting, adult failure to thrive, altered mental status, unsteadiness on feet, hypertension (high blood pressure), Type 2 diabetes mellitus, hyperlipidemia (high cholesterol), and vascular dementia. Record review of Resident #1's admission MDS assessment, dated 06/02/23 revealed his BIMS score was 07 indicating severe cognitive impairment. His Functional Status for activities of daily living indicated he required limited assistance with one person assist with dressing and toileting. Resident #1 uses a wander/elopement alarm daily. Supervision for personal hygiene. Independent with bed mobility, transfers, walking in and out of the room, walking on and off the unit, and with eating. Record review of Resident #1's care plan, last care conference 05/24/23, revealed care areas 1-3 were revised on 06/16/23 reflected: 1. Resident #1 at risk for dehydration (problem started 06/02/23) due to complaints of frequently being cold and dresses in winter like attire. Goal: Resident will be free of signs and symptoms of dehydration/over-exposure to the sun, brought on by heat exposure while dressed in winter like attire. Approach: Encourage Resident #1 to drink cool fluids at least hourly while outside. Explain potential negative outcomes related to wearing winter like clothing while outside in warm weather. Allow him time and opportunity to process this information, ask questions and voice concerns or consent/refusal. If dehydration or over-exposure to the sun, notify the DON, Administrator and Medical Director/Nurse Practitioner. If noted for dehydration, remove Resident #1 from sun exposure, remove outer wear, apply cool towels, take vital signs, and encourage fluids. If Resident #1 is noted as being dressed in winter-like attire and wants to go out for sun exposure, offer alternate attire. Monitor Resident #1 for signs and symptoms of dehydration (dry mouth, extreme thirst, fatigue, dizziness, extreme sweating, or confusion). 2. Resident #1 at risk for wandering/attempting elopement (problem started 06/02/23) related to impaired memory/dementia as evidenced by resident wandering throughout the building often asking where he can go outside. Goal: Resident will remain inside long term care facility. Approach: Resident to have wander guard on at all times. Staff to redirect resident as needed. Staff will check functionality of wander guard daily. Staff will check to ensure wander guard is in place every shift. 3. Resident #1 has impaired cognition (problem started 06/02/23) with expected decline in cognitive impairment over a period of time as a natural progression of the disease process. Goal: Resident will be safe in his environment over the next 90 days. Approach: Reorient resident to person, place and time as needed when confusion is noted. Monitor resident whereabouts in the facility to ensure safe environment. Record review of Resident #1's progress notes dated 06/10/23 at 8:42 PM written by LVN B reflected, At about 1PM while the lunch was been served, resident was found in the courtyard sitting on a chair under the triple digit heat of the sun unresponsive, the attention of the nurses was called by the medication aide who noticed him while she was about to give him his medication his was sweating profusely under his thick jacket, his temp at this time was 106 degrees [Fahrenheit], he was rushed into the building while cold water was been poured on him continuously, he will not open his eyes and both temperature and blood pressure been taking at intervals of 5 mins until when these assessments record was at 97.8 [degrees Fahrenheit] and 133/78 [blood pressure] respectively, he was giving cold water and juice to drink, fed with food tray, then he started responding and talking as he used to, resident was praising God continually, saying God is good repeatedly, Resident Responsible Party cannot be reached as the phone number was declining. Record review of Resident #1's progress notes dated 06/11/23 at 5:50 AM written by LVN C reflected, Resident stayed up for some time refusing to stay in bed. Very weak to walk by himself. Dragging feet and would get frozen nearly falling. Put in wheelchair but is not able to propel self. Incontinent in the hallway times two - trying to sit down in his pee. Resident very upset when this nurse tried to redirect him stating that you think I don't think. Resident cleaned up and given incontinent brief. Eventually fell asleep. Has been sleeping since then. Bed in low position. Vitals taken 97.8 86 18 147/74 97% RA. Record review of Resident #1's progress notes dated 06/12/23 at 2:06 AM written by LVN C reflected, Resident in bed but keeps on getting up. He is kind of confused and has been asking for French Fries. Resident not able to walk with steady gait, has been using wheelchair if he agrees to. Continues using incontinence products. Resident a feeder at the moment, is not able to steadily hold silverware when eating and would need cueing. Staff continue keeping constant checks on resident to maintain safety. Bed in low position and call light within reach. Will continue to monitor. Record review of Resident #1's progress notes dated 06/12/23 at 11:31 AM written by LVN D reflected, Resident alert and oriented to name and present situation. Resident has been ambulatory, with un-steady gait resident was then placed in wheelchair for safety. Neurochecks done within normal limits. Resident extensively assisted with all activities of daily living and transfers. Resident's wander guard in place and functional. Fluids by mouth offered and encouraged. Able to make needs known responds appropriately when spoken to in conversation. Record review of Resident #1's progress notes dated 06/12/23 at 11:49 AM written by LVN D documented Notified Nurse Practitioner in regard to recent heat exposure. New orders received as follows: 1) STAT CBC, BMP (urgent overall blood lab test gives an overall view of your health, lab test that show how well your kidneys work) 2) UA C&S (test that checks for bacteria in urine). Unable to reach Resident's Responsible Party message left on answering machine to return call back to facility when available. Nursing to follow. Record review of Resident #1's progress notes dated 06/12/23 at 1:15 PM written by LVN D reflected, Reported to Director of Nursing of new orders given via Nurse Practitioner, Director of Nursing stated to call emergency medical transportation and send resident out to the emergency room for further evaluation and treatment. Nurse Practitioner made aware of resident's transfer to hospital. 12:10 PM emergency medical services arrives via stretcher accompanied by 2 attendants to transport resident to hospital. 12:20 PM [LVN D] was able to reach [family members] to update her on resident's care and transfer to emergency room . Record review of accident and incident reports dated 03/14/23 - 06/14/23 did not indicate Resident #1 was found unresponsive on 06/10/23 or went to the hospital on 06/12/23. Attempts were made to contact Resident #1's family members by phone on 06/15/23 at 9:16 AM; however, the attempts were not successful. Review of weather temperatures for the city in which the facility was located for 06/10/23 retrieved at www.accuweather.com and https://www.timeanddate.com/weather/usa/[NAME]/historic reflected the high for 06/10/23 was 95 degrees Fahrenheit (35 degrees Celsius). During an interview on 06/15/23 at 9:34 AM with the Nurse Practitioner revealed she was not on-call on 06/10/23; however, she was on-call on Monday, 06/12/23. The Nurse Practitioner stated LVN D notified her on 06/12/23 at 10:57 AM that Resident #1 was going to the hospital, he was found outside, on the ground unresponsive. The Nurse Practitioner stated she was not aware of the situation or a significant change of condition until Monday, 06/12/23, according to the weekend notes, the on-call phone was not contacted about Resident #1's situation. The Nurse Practitioner stated had she been on call or notified about the situation she would have sent Resident #1 to the hospital for further evaluation and or treatment. Being exposed to heat could cause a range of reactions for example Resident #1 was found unresponsive. The Nurse Practitioner stated not sending Resident #1 to the hospital immediately could prevent medical treatment. During an interview on 06/15/23 at 10:18 AM with the Administrator revealed Resident #1 ambulated around the facility without assistance, did wear a wander guard, liked to dress with shoes, socks, pants, long-sleeved shirt, and a sweatshirts. The Administrator stated on Monday 06/12/23, she was reading through progress notes, and it was noted that on Saturday, 06/10/23, Resident #1 was found unresponsive outside. The Administrator stated LVN A and Medication Aide E brought him inside to cool him down, it was unknown how long Resident #1 had been outside or when the last time he had been seen by his nurse. The Administrator stated Resident #1 had a change of condition due to neglect so the protocol should have been followed. The Administrator stated the charge nurse on the floor should have competed an assessment, notified the physician or nurse practitioner and 911 to send the resident out to the hospital. The Administrator stated not following protocol could result in residents having a delay in treatment. The Administrator stated it was the responsibility of the nursing staff to contact the physician, director of nursing, The Administrator and family, to alert them of any situation affecting residents. The Administrator stated all staff had been trained to recognize neglect and change of conditions so she was surprised to hear the ball had been dropped. During an interview on 06/15/23 at 10:18 AM with LVN A revealed Resident #1 was usually observed in his room, sitting at the nursing station, or walking around the building. LVN A stated she was sitting at the nursing station documenting, about 1:25 PM when she heard Medication Aide E saying something and walking fast. She stated Medication Aide E then grabbed a wheelchair and headed towards the courtyard and LVN A followed. LVN A stated once the doors opened, she saw Resident #1 sitting in a chair, and she could not tell if Resident #1 was sleeping or not. LVN A stated she could not tell how long Resident #1 had been outside. LVN A stated he was leaned back, head arched back, face towards the sky, and his arms were open branched out to his sides. LVN A stated she knew it was hot outside and noted he had on a big bubble coat and pants. She stated the first thing she did was unzip his coat. LVN A stated Resident #1 did not have on a shirt, and was sweating a lot under the coat. LVN A stated LVN B came out behind her, and she then stated she needed a thermometer, cold towels and to get him inside the building. LVN A stated Resident #1 was really hot, his skin was hot, and his face started to turn red, and he was very weak. LVN A stated once back inside the facility at Resident #1's room she removed wool socks, shoes, joggers, his briefs and administered cold towels to his face and body. LVN A stated chest rubs were being done. She stated Resident #1's eye were closed, he was not moving much because he was very weak, and he was trying to respond but could not. LVN A stated she kept applying fresh wet towels and rubbing his sternum for at least 30 minutes until he finally started to come to. LVN A stated there was several attempts at checking his temperature; once he was alert his temperature reading was 102 degrees Fahrenheit. Resident #1's head of bed was lifted slowly, and they began giving him something to drink (ice water, Gatorade, and juice). Medication Aide E checked his blood pressure to read 157/98, LVN A rechecked his temperature to read 98.3 degrees Fahrenheit, LVN B was saying that was a good place to stop. According to LVN A she said. No, we are not done, let me check his hands and feet (which were still warm), it took a while before his legs were coming to a reasonable temperature. LVN A stated it was the end of the shift, Resident #1 was drinking more, continued to check his vitals which his temperature was 99.4 degrees Fahrenheit and his blood pressure was 136/80. LVN A stated she told LVN B you may want to call the physician and see if they want to send him out for further evaluation. LVN A stated Resident #1 was not her resident, so she left his care in LVN B's hands, and she was not sure if he contacted the doctor. LVN A stated she gave report to the nurse that was replacing her for the next shift. LVN A stated from what she could see at the time he was back at his baseline. LVN A stated it was the responsibility of the charge nurse to contact the physician, Director of Nursing, Administrator, and the family, and not doing so would be harmful to resident care. According to LVN A Resident #1 should have been sent out to the hospital for further evaluation. An attempted phone call interview on 06/15/23 at 11:20 AM with Medication Aide E was unsuccessful. During an interview on 06/15/23 at 11:27 AM with LVN B revealed Resident #1 was ambulatory, liked to walk around the facility and was usually sitting in front of the nursing station. LVN B stated he was the charge nurse for Resident #1 on June 10, 2023. LVN B stated it was a very terrible day for him because he had both nursing and certified nursing aide responsibilities and could not recall when Resident #1 went outside or how long he had been outside, he stated he last recalled seeing Resident #1 around 7:30 AM that morning during medication pass. LVN B stated around 1:00 PM Medication Aide E stated she was looking for Resident #1 to administer his medication. LVN B stated Medication Aide E ran into the facility stating Resident #1 was sitting out in the courtyard sweating, and another nurse ran out behind her. LVN B stated he assisted with getting Resident #1 inside to his room, he was observed sweating, skin was hot, and his temperature was high, around 106 degrees Fahrenheit or something like that. According to LVN B staff immediately began interventions with cold water, bed baths and checking vitals every 5 minutes. LVN B stated Resident #1's temperature came down to between 101 - 97.8 degrees Fahrenheit and his blood pressure reading was 133/77. According to LVN B after 15 minutes or so Resident #1 was fine. LVN B stated Resident #1 was administered orange juice to drink and completed his lunch tray. LVN B stated Resident #1 started praising God which was something he would usually do. LVN B stated after an hour Resident #1 got up from bed and requested to go outside and see the sun. LVN B stated, [Resident #1] did not go to the hospital at that time because I just felt he was back to normal, he was fine, and he was his normal self. LVN B stated he did not contact the physician, Director of Nursing, or the Administrator, however attempted to contact [Resident #1's] family members but had not spoken with anyone. LVN B stated he was so happy that [Resident #1] was ok and was at his baseline that he just entered the progress note. I did not find it necessary to contact the physician or the Director of Nursing. LVN B stated the protocol was to immediately complete an assessment, call the physician if I need, most of the time I don't want to take a chance to call the physician or emergency medical services because they are busy or may take long to call me back. LVN B stated, In this case I should have checked the vitals, called 911, and documented. LVN B stated I should have notified the physician, Director of Nursing, and the Administrator along with the family. According to LVN B it was his responsibility to follow facility policy and alert the medical team of the resident's change of condition. LVN B stated he has had several trainings and inservices on neglect, LVN B stated many times he had made the call to send residents out to the hospital and just followed up with the physician, but did not feel this was one of those times to send Resident #1 out. LVN B stated not following protocol put [Resident #1] at risk of not having proper medical treatment. LVN B stated he was aware of abuse and neglect policy and was able to recognize signs and symptoms of neglect. LVN B stated The Administrator was the Abuse and Neglect Coordinator and he should have alerted her immediately. LVN B stated not being able to place eyes on your resident at all times is harmful to the residents, especially in this case, however LVN B stated he had many task going on during the lunch hour and he was only one person that could not be everywhere at the same time. During an interview on 06/15/23 at 12:02 PM with LVN D revealed Resident #1 was pleasant, disoriented, required redirection, and usually sat at the nursing station. LVN D stated she encouraged the resident to sit at the nursing station at all times to have eyes on him because he liked to go to the restroom, and he was with an unsteady gait and now required assistance. He is usually dressed in sweats, jeans, hoodies, and jackets because he was cold natured. LVN D stated she never saw Resident #1 go outside during her shift, so it was odd to hear he was outside. LVN D stated she was informed by LVN C the morning upon arrival of her shift beginning at 6:00 AM, on June 12, 2023 that Resident #1 was found outside with an elevated temperature on Saturday, June 10, 2023. Nursing staff brought Resident #1 inside to cool him down with cold compress towels and hydrated him with fluids. LVN D stated she was told by LVN C during the weekend that Resident #1 required assistance with incontinent care and feeding during meals. LVN D stated LVN C also said Resident #1 was not sent out to the hospital, that she may want to contact the physician. According to LVN D she observed Resident #1 to have signs of weakness, which was a change in condition from the last time she saw him (Friday, June 09, 2023) and considering what happened over the weekend, she needed to notify the physician. LVN D stated she contacted the doctor on June 12, 2023 about 11:30AM, followed up with the Director of Nursing and it was discussed to send him out to the hospital. LVN D stated not sending Resident #1 to the hospital in a timely manner prevented a quicker turn around for care. LVN D stated it was the responsibility of the charge nurse to make the proper calls to the physician and the Director of Nursing. LVN D stated she had been trained on neglect, and was aware she needed to notify the Administrator immediately. LVN D stated she was able to recognize signs and symptoms of neglect, and in this situation knew that Resident #1 needed to be under further evaluation so she contacted the physician for further instructions. During an interview on 06/15/23 at 12:24 PM with Administrator revealed the facility was continuing to complete the investigation and in-services that started on Monday June 12, 2023, on abuse and neglect, accidents, hazards, and supervision regarding heat illnesses, and staying hydrated during high temperatures and reporting changes. The Administrator stated the facility was continuing to educate residents to come inside when temperatures were high. The Administrator stated staff had been trained to monitor for proper clothing, staying hydrated, and the use of the water cooler on the patio. The facility would also provide Gatorade. The Administrator stated she, and the Director of Nursing are doing frequent checks along with staff outside during smoking times throughout the day to ensure resident are not showing signs and symptoms of heat exhaustion. During an interview on 06/15/23 at 12:40 PM with LVN C revealed when she entered for her shift on June 10, 2023 at 2:30 PM, she observed staff working with Resident #1 after he was found outside; she saw staff trying to give him drinks and food. LVN C stated Medication Aide E explained Resident #1 was found sitting outside in the sun, not under the shade and could not open his eyes. Staff brought him inside for cold water because his temperature was 106 degrees Fahrenheit. According to LVN C when she worked with him later that night, he was very weak and confused. LVN C stated Resident #1 urinated twice on the floor and wanted to sit in it, and he would get upset when he attempted to redirect him. LVN C stated she had to watch him closely because he would try walking but was not steady and unbalanced, he was very weak. LVN C stated at that point she provided him with briefs so that he did not have to attempt going to the restroom and risk falling. LVN C stated he would usually be up walking very slow or sitting at the nursing station however at that time he was too weak. LVN C stated on Sunday, June 11, 2023, Resident #1 was the same, not strong, and was too weak to walk. LVN C stated she monitored him and had frequent vital checks which were within normal limits. LVN C stated she questioned if his temperature read 106 degrees Fahrenheit why wouldn't they send him out to the hospital, and stated if it was me, I would have sent him out. LVN C stated on Sunday his vitals were ok, the only difference with him was that he was weak, briefs was placed on him so he would not attempt to toilet alone. According to LVN C it was the nurse's responsibility to make the call to contact the physician and the Director of Nursing and inform what is going on. LVN C stated she was not sure if that happened but thought when she had seen staff working with him in his room with the wet bed, feeding him and giving him drinks that the physician had been contacted and the nurses were following physician's orders. During an interview on 06/15/23 at 1:36 PM from the hospital case worker revealed Resident #1 was brought in by emergency medical services on June 12, 2023, for evaluation. Resident #1 was usually alert times 2 (Resident #1 was aware of his name and surroundings), however was showing signs of confusion and alert times 1(Resident #1 was aware of his name). Resident #1 presented with warm, dry skin, able to transfer, no fever, no wounds and would be discharged on this day. Case Worker stated Resident #1 was presented with fluids due to acute kidney injury on 06/13/23 until his discharge on 06/15/23. During an interview on 06/15/23 at 2:05 PM with the Director of Nursing revealed when she entered the facility on Monday, June 12, 2023, she was notified during a clinical meeting that Resident #1 had an incident. The Director of Nursing stated she was reviewing the notes from the weekend, she started asking questions and it was told to her that Resident #1 was outside, and staff had to bring him inside to get his body temperature down. The Director of Nursing stated, No one had informed her of the incident. The Director of Nursing stated she had the charge nurse contact the physician while she contacted their regional consultant. According to the Director of Nursing it was decided by corporate to send Resident #1 to the hospital. The Director of Nursing stated staff followed up with the hospital later that day and it was revealed there were no critical findings and they were waiting on the doctor to complete an evaluation and then he would discharge. The Director or Nursing stated her expectations were to have immediately notify the physician and have contacted her about Resident #1 having heat exhaustion and found unresponsive. The Director of Nursing stated she would have had the nurse to send Resident #1 out immediately to the hospital for further evaluation. The Director of Nursing stated she started in-services on Monday June 12, 2023, on heat exposure and what to do, signs and symptoms of heat exposure along with a quiz for understanding. The Director of Nursing stated it was the responsibility of the nursing staff to act quickly to notify the physician and then The Director of Nursing if there is a change of condition with residents. The Director of Nursing stated not notifying the physician or The Director of Nursing of the incident could have caused delayed treatment for the resident. The Director of Nursing stated during her investigation with LVN B he stated he did not alert the physician or the Director of Nursing because the resident was brought back inside and got him back to his baseline and he was fine. The Director of Nursing stated LVN B was placed on suspension during the investigation. According to Director of Nursing, the staff has been trained and is aware of how she liked the floor to operate, which was by policy and procedures, and to notify her of any change of condtion. Record review of facility policy revised 01/09/23 titled Abuse Prevention Program stated The Administrator is responsible for the overall coordination and implementation of our Center's prevention program policies and procedures. Our residents have the right to be free form abuse, neglect, misappropriation of resident property and exploitation. Our Center will implement and permanently maintain an effective training program for all staff, which includes, at a minimum training on neglect. As part of the resident abuse program, the administration will ensure that any further neglect is prevented. All allegged violations of neglect will be reported by the Administrator. All alleged violations of neglect will be reported to the Administrator. CMS defines Neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, mental anguish, or emotional distress. All violations involving neglect will be reported by the Center Administrator and the resident's Attending Physician and/or Medical Director immediately. Review of facility policy revised 04/20/23 titled Change in a Resident's Condition or Status stated Our facility promptly notified the resident, his or her attending physician, health care provider and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) The nurse will notify the resident's attending physician, health care provider or physician on call when there has been a(an): Accident or incident involving the resident. D. significant change in the resident's physical/emotional/mental condition. G. Need to transfer the resident to a hospital/treatment center. A significant change of condition is a major decline or improvement in the resident's status that: A. will not normally resolve itself without intervention by staff . B. impacts more than one area of the president's health status. C. requires interdisciplinary review and/or revision to the care plan; and D. ultimately is based on the judgement of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. On 06/15/23 at 4:00 PM the Administrator was notified of an Immediate Threat had been identified. The facility's Plan of Removal was accepted on 06/16/23 at 9:51 AM. The Plan of Removal reflected the following: .Charge Nurse assigned to [Resident #1] member [sic] identified in the alleged deficient practice was suspended pending investigation. Education: In-services was conducted on the following policies: 1. Abuse/Neglect. (All Staff) 2. Heat and dehydration Signs and symptoms. Accidents, hazards and supervisions. (All Staff) 3. Hydration during warm weather. (All Staff) 4. Reporting to include when to notify the administrator and DON of reportable incidents or other serious incidents. (All Staff) 5. Assess for change of condition, physician/family/POA notification, significant change of condition is a major decline in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard clinical interventions (is not self-limiting) will result in a call to emergency services. Change in Condition will be documented in the progress notes in the electronic medical record. All residents with new progress notes will be reviewed in clinical meeting, daily, x5 days by Director of Nursing and or designee. (Charge Nurses) All current staff will be in-serviced prior to working their next shift, all new staff will be in-serviced regarding the above information prior to working their first shift. Completed by Director of Nurses, Assistant Director of Nurses, and/or designee. Review and identify residents who wander and have an increased risk of exposure to elements. Monitor: 1. Staff assigned to Monitor Courtyard hourly. (staff are aware of their assignment through education, staff responsible for monitoring will vary.) Staff will monitor courtyard for residents who wander; wandering residents have been identified through audit and will be communicated to staff for monitoring. Administrator and or designee will provide oversight of monitoring. This will include the log audit for completion. Administrator and/or designee has created a schedule for courtyard monitoring. The courtyard monitoring log will be reviewed/audited, daily, x5 days. Any concerns noted on the log will result in education and up to disciplinary action for staff assigned/responsible. 2. Staff responsible for monitoring will offer hydration during their assigned monitoring time and as needed. 3. DON/designee to correct any noted concerns and report to the Administrator. 4. Administrator will report, in summary, noted concerns to QAA Committee. Out of Cycle QAPI meeting to discuss concerns and approaches to correct. During observation and interview on 06/16/23 at 10:13 AM with Resident #1 revealed Resident #1 in bed under a blanket. The head of the bed was elevated, and Resident #1 was slumped over leaning to the right side. Resident #1 has his knees bent. According to Resident #1 he did not recall going to the hospital. He stated he did not have breakfast but would like to have some juice. Resident #1 stated he was having some pain in the right hand and right knee. Resident #1 requested pain medication. Further monitoring on 06/16/23 during re-interviews and interviews consisting of both day and night shifts revealed the following: Interviews on 06/16/23 from 1:00 PM through 06/17/23 10:30 AM with the Business Office Manager, LVN A, LVN B, LVN C, LVN D, Medication Aide E, Medication Aide F, LVN G, LVN H, LVN I, RN J, RN K , CNA L, CNA M, CNA N, CNA O, CNA P, who worked the shifts of 6:00 AM-2:00 PM, 2:00 PM-10:00PM and 6:00 PM-6:00 AM were able to verify education was provided to them; nursing staff were able to accurately summarize abuse and neglect policy, definitions and examples of change of condition and how, who, and when to report changes. The nursing staff revealed signs and symptoms of heat illnesses and what to look for and do if heat exhaustion is identified. The nursing staff expressed understanding of the importance of accidents, hazards, and supervision and how that plays in part to resident safety. During observations on 06/16/23-06/17/23 between 8:00 AM-5:00 PM revealed staff

Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit neglect for one (Resident #1) of eleven residents reviewed for incidents. The facility failed to implement their abuse and neglect policy by failing to ensure Resident #1 was free from neglect. Over several days, multiple staff did not provide goods and services of proper care. The facility failed to ensure LVN B did not neglect Resident #1 when she failed to notify the physician on 06/10/23 when Resident #1 suffered from heat exhaustion when the temperature reached 95 degrees Fahrenheit. Resident #1 was found unresponsive outside by the patio, which resulted in the resident having a change of condition. Once the Immediate Jeporady was removed, the facility remained out of complaince at a scope of pattern and severity of actual harm. An IJ was identified on 06/15/23, and while the IJ was removed on 06/17/23, the facility remained out of compliance at a scope of pattern and a severity level of actual harm because all staff had not been trained on change in condition, physician notification, and resident neglect and following facility policy. This failure placed residents at risk of a delay in treatment, and a worsening of their condition or could result in death Findings included: Record review of Resident #1's face sheet dated 06/17/23 revealed Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included nontraumatic subdural hemorrhage (complication of head trauma), history of falling, nausea with vomiting, adult failure to thrive, altered mental status, unsteadiness on feet, hypertension (high blood pressure), Type 2 diabetes mellitus, hyperlipidemia (high cholesterol), and vascular dementia. Record review of Resident #1's admission MDS assessment, dated 06/02/23 revealed his BIMS score was 07 indicating severe cognitive impairment. His Functional Status for activities of daily living indicated he required limited assistance with one person assist with dressing and toileting. Resident #1 uses a wander/elopement alarm daily. Supervision for personal hygiene. Independent with bed mobility, transfers, walking in and out of the room, walking on and off the unit, and with eating. Record review of Resident #1's care plan, last care conference 05/24/23, revealed care areas 1-3 were revised on 06/16/23, 1. Resident #1 at risk for dehydration (problem started 06/02/23) due to complaints of frequently being cold and dresses in winter like attire. Goal: Resident will be free of signs and symptoms of dehydration/over-exposure to the sun, brought on by heat exposure while dressed in winter like attire. Approach: Encourage Resident #1 to drink cool fluids at least hourly while outside. Explain potential negative outcomes related to wearing winter like clothing while outside in warm weather. Allow him time and opportunity to process this information, ask questions and voice concerns or consent/refusal. If dehydration or over-exposure to the sun, notify the DON, Administrator and Medical Director/Nurse Practitioner. If noted for dehydration, remove Resident #1 from sun exposure, remove outer wear, apply cool towels, take vital signs, and encourage fluids. If Resident #1 is noted as being dressed in winterlike attire and wants to go out for sun exposure, offer alternate attire. Monitor Resident #1 for signs and symptoms of dehydration (dry mouth, extreme thirst, fatigue, dizziness, extreme sweating, or confusion). 2. Resident #1 at risk for wandering/attempting elopement (problem started 06/02/23) related to impaired memory/dementia as evidenced by resident wandering throughout the building often asking where he can go outside. Goal: Resident will remain inside long term care facility. Approach: Resident to have wander guard on at all times. Staff to redirect resident as needed. Staff will check functionality of wander guard daily. Staff will check to ensure wander guard is in place every shift. 3. Resident #1 has impaired cognition (problem started 06/02/23) with expected decline in cognitive impairment over a period of time as a natural progression of the disease process. Goal: Resident will be safe in his environment over the next 90 days. Approach: Reorient resident to person, place and time as needed when confusion is noted. Monitor resident whereabouts in the facility to ensure safe environment. Record review of Resident #1's progress notes dated 06/10/23 at 8:42 PM written by LVN B reflected, At about 1PM while the lunch was been served, resident was found in the courtyard sitting on a chair under the triple digit heat of the sun unresponsive, the attention of the nurses was called by the medication aide who noticed him while she was about to give him his medication his was sweating profusely under his thick jacket, his temp at this time was 106 degrees [Fahrenheit], he was rushed into the building while cold water was been poured on him continuously, he will not open his eyes and both temperature and blood pressure been taking at intervals of 5 mins until when these assessments record was at 97.8 [degrees Fahrenheit] and 133/78 [blood pressure] respectively, he was giving cold water and juice to drink, fed with food tray, then he started responding and talking as he used to, resident was praising God continually, saying God is good repeatedly, Resident Responsible Party cannot be reached as the phone number was declining. Record review of Resident #1's progress notes dated 06/11/23 at 5:50 AM written by LVN C reflected, Resident stayed up for some time refusing to stay in bed. Very weak to walk by himself. Dragging feet and would get frozen nearly falling. Put in wheelchair but is not able to propel self. Incontinent in the hallway times two - trying to sit down in his pee. Resident very upset when this nurse tried to redirect him stating that you think I don't think. Resident cleaned up and given incontinent brief. Eventually fell asleep. Has been sleeping since then. Bed in low position. Vitals taken 97.8 86 18 147/74 97% RA. Record review of Resident #1's progress notes dated 06/12/23 at 2:06 AM written by LVN C reflected, Resident in bed but keeps on getting up. He is kind of confused and has been asking for French Fries. Resident not able to walk with steady gait, has been using wheelchair if he agrees to. Continues using incontinence products. Resident a feeder at the moment, is not able to steadily hold silverware when eating and would need cueing. Staff continue keeping constant checks on resident to maintain safety. Bed in low position and call light within reach. Will continue to monitor. Record review of Resident #1's progress notes dated 06/12/23 at 11:31 AM written by LVN D reflected, Resident alert and oriented to name and present situation. Resident has been ambulatory, with un-steady gait resident was then placed in wheelchair for safety. Neurochecks done within normal limits. Resident extensively assisted with all activities of daily living and transfers. Resident's wander guard in place and functional. Fluids by mouth offered and encouraged. Able to make needs known responds appropriately when spoken to in conversation. Record review of Resident #1's progress notes dated 06/12/23 at 11:49 AM written by LVN D documented Notified Nurse Practitioner in regard to recent heat exposure. New orders received as follows: 1) STAT CBC, BMP (urgent overall blood lab test gives an overall view of your health, lab test that show how well your kidneys work) 2) UA C&S (test that checks for bacteria in urine). Unable to reach Resident's Responsible Party message left on answering machine to return call back to facility when available. Nursing to follow. Record review of Resident #1's progress notes dated 06/12/23 at 1:15 PM written by LVN D reflected, Reported to Director of Nursing of new orders given via Nurse Practitioner, Director of Nursing stated to call emergency medical transportation and send resident out to the emergency room for further evaluation and treatment. Nurse Practitioner made aware of resident's transfer to hospital. 12:10 PM emergency medical services arrives via stretcher accompanied by 2 attendants to transport resident to hospital. 12:20 PM [LVN D] was able to reach ex-wife or son to update her on resident's care and transfer to emergency room . Record review of accident and incident reports dated 03/14/23 - 06/14/23 did not indicate Resident #1 was found unresponsive on 06/10/23 or went to the hospital on 06/12/23. Attempts were made to contact Resident #1's family members by phone on 06/15/23 at 9:16 AM; however, the attempts were not successful. Review of weather temperatures for the city in which the facility was located for 06/10/23 retrieved at www.accuweather.com and https://www.timeanddate.com/weather/usa/[NAME]/historic reflected the high for 06/10/23 was 95 degrees Fahrenheit (35 degrees Celsius). During an interview on 06/15/23 at 9:34 AM with the Nurse Practitioner revealed she was not on-call on June 10, 2023, however, was she on-call on Monday June 12,, 2023. The Nurse Practitioner stated LVN D notified her on 06/12/23 at 10:57 AM that Resident #1 was going to the hospital, he was found outside, on the ground unresponsive. The Nurse Practitioner stated she was not aware of the situation or a significant change of condition until Monday, June 12, 2023, according to the weekend notes, the on-call phone was not contacted about Resident #1's situation. The Nurse Practitioner stated had she been on call or notified about the situation she would have sent Resident #1 to the hospital for further evaluation and or treatment. Being exposed to heat could cause a range of reactions for example Resident #1 was found unresponsive. The Nurse Practitioner stated not sending Resident #1 to the hospital immediately could prevent medical treatment. During an interview on 06/15/23 at 9:52 AM with the Administrator revealed Resident #1 ambulated around the facility without assistance, did wear a wander guard, liked to dress with shoes, socks, pants, long-sleeved shirt, and a hoodie. The Administrator stated on Monday June 12, 2023, she was reading through progress notes, and it was noted that on Saturday, June 10, 2023, Resident #1 was found unresponsive outside. The Administrator stated LVN A and Medication Aide E brought him inside to cool him down. The Administrator stated Resident #1 had a change of condition so the protocol should have been followed. The Administrator stated the charge nurse on the floor should have competed an assessment, notified the physician or nurse practitioner and 911 to send the resident out to the hospital. The Administrator stated not following protocol could result in residents having a delay in treatment. The Administrator stated it was the responsibility of the nursing staff to contact the physician, director of nursing, and family to alert them of any situation affecting residents. During an interview on 06/15/23 at 9:52 AM with LVN A revealed Resident #1 was usually observed in his room, sitting at the nursing station, or walking around the building. LVN A stated she was sitting at the nursing station documenting, about 1:25 PM when she heard Medication Aide E saying something and walking fast. She stated Medication Aide E then grabbed a wheelchair and headed towards the courtyard and LVN A followed. LVN A stated once the doors opened, she saw Resident #1 sitting in a chair, and she could not tell if Resident #1 was sleeping or not. LVN A stated she could not tell how long Resident #1 had been outside. LVN A stated he was leaned back, head arched back, face towards the sky, and his arms were open branched out to his sides. LVN A stated she knew it was hot outside and noted he had on a big bubble coat and pants. She stated the first thing she did was unzip his coat. LVN A stated Resident #1 did not have on a shirt, and was sweating a lot under the coat. LVN A stated LVN B came out behind her, and she then stated she needed a thermometer, cold towels and to get him inside the building. LVN A stated Resident #1 was really hot, his skin was hot, and his face started to turn red, and he was very weak. LVN A stated once back inside the facility at Resident #1's room she removed wool socks, shoes, joggers, his briefs and administered cold towels to his face and body. LVN A stated chest rubs were being done. She stated Resident #1's eye were closed, he was not moving much because he was very weak, and he was trying to respond but could not. LVN A stated she kept applying fresh wet towels and rubbing his sternum for at least 30 minutes until he finally started to come to. LVN A stated there was several attempts at checking his temperature; once he was alert his temperature reading was 102 degrees Fahrenheit. Resident #1's head of bed was lifted slowly, and they began giving him something to drink (ice water, Gatorade, and juice). Medication Aide E checked his blood pressure to read 157/98, LVN A rechecked his temperature to read 98.3 degrees Fahrenheit, LVN B was saying it was good time to end the cold towels. According to LVN A she said. No, we are not done, let me check his hands and feet (which were still warm), it took a while before his legs were coming to a reasonable temperature. LVN A stated it was the end of the shift, Resident #1 was drinking more, continued to check his vitals which his temperature was 99.4 degrees Fahrenheit and his blood pressure was 136/80. LVN A stated she told LVN B you may want to call the physician and see if they want to send him out for further evaluation. LVN A stated Resident #1 was not her resident, so she left his care in LVN B's hands, and she was not sure if he contacted the doctor. LVN A stated she gave report to the nurse that was replacing her for the next shift. LVN A stated from what she could see at the time he was back at his baseline. LVN A stated it was the responsibility of the charge nurse to contact the physician, Director of Nursing, Administrator, and the family, and not doing so would be harmful to resident care. According to LVN A Resident #1 should have been sent out to the hospital for further evaluation. An attempted phone call interview on 06/15/23 at 11:20 AM with Medication Aide E was unsuccessful. During an interview on 06/15/23 at 11:27 AM with LVN B revealed Resident #1 was ambulatory, liked to walk around the facility and was usually sitting in front of the nursing station. LVN B stated he was the charge nurse for Resident #1 on June 10, 2023. LVN B stated it was a very terrible day for him because he had both nursing and certified nursing aide responsibilities and could not recall when Resident #1 went outside or how long he had been outside. LVN B stated around 1:00 PM Medication Aide E stated she was looking for Resident #1 to administer his medication. LVN B stated Medication Aide E ran into the facility stating Resident #1 was sitting out in the courtyard sweating, and another nurse ran out behind her. LVN B stated he assisted with getting Resident #1 inside to his room, he was observed sweating, skin was hot, and his temperature was high, around 106 degrees Fahrenheit or something like that. According to LVN B staff immediately began interventions with cold water, bed baths and checking vitals every 5 minutes. LVN B stated Resident #1's temperature came down to between 101 - 97.8 degrees Fahrenheit and his blood pressure reading was 133/77. According to LVN B after 15 minutes or so Resident #1 was fine. LVN B stated Resident #1 was administered orange juice to drink and completed his lunch tray. LVN B stated Resident #1 started praising God which was something he would usually do. LVN B stated after an hour Resident #1 got up from bed and requested to go outside and see the sun. LVN B stated, [Resident #1] did not go to the hospital at that time because I just felt he was back to normal, he was fine, and he was his normal self. LVN B stated he did not contact the physician, Director of Nursing, or the Administrator, however attempted to contact [Resident #1's] responsible party and family but had not spoken with anyone. LVN B stated he was so happy that [Resident #1] was ok and was at his baseline. I just entered the progress note. I did not find it necessary to contact the physician or the Director of Nursing. LVN B stated the protocol was to immediately complete an assessment, call the physician if I need, most of the time I don't want to take a chance to call the physician or emergency medical services because they are busy or may take long to call me back. LVN B stated, In this case I should have checked the vitals, called 911, and documented. LVN B stated I should have notified the physician, Director of Nursing, and the Administrator along with the family. According to LVN B it was his responsibility to follow facility policy and alert the medical team of the resident's change of condition. LVN B stated not doing so put [Resident #1] at risk of not having proper medical treatment. During an interview on 06/15/23 at 12:02 PM with LVN D revealed Resident #1 was pleasant, disoriented, required redirection, and usually sat at the nursing station. LVN D stated she encouraged the resident to sit at the nursing station to have eyes on him because he liked to go to the restroom, and he is with unsteady gait and now required assistance. He is usually dressed in sweats, jeans, hoodies, and jackets because he is cold natured. LVN D stated she never saw Resident #1 go outside during her shift, so the it was odd to hear he was outside. LVN D stated she was informed by LVN C in the morning upon her shift beginning at 6:00 AM, on June 12, 2023 that Resident #1 was found outside with an elevated temperature on Saturday, June 10, 2023. Nursing staff brought Resident #1 inside to cool him down with cold compress towels and hydrated him with fluids. LVN D stated she was told by LVN C during the weekend that Resident #1 required assistance with incontinent care and feeding during meals. LVN D stated LVN C also stated Resident #1 was not sent out to the hospital, that she may want to contact the physician. According to LVN D she observed Resident #1 to have signs of weakness, which was a change in condition from the last time she saw him (Friday, June 09, 2023) and considering what happened over the weekend, she needed to notify the physician. LVN D stated she contacted the doctor on June 12, 2023 about 11:30AM, followed up with the Director of Nursing and it was discussed to send him out to the hospital. LVN D stated not sending Resident #1 to the hospital in a timely manner prevented a quicker turn around for care. LVN D stated it was the responsibility of the charge nurse to make the proper calls to the physician and the Director of Nursing. During an interview on 06/15/23 at 12:24 PM with Administrator revealed the facility was continuing to complete the investigation and in-services that started on Monday June 12, 2023, on abuse and neglect, accidents, hazards, and supervision regarding heat illnesses, and staying hydrated during high temperatures and reporting changes. The Administrator stated the facility was continuing to educate residents to come inside when temperatures were high. The Administrator stated staff had been trained to monitor for proper clothing, staying hydrated, and the use of the water cooler on the patio. The facility would also provide Gatorade. The Administrator stated she, and the Director of Nursing are doing frequent checks along with staff outside during smoking times throughout the day to ensure resident are not showing signs and symptoms of heat exhaustion. During an interview on 06/15/23 at 12:40 PM with LVN C revealed when she entered for her shift on June 10, 2023 at 2:30 PM, she observed staff working with Resident #1 after he was found outside; she saw staff trying to give him drinks and food. LVN C stated Medication Aide E explained Resident #1 was found sitting outside in the sun, not under the shade and could not open his eyes. Staff brought him inside for cold water because his temperature was 106 degrees Fahrenheit. According to LVN C when she worked with him later that night, he was very weak and confused. LVN C stated Resident #1 urinated twice on the floor and wanted to sit in it, and he would get upset when he attempted to redirect him. LVN C stated she had to watch him closely because he would try walking but was not steady and unbalanced, he was very weak. LVN C stated at that point she provided him with briefs so that he did not have to attempt going to the restroom and risk falling. LVN C stated he would usually be up walking very slow or sitting at the nursing station however at that time he was too weak. LVN C stated on Sunday, June 11, 2023, Resident #1 was the same, not strong, and was too weak to walk. LVN C stated she monitored him and had frequent vital checks which were within normal limits. LVN C stated she questioned if his temperature read 106 degrees Fahrenheit why wouldn't they send him out to the hospital, and stated if it was me, I would have sent him out. LVN C stated on Sunday his vitals were ok, the only difference with him was that he was weak, briefs was placed on him so he would not attempt to toilet alone. According to LVN C it was the nurse's responsibility to make the call to contact the physician and the Director of Nursing and inform what is going on. LVN C stated she was not sure if that happened but thought when she had seen staff working with him in his room with the wet bed, feeding him and giving him drinks that the physician had been contacted and the nurses were following physician's orders. During an interview on 06/15/23 at 1:36 PM from the hospital case worker revealed Resident #1 was brought in by emergency medical services on June 12, 2023, for evaluation. Resident #1 was usually alert times 2 (Resident #1 was aware of his name and surroundings), however was showing signs of confusion and alert times 1(Resident #1 was aware of his name). Resident #1 presented with warm, dry skin, able to transfer, no fever, no wounds and would be discharged on this day. Case Worker stated Resident #1 was presented with fluids due to acute kidney injury on 06/13/23 until his discharge on 06/15/23. During an interview on 06/15/23 at 2:05 PM with the Director of Nursing revealed when she entered the facility on Monday, June 12, 2023, she was notified during a clinical meeting that Resident #1 had an incident. The Director of Nursing stated she was reviewing the notes from the weekend, she started asking questions and it was told to her that Resident #1 was outside, and staff had to bring him inside to get his body temperature down. The Director of Nursing stated, No one had informed her of the incident. The Director of Nursing stated she had the charge nurse contact the physician while she contacted their regional consultant. According to the Director of Nursing it was decided by corporate to send Resident #1 to the hospital. The Director of Nursing stated staff followed up with the hospital later that day and it was revealed there were no critical findings and they were waiting on the doctor to complete an evaluation and then he would discharge. The Director or Nursing stated her expectations were to have immediately notify the physician and have contacted her about Resident #1 having heat exhaustion and found unresponsive. The Director of Nursing stated she would have had the nurse to send Resident #1 out immediately to the hospital for further evaluation. The Director of Nursing stated she started in-services on Monday June 12, 2023, on heat exposure and what to do, signs and symptoms of heat exposure along with a quiz for understanding. The Director of Nursing stated it was the responsibility of the nursing staff to act quickly to notify the physician and then The Director of Nursing if there is a change of condition with residents. The Director of Nursing stated not notifying the physician or The Director of Nursing of the incident could have caused delayed treatment for the resident. The Director of Nursing stated during her investigation with LVN B he stated he did not alert the physician or the Director of Nursing because the resident was brought back inside and got him back to his baseline and he was fine. The Director of Nursing stated LVN B was placed on suspension during the investigation. According to Director of Nursing, the staff has been trained and is aware of how she liked the floor to operate, which was by policy and procedures, and to notify her of any change of condtion. Record review of facility policy revised 01/09/23 titled Abuse Prevention Program stated The Administrator is responsible for the overall coordination and implementation of our Center's prevention program policies and procedures. Our residents have the right to be free form abuse, neglect, misappropriation of resident property and exploitation. Our Center will implement and permanently maintain an effective training program for all staff, which includes, at a minimum training on neglect. As part of the resident abuse program, the administration will ensure that any further neglect is prevented. All allegged violations of neglect will be reported by the Administrator. All alleged violations of neglect will be reported to the Administrator. CMS defines Neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, mental anguish, or emotional distress. All violations involving neglect will be reported by the Center Administrator and the resident's Attending Physician and/or Medical Director immediately. Review of facility policy revised 04/20/23 titled Change in a Resident's Condition or Status stated Our facility promptly notified the resident, his or her attending physician, health care provider and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) The nurse will notify the resident's attending physician, health care provider or physician on call when there has been a(an): Accident or incident involving the resident. D. significant change in the resident's physical/emotional/mental condition. G. Need to transfer the resident to a hospital/treatment center. A significant change of condition is a major decline or improvement in the resident's status that: A. will not normally resolve itself without intervention by staff . B. impacts more than one area of the president's health status. C. requires interdisciplinary review and/or revision to the care plan; and D. ultimately is based on the judgement of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. On 06/15/23 at 4:00 PM the Administrator was notified of an Immediate Threat had been identified. The facility's Plan of Removal was accepted on 06/16/23 at 9:51 AM. The Plan of Removal reflected the following: .Charge Nurse assigned to [Resident #1] member [sic] identified in the alleged deficient practice was suspended pending investigation. Education: In-services was conducted on the following policies: 1. Abuse/Neglect. (All Staff) 2. Heat and dehydration Signs and symptoms. Accidents, hazards and supervisions. (All Staff) 3. Hydration during warm weather. (All Staff) 4. Reporting to include when to notify the administrator and DON of reportable incidents or other serious incidents. (All Staff) 5. Assess for change of condition, physician/family/POA notification, significant change of condition is a major decline in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard clinical interventions (is not self-limiting) will result in a call to emergency services. Change in Condition will be documented in the progress notes in the electronic medical record. All residents with new progress notes will be reviewed in clinical meeting, daily, x5 days by Director of Nursing and or designee. (Charge Nurses) All current staff will be in-serviced prior to working their next shift, all new staff will be in-serviced regarding the above information prior to working their first shift. Completed by Director of Nurses, Assistant Director of Nurses, and/or designee. Review and identify residents who wander and have an increased risk of exposure to elements. Monitor: 1. Staff assigned to Monitor Courtyard hourly. (staff are aware of their assignment through education, staff responsible for monitoring will vary.) Staff will monitor courtyard for residents who wander; wandering residents have been identified through audit and will be communicated to staff for monitoring. Administrator and or designee will provide oversight of monitoring. This will include the log audit for completion. Administrator and/or designee has created a schedule for courtyard monitoring. The courtyard monitoring log will be reviewed/audited, daily, x5 days. Any concerns noted on the log will result in education and up to disciplinary action for staff assigned/responsible. 2. Staff responsible for monitoring will offer hydration during their assigned monitoring time and as needed. 3. DON/designee to correct any noted concerns and report to the Administrator. 4. Administrator will report, in summary, noted concerns to QAA Committee. Out of Cycle QAPI meeting to discuss concerns and approaches to correct. During observation and interview on 06/16/23 at 10:13 AM with Resident #1 revealed Resident #1 in bed under a blanket. The head of the bed was elevated, and Resident #1 was slumped over leaning to the right side. Resident #1 has his knees bent. According to Resident #1 he did not recall going to the hospital. He stated he did not have breakfast but would like to have some juice. Resident #1 stated he was having some pain in the right hand and right knee. Resident #1 requested pain medication. Further monitoring on 06/16/23 during re-interviews and interviews consisting of both day and night shifts revealed the following: Interviews on 06/16/23 from 1:00 PM through 06/17/23 10:30 AM with the Business Office Manager, LVN A, LVN B, LVN C, LVN D, Medication Aide E, Medication Aide F, LVN G, LVN H, LVN I, RN J, RN K , CNA L, CNA M, CNA N, CNA O, CNA P, who worked the shifts of 6:00 AM-2:00 PM, 2:00 PM-10:00PM and 6:00 PM-6:00 AM were able to verify education was provided to them; nursing staff were able to accurately summarize abuse and neglect policy, definitions and examples of change of condition and how, who, and when to report changes. The nursing staff revealed signs and symptoms of heat illnesses and what to look for and do if heat exhaustion is identified. The nursing staff expressed understanding of the importance of accidents, hazards, and supervision and how that plays in part to resident safety. During observations on 06/16/23-06/17/23 between 8:00 AM-5:00 PM revealed staff walking outside hourly to monitor residents in the courtyard. Staff were observed engaging with residents, offering water, and completing education about heat exhaustion and wearing proper attire when outside. Record review of the facility plan of correction monitoring tool form revised 10/2022 titled Courtyard & Hydration Monitor indicated log started on 06/16/23 at 8:00 AM with slots for signatures, concerns, action taken, date, Y/N to Hydration . While the IJ was removed on 06/17/23, the facility remained out of compliance at a scope of pattern and a severity level of actual harm because all staff had not been trained on change in condition, physician notification, and resident neglect and following facility policy.

Based on observation, interview and record review, the facility failed to ensure that each resident received adequate supervision to prevent heat exhaustion while outside in the courtyard for 1 (Resident #1) of eleven residents reviewed for accident hazards and supervision. The facility failed to provide necessary supervision to prevent accidents by failing to have measures in place to ensure residents who went outside on high heat days was provided with supervision, this failure resulted in Resident #1 being found in the courtyard unresponsive due to extreme heat exposure. An IJ was identified on 06/15/23, and while the IJ was removed on 06/17/23, the facility remained out of compliance at a scope of pattern and a severity level of actual harm because all staff had not been trained on change in condition, physician notification, and resident neglect and following facility policy. This failure placed residents at risk of not having proper supervision, dehydration and extreme heat exposure. Findings included: Record review of Resident #1's face sheet dated 06/17/23 revealed Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included nontraumatic subdural hemorrhage (complication of head trauma), history of falling, nausea with vomiting, adult failure to thrive, altered mental status, unsteadiness on feet, hypertension (high blood pressure), Type 2 diabetes mellitus, hyperlipidemia (high cholesterol), and vascular dementia. Record review of Resident #1's admission MDS assessment, dated 06/02/23 revealed his BIMS score was 07 indicating severe cognitive impairment. His Functional Status for activities of daily living indicated he required limited assistance with one person assist with dressing and toileting. Resident #1 uses a wander/elopement alarm daily. Supervision for personal hygiene. Independent with bed mobility, transfers, walking in and out of the room, walking on and off the unit, and with eating. Record review of Resident #1's care plan, last care conference 05/24/23, revealed care areas 1-3 were revised on 06/16/23: 1. Resident #1 at risk for dehydration (problem started 06/02/23) due to complaints of frequently being cold and dresses in winter like attire. Goal: Resident will be free of signs and symptoms of dehydration/over-exposure to the sun, brought on by heat exposure while dressed in winter like attire. Approach: Encourage Resident #1 to drink cool fluids at least hourly while outside. Explain potential negative outcomes related to wearing winter like clothing while outside in warm weather. Allow him time and opportunity to process this information, ask questions and voice concerns or consent/refusal. If dehydration or over-exposure to the sun, notify the DON, Administrator and Medical Director/Nurse Practitioner. If noted for dehydration, remove Resident #1 from sun exposure, remove outer wear, apply cool towels, take vital signs, and encourage fluids. If Resident #1 is noted as being dressed in winterlike attire and wants to go out for sun exposure, offer alternate attire. Monitor Resident #1 for signs and symptoms of dehydration (dry mouth, extreme thirst, fatigue, dizziness, extreme sweating, or confusion). 2. Resident #1 at risk for wandering/attempting elopement (problem started 06/02/23) related to impaired memory/dementia as evidenced by resident wandering throughout the building often asking where he can go outside. Goal: Resident will remain inside long term care facility. Approach: Resident to have wander guard on at all times. Staff to redirect resident as needed. Staff will check functionality of wander guard daily. Staff will check to ensure wander guard is in place every shift. 3. Resident #1 has impaired cognition (problem started 06/02/23) with expected decline in cognitive impairment over a period of time as a natural progression of the disease process. Goal: Resident will be safe in his environment over the next 90 days. Approach: Reorient resident to person, place and time as needed when confusion is noted. Monitor resident whereabouts in the facility to ensure safe environment. Record review of Resident #1's progress notes dated 06/10/23 at 8:42 PM written by LVN B reflected, At about 1PM while the lunch was been served, resident was found in the courtyard sitting on a chair under the triple digit heat of the sun unresponsive, the attention of the nurses was called by the medication aide who noticed him while she was about to give him his medication his was sweating profusely under his thick jacket, his temp at this time was 106 degrees [Fahrenheit], he was rushed into the building while cold water was been poured on him continuously, he will not open his eyes and both temperature and blood pressure been taking at intervals of 5 mins until when these assessments record was at 97.8 [degrees Fahrenheit] and 133/78 [blood pressure] respectively, he was giving cold water and juice to drink, fed with food tray, then he started responding and talking as he used to, resident was praising God continually, saying God is good repeatedly, Resident Responsible Party cannot be reached as the phone number was declining . Record review of Resident #1's progress notes dated 06/11/23 at 5:50 AM written by LVN C reflected, Resident stayed up for some time refusing to stay in bed. Very weak to walk by himself. Dragging feet and would get frozen nearly falling. Put in wheelchair but is not able to propel self. Incontinent in the hallway times two - trying to sit down in his pee. Resident very upset when this nurse tried to redirect him stating that you think I don't think. Resident cleaned up and given incontinent brief. Eventually fell asleep. Has been sleeping since then. Bed in low position. Vitals taken 97.8 86 18 147/74 97% RA. Record review of Resident #1's progress notes dated 06/12/23 at 2:06 AM written by LVN C reflected, Resident in bed but keeps on getting up. He is kind of confused and has been asking for French Fries. Resident not able to walk with steady gait, has been using wheelchair if he agrees to. Continues using incontinence products. Resident a feeder at the moment, is not able to steadily hold silverware when eating and would need cueing. Staff continue keeping constant checks on resident to maintain safety. Bed in low position and call light within reach. Will continue to monitor. Record review of Resident #1's progress notes dated 06/12/23 at 11:31 AM written by LVN D reflected: Resident alert and oriented to name and present situation. Resident has been ambulatory, with un-steady gait resident was then placed in wheelchair for safety. Neurochecks done within normal limits. Resident extensively assisted with all activities of daily living and transfers. Resident's wander guard in place and functional. Fluids by mouth offered and encouraged. Able to make needs known responds appropriately when spoken to in conversation. Record review of Resident #1's progress notes dated 06/12/23 at 11:49 AM written by LVN D documented Notified Nurse Practitioner in regard to recent heat exposure. New orders received as follows: 1) STAT CBC, BMP (urgent overall blood lab test gives an overall view of your health, lab test that show how well your kidneys work) 2) UA C&S (test that checks for bacteria in urine). Unable to reach Resident's Responsible Party message left on answering machine to return call back to facility when available. Nursing to follow. Record review of Resident #1's progress notes dated 06/12/23 at 1:15 PM written by LVN D reflected, Reported to Director of Nursing of new orders given via Nurse Practitioner, Director of Nursing stated to call emergency medical transportation and send resident out to the emergency room for further evaluation and treatment. Nurse Practitioner made aware of resident's transfer to hospital. 12:10 PM emergency medical services arrives via stretcher accompanied by 2 attendants to transport resident to hospital. 12:20 PM [LVN D] was able to reach [family members] to update her on resident's care and transfer to emergency room . Record review of accident and incident reports dated 03/14/23 - 06/14/23 did not indicate Resident #1 was found unresponsive on 06/10/23 or went to the hospital on 06/12/23. Attempts were made to contact Resident #1's family members by phone on 06/15/23 at 9:16 AM; however, the attempts were not successful. Review of weather temperatures for the city in which the facility was located for 06/10/23 retrieved at www.accuweather.com and https://www.timeanddate.com/weather/usa/[NAME]/historic reflected the high for 06/10/23 was 95 degrees Fahrenheit (35 degrees Celsius). During an interview on 06/15/23 at 9:34 AM with the Nurse Practitioner revealed she was not on-call on 06/10/23, however, was she on-call on Monday 06/12/23. The Nurse Practitioner stated LVN D notified her on 06/12/23 at 10:57 AM that Resident #1 was going to the hospital, he was found outside, on the ground unresponsive. The Nurse Practitioner stated she was not aware of the situation or a significant change of condition until Monday, 06/12/23, according to the weekend notes, the on-call phone was not contacted about Resident #1's situation. The Nurse Practitioner stated had she been on call or notified about the situation she would have sent Resident #1 to the hospital for further evaluation and or treatment. Being exposed to heat could cause a range of reactions for example Resident #1 was found unresponsive. The Nurse Practitioner stated not sending Resident #1 to the hospital immediately could prevent medical treatment. During an interview on 06/15/23 at 9:52 AM with the Administrator revealed Resident #1 ambulated around the facility without assistance, did wear a wander guard, liked to dress with shoes, socks, pants, long-sleeved shirt, and a hoodie. The Administrator stated although residents are welcome to go outside at any time, majority are outside during smoking times (9AM, 11AM, 2PM, 4 PM, 6:30 PM, 8:30 PM) when there was staff outside. The Administrator stated staff were not monitoring residents for heat exhaustion prior to the incident with Resident #1, however this is something staff should notice while outside monitoring residents for smoking. The Administrator stated on Monday June 12, 2023, she was reading through progress notes, and it was noted that on Saturday, June 10, 2023, Resident #1 was found unresponsive outside. The Administrator stated LVN A and Medication Aide E brought him inside to cool him down. The Administrator stated Resident #1 had a change of condition so the protocol should have been followed. The Administrator stated the charge nurse on the floor should have competed an assessment, notified the physician or nurse practitioner and 911 to send the resident out to the hospital. The Administrator stated not following protocol could result in residents having a delay in treatment. The Administrator stated it was the responsibility of the nursing staff to contact the physician, director of nursing, and family to alert them of any situation affecting residents as they have been trained to do. The Administrator stated The Director of Nursing is very through and firm with staff to follow protocol. During an interview on 06/15/23 at 10:018 AM with LVN A revealed Resident #1 was usually observed in his room, sitting at the nursing station, or walking around the building. LVN A stated she was sitting at the nursing station documenting, about 1:25 PM when she heard Medication Aide E saying something and walking fast. She stated Medication Aide E then grabbed a wheelchair and headed towards the courtyard and LVN A followed. LVN A stated once the doors opened, she saw Resident #1 sitting in a chair, and she could not tell if Resident #1 was sleeping or not. LVN A stated she could not tell how long Resident #1 had been outside. LVN A stated he was leaned back, head arched back, face towards the sky, and his arms were open branched out to his sides. LVN A stated she knew it was hot outside and noted he had on a big bubble coat and pants. She stated the first thing she did was unzip his coat. LVN A stated Resident #1 did not have on a shirt and was sweating a lot under the coat. LVN A stated LVN B came out behind her, and she then stated she needed a thermometer, cold towels and to get him inside the building. LVN A stated Resident #1 was really hot, his skin was hot, and his face started to turn red, and he was very weak. LVN A stated once back inside the facility at Resident #1's room she removed wool socks, shoes, pants, his briefs and administered cold towels to his face and body. LVN A stated chest rubs were being done. She stated Resident #1's eye were closed, he was not moving much because he was very weak, and he was trying to respond but could not. LVN A stated she kept applying fresh wet towels and rubbing his sternum for at least 30 minutes until he finally started to come to. LVN A stated there was several attempts at checking his temperature; once he was alert his temperature reading was 102 degrees Fahrenheit. Resident #1's head of bed was lifted slowly, and they began giving him something to drink (ice water, Gatorade, and juice). Medication Aide E checked his blood pressure to read 157/98, LVN A rechecked his temperature to read 98.3 degrees Fahrenheit, LVN B was saying that was good. According to LVN A she responded No, we are not done, let me check his hands and feet (which were still warm), it took a while before his legs were coming to a reasonable temperature. LVN A stated it was the end of the shift, Resident #1 was drinking more, continued to check his vitals which his temperature was 99.4 degrees Fahrenheit, and his blood pressure was 136/80. LVN A stated she told LVN B you may want to call the physician and see if they want to send him out for further evaluation. LVN A stated Resident #1 was not her resident, however she is aware of the facility policy and have been trained on what to do when there was a change of condition with residents, so she left his care in LVN B's hands, and she was not sure if he contacted the doctor. LVN A stated it was the responsibility of the charge nurse to contact the physician, Director of Nursing, Administrator, and the family, and not doing so would be harmful to resident care. According to LVN A Resident #1 should have been sent out to the hospital for further evaluation. LVN A stated she had been trained and was aware to complete rounds, have eyes on residents, and address resident care needs at all times. LVN A stated The Administrator was the Abuse Coordinator and she had been trained on abuse and neglect policy. LVN A stated prior to the incident she would walk through the courtyard to as a short cut before and after lunch, LVN A stated she would see residents in the courtyard at that time and would have noted if a resident required assistance however, she would not have made it a point to walk to the courtyard and check on residents for heat exhaustion. LVN A stated staff were always present during smoke breaks. An attempted phone call interview on 06/15/23 at 11:20 AM with Medication Aide E was unsuccessful. During an interview on 06/15/23 at 11:27 AM with LVN B revealed Resident #1 was ambulatory, liked to walk around the facility, he had a wander guard and was usually sat in front of the nursing station. LVN B stated Resident #1 required redirection, always asking for the restroom. LVN B stated he was the charge nurse for Resident #1 on June 10, 2023. LVN B stated it was a very terrible day for him because he had both nursing and certified nursing aide responsibilities and could not recall when Resident #1 went outside or how long he had been outside. LVN B stated around 1:00 PM Medication Aide E stated she was looking for Resident #1 to administer his medication. LVN B stated Medication Aide E ran into the facility stating Resident #1 was sitting out in the courtyard sweating, and another nurse ran out behind her. LVN B stated he assisted with getting Resident #1 inside to his room, he was observed sweating, skin was hot, and his temperature was high, around 106 degrees Fahrenheit or something like that. According to LVN B staff immediately began interventions with cold water, bed baths and checking vitals every 5 minutes. LVN B stated Resident #1's temperature came down to between 101 - 97.8 degrees Fahrenheit and his blood pressure reading was 133/77. According to LVN B after 15 minutes or so Resident #1 was fine. LVN B stated Resident #1 was administered orange juice to drink and completed his lunch tray. LVN B stated Resident #1 started praising God which was something he would usually do. LVN B stated after an hour Resident #1 got up from bed and requested to go outside and see the sun. LVN B stated, [Resident #1] did not go to the hospital at that time because I just felt he was back to normal, he was fine, and he was his normal self. LVN B stated he did not contact the physician, Director of Nursing, or the Administrator, however attempted to contact [Resident #1's] responsible party and family but had not spoken with anyone. LVN B stated he was so happy that [Resident #1] was ok and was at his baseline. I just entered the progress note. I did not find it necessary to contact the physician or the Director of Nursing. LVN B stated the protocol was to immediately complete an assessment, call the physician if I need, most of the time I don't want to take a chance to call the physician or emergency medical services because they are busy or may take long to call me back. LVN B stated, In this case I should have checked the vitals, called 911, and documented. LVN B stated I should have notified the physician, Director of Nursing, and the Administrator along with the family. According to LVN B it was his responsibility to follow facility policy and alert the medical team of the resident's change of condition. LVN B stated not doing so put [Resident #1] at risk of not having proper medical treatment. LVN B stated he was aware to complete rounds to check on residents and has aides to assist him, LVN B stated this day he was very busy and was not aware that Resident #1 had went outside so he could not say how long Resident #1 was outside. LVN B stated he recalled last seeing Resident #1 around 7:30 AM on June 10, 2023. LVN B stated he did not monitor the courtyard before this day for heat exhaustion, several residents smoke and would visit the courtyard to smoke with staff and return inside the building, never staying outside for long periods of time. During an interview on 06/15/23 at 12:02 PM with LVN D revealed Resident #1 was pleasant, disoriented, required redirection, and usually sat at the nursing station. LVN D stated she encouraged the resident to sit at the nursing station to have eyes on him because he liked to go to the restroom, and he is with unsteady gait and now required assistance. He is usually dressed in sweat pants, jeans, hoodies, and jackets because he was cold natured. LVN D stated she never saw Resident #1 go outside during her shift, so the it was odd to hear he was outside. LVN D stated she was informed by LVN C in the morning upon her shift beginning at 6:00 AM, on June 12, 2023 that Resident #1 was found outside with an elevated temperature on Saturday, June 10, 2023. Nursing staff brought Resident #1 inside to cool him down with cold compress towels and hydrated him with fluids. LVN D stated she was told by LVN C during the weekend that Resident #1 required assistance with incontinent care and feeding during meals. LVN D stated LVN C also stated Resident #1 was not sent out to the hospital, that she may want to contact the physician. According to LVN D she observed Resident #1 to have signs of weakness, which was a change in condition from the last time she saw him (Friday, June 09, 2023) and considering what happened over the weekend, she needed to notify the physician. LVN D stated she contacted the doctor on June 12, 2023 about 11:30AM, followed up with the Director of Nursing and it was discussed to send him out to the hospital. LVN D stated not sending Resident #1 to the hospital in a timely manner prevented a quicker turn around for care. LVN D stated it was the responsibility of the charge nurse to make the proper calls to the physician and the Director of Nursing when residents have a change of condition. LVN D stated she had been trained on recognizing the signs and symptoms of a change in condition. LVN D stated residents had access to the courtyard at any time of the day, there are designated smoking times that residents are outside with staff at that time for supervision. LVN D stated she had not gone to the courtyard to monitor residents for heat exhaustion, however due to this incident she had been inserviced to make rounds to the courtyard hourly to look for signs of dehydration and heat exhaustion. During an interview on 06/15/23 at 12:24 PM with Administrator revealed the facility was continuing to complete the investigation and in-services that started on Monday June 12, 2023, on abuse and neglect, accidents, hazards, and supervision regarding heat illnesses, and staying hydrated during high temperatures and reporting changes. The Administrator stated the facility was continuing to educate residents to come inside when temperatures were high. The Administrator stated staff had been trained to monitor for proper clothing, staying hydrated, and the use of the water cooler on the patio. The facility would also provide Gatorade. The Administrator stated she, and the Director of Nursing are doing frequent checks along with staff outside during smoking times throughout the day to ensure resident are not showing signs and symptoms of heat exhaustion. During an interview on 06/15/23 at 12:40 PM with LVN C revealed when she entered for her shift on June 10, 2023 at 2:30 PM, she observed staff working with Resident #1 after he was found outside; she saw staff trying to give him drinks and food. LVN C stated Medication Aide E explained Resident #1 was found sitting outside in the sun, not under the shade and could not open his eyes. Staff brought him inside for cold water because his temperature was 106 degrees Fahrenheit. According to LVN C when she worked with him later that night, he was very weak and confused. LVN C stated Resident #1 urinated twice on the floor and wanted to sit in it, and he would get upset when he attempted to redirect him. LVN C stated she had to watch him closely because he would try walking but was not steady and unbalanced, he was very weak. LVN C stated at that point she provided him with briefs so that he did not have to attempt going to the restroom and risk falling. LVN C stated he would usually be up walking very slow or sitting at the nursing station however at that time he was too weak. LVN C stated on Sunday, June 11, 2023, Resident #1 was the same, not strong, and was too weak to walk. LVN C stated she monitored him and had frequent vital checks which were within normal limits. LVN C stated she questioned if his temperature read 106 degrees Fahrenheit why wouldn't they send him out to the hospital, and stated if it was me, I would have sent him out as this was the policy. LVN C stated on Sunday his vitals were ok, the only difference with him was that he was weak, briefs was placed on him so he would not attempt to toilet alone. According to LVN C it was the nurse's responsibility to make the call to contact the physician and the Director of Nursing and inform what is going on. LVN C stated she was not sure if that happened but thought when she had seen staff working with him in his room with the wet bed, feeding him and giving him drinks that the physician had been contacted and the nurses were following physician's orders. LVN C stated she usually did not frequent the courtyard to monitor residents for heat exhaustion, during smoking breaks there was always staff outside with residents. LVN C stated during her shifts she monitors her residents closely those that have had an incident, injury or fall. During an interview on 06/15/23 at 1:36 PM from the hospital case worker revealed Resident #1 was brought in by emergency medical services on June 12, 2023, for evaluation. Resident #1 was usually alert times 2 (Resident #1 was aware of his name and surroundings), however was showing signs of confusion and alert times 1(Resident #1 was aware of his name). Resident #1 presented with warm, dry skin, able to transfer, no fever, no wounds and would be discharged on this day. Case Worker stated Resident #1 was presented with fluids due to acute kidney injury on 06/13/23 until his discharge on 06/15/23. During an interview on 06/15/23 at 2:05 PM with the Director of Nursing revealed when she entered the facility on Monday, June 12, 2023, she was notified during a clinical meeting that Resident #1 had an incident. The Director of Nursing stated she was reviewing the notes from the weekend, she started asking questions and it was told to her that Resident #1 was outside, and staff had to bring him inside to get his body temperature down. The Director of Nursing stated, No one had informed her of the incident. The Director of Nursing stated she had the charge nurse contact the physician while she contacted their regional consultant. According to the Director of Nursing it was decided by corporate to send Resident #1 to the hospital. The Director of Nursing stated staff followed up with the hospital later that day and it was revealed there were no critical findings and they were waiting on the doctor to complete an evaluation and then he would discharge. The Director or Nursing stated her expectations were to have immediately notify the physician and have contacted her about Resident #1 having heat exhaustion and found unresponsive. The Director of Nursing stated she would have had the nurse to send Resident #1 out immediately to the hospital for further evaluation. The Director of Nursing stated she started in-services on Monday June 12, 2023, on heat exposure and what to do, signs and symptoms of heat exposure along with a quiz for understanding. The Director of Nursing stated it was the responsibility of the nursing staff to act quickly to notify the physician and then The Director of Nursing if there is a change of condition with residents. The Director of Nursing stated not notifying the physician or The Director of Nursing of the incident could have caused delayed treatment for the resident. The Director of Nursing stated during her investigation with LVN B he stated he did not alert the physician or the Director of Nursing because the resident was brought back inside and got him back to his baseline and he was fine. The Director of Nursing stated LVN B was placed on suspension during the investigation. According to Director of Nursing, the staff had been trained and is aware of how she liked the floor to operate, which was by policy and procedures, and to notify her of any change of condition. The Director of Nursing revealed there was not a plan in place to monitor residents on the courtyard for heat exhaustion. A request for facility policy on 06/15/23 4:00 PM accident, hazards and supervision was made however the Administrator stated they did not have a policy to present at this time, and one was not provided prior to exit. On 06/15/23 at 4:00 PM the Administrator was notified of Immediate Jeopardy, Immediate Threat, and Substandard Quality of Care in the areas of Quality of Care, Resident Rights, and Resident Neglect and not following facility policy. The facilities Plan of Removal was accepted on 06/16/23 at 9:51 AM. The Plan of Removal reflected the following: .Charge Nurse assigned to [Resident #1] member [sic] identified in the alleged deficient practice was suspended pending investigation. Education: In-services was conducted on the following policies: 1. Abuse/Neglect. (All Staff) 2. Heat and dehydration Signs and symptoms. Accidents, hazards and supervisions. (All Staff) 3. Hydration during warm weather. (All Staff) 4. Reporting to include when to notify the administrator and DON of reportable incidents or other serious incidents. (All Staff) 5. Assess for change of condition, physician/family/POA notification, significant change of condition is a major decline in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard clinical interventions (is not self-limiting) will result in a call to emergency services. Change in Condition will be documented in the progress notes in the electronic medical record. All residents with new progress notes will be reviewed in clinical meeting, daily, x5 days by Director of Nursing and or designee. (Charge Nurses) All current staff will be in-serviced prior to working their next shift, all new staff will be in-serviced regarding the above information prior to working their first shift. Completed by Director of Nurses, Assistant Director of Nurses, and/or designee. Review and identify residents who wander and have an increased risk of exposure to elements. Monitor: 1. Staff assigned to Monitor Courtyard hourly. (staff are aware of their assignment through education, staff responsible for monitoring will vary.) Staff will monitor courtyard for residents who wander; wandering residents have been identified through audit and will be communicated to staff for monitoring. Administrator and or designee will provide oversight of monitoring. This will include the log audit for completion. Administrator and/or designee has created a schedule for courtyard monitoring. The courtyard monitoring log will be reviewed/audited, daily, x5 days. Any concerns noted on the log will result in education and up to disciplinary action for staff assigned/responsible. 2. Staff responsible for monitoring will offer hydration during their assigned monitoring time and as needed. 3. DON/designee to correct any noted concerns and report to the Administrator. 4. Administrator will report, in summary, noted concerns to QAA Committee. Out of Cycle QAPI meeting to discuss concerns and approaches to correct. During observation and interview on 06/16/23 at 10:13 AM with Resident #1 revealed Resident #1 in bed under a blanket. The head of the bed was elevated, and Resident #1 was slumped over leaning to the right side. Resident #1 has his knees bent. According to Resident #1 he did not recall going to the hospital. He stated he did not have breakfast but would like to have some juice. Resident #1 stated he was having some pain in the right hand and right knee. Resident #1 requested pain medication. Further monitoring on 06/16/23 during re-interviews and interviews consisting of both day and night shifts revealed the following: Interviews on 06/16/23 from 1:00 PM through 06/17/23 10:30 AM with the Business Office Manager, LVN A, LVN B, LVN C, LVN D, Medication Aide E, Medication Aide F, LVN G, LVN H, LVN I, RN J, RN K , CNA L, CNA M, CNA N, CNA O, CNA P, who worked the shifts of 6:00 AM-2:00 PM, 2:00 PM-10:00 PM and 6:00 PM-6:00 AM were able to verify education was provided to them; nursing staff were able to accurately summarize abuse and neglect policy, definitions and examples of change of condition and how, who, and when to report changes. The nursing staff revealed signs and symptoms of heat illnesses and what to look for and do if heat exhaustion is identified. The nursing staff expressed understanding of the importance of accidents, hazards, and supervision and how that plays in part to resident safety. During observations on 06/16/23-06/17/23 between 8:00 AM-5:00 PM revealed staff walking outside hourly to monitor residents in the courtyard. Staff were observed engaging with residents, offering water, and completing education about heat exhaustion and wearing proper attire when outside. Record review of the facility plan of correction monitoring tool form revised October 2022 titled Courtyard & Hydration Monitor indicated log started on 06/16/23 at 8:00 AM with slots for signatures, concerns, action taken, date, yes (Y) or no (N) to Hydration. Whil [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision to prevent accidents for 1 (Resident # 67) of 18 residents reviewed for smoking. CNA D failed to comply with the facility's smoking policy, when she failed to provide continuous direct supervision to residents during their smoke break, which resulted in Resident #67's hair and scalp being burned. Another resident had to pat out the burning hair, and Resident #67 sustained a superficial burn (affecting the top layer of skin) to her scalp. An Immediate Jeopardy (IJ) was identified to have existed from 01/18/23 through 01/25/23. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the survey. This failure placed residents at risk of harm and/or serious injury. Findings included: Record review of Resident #67's face sheet revealed the resident was a [AGE] year-old female admitted to the facility 06/15/22 with diagnoses to include depression (mental health disorder), insomnia (lack of sleep), gastro-esophageal reflux disease, schizophrenia (a disorder that affects a person ability to think, feel and behave clearly), hypertension, and cerebral infarction (damage to tissues in the brain due to loss of oxygen to the area). Record review of Resident #67's quarterly MDS assessment, dated 12/22/22, revealed the resident's cognitive skills for daily decision making were intact. Resident #67's BIMS score was 15. Record review of Resident #67's care plan revised 01/13/23 revealed the resident was a smoker. She was supposed to smoke in the designated area at designated times with staff supervision and remain free of injuries. Record review of Resident #67's Smoking Risk Assessment, dated 12/23/22, revealed the resident had a score of 3 indicating she was a safe smoker and needed to follow the facility's smoking policy. Resident #67's Smoking Risk Assessments, dated 08/18/22 and 01/18/23, revealed the resident had a score of 10 indicating she was a potentially unsafe smoker and needed to follow the facility's smoking policy. Review of Resident #67's incident report, dated 01/18/23, reflected the resident was out smoking in the designated smoking area when a gust of wind blew her hair into her face. She attempted to remove the hair from her face using the hand in which she held a cigarette, which caused the resident's hair to burn. The incident report reflected the resident had gone to a beauty shop with her son earlier in the day and her hair was held in place with hair spray which had a potential to accelerate combustion. The resident was assessed by the nurse, and she had a superficial burn to the scalp. The resident was referred to the emergency room for further management. Review of Resident #67's hospital records revealed the resident presented to theER on [DATE] after her hair caught fire while smoking a cigarette. She was noted to have singed hair to the front left side of her head that extended to the back of her head. The resident sustained a superficial burn to her scalp, and she was discharged back to the facility with orders for silver sulfadiazine 1% cream to be applied topically for 7 days to the burn. Interview with the Administrator on 02/23/23 at 2:08 PM revealed CNA D was suspended because of Resident #67's hair catching fire while she was under the supervision of CNA D. Just before Resident #67's hair caught fire on 01/18/23, CNA D was assigned to supervise residents during the smoking break. CNA D left the residents alone during the smoking area, and she went back inside the facility to use the bathroom. CNA D did not ask other staff to watch over the residents. The Administrator stated CNA D failed to supervise the resident as directed by the facility policy. CNA D was not available for interview as she was not a regular staff and only worked as needed. The Administrator stated it was important for facility staff to follow the facility's smoking policy regarding supervision and safety to prevent accidents and resident injury. She stated CNA D was suspended and later reinstated. She stated assessments were done for all residents and those who were safe smokers were put on a liberalized smoking schedule and those who needed supervision were identified. She stated all residents smoked at the same time and there was always staff supervising. She stated they did some modifications to the smoking shade to block the wind in the smoking area, and they had a blanket and fire extinguisher readily available in the smoking area. She stated she did one-on-one training with CNA D and all other staff regarding safe smoking, fire safety, liberalized smoking, and abuse and neglect. Interview with the DON on 02/23/23 at 2:39 PM revealed she was new when the incident happened. She stated when they reviewed the document all smoking residents had a smoking assessment. She stated they did another assessment, and they identified the residents who were safe smokers and did not need supervision and those who needed supervision. She stated they all went to the smoking area at the same time with supervision. She stated when they got the information a resident was screaming, they ran out to the smoking area and Resident #67 stated she was smoking when her hair caught fire. The DON stated when she got out CNA D was not there, and the residents were left alone. She stated CNA D was away less than 5 minutes. The Administrator and the DON called the doctor, and they received an order to send the resident to the emergency room . She stated they have since educated the staff and the residents on smoking safety and on the smoking policy. Observation of residents while smoking during the smoking breaks on 02/22/23 at 9:07 AM, 02/23/23 at 9:30 AM and 02/23/23 at 4:04 PM revealed staff were supervising the residents. Some residents that needed assistance with smoking were observed wearing smoking aprons. An Immediate Jeopardy (IJ) was identified to have existed from 01/18/23 through 01/25/23. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the survey. The facility took the following actions to correct the non-compliance prior to the investigation: Review of in-service records dated 01/19/23 through 01/25/23 revealed all nursing staff including CNA D were educated on safe smoking, liberalized smoking, abuse and neglect, and fire safety. In case of fire the facility had implemented fire safety items located in the designated smoking area including a fire blanket, fire extinguisher and smoking aprons. The in-service reflected in case of fire staff should PASS: Pull. Aim Squeeze, Sweep with a fire extinguisher, and smoke blankets should be used to smolder fires immediately. The center had adopted a liberalized smoking policy for residents. Residents were now allowed to smoke during non-designated times. Interviews were conducted with four CNAs and four LVNs on 02/23/23 from 6:00 AM-2:00 PM and 2:00 PM-10:00 PM shifts. The nursing staff were able to accurately summarize the smoking safety and fire safety training they received, and the facility's no leaving smoking residents unattended policy. The records revealed a plan of action had been initiated to include supervision prior to entry on 02/21/23. Review of the following reflected the facility was in compliance on 02/23/23. Review of the facility's policy entitled Smoking Policy-Residents dated August 2019 revealed in part: .9. All resident shall have the direct supervision of a staff member while smoking. 11. All residents smoking paraphernalia (equipment's, apparatus used for the activity of smoking.) must be checked in with the nurse.

Based on interviews and record reviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (Resident #1) of five residents reviewed for elopements. 1. The facility failed to provide adequate supervision to Resident #1 during a power outage on 8/1/21. As a result, he eloped from the facility and was missing for approximately 10hrs before staff realized he was not in the facility. 2. The facility failed to ensure staff were trained on monitoring residents during emergency situations and aware of what to do to prevent residents from eloping. An Immediate Jeopardy was identified on 08/26/21 at 3:00 PM. While the Immediate Jeopardy was removed on 08/27/21, the facility remained out of compliance at the severity level of potential for more than minimal harm that is not immediate jeopardy and at a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure could affect residents by placing them at risk for injury related harm, accidents, falls, and lack of proper supervision. Findings included: Review of Resident #1's face sheet, dated 08/02/21, revealed the resident was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1's diagnoses included: dementia, [CONDITION(S)] disorder, [CONDITION(S)] disorder, mood disorder, [CONDITION(S)], and major depressive disorder. Review of an Event Report dated 08/02/21 reflected Resident #1 eloped and was returned by Police at 10:30 AM. Review of Resident #1's Annual MDS (Minimum Data Set) assessment dated [DATE], reflected he had a BIMS (Brief Interview for Mental Status) of 09 indicating moderate impairment. Further review revealed Resident #1 had not exhibited behavior of wandering. Review of Resident #1's Care Plan dated 06/30/21 but revised 08/02/21, revealed Resident #1 was at risk for wandering as evidenced by: dementia and previous elopement from other facility [sic]. The goal was for Resident #1 to not wander outside the facility with approaches to monitor for attempts to leave the facility. Further review revealed Resident #1 had potential for elopement and used a wander guard to LLE (left lower extremity ). The goal was for Resident #1 to not wander from the facility with approaches to re-direct if resident attempts to elope. Review of Resident #1's progress notes dated 08/02/ 21 reflected Resident #1 was noted missing at 7:35 AM, Code Pink was announced at 08/02/21 at 7:38 AM. Resident was last seen at approximately: 08/01/21 9:00 PM. Resident was last seen by [RN A] and LVN B. Resident was last seen in Station 2. Resident was wearing: Red/orange top. Reviewed Facility Sign Out Log and: Resident Was Not Signed Out. Notified; Facility Administrator of CODE PINK Activation, Facility Director of Nursing of CODE PINK Activation. Initial Search of Facility Interior and External Grounds Conducted by Facility Personnel Started at: 08/02/21 7:35 AM. After the Initial Search, the Resident: Was Not Found and Police Immediately Notified. Police were Informed of/Provided the following information; What the Resident was Wearing, Mobility Devices Used, Possible Locations the Resident May Be Going, Resident's Cognitive Status, A Photo of the Resident. Residents Responsible Representative Was Notified of the Event at: 08/02/21 8:30 AM. Resident's Medical Provider was Notified of the Event at: 08/02/21 9:41 AM. Resident was Located, Returned to the Facility and CODE PINK Cancelled at: 08/02/21 10:30 AM. The Following Individuals were Notified of Resident's Return to Facility: Resident's Responsible Representative, Police, Facility Administrator, Facility Search Team Members, Facility Director of Nursing, Resident's Medical Provider. Upon Return to the Facility: A Physical Evaluation was Performed to Evaluate for Injury (See Focused Observation), Resident Offered Nutrition and Fluids, Updated Medical Provider of on Resident's Status, Resident Offered Allowable Missed Doses of Medication as Directed by Medical Provider. (See MAR). Additional Notes: Head to assessment conducted upon resident return to the facility. Resident accompanied by [NAME] PD Officer C and Resident [RP D] resident very agitated and cursing staff. Resident taken back to room and was reassured and allowed nursing staff to complete assessment. No bruising or physical injury noted. Missed medication was administered. Resident was offered food and water but was still agitated. Resident was open to getting food from outside. [RP D] noted that he will take care of it. [sic] Review of Resident #1's Elopement Evaluation dated 08/02/21 reflected Resident #1 was at risk for elopement. In an interview via phone on 08/24/21 at 1:36 PM with CNA F revealed he was working the night of 08/01/21 when Resident #1 eloped from the facility during the power outage. CNA F said there was one person who was supposed to sit near the doors and watch them because they were not currently working. CNA F was unable to identify who that employee was but said he was busy assisting residents throughout his shift and was moving constantly checking on his own residents. In an interview via phone on 08/24/21 at 1:40 PM with RN A revealed he was working the night of 08/01/21 when Resident #1 eloped from the facility during the power outage. RN A said he was at the facility when the power went off which was around 6 PM and called the Administrator to tell him about it. RN A said the facility had a generator that helped to power some parts of the facility but not the doors. RN A said he had a CNA sit at the main door who was also responsible for watching the kitchen doors but could not remember who that CNA was. RN A said the nurse assigned to station two was responsible for watching the door near the nurse's station. RN A said Resident #1 was super smart and probably slipped out when someone went to the bathroom or something like that. RN A said staff were so busy helping residents with oxygen and helping residents in their rooms that sometimes they did leave their area because there was not enough staff in the building. In an interview on 08/24/21 at 2:08 PM with LVN I revealed he was working the night of 08/01/21 when Resident #1 eloped from the facility during the power outage. LVN I said he was running around checking on residents to keep them safe and trying to get them on oxygen tanks due to the oxygen concentrators not working. LVN I said he suspected an elopement might occur so he delegated a CNA to be on the side of the dining room to watch down the hallway to make sure no resident tried to go towards the doors. LVN I said the next day when Resident #1 was found and returned to the facility Resident #1 explained he had waited until staff were not looking and then left out the door. LVN I said he was not watching the doors because he was busy assisting residents on oxygen. In an interview via phone on 08/24/21 at 2:20 PM with CNA J revealed she was working the night of 08/01/21 when Resident #1 eloped form the facility during the power outage. CNA J said she was not assigned to watch the doors, that someone else did that but she was not sure if they stayed at the doors the whole time. CNA J said she was busy helping residents and did not pay much attention to anything else during her shift. In an interview via phone on 08/24/21 at 6:55 PM with LVN K revealed he was the nurse assigned to Resident #1 the night of 08/01/21 when he eloped form the facility during the power outage. LVN K said he was sitting at a door until 10 PM when he relieved the other nurse working. LVN K said there were only three CNA's and two nurses to take care of all the residents for the overnight shift when the power was out. LVN K said he assigned a CNA to watch the doors while he assisted residents on oxygen. LVN K said he had three residents who used oxygen and the residents were panicking about their oxygen so he was busy with them and was not watching the doors. LVN K said when he was not monitoring residents on oxygen tanks he was trying to find extension cords to connect the oxygen concentrators to the emergency outlets in the hallways. LVN K said he began charting for the night and realized between 4:00 AM and 6:00 AM that he did not see Resident #1 the whole night. LVN K said he went to Resident #1's room and the dining room where he often frequented and could not find him. LVN K said he began searching with the rest of the staff for Resident #1 and initiated the missing resident code. LVN K said he called the DON when Resident #1 could not be found around 6:00 AM. LVN K said there were lots of exit doors in the facility and he thought the CNA's were watching the exit doors while he was taking care of his three residents with respiratory issues. LVN K said he did not call the Administrator or DON to ask for more help during the night because he thought the power would come back on quickly so he was trying to manage the situation himself . LVN K said there were two nurses and about three CNA's working the overnight shift. (LVN K could not provide a more detailed timeline on when he originally noticed Resident #1 was missing and when he had called the DON to report it, since the incident happened weeks ago.) In an interview on 08/24/21 at 3:07 PM with the DON revealed there was a storm the night of 08/01/21 that knocked the power out at the facility. The DON said he told the nurses to assign staff on halls to monitor exits because the doors were unlocked. The DON said LVN K called him at 7:30 AM the next day (08/02/21) and was told Resident #1 was missing from the facility. The DON said Resident #1 was found around 10:00 AM later that morning. The DON said Resident #1 was very confused and had eloped from another facility before so staff knew he was an elopement risk. The DON said Resident #1 was very smart and once he realized the power was off, he used it has his chance to leave; although Resident #1 had not made prior attempts to elope from the facility. The DON said he found out from the police that Resident #1 left around 9:00 PM or 10:00 PM that night after the CNA who was watching the front door left to help another CNA down the hall. The DON said a community member picked Resident #1 up outside the facility that night but did not have any other details about what happened afterwards. The DON said he assumed staff were watching all the exit doors and that there were enough staff to care for residents and watch the doors. The DON said Resident #1 wore a wander guard but it would not set the alarm off at the doors when the power was off so it was useless. The DON said after the incident happened, staff were in-serviced on utility outages, elopements, and wander guards. In an interview on 08/24/21 at 4:09 PM with the Administrator revealed there was a power outage due to a thunderstorm the night of 08/01/21. The Administrator said he was not sure what time Resident #1 actually eloped because he did not see the footage the police told him about which showed Resident #1 leaving the facility out the front door around 9:15 PM. The Administrator said Resident #1 was picked up on the street by a community member who took him to a hotel down the street. The Administrator said the community member saw a missing person's post on social media and called the police to say that she had Resident #1 at her house the morning of 08/02/21. The Administrator said the police returned Resident #1 to the facility around 10:30 AM. The Administrator said he received a phone call the next morning (08/02/21) at 7:30 AM that Resident #1 was missing, and staff thought he eloped the night before. The Administrator said Resident #1 had eloped from a facility in years prior and wore a wander guard since he was identified as an elopement risk. The Administrator said staff did the best they could watching the doors and caring for residents during the power outage. The Administrator said when the power goes out the doors to the facility were unlocked so the wander guard system would not work. The Administrator said he fully believed since it was nighttime that residents would generally be more settled, so they did not need a ton of people in the building keeping residents safe. The Administrator said the explanation he was given by staff working that night was that staff were watching multiple exits and helping residents. The Administrator said Resident #1 told him that Residnet #1 noticed the power was out and waited for a staff member to turn around to go to the bathroom and left out the front door. The Administrator said he was amazed staff did not notice Resident #1 was missing for so long and obviously what they did was not working. The Administrator said staff were in-serviced on elopements, wandering residents, and utility outage policy. In an interview via phone on 08/25/21 at 8:33 AM with the Community Member revealed she was on her way to work the night of 08/01/21 when she saw Resident #1 on the street a block away from the facility. The Community Member said she saw Resident #1 in the street stuck in his wheelchair. The Community Member said Resident #1 told her he got into a fight with his wife and she told him to leave, so she took Resident #1 to a nearby hotel. The Community Member said she picked up Resident #1 from the hotel the next morning (08/02/21) and took him back to her house where she saw the missing person's post on social media. The Community Member said the police came to pick up Resident #1 at her house that morning to take him back to the facility. In an attempted interview via phone on 08/25/21 at 8:42 AM with Resident #1's RP was unsuccessful. In a follow-up interview on 08/25/21 at 10:00 AM with the Administrator revealed the policy for a utility outage said to monitor residents which to him meant to use their best judgement. The Administrator said he did not have a more solid or defined plan in place for what to do when the power was out to monitor and secure the doors in the facility. The Administrator said the policies and procedures had not changed since the incident occurred and nothing new was put in place to keep residents from eloping in the case of a utility outage. In an interview via phone on 08/25/21 at 1:59 PM with CNA H revealed she was working the night of 08/01/21 when Resident #1 eloped from the facility during the power outage. CNA H said she was sitting near the dining area and watching the exit door but was also helping residents. CNA H said multiple residents did not want to go to bed so they were moving through the halls in their wheelchairs. CNA H said she was watching these residents and then started taking the residents to their rooms to go to bed when they requested that. CNA H said she would leave the area she was supposed to be watching to help the residents because there was not enough staff . CNA H said there was not enough staff working to help residents and watch the doors. In an interview via phone on 08/25/21 at 2:26 PM with CNA E revealed she was working the night of 08/01/21 when Resident #1 eloped from the facility during the power outage. CNA E said she was sitting in a hallway watching the entrance/exit doors and assisting residents with care. CNA E said she was supposed to be watching multiple doors in the facility and assisting residents across two hallways while the power was out. CNA E said the nurses were busy helping residents who used oxygen. CNA E said there was only a few people working that night but not enough to help residents and ensure the doors were secured. In an interview via phone on 08/25/21 at 2:35 PM with MA G revealed she was working the night of 08/01/21 when Resident #1 eloped from the facility during the power outage. MA G said she was passing medications to residents in the building. MA G said she saw sometimes where a door was not being monitored by staff because they were helping residents. MA G said she was busy passing medications and did not think a resident would have left the facility. Review of the facility's policy dated June 2020, and titled Emergency Procedure- Utility Outage reflected: 1. Staff will implement safety precautions and comfort measures for residents during a temporary loss of power .10. Monitor residents to ensure they are safe and check resident-used medical equipment .16. Account for staff members and residents. Further review reflected: .Monitor resident safety. Review of the facility's policy dated May 2020, and titled Emergency Procedure- Missing Resident reflected: 1. Residents at risk for wandering and/or elopement will be monitored and staff will take necessary precautions to ensure their safety. 2. Staff will implement the protocol for missing resident immediately upon discovering that a resident cannot be located. Review of the facility's policy, dated June 2020, and titled Call-In of Off-Duty Personnel/Recall Roster reflected: 1. In case of an emergency situation or disaster in our facility, the Incident Commander has the authority to recall off-duty personnel. Review of the facility's policy dated June 2020, and titled Planning for Additional Staffing Needs reflected: 1. As part of emergency preparedness planning, the facility recognizes the need for additional staffing resources. Review of the facility's policy dated March 2019, and titled Wandering and Elopements reflected: 3. If a resident is missing, initiate the elopement/missing resident emergency procedure: a. Determine if the resident is out on an authorized leave or pass; b. If the resident was not authorized to leave, initiate a search of the building(s) and premises; and c. If the resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative, the Attending Physician, law enforcement officials, and (as necessary) volunteer agencies (i.e., Emergency Management, Rescue Squads, etc.). Review of in-services reflected: Wandering/Elopement completed on 08/02/21, Abuse/Neglect completed on 08/02/21, and Power Loss Procedure/Policy completed on 08/02/21. An Immediate Jeopardy was identified on 08/26/21 at 3:00 PM and the Administrator was informed of IJ in the area of accidents/supervision and the IJ template was provided to him via email at 3:00 PM. The plan of removal was accepted on 08/27/21 at 3:03 PM and included: [Facility Name] [Facility Address] Plan of Removal Action: --8/26: Administrator, DON, and/or designee will initiate an in-service regarding: --The importance of monitoring doors if they were to release in case of an emergency. --Administration will ensure the center employees understand that watching the exit doors, while they are released, is the upmost priority-therefore, they will assign people to the doors and the others will provide patient care and perform other center duties, such as grabbing extension cords for concentrators. *All staff scheduled to work through 9/3/2021 will be in-serviced by end of 8/27/2021 any outlying staff will be in-serviced prior to next shift worked. --The elopement took place on 2p-10p shift in which there were 14 employees present at the time of the elopement, which was sufficient staff to cover the exit doors. --Administrator, DON, and corporate IDT [Interdisciplinary Team] team will develop a test to ensure employee's competencies on power outage procedure as it pertains to resident safety. This test will be administered by administrator, DON, or designee. *All staff scheduled to work through 9/3/2021 will be tested by end of 8/27/2021 any outlying staff will be in-serviced prior to next shift worked. --The center has placed 5 extension cords at each nurse's station, center will ensure staff knows the location via in-service along with, the importance of monitoring doors if they were to release in case of an emergency which includes a description and location of said extension chords [sic] given by administrator/ DON or designee. **All staff scheduled to work through 9/3/2021 will be in-serviced by end of 8/27/2021 any outlying staff will be in-serviced prior to next shift worked. --In the event of a power outage the charge nurse or applicable manager on site will assign duties to the staff on hand to monitor the 6 exit doors, aide in patient care, and address facility needs. Identified Residents at Risk: Residents requiring wander-guards (15 currently in house). Only 1 resident was affected regarding this incident, resident was not harmed as a result of this elopement. Systemic Changes: --In the event of doors being released the Administrator and/or Director of Nurses will be notified via telephone call by the charge nurse(s). At this time the administrator and/or DON will deploy to the building (if not already present) and/or call-in additional staff to cover the exit doors. --In the event of a power outage with insufficient staff to cover exits and perform care, the applicable member of the administrative team (if present in the center) or the charge nurse will identify at risk residents, and those identified residents will be brought to a central location (dining room) to be monitored until we can get additional staff to monitor 6 exit doors and to provide care. --Staff to be in-serviced monthly for the next 3 months on emergency power outage procedure. Responsibility: --It is the administrator, or designee, and the Director of Nursing, or designee's responsibility to follow the actions and systematic changes listed above. The administrator, or designee, and The Director of Nursing, or designee, will report their findings of the above actions and systematic changes through their QAPI [Quality Assessment Performance Improvement] process. Monitoring interviews for the Immediate Jeopardy were started on 08/27/21 at 8:30 AM and continued through 08/27/21 at 4:00 PM with 54 staff across all three shifts, including weekdays and weekends, including all departments. The staff were interviewed about what to do when there is not enough staff in the building to cover all exits during a power outage, what to do when they were assigned a door to monitor during a power outage, and where to find extension cords during a power outage. The following staff's in-service logs and competency tests were reviewed and they were interviewed during the monitoring time frame and were able to articulate what they had been taught, new protocols and procedures related to elopements during a power outage, and where extension cords can be found: CNA F, RN A, LVN I, CNA J, LVN K, CNA E, MA G, CNA H, CNA B, the Driver, HK C, the AD, the SW, CNA L, the BOM, LVN D, HK M, LVN O, CNA N, CNA P, the ST, the DOR, LVN Q, LVN R, MA S, CNA T, CNA U, HK V, LVN W, the DM, the Clinical Case Manager, DA Y, MA Z, CNA AA, DA BB, LVN CC, LVN DD, the ADON, the PT, CNA EE, DA FF, DA GG, CNA HH, CNA II, LVN JJ, LVN KK, CNA LL, HK MM, LVN NN, RN OO, LVN PP, MA QQ, CNA RR, the Administrator, and the DON. While the Immediate Jeopardy was removed on 08/27/21, the facility remained out of compliance due to the facility's need to evaluate the effectiveness of the Plan of Removal.

Based on observation, interview and record review, it was determined the facility failed to implement written policies and procedures that prohibit neglect for two (Residents #10 and #3) of four residents reviewed for falls. 1. The facility failed to develop and implement interventions to prevent Resident #10, who was identified as a high fall risk, from falling. Resident #10 fell on [DATE] and again on 10/04/13 and sustained a [MEDICAL CONDITION]. She was sent to the hospital and admitted . Resident #10 was readmitted to the facility on [DATE]. 2. The facility failed to develop and implement individualized interventions to prevent Resident #10, who had a [MEDICAL CONDITION] and was still at high risk for falls, from falling. 3. The facility failed to implement individualized interventions to prevent Resident #3, who was at high risk for falls, from falling. On 10/21/13 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 10/23/13, the facility remained out of compliance at severity level of "actual harm that is not immediate jeopardy" and a scope of "pattern" because staff were still being in-serviced, and the facility was monitoring the effectiveness of their plan of removal. These failures could affect the 43 residents, including Residents #3 and #10, who were at high risk for falls, by placing them at risk for falls, bruises, fractures, and/or death. Findings included: 1. Resident #10's MDS assessment, dated 07/04/13, reflected the resident was a [AGE] year-old female, who was admitted to the facility on [DATE] and her [DIAGNOSES REDACTED]. She spoke clearly, was able to make herself understood and had the ability to understand others. Resident #10 was moderately impaired cognitively. She needed extensive assistance with toileting, her gait was unsteady and she needed assistance to stabilize during transfers to her wheelchair. Resident #10's range of motion was not impaired, and she was continent of bladder and occasionally incontinent of bowel. The MDS assessment also reflected she was 63 inches in height and weighed 238 pounds. Resident #10's Fall Risk Assessment Form, dated 07/14/13 and completed by LVN A, reflected a score of 13, which indicated she was at high risk for falls. Resident #10's "Comprehensive Plan of Care," dated 04/13/13 and updated on 07/10/13, did not reflect a plan of care to prevent falls. Interview on 10/21/13 at 2:00 p.m. with the DON revealed there were no care plan interventions in place to prevent Resident #10 from falling prior to 10/07/13. Resident #10's undated quarterly assessment "Bladder Incontinence Evaluation" reflected she was continent and no further assessment was needed. Resident #10's unsigned and undated Safety Assessment Informed Consent reflected she was alert, was aware of safety needs, was unsteady on her feet, lost her balance, propelled her wheelchair, was non-ambulatory, experienced a recent transfer, was continent and needed assistance. This form reflected, "This form has been developed to adequately assess all aspects of the resident's well-being (physical, mental, emotional, environmental, and social considerations) prior to the use of either chemical or physical restraints in order to identify the least restrictive intervention. It is to be completed by a licensed nurse or licensed physical/occupational therapist. This assessment is to be completed upon admission, quarterly, and with any change in condition." The Referrals/Recommendations section was blank. Interview on 10/22/13 at 7:04 p.m. with the RNC revealed the "Safety Assessment Informed Consent" was part of the system for the staff (nurses and therapists) to utilize on admission, readmission, quarterly, and change in condition to assess the residents concerning safety. The RNC said these forms were part of the system for fall prevention. The forms were to allow the staff to recognize and identify the need for intervention and to assist in identifying safety issues the resident might have. Resident #10's Nurse's Notes, dated 10/01/13 at 11:00 a.m., reflected she was sitting in her wheelchair, was alert with episodes of confusion, and was a two person transfer. Resident #10 was continent with episodes of incontinence. Resident #10's Nurse's Notes, dated 10/01/13 at 12:20 p.m., reflected, "Observed residents trying to get up from wc (wheelchair). Resident stood up & (and) then set (sic) back down. Resident instructed to wait. Turned away from doorway to ask aide for assistance. Turned back to resident. Resident then stating she fell . When asked how she fell and got back up while this nurse was standing there, Resident stated she 'sat back down in wc, not fell .' She also stated 'I scraped my arm.' (Left) arm assessed. No scrapes, bleeding, or hematoma notes. Resident appears to have delayed thought process & slow speech. Notified MD (physician). Received in/O (new order) for labs for CBC, CMP, UA (with) C&S. Will continue to monitor." Interview on 10/22/13 at 11:03 a.m. with LVN A revealed she was the nurse when Resident #10 was standing up and sitting down in her wheelchair on 10/01/13. LVN A said she had gotten the order from the physician for the labs, but by the time she saw the lab results Resident #10 had already fallen and was in the hospital for the broken hip. LVN A revealed Resident #10 fell on [DATE] and she did everything she was supposed to do as a nurse, including the Incident/Accident Report. When asked why she thought Resident #10 was standing up and down out of the wheelchair on 10/01/13, LVN A replied she thought the resident needed to go to the bathroom and she might have an Urinary Tract Infection. Resident #10's Urinalysis Results, dated 10/03/13 and received at the facility at 4:10 p.m., reflected a trace of blood, large amount of white blood cells, and many bacteria in her urine. The Urinalysis Report had a handwritten note from the nursing staff, which reflected it was faxed to the physician on 10/05/13. Resident #10's Nurse's Notes, dated 10/03/13 at 10:40 a.m., reflected she was on the floor at 10:22 a.m., a full body assessment was conducted by LVN A, and the resident complained of left hip pain. The Notes also reflected LVN A obtained a physician's orders [REDACTED]. Interview on 10/22/13 at 11:03 a.m. with LVN A revealed Resident #10 had her call light on and when she had entered the room to see what the resident wanted on 10/03/13, Resident #10 was on the floor. LVN A said Resident #10 wanted to go to the bathroom and nobody had come. When asked if the nursing staff was involved in any meetings to discuss interventions concerning residents who had fallen, she replied, "No." When asked if the nursing staff had any protocols to follow concerning interventions when a resident fell , LVN A replied, "No." When asked if there was a bowel and bladder program for Resident #10, she responded they completed bowel and bladder assessments on admission, quarterly and yearly, but nothing happened. LVN A stated the assessment forms stayed in the resident's clinical records. She revealed those were the only forms they had to use. LVN A said they had never been told or given any other types of forms to use. LVN A revealed the staff was trying to get some type of program (Bowel and Bladder) "going" with Resident #10, but the whole staff was not doing the same thing and it was hard when there was no consistency or communication between the nurses and the DON concerning residents. Interview on 10/22/13 at 9:15 a.m. with CNA E revealed when asked if she was working on 10/03/13 when Resident #10 fell , CNA E replied she was working, but was on break. She revealed she learned of the fall from LVN A when she returned from her break. When asked if she was working on 10/01/13 when Resident #10 was standing up and sitting down in her wheelchair, CNA E replied she worked and helped the nurse place the resident back in the bed. When asked what she thought Resident #10 wanted on 10/01/13, she responded the resident wanted to go to the bathroom. CNA E said the staff tried to take Resident #10 to the bathroom, but they could not get the rest of the staff on the "same page. We (CNAs) had no paperwork to tell us if the resident was on any type of bowel and bladder program." CNA E revealed sometimes Resident #10 was taken to the bathroom and sometimes she was not taken. She stated occasionally Resident #10 rang her call light and wanted to go the bathroom. When asked if she had seen any fall interventions for Resident #10 prior to her going to the hospital, CNA E replied, "No." Resident #10's Physician's Telephone Order, dated 10/03/13, reflected to x-ray her left hip due to a fall. Resident #10's X-ray Results, dated 10/03/13 reflected, "Moderate [MEDICAL CONDITION] of the left hip within limits." A handwritten note on the x-ray results reflected the results were faxed to the physician on 10/03/13. Review of the facility's Incident/Accident book for the months of August 2013, September 2013, and October 2013 did not reveal any Incident/Accident Reports for Resident #10 on 10/01/13 or 10/03/13. An interview with the DON on 10/21/13 at 2:20 p.m. revealed Resident #10 only had one fall on 10/04/13. She stated the Incident/Accident Report, dated 10/04/13, was the only Report she had for Resident #10. Further interview on 10/21/13 at 3:45 p.m. with the DON revealed the nursing staff was required to complete an Incident/Accident Report anytime a resident had a fall, bruise, skin tear, or any unusual injury. The staff was required to call her about all incidents, if she was not in the facility. The DON revealed the staff placed the reports in a box at the Nurse's Station, and she picked them up every day and went over every report in the morning stand-up meeting. She stated after the meeting, she looked at the reports to see what all was reviewed such as therapy needs, medications, and a need for alarms. When asked if there was not an Incident/Accident Report how would she know a resident had an occurrence, the DON replied she reviewed "Twenty-Four Hour Reports" every day and if it was on there then she would know. The DON said they still had to call her with every incident. Resident #10's Fall Risk Assessment Form, dated 10/04/13 and completed by LVN A, reflected a score of 17, which indicated the resident was at high risk of falls. An interview with LVN A on 10/22/13 at 11:03 a.m. revealed the Fall Risk Assessments were to be completed on admission, quarterly, readmission, and following an incident/accident. When asked what happened if a resident scored as a high risk for falls, she replied, "Nothing. I just know we are supposed to fill them out and put them in the chart and the DON gets a copy following a fall." LVN A said there were other forms that were completed when a resident had a fall including a form about the resident's cognition and a "tree" for identifying what to do when the resident falls. LVN A said there was a "Safety Form" but she was unclear what to do with this form. LVN A said she just completed the forms and then placed them in the chart. The facility's Incident/Accident Report, dated 10/04/13, reflected Resident #10 was calling out for help and when the nurse heard her calling she found her in in the bathroom with her back against the toilet sitting on the floor. The nurse assessed her, and she had right leg pain. The nurse contacted the physician, who ordered x-rays. The unsigned and undated "Final Deposition Report" identified as completed by the DON on 10/21/13 at 2:00 p.m., reflected the reasonable root cause of the occurrence was Resident #10 attempting to transfer herself. The "Final Deposition Report" included as part of the incident/accident report, reflected the resident did not use the call light, and she was transferred to the hospital. Interview on 10/21/13 at 5:50 p.m. with LVN C revealed she was aware Resident #10 had fallen the day before, 10/03/13, because it was on the "Twenty-Four Hour Report" and neurological checks were in progress from that fall. LVN C said Resident #10 fell again during her shift on 10/04/13, which caused her to contact the physician and get x-rays ordered due to the resident complaining of pain to her right leg. LVN C revealed Resident #10 was in the bathroom, and she did not know how she got in the bathroom. She stated Resident #10 could propel her wheelchair, but could not walk more than a few steps. LVN C said Resident #10 said she was trying to go the bathroom, but she thought she could do this on her own. LVN C said the nurses were supposed to complete an Incident/Accident Report, place it in the box and put it on the "Twenty-Four Hour Report," then contact the physician and the family, and follow any orders the physician gave. Resident #10's X-ray Results, dated 10/04/13, reflected comminuted (shattered into pieces) [MEDICAL CONDITION] right femur. Further review reflected a handwritten fax reflected, the x-ray results had been faxed to the physician. Resident #10's Physician's Telephone Order, 10/04/13, reflected to send her to to the emergency room due to femur fracture. Resident #10's "Cognitive/Behavior Collection," dated 10/04/13, reflected she required interventions 1-6 days per week for orientation and memory, resident exhibited attention seeking behaviors that required frequent redirection and/or verbal reassurance, resident was very forgetful, required frequent reminders concerning task at hand, and the outcome to these interventions had little effect. The "Fall Risk Assessment Algorithm," dated 10/04/13 reflected no additional services requested, discipline already ordered. When asked on 10/22/13 at 11:03 a.m., why there was no further recommendations made concerning Resident #10, LVN A replied the resident was already receiving Restorative Therapy and had been receiving it for some time. Interview on 10/21/13 at 2:20 p.m. with the DON revealed she only had one Incident/Accident Report for Resident #10, dated 10/04/13. She stated Resident #10 stood up and sat down in her room sometime around the first part of the month, but she did not fall, so an Incident Report was not completed. The facility's "Twenty-four Hour Report," dated 10/04/13, reflected LVN C documented Resident #10 had fallen, x-rays had been ordered, and neurological checks were in progress. Resident #10's Comprehensive Plan of Care, dated 10/07/13 while the resident was in the hospital, reflected a history of falls and a high risk for increased falls and fractures as evidenced by cognitive impairment and an unsteady gait. The goal of the Plan of Care was for Resident #10's dignity to be maintained, the incidences of falls to be reduced, and no injuries to occur over the next 90 days. The Plan of Care's Approaches were 1) Encourage resident to ask for assistance from staff. 2) Ensure call light is in reach, answer promptly 3) Therapy to eval and treat per orders 4) Anticipate needs, provide prompt assistance 5) Assure lighting is adequate and areas are free of clutter 6) Encourage socialization and activity attendance-as tolerated. Resident #10's Comprehensive Plan of Care, dated 10/07/13, while the resident was still in the hospital, reflected Resident #10 was noncompliant with care as evidenced by her failure to use the call light. The Approaches included the nurse physically seeing the residents per policy and procedure and frequently by nursing staff to ensure safety. Resident #10's MDS assessment, dated 10/16/13, reflected the resident was readmitted to the facility on [DATE]. Resident #10 required the extensive assistance (resident involved in activity, staff provide weight bearing support) of one person for transfers. Resident #10's range of motion in her lower extremity (hip, knee, ankle, foot) was impaired on one side. She was incontinent of bladder and incontinent of bowel. The MDS assessment also reflected [DIAGNOSES REDACTED]. Interview on 10/21/13 at 12:30 p.m. with Resident #10 revealed the staff had to use a lift now to get her up. She stated she wished her leg, which was bothering her, would get better. When asked what she meant, the resident replied she fell a time back out of her wheelchair. Resident #10 revealed she recalled leaning forward, but she did not remember anything else. She stated she broke her hip. Resident #10 said that was the only fall she had. When asked if she could walk prior to this happening, she replied she could not remember, but she thought she could. Resident #10 revealed she remembered falling. Interview on 10/22/13 at 9:15 a.m. with CNA E revealed she had been caring for Resident #10 for some time now. CNA E said Resident #10 was able to stand and pivot herself, but now with her broken hip, they had to use the Hoyer Lift. CNA E revealed Resident #10 could still propel her own wheelchair. She stated Resident #10 was forgetful and at times got upset with the staff because the resident thought the staff had forgotten to do "stuff" for her. CNA E stated Resident #10 got the scoop mattress after she returned from the hospital. CNA E also revealed since surveyor inquiry, Resident #10 was identified as a resident the CNAs take to the bathroom now, and then they placed an alarm on her chair. Resident #10's Comprehensive Care Plan, dated 10/07/13, did not address transfers or the need for Resident #10 to be transferred via Hoyer lift. Interview on 10/22/13 at 11:00 a.m. with the DON revealed she had communicated with the staff on 10/21/13 at 7:00 p.m., concerning the safety needs of Resident #10. She realized putting an alarm on her wheelchair would remind the resident to sit down and taking the resident to the bathroom would help keep the resident safer. Interview on 10/23/13 at 1:00 p.m. with Rehab Manager revealed Resident #10 had been on the Restorative Program for some time. The Rehab Manager said Resident #10 had been re-evaluated for services following her hospitalization for the fall and the fracture. The Rehab Manager stated he did not recall any discussion in the morning stand up meetings about Resident #10 falling. When asked if staff ever came to him about interventions for other residents, he replied they did at times, but he had never been asked about Resident #10. The Rehab Director said he noticed a chair alarm was placed on Resident #10, which he thought was a good idea. He stated he was going to speak to the surgeon concerning placing a positioning cushion to prevent Resident #10 from leaning forward in the chair, but wanted to make sure it would not affect the healing of the hip. The "Nursing Restorative Care Program" reflected Resident #10 had been on service from April 2013 through October 2013. The Restorative Plan included: range of motion and mobility goals. During this time there were no changes in goals or approaches. The Program reflected increasing and maintaining strength, range of motion to lower extremities, ambulation with rolling walker as tolerated, and stationary lower extremities peddler as tolerated. 2. Resident #3's most recent MDS assessment, dated 10/08/13, reflected the resident was a [AGE] year-old male, who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the MDS assessment, the resident required the extensive assistance of one person with transfers, bed mobility and dressing. Resident #3's admission orders [REDACTED]. Resident #3's Admission Care Plan, dated 10/01/13, addressed the problem of falls. The goal reflected he would remain free of injuries and falls. The Care Plan's interventions included keeping the call light in reach, encouraging the use of the call light, and a personal alarm if needed. Resident #3's Nurse's Notes, dated 10/03/13 at 2:15 p.m., reflected the resident was found on the floor, assessed and assisted to the chair. According to the Notes, Resident #3 had poor motor skills. The Notes reflected no injuries were sustained during the fall. An interview with LVN F on 10/22/13 at 3:30 p.m. revealed he was the author of the Nurse's Notes, dated 10/03/13 at 2:15 p.m. The nurse stated the resident was found on the floor of his room. According to the nurse, he had completed an Incident/Accident Report and placed it in the Twenty-four Hour Nurse's book. LVN F further stated the resident told him he had leaned too far over in the wheelchair and fell forward. LVN F stated he had worked in the facility for four years and nurses always placed the completed Incident/Accident Reports in the Twenty-four Hour Nurse's book. Additionally, LVN F stated when he returned to work the next day on 10/04/13 the Incident/Accident Report was gone. The facility's "Twenty-four Hour Reports," dated 10/03/13 and 10/04/13 reflected Resident #3 was listed as being in follow-up status due to a fall. According to the reports, neurological checks were in progress during the follow-up. The facility's Incident/Accident Reports for August 2013, September 2013 and October 2013 did not reflect Resident #3's fall. A safety assessment, dated 10/04/13, reflected Resident #3 was aware of safety needs but exhibited impaired decision making and had a history of [REDACTED]. Resident #3's Fall Risk Assessment, dated 10/05/13, reflected a score of 17, which indicated the resident was at high risk for falls. Resident #3's Admission Care Plan, dated 10/01/13, did not reflect an update or review regarding Resident #3's fall on 10/03/13 or that he was at high risk for falls. Resident #3 was initially observed sitting in a wheelchair in his room during rounds on 10/21/13 at 9:15 a.m. with LVN D. The nurse described the resident as being blind, continent of bowel/bladder and requiring assistance with eating. Resident #3's Comprehensive Plan of Care, dated 10/11/13, did not reflect the resident was at high risk for falls. There was no review or revision to address Resident #3's fall on 10/03/13. Interview on 10/21/13 at 2:20 p.m. with the DON revealed she was not aware Resident #3 had a fall. She stated she did not have an Incident/Accident Report for Resident #3. Interview on 10/21/13 at 3:45 p.m. with the DON revealed the nursing staff was required to complete an Incident/Accident Report anytime a resident had a fall, bruise, skin tear, or any unusual injury. The staff was required to call her about all incidents, if she was not in the facility. The DON revealed the staff placed the reports in a box at the Nurse's Station, and she picked them up every day and went over every report in the morning stand-up meeting. She stated after the meeting, she looked at the reports to see what all was reviewed such as therapy needs, medications, and a need for alarms. When asked if there was not an Incident/Accident Report how would she know a resident had an occurrence, the DON replied she reviewed "Twenty-Four Hour Reports" every day and if it was on there then she would know. The DON said they still had to call her with every incident. When asked again about an Incident/Accident Report for Resident #3, the DON replied there was not one. 3. The facility's current policy, Abuse - Reportable Events, revised March 2012 reflected, "It is the policy of this home to prohibit resident abuse or neglect in any form...Neglect: The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness...b. It is the responsibility of every employee to report immediately anything could be adversely affect the health and welfare of any resident...b. Incident/Accident Reports will be reviewed by the Administrator and Director of Nurses or designee to identify possible incidents of abuse...." The facility's current policy, Falls-Evaluation and Prevention, dated March 2012, reflected the policy was to evaluate residents' fall risk and develop interventions to prevent falls. The residents were to be assessed on admission/readmission, following any change of status that may affect balance, mobility, or safety, falling a fall and quarterly. The procedures included the nursing staff/interdisciplinary care team determining if a resident was at risk for falls and developing appropriate interventions based on the evaluation. The goal was to prevent falls if possible and avoid any injury related to falls. The care plan should only specify a few interventions at a time, so the staff could determine what interventions were not successful and needed to be changed. The policy also reflected after a fall, the resident's plan of care should be reviewed and interventions updated as appropriate, staff should be educated on fall prevention, providing a safe environment for residents, and the cause/risk factors for falls as well as the interventions to manage the risk. 4. An IJ was identified on 10/21/13. The Administrator, DON, and ADON were informed on 10/21/13 at 5:04 p.m. of the IJ and a Plan of Removal was requested at that time. 5. Interview on 10/23/13 at 3:41 p.m. with the DON revealed she knew the IJ occurred because she did not have enough interventions in place for Resident #10 to ensure safety. The DON said she still did not think the fact that she had not put any interventions in place when the resident was standing up and sitting down was a part of the immediacy because she thought that was something the nurses saw and dealt with every day. She asked how was she supposed to know that would lead to the resident falling and breaking her hip. The DON said they now had systems of reporting, communicating, and follow-up concerning residents' changes and incidents. 6. The facility's Plan of Removal, dated and accepted on 10/22/13, reflected all residents would have fall risk assessments, and all fall risk assessments were redone on 10/21/13 for accuracy and following policy for all residents. Fall risk assessments would be completed upon admission/readmission, change of condition, and quarterly. Fall safety evaluations for fall prevention and recommendations from Therapy for prevention of falls were all started on 10/21/13 and completed on 10/22/13. Any resident with a score of "10" or higher who was identified as high fall risk or who had a fall was referred to therapy. Individualized Care Plans were updated on 10/21/13 reflecting interventions, and Aides' Care Plans were also updated to reflect interventions. The 43 residents, who were identified as "high risk" for falls, care plans were individualized on 10/21/13. The Safety Assessments by therapy for cognitive impairment, non-weight bearing, physical impairment, and unsteady gait were completed and provided to the DON/ADON and Admin for interventions to be placed and monitored by 10/22/13. The Restorative aide would monitor interventions, for placement and working order daily and a complete checklist that would be turned in daily to the ADON/DON, at which time they would notify Administration of any issues and also present to the Quality Assurance Committee fall prevention devices were in place for each resident. An in-service was initiated by the Administrator/Regional Clinical Director, DON, and ADON. The in-service would continue each shift to ensure all staff had the training. Arrangements were made with staff to attend individual training. In-services were related to: validating placement of alarms/fall mats/fall interventions and specialty equipment with a validation of training by a "Fall Care Basics" test with a passing score of 80% or higher. All staff with a lower score would be retrained and retested until a score of 80% or higher. Fall assessment and prevention would be part of the orientation process and ongoing in-service for all departments including the weekend staff. 7. Interviews conducted on 10/23/13 at 9:40 a.m. and 2:20 p.m. with LVNs D and F revealed they received training on 10/22/13 regarding fall prevention. The nurses stated training included nursing staff participating and implementing interventions for residents who fall and residents who were assessed to be at a high risk for falls. The nurses were able to explain when the fall risk assessment would be completed, on admission, readmission, changes in conditions, following a fall and quarterly. The nurses were able to explain the scoring system associated with the fall risk assessments and the therapy department referral process. On 10/23/13 at 10:45 a.m., Laundry Aide I was interviewed regarding falls and fall prevention. Laundry Aide I stated she recently had training regarding resident falls and actions to take. Laundry Aide I stated she was unable to physically assist a resident but would immediately notify the charge nurse if she found a resident after a fall. On 10/23/13 at 10:54 a.m. LVN B was interviewed regarding falls and fall prevention. LVN B stated training was held the afternoon of 10/22/13 and covered fall prevention such as removing clutter from a resident's room and ensuring that residents with visual impairment wear their glasses. LVN B stated that residents would be referred to therapy after a fall and fall assessments were to be completed after a resident's fall, significant change in status, readmission to the facility and upon admission. Interview on 10/23/13 at 11:28 a.m. with CNA H revealed the CNA received training regarding falls and fall prevention on the evening of 10/22/13. CNA H said following the in-service a test was given and staff had to make 80% on the test to pass it. CNA H understood trying to keep the residents safe and if a fall was witnessed, the charge nurse was to be notified. CNA H also revealed if staff thought something could cause a problem for the resident to report it to the nurse. On 10/23/13 at 12:36 p.m., CNA E was interviewed regarding falls and fall prevention. CNA E stated she had training on 10/22/13 along with a test given afterwards. CNA E stated if a resident had a fall, she would notify the nurse and then report the fall to the Administrator. CNA E also stated she would try and prevent resident falls by asking residents if they needed something before leaving their room and checking for environmental hazards. 8. The Administrator, RNC, and ADON were informed on 10/23/13 at 4:30 p.m. that the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of "pattern" because the facility was still in-servicing staff and monitoring the effectiveness of the Plan of Removal. 9. The facility's Form CMS-802, Roster/Sample Matrix provided on 10/21/13 by the DON reflected four residents had sustained falls out of the 43 residents identified by the facility as high risk for falls, following re-screening all residents for fall risk, provided by the DON on 10/22/13.

Based on observation, interview and record review, it was determined the facility failed to follow its policies and procedures that prohibit neglect for two (Residents #10 and #3) of four residents reviewed for falls. 1. The facility failed to develop and implement interventions to prevent Resident #10, who was identified as a high fall risk, from falling. Resident #10 fell on [DATE] and again on 10/04/13 and sustained a [MEDICAL CONDITION]. She was sent to the hospital and admitted . Resident #10 was readmitted to the facility on [DATE]. 2. The facility failed to develop and implement individualized interventions to prevent Resident #10, who had a [MEDICAL CONDITION] and was still at high risk for falls, from falling. 3. The facility failed to implement individualized interventions to prevent Resident #3, who was at high risk for falls, from falling. On 10/21/13 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 10/23/13, the facility remained out of compliance at severity level of "actual harm that is not immediate jeopardy" and a scope of "pattern" because staff were still being in-serviced, and the facility was monitoring the effectiveness of their plan of removal. These failures could affect the 43 residents, including Residents #3 and #10, who were at high risk for falls, by placing them at risk for falls, bruises, fractures, and/or death. Findings included: 1. The facility's current policy, Abuse - Reportable Events, revised March 2012 reflected, "It is the policy of this home to prohibit resident abuse or neglect in any form...Neglect: The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness...b. It is the responsibility of every employee to report immediately anything could be adversely affect the health and welfare of any resident...b. Incident/Accident Reports will be reviewed by the Administrator and Director of Nurses or designee to identify possible incidents of abuse...." 2. Resident #10's MDS assessment, dated 07/04/13, reflected the resident was a [AGE] year-old female, who was admitted to the facility on [DATE] and her [DIAGNOSES REDACTED]. She spoke clearly, was able to make herself understood and had the ability to understand others. Resident #10 was moderately impaired cognitively. She needed extensive assistance with toileting, her gait was unsteady and she needed assistance to stabilize during transfers to her wheelchair. Resident #10's range of motion was not impaired, and she was continent of bladder and occasionally incontinent of bowel. The MDS assessment also reflected she was 63 inches in height and weighed 238 pounds. Resident #10's Fall Risk Assessment Form, dated 07/14/13 and completed by LVN A, reflected a score of 13, which indicated she was at high risk for falls. Resident #10's "Comprehensive Plan of Care," dated 04/13/13 and updated on 07/10/13, did not reflect a plan of care to prevent falls. Interview on 10/21/13 at 2:00 p.m. with the DON revealed there were no care plan interventions in place to prevent Resident #10 from falling prior to 10/07/13. Resident #10's undated quarterly assessment "Bladder Incontinence Evaluation" reflected she was continent and no further assessment was needed. Resident #10's unsigned and undated Safety Assessment Informed Consent reflected she was alert, was aware of safety needs, was unsteady on her feet, lost her balance, propelled her wheelchair, was non-ambulatory, experienced a recent transfer, was continent and needed assistance. This form reflected, "This form has been developed to adequately assess all aspects of the resident's well-being (physical, mental, emotional, environmental, and social considerations) prior to the use of either chemical or physical restraints in order to identify the least restrictive intervention. It is to be completed by a licensed nurse or licensed physical/occupational therapist. This assessment is to be completed upon admission, quarterly, and with any change in condition." The Referrals/Recommendations section was blank. Interview on 10/22/13 at 7:04 p.m. with the RNC revealed the "Safety Assessment Informed Consent" was part of the system for the staff (nurses and therapists) to utilize on admission, readmission, quarterly, and change in condition to assess the residents concerning safety. The RNC said these forms were part of the system for fall prevention. The forms were to allow the staff to recognize and identify the need for intervention and to assist in identifying safety issues the resident might have. Resident #10's Nurse's Notes, dated 10/01/13 at 11:00 a.m., reflected she was sitting in her wheelchair, was alert with episodes of confusion, and was a two person transfer. Resident #10 was continent with episodes of incontinence. Resident #10's Nurse's Notes, dated 10/01/13 at 12:20 p.m., reflected, "Observed residents trying to get up from wc (wheelchair). Resident stood up & (and) then set (sic) back down. Resident instructed to wait. Turned away from doorway to ask aide for assistance. Turned back to resident. Resident then stating she fell . When asked how she fell and got back up while this nurse was standing there, Resident stated she 'sat back down in wc, not fell .' She also stated 'I scraped my arm.' (Left) arm assessed. No scrapes, bleeding, or hematoma notes. Resident appears to have delayed thought process & slow speech. Notified MD (physician). Received in/O (new order) for labs for CBC, CMP, UA (with) C&S. Will continue to monitor." Interview on 10/22/13 at 11:03 a.m. with LVN A revealed she was the nurse when Resident #10 was standing up and sitting down in her wheelchair on 10/01/13. LVN A said she had gotten the order from the physician for the labs, but by the time she saw the lab results Resident #10 had already fallen and was in the hospital for the broken hip. LVN A revealed Resident #10 fell on [DATE] and she did everything she was supposed to do as a nurse, including the Incident/Accident Report. When asked why she thought Resident #10 was standing up and down out of the wheelchair on 10/01/13, LVN A replied she thought the resident needed to go to the bathroom and she might have an Urinary Tract Infection. Resident #10's Urinalysis Results, dated 10/03/13 and received at the facility at 4:10 p.m., reflected a trace of blood, large amount of white blood cells, and many bacteria in her urine. The Urinalysis Report had a handwritten note from the nursing staff, which reflected it was faxed to the physician on 10/05/13. Resident #10's Nurse's Notes, dated 10/03/13 at 10:40 a.m., reflected she was on the floor at 10:22 a.m., a full body assessment was conducted by LVN A, and the resident complained of left hip pain. The Notes also reflected LVN A obtained a physician's orders [REDACTED]. Interview on 10/22/13 at 11:03 a.m. with LVN A revealed Resident #10 had her call light on and when she had entered the room to see what the resident wanted on 10/03/13, Resident #10 was on the floor. LVN A said Resident #10 wanted to go to the bathroom and nobody had come. When asked if the nursing staff was involved in any meetings to discuss interventions concerning residents who had fallen, she replied, "No." When asked if the nursing staff had any protocols to follow concerning interventions when a resident fell , LVN A replied, "No." When asked if there was a bowel and bladder program for Resident #10, she responded they completed bowel and bladder assessments on admission, quarterly and yearly, but nothing happened. LVN A stated the assessment forms stayed in the resident's clinical records. She revealed those were the only forms they had to use. LVN A said they had never been told or given any other types of forms to use. LVN A revealed the staff was trying to get some type of program (Bowel and Bladder) "going" with Resident #10, but the whole staff was not doing the same thing and it was hard when there was no consistency or communication between the nurses and the DON concerning residents. Interview on 10/22/13 at 9:15 a.m. with CNA E revealed when asked if she was working on 10/03/13 when Resident #10 fell , CNA E replied she was working, but was on break. She revealed she learned of the fall from LVN A when she returned from her break. When asked if she was working on 10/01/13 when Resident #10 was standing up and sitting down in her wheelchair, CNA E replied she worked and helped the nurse place the resident back in the bed. When asked what she thought Resident #10 wanted on 10/01/13, she responded the resident wanted to go to the bathroom. CNA E said the staff tried to take Resident #10 to the bathroom, but they could not get the rest of the staff on the "same page. We (CNAs) had no paperwork to tell us if the resident was on any type of bowel and bladder program." CNA E revealed sometimes Resident #10 was taken to the bathroom and sometimes she was not taken. She stated occasionally Resident #10 rang her call light and wanted to go the bathroom. When asked if she had seen any fall interventions for Resident #10 prior to her going to the hospital, CNA E replied, "No." Resident #10's Physician's Telephone Order, dated 10/03/13, reflected to x-ray her left hip due to a fall. Resident #10's X-ray Results, dated 10/03/13 reflected, "Moderate [MEDICAL CONDITION] of the left hip within limits." A handwritten note on the x-ray results reflected the results were faxed to the physician on 10/03/13. Review of the facility's Incident/Accident book for the months of August 2013, September 2013, and October 2013 did not reveal any Incident/Accident Reports for Resident #10 on 10/01/13 or 10/03/13. An interview with the DON on 10/21/13 at 2:20 p.m. revealed Resident #10 only had one fall on 10/04/13. She stated the Incident/Accident Report, dated 10/04/13, was the only Report she had for Resident #10. Further interview on 10/21/13 at 3:45 p.m. with the DON revealed the nursing staff was required to complete an Incident/Accident Report anytime a resident had a fall, bruise, skin tear, or any unusual injury. The staff was required to call her about all incidents, if she was not in the facility. The DON revealed the staff placed the reports in a box at the Nurse's Station, and she picked them up every day and went over every report in the morning stand-up meeting. She stated after the meeting, she looked at the reports to see what all was reviewed such as therapy needs, medications, and a need for alarms. When asked if there was not an Incident/Accident Report how would she know a resident had an occurrence, the DON replied she reviewed "Twenty-Four Hour Reports" every day and if it was on there then she would know. The DON said they still had to call her with every incident. Resident #10's Fall Risk Assessment Form, dated 10/04/13 and completed by LVN A, reflected a score of 17, which indicated the resident was at high risk of falls. An interview with LVN A on 10/22/13 at 11:03 a.m. revealed the Fall Risk Assessments were to be completed on admission, quarterly, readmission, and following an incident/accident. When asked what happened if a resident scored as a high risk for falls, she replied, "Nothing. I just know we are supposed to fill them out and put them in the chart and the DON gets a copy following a fall." LVN A said there were other forms that were completed when a resident had a fall including a form about the resident's cognition and a "tree" for identifying what to do when the resident falls. LVN A said there was a "Safety Form" but she was unclear what to do with this form. LVN A said she just completed the forms and then placed them in the chart. The facility's Incident/Accident Report, dated 10/04/13, reflected Resident #10 was calling out for help and when the nurse heard her calling she found her in in the bathroom with her back against the toilet sitting on the floor. The nurse assessed her, and she had right leg pain. The nurse contacted the physician, who ordered x-rays. The unsigned and undated "Final Deposition Report" identified as completed by the DON on 10/21/13 at 2:00 p.m., reflected the reasonable root cause of the occurrence was Resident #10 attempting to transfer herself. The "Final Deposition Report" included as part of the incident/accident report, reflected the resident did not use the call light, and she was transferred to the hospital. Interview on 10/21/13 at 5:50 p.m. with LVN C revealed she was aware Resident #10 had fallen the day before, 10/03/13, because it was on the "Twenty-Four Hour Report" and neurological checks were in progress from that fall. LVN C said Resident #10 fell again during her shift on 10/04/13, which caused her to contact the physician and get x-rays ordered due to the resident complaining of pain to her right leg. LVN C revealed Resident #10 was in the bathroom, and she did not know how she got in the bathroom. She stated Resident #10 could propel her wheelchair, but could not walk more than a few steps. LVN C said Resident #10 said she was trying to go the bathroom, but she thought she could do this on her own. LVN C said the nurses were supposed to complete an Incident/Accident Report, place it in the box and put it on the "Twenty-Four Hour Report," then contact the physician and the family, and follow any orders the physician gave. Resident #10's X-ray Results, dated 10/04/13, reflected comminuted (shattered into pieces) [MEDICAL CONDITION] right femur. Further review reflected a handwritten fax reflected, the x-ray results had been faxed to the physician. Resident #10's Physician's Telephone Order, 10/04/13, reflected to send her to to the emergency room due to femur fracture. Resident #10's "Cognitive/Behavior Collection," dated 10/04/13, reflected she required interventions 1-6 days per week for orientation and memory, resident exhibited attention seeking behaviors that required frequent redirection and/or verbal reassurance, resident was very forgetful, required frequent reminders concerning task at hand, and the outcome to these interventions had little effect. The "Fall Risk Assessment Algorithm," dated 10/04/13 reflected no additional services requested, discipline already ordered. When asked on 10/22/13 at 11:03 a.m., why there was no further recommendations made concerning Resident #10, LVN A replied the resident was already receiving Restorative Therapy and had been receiving it for some time. Interview on 10/21/13 at 2:20 p.m. with the DON revealed she only had one Incident/Accident Report for Resident #10, dated 10/04/13. She stated Resident #10 stood up and sat down in her room sometime around the first part of the month, but she did not fall, so an Incident Report was not completed. The facility's "Twenty-four Hour Report," dated 10/04/13, reflected LVN C documented Resident #10 had fallen, x-rays had been ordered, and neurological checks were in progress. Resident #10's Comprehensive Plan of Care, dated 10/07/13 while the resident was in the hospital, reflected a history of falls and a high risk for increased falls and fractures as evidenced by cognitive impairment and an unsteady gait. The goal of the Plan of Care was for Resident #10's dignity to be maintained, the incidences of falls to be reduced, and no injuries to occur over the next 90 days. The Plan of Care's Approaches were 1) Encourage resident to ask for assistance from staff. 2) Ensure call light is in reach, answer promptly 3) Therapy to eval and treat per orders 4) Anticipate needs, provide prompt assistance 5) Assure lighting is adequate and areas are free of clutter 6) Encourage socialization and activity attendance-as tolerated. Resident #10's Comprehensive Plan of Care, dated 10/07/13, while the resident was still in the hospital, reflected Resident #10 was noncompliant with care as evidenced by her failure to use the call light. The Approaches included the nurse physically seeing the residents per policy and procedure and frequently by nursing staff to ensure safety. Resident #10's MDS assessment, dated 10/16/13, reflected the resident was readmitted to the facility on [DATE]. Resident #10 required the extensive assistance (resident involved in activity, staff provide weight bearing support) of one person for transfers. Resident #10's range of motion in her lower extremity (hip, knee, ankle, foot) was impaired on one side. She was incontinent of bladder and incontinent of bowel. The MDS assessment also reflected [DIAGNOSES REDACTED]. Interview on 10/21/13 at 12:30 p.m. with Resident #10 revealed the staff had to use a lift now to get her up. She stated she wished her leg, which was bothering her, would get better. When asked what she meant, the resident replied she fell a time back out of her wheelchair. Resident #10 revealed she recalled leaning forward, but she did not remember anything else. She stated she broke her hip. Resident #10 said that was the only fall she had. When asked if she could walk prior to this happening, she replied she could not remember, but she thought she could. Resident #10 revealed she remembered falling. Interview on 10/22/13 at 9:15 a.m. with CNA E revealed she had been caring for Resident #10 for some time now. CNA E said Resident #10 was able to stand and pivot herself, but now with her broken hip, they had to use the Hoyer Lift. CNA E revealed Resident #10 could still propel her own wheelchair. She stated Resident #10 was forgetful and at times got upset with the staff because the resident thought the staff had forgotten to do "stuff" for her. CNA E stated Resident #10 got the scoop mattress after she returned from the hospital. CNA E also revealed since surveyor inquiry, Resident #10 was identified as a resident the CNAs take to the bathroom now, and then they placed an alarm on her chair. Resident #10's Comprehensive Care Plan, dated 10/07/13, did not address transfers or the need for Resident #10 to be transferred via Hoyer lift. Interview on 10/22/13 at 11:00 a.m. with the DON revealed she had communicated with the staff on 10/21/13 at 7:00 p.m., concerning the safety needs of Resident #10. She realized putting an alarm on her wheelchair would remind the resident to sit down and taking the resident to the bathroom would help keep the resident safer. Interview on 10/23/13 at 1:00 p.m. with Rehab Manager revealed Resident #10 had been on the Restorative Program for some time. The Rehab Manager said Resident #10 had been re-evaluated for services following her hospitalization for the fall and the fracture. The Rehab Manager stated he did not recall any discussion in the morning stand up meetings about Resident #10 falling. When asked if staff ever came to him about interventions for other residents, he replied they did at times, but he had never been asked about Resident #10. The Rehab Director said he noticed a chair alarm was placed on Resident #10, which he thought was a good idea. He stated he was going to speak to the surgeon concerning placing a positioning cushion to prevent Resident #10 from leaning forward in the chair, but wanted to make sure it would not affect the healing of the hip. The "Nursing Restorative Care Program" reflected Resident #10 had been on service from April 2013 through October 2013. The Restorative Plan included: range of motion and mobility goals. During this time there were no changes in goals or approaches. The Program reflected increasing and maintaining strength, range of motion to lower extremities, ambulation with rolling walker as tolerated, and stationary lower extremities peddler as tolerated. 3. Resident #3's most recent MDS assessment, dated 10/08/13, reflected the resident was a [AGE] year-old male, who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the MDS assessment, the resident required the extensive assistance of one person with transfers, bed mobility and dressing. Resident #3's admission orders [REDACTED]. Resident #3's Admission Care Plan, dated 10/01/13, addressed the problem of falls. The goal reflected he would remain free of injuries and falls. The Care Plan's interventions included keeping the call light in reach, encouraging the use of the call light, and a personal alarm if needed. Resident #3's Nurse's Notes, dated 10/03/13 at 2:15 p.m., reflected the resident was found on the floor, assessed and assisted to the chair. According to the Notes, Resident #3 had poor motor skills. The Notes reflected no injuries were sustained during the fall. An interview with LVN F on 10/22/13 at 3:30 p.m. revealed he was the author of the Nurse's Notes, dated 10/03/13 at 2:15 p.m. The nurse stated the resident was found on the floor of his room. According to the nurse, he had completed an Incident/Accident Report and placed it in the Twenty-four Hour Nurse's book. LVN F further stated the resident told him he had leaned too far over in the wheelchair and fell forward. LVN F stated he had worked in the facility for four years and nurses always placed the completed Incident/Accident Reports in the Twenty-four Hour Nurse's book. Additionally, LVN F stated when he returned to work the next day on 10/04/13 the Incident/Accident Report was gone. The facility's "Twenty-four Hour Reports," dated 10/03/13 and 10/04/13 reflected Resident #3 was listed as being in follow-up status due to a fall. According to the reports, neurological checks were in progress during the follow-up. The facility's Incident/Accident Reports for August 2013, September 2013 and October 2013 did not reflect Resident #3's fall. A safety assessment, dated 10/04/13, reflected Resident #3 was aware of safety needs but exhibited impaired decision making and had a history of [REDACTED]. Resident #3's Fall Risk Assessment, dated 10/05/13, reflected a score of 17, which indicated the resident was at high risk for falls. Resident #3's Admission Care Plan, dated 10/01/13, did not reflect an update or review regarding Resident #3's fall on 10/03/13 or that he was at high risk for falls. Resident #3 was initially observed sitting in a wheelchair in his room during rounds on 10/21/13 at 9:15 a.m. with LVN D. The nurse described the resident as being blind, continent of bowel/bladder and requiring assistance with eating. Resident #3's Comprehensive Plan of Care, dated 10/11/13, did not reflect the resident was at high risk for falls. There was no review or revision to address Resident #3's fall on 10/03/13. Interview on 10/21/13 at 2:20 p.m. with the DON revealed she was not aware Resident #3 had a fall. She stated she did not have an Incident/Accident Report for Resident #3. Interview on 10/21/13 at 3:45 p.m. with the DON revealed the nursing staff was required to complete an Incident/Accident Report anytime a resident had a fall, bruise, skin tear, or any unusual injury. The staff was required to call her about all incidents, if she was not in the facility. The DON revealed the staff placed the reports in a box at the Nurse's Station, and she picked them up every day and went over every report in the morning stand-up meeting. She stated after the meeting, she looked at the reports to see what all was reviewed such as therapy needs, medications, and a need for alarms. When asked if there was not an Incident/Accident Report how would she know a resident had an occurrence, the DON replied she reviewed "Twenty-Four Hour Reports" every day and if it was on there then she would know. The DON said they still had to call her with every incident. When asked again about an Incident/Accident Report for Resident #3, the DON replied there was not one. 4. An IJ was identified on 10/21/13. The Administrator, DON, and ADON were informed on 10/21/13 at 5:04 p.m. of the IJ, and a Plan of Removal was requested at that time. 5. Interview on 10/23/13 at 3:41 p.m. with the DON revealed she knew the IJ occurred because she did not have enough interventions in place for Resident #10 to ensure safety. The DON said she still did not think the fact that she had not put any interventions in place when the resident was standing up and sitting down was a part of the immediacy because she thought that was something the nurses saw and dealt with every day. She asked how was she supposed to know that would lead to the resident falling and breaking her hip. The DON said they now had systems of reporting, communicating, and follow-up concerning residents' changes and incidents. 6. The facility's Plan of Removal, dated and accepted on 10/22/13, reflected all residents would have fall risk assessments, and all fall risk assessments were redone on 10/21/13 for accuracy and following policy for all residents. Fall risk assessments would be completed upon admission/readmission, change of condition, and quarterly. Fall safety evaluations for fall prevention and recommendations from Therapy for prevention of falls were all started on 10/21/13 and completed on 10/22/13. Any resident with a score of "10" or higher who was identified as high fall risk or who had a fall was referred to therapy. Individualized Care Plans were updated on 10/21/13 reflecting interventions, and Aides' Care Plans were also updated to reflect interventions. The 43 residents, who were identified as "high risk" for falls, care plans were individualized on 10/21/13. The Safety Assessments by therapy for cognitive impairment, non-weight bearing, physical impairment, and unsteady gait were completed and provided to the DON/ADON and Admin for interventions to be placed and monitored by 10/22/13. The Restorative aide would monitor interventions, for placement and working order daily and a complete checklist that would be turned in daily to the ADON/DON, at which time they would notify Administration of any issues and also present to the Quality Assurance Committee fall prevention devices were in place for each resident. An in-service was initiated by the Administrator/Regional Clinical Director, DON, and ADON. The in-service would continue each shift to ensure all staff had the training. Arrangements were made with staff to attend individual training. In-services were related to: validating placement of alarms/fall mats/fall interventions and specialty equipment with a validation of training by a "Fall Care Basics" test with a passing score of 80% or higher. All staff with a lower score would be retrained and retested until a score of 80% or higher. Fall assessment and prevention would be part of the orientation process and ongoing in-service for all departments including the weekend staff. 7. Interviews conducted on 10/23/13 at 9:40 a.m. and 2:20 p.m. with LVNs D and F revealed they received training on 10/22/13 regarding fall prevention. The nurses stated training included nursing staff participating and implementing interventions for residents who fall and residents who were assessed to be at a high risk for falls. The nurses were able to explain when the fall risk assessment would be completed, on admission, readmission, changes in conditions, following a fall and quarterly. The nurses were able to explain the scoring system associated with the fall risk assessments and the therapy department referral process. On 10/23/13 at 10:45 a.m., Laundry Aide I was interviewed regarding falls and fall prevention. Laundry Aide I stated she recently had training regarding resident falls and actions to take. Laundry Aide I stated she was unable to physically assist a resident but would immediately notify the charge nurse if she found a resident after a fall. On 10/23/13 at 10:54 a.m. LVN B was interviewed regarding falls and fall prevention. LVN B stated training was held the afternoon of 10/22/13 and covered fall prevention such as removing clutter from a resident's room and ensuring that residents with visual impairment wear their glasses. LVN B stated that residents would be referred to therapy after a fall and fall assessments were to be completed after a resident's fall, significant change in status, readmission to the facility and upon admission. Interview on 10/23/13 at 11:28 a.m. with CNA H revealed the CNA received training regarding falls and fall prevention on the evening of 10/22/13. CNA H said following the in-service a test was given and staff had to make 80% on the test to pass it. CNA H understood trying to keep the residents safe and if a fall was witnessed, the charge nurse was to be notified. CNA H also revealed if staff thought something could cause a problem for the resident to report it to the nurse. On 10/23/13 at 12:36 p.m., CNA E was interviewed regarding falls and fall prevention. CNA E stated she had training on 10/22/13 along with a test given afterwards. CNA E stated if a resident had a fall, she would notify the nurse and then report the fall to the Administrator. CNA E also stated she would try and prevent resident falls by asking residents if they needed something before leaving their room and checking for environmental hazards. 8. The Administrator, RNC, and ADON were informed on 10/23/13 at 4:30 p.m. that the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of "pattern" because the facility was still in-servicing staff and monitoring the effectiveness of the Plan of Removal. 9. The facility's Form CMS-802, Roster/Sample Matrix provided on 10/21/13 by the DON reflected four residents had sustained falls out of the 43 residents identified by the facility as high risk for falls, following re-screening all residents for fall risk, provided by the DON on 10/22/13.

Based on observation, interview and record review, it was determined the facility failed to ensure each resident received adequate supervision to prevent accidents for two (Residents #10 and #3) of four residents reviewed for falls. 1. The facility failed to develop and implement interventions to prevent Resident #10, who was identified as a high fall risk, from falling. Resident #10 fell on [DATE] and again on 10/04/13 and sustained a fractured hip. She was sent to the hospital and admitted . Resident #10 was readmitted to the facility on [DATE]. 2. The facility failed to develop and implement individualized interventions to prevent Resident #10, who had a fractured hip and was still at high risk for falls, from falling. 3. The facility failed to implement individualized interventions to prevent Resident #3, who was at high risk for falls, from falling. On 10/21/13 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 10/23/13, the facility remained out of compliance at severity level of "actual harm that is not immediate jeopardy" and a scope of "pattern" because staff were still being in-serviced, and the facility was monitoring the effectiveness of their plan of removal. These failures could affect the 43 residents, including Residents #3 and #10, who were at high risk for falls, by placing them at risk for falls, bruises, fractures, and/or death. Findings included: 1. Resident #10's MDS assessment, dated 07/04/13, reflected the resident was a [AGE] year-old female, who was admitted to the facility on [DATE] and her [DIAGNOSES REDACTED]. She spoke clearly, was able to make herself understood and had the ability to understand others. Resident #10 was moderately impaired cognitively. She needed extensive assistance with toileting, her gait was unsteady and she needed assistance to stabilize during transfers to her wheelchair. Resident #10's range of motion was not impaired, and she was continent of bladder and occasionally incontinent of bowel. The MDS assessment also reflected she was 63 inches in height and weighed 238 pounds. Resident #10's Fall Risk Assessment Form, dated 07/14/13 and completed by LVN A, reflected a score of 13, which indicated she was at high risk for falls. Resident #10's "Comprehensive Plan of Care," dated 04/13/13 and updated on 07/10/13, did not reflect a plan of care to prevent falls. Interview on 10/21/13 at 2:00 p.m. with the DON revealed there were no care plan interventions in place to prevent Resident #10 from falling prior to 10/07/13. Resident #10's undated quarterly assessment "Bladder Incontinence Evaluation" reflected she was continent and no further assessment was needed. Resident #10's unsigned and undated Safety Assessment Informed Consent reflected she was alert, was aware of safety needs, was unsteady on her feet, lost her balance, propelled her wheelchair, was non-ambulatory, experienced a recent transfer, was continent and needed assistance. This form reflected, "This form has been developed to adequately assess all aspects of the resident's well-being (physical, mental, emotional, environmental, and social considerations) prior to the use of either chemical or physical restraints in order to identify the least restrictive intervention. It is to be completed by a licensed nurse or licensed physical/occupational therapist. This assessment is to be completed upon admission, quarterly, and with any change in condition." The Referrals/Recommendations section was blank. Interview on 10/22/13 at 7:04 p.m. with the RNC revealed the "Safety Assessment Informed Consent" was part of the system for the staff (nurses and therapists) to utilize on admission, readmission, quarterly, and change in condition to assess the residents concerning safety. The RNC said these forms were part of the system for fall prevention. The forms were to allow the staff to recognize and identify the need for intervention and to assist in identifying safety issues the resident might have. Resident #10's Nurse's Notes, dated 10/01/13 at 11:00 a.m., reflected she was sitting in her wheelchair, was alert with episodes of confusion, and was a two person transfer. Resident #10 was continent with episodes of incontinence. Resident #10's Nurse's Notes, dated 10/01/13 at 12:20 p.m., reflected, "Observed residents trying to get up from wc (wheelchair). Resident stood up & (and) then set (sic) back down. Resident instructed to wait. Turned away from doorway to ask aide for assistance. Turned back to resident. Resident then stating she fell . When asked how she fell and got back up while this nurse was standing there, Resident stated she 'sat back down in wc, not fell .' She also stated 'I scraped my arm.' (Left) arm assessed. No scrapes, bleeding, or hematoma notes. Resident appears to have delayed thought process & slow speech. Notified MD (physician). Received in/O (new order) for labs for CBC, CMP, UA (with) C&S. Will continue to monitor." Interview on 10/22/13 at 11:03 a.m. with LVN A revealed she was the nurse when Resident #10 was standing up and sitting down in her wheelchair on 10/01/13. LVN A said she had gotten the order from the physician for the labs, but by the time she saw the lab results Resident #10 had already fallen and was in the hospital for the broken hip. LVN A revealed Resident #10 fell on [DATE] and she did everything she was supposed to do as a nurse, including the Incident/Accident Report. When asked why she thought Resident #10 was standing up and down out of the wheelchair on 10/01/13, LVN A replied she thought the resident needed to go to the bathroom and she might have an Urinary Tract Infection. Resident #10's Urinalysis Results, dated 10/03/13 and received at the facility at 4:10 p.m., reflected a trace of blood, large amount of white blood cells, and many bacteria in her urine. The Urinalysis Report had a handwritten note from the nursing staff, which reflected it was faxed to the physician on 10/05/13. Resident #10's Nurse's Notes, dated 10/03/13 at 10:40 a.m., reflected she was on the floor at 10:22 a.m., a full body assessment was conducted by LVN A, and the resident complained of left hip pain. The Notes also reflected LVN A obtained a physician's orders [REDACTED]. Interview on 10/22/13 at 11:03 a.m. with LVN A revealed Resident #10 had her call light on and when she had entered the room to see what the resident wanted on 10/03/13, Resident #10 was on the floor. LVN A said Resident #10 wanted to go to the bathroom and nobody had come. When asked if the nursing staff was involved in any meetings to discuss interventions concerning residents who had fallen, she replied, "No." When asked if the nursing staff had any protocols to follow concerning interventions when a resident fell , LVN A replied, "No." When asked if there was a bowel and bladder program for Resident #10, she responded they completed bowel and bladder assessments on admission, quarterly and yearly, but nothing happened. LVN A stated the assessment forms stayed in the resident's clinical records. She revealed those were the only forms they had to use. LVN A said they had never been told or given any other types of forms to use. LVN A revealed the staff was trying to get some type of program (Bowel and Bladder) "going" with Resident #10, but the whole staff was not doing the same thing and it was hard when there was no consistency or communication between the nurses and the DON concerning residents. Interview on 10/22/13 at 9:15 a.m. with CNA E revealed when asked if she was working on 10/03/13 when Resident #10 fell , CNA E replied she was working, but was on break. She revealed she learned of the fall from LVN A when she returned from her break. When asked if she was working on 10/01/13 when Resident #10 was standing up and sitting down in her wheelchair, CNA E replied she worked and helped the nurse place the resident back in the bed. When asked what she thought Resident #10 wanted on 10/01/13, she responded the resident wanted to go to the bathroom. CNA E said the staff tried to take Resident #10 to the bathroom, but they could not get the rest of the staff on the "same page. We (CNAs) had no paperwork to tell us if the resident was on any type of bowel and bladder program." CNA E revealed sometimes Resident #10 was taken to the bathroom and sometimes she was not taken. She stated occasionally Resident #10 rang her call light and wanted to go the bathroom. When asked if she had seen any fall interventions for Resident #10 prior to her going to the hospital, CNA E replied, "No." Resident #10's Physician's Telephone Order, dated 10/03/13, reflected to x-ray her left hip due to a fall. Resident #10's X-ray Results, dated 10/03/13 reflected, "Moderate Osteoarthritis of the left hip within limits." A handwritten note on the x-ray results reflected the results were faxed to the physician on 10/03/13. Review of the facility's Incident/Accident book for the months of August 2013, September 2013, and October 2013 did not reveal any Incident/Accident Reports for Resident #10 on 10/01/13 or 10/03/13. An interview with the DON on 10/21/13 at 2:20 p.m. revealed Resident #10 only had one fall on 10/04/13. She stated the Incident/Accident Report, dated 10/04/13, was the only Report she had for Resident #10. Further interview on 10/21/13 at 3:45 p.m. with the DON revealed the nursing staff was required to complete an Incident/Accident Report anytime a resident had a fall, bruise, skin tear, or any unusual injury. The staff was required to call her about all incidents, if she was not in the facility. The DON revealed the staff placed the reports in a box at the Nurse's Station, and she picked them up every day and went over every report in the morning stand-up meeting. She stated after the meeting, she looked at the reports to see what all was reviewed such as therapy needs, medications, and a need for alarms. When asked if there was not an Incident/Accident Report how would she know a resident had an occurrence, the DON replied she reviewed "Twenty-Four Hour Reports" every day and if it was on there then she would know. The DON said they still had to call her with every incident. Resident #10's Fall Risk Assessment Form, dated 10/04/13 and completed by LVN A, reflected a score of 17, which indicated the resident was at high risk of falls. An interview with LVN A on 10/22/13 at 11:03 a.m. revealed the Fall Risk Assessments were to be completed on admission, quarterly, readmission, and following an incident/accident. When asked what happened if a resident scored as a high risk for falls, she replied, "Nothing. I just know we are supposed to fill them out and put them in the chart and the DON gets a copy following a fall." LVN A said there were other forms that were completed when a resident had a fall including a form about the resident's cognition and a "tree" for identifying what to do when the resident falls. LVN A said there was a "Safety Form" but she was unclear what to do with this form. LVN A said she just completed the forms and then placed them in the chart. The facility's Incident/Accident Report, dated 10/04/13, reflected Resident #10 was calling out for help and when the nurse heard her calling she found her in in the bathroom with her back against the toilet sitting on the floor. The nurse assessed her, and she had right leg pain. The nurse contacted the physician, who ordered x-rays. The unsigned and undated "Final Deposition Report" identified as completed by the DON on 10/21/13 at 2:00 p.m., reflected the reasonable root cause of the occurrence was Resident #10 attempting to transfer herself. The "Final Deposition Report" included as part of the incident/accident report, reflected the resident did not use the call light, and she was transferred to the hospital. Interview on 10/21/13 at 5:50 p.m. with LVN C revealed she was aware Resident #10 had fallen the day before, 10/03/13, because it was on the "Twenty-Four Hour Report" and neurological checks were in progress from that fall. LVN C said Resident #10 fell again during her shift on 10/04/13, which caused her to contact the physician and get x-rays ordered due to the resident complaining of pain to her right leg. LVN C revealed Resident #10 was in the bathroom, and she did not know how she got in the bathroom. She stated Resident #10 could propel her wheelchair, but could not walk more than a few steps. LVN C said Resident #10 said she was trying to go the bathroom, but she thought she could do this on her own. LVN C said the nurses were supposed to complete an Incident/Accident Report, place it in the box and put it on the "Twenty-Four Hour Report," then contact the physician and the family, and follow any orders the physician gave. Resident #10's X-ray Results, dated 10/04/13, reflected comminuted (shattered into pieces) fracture of the distal right femur. Further review reflected a handwritten fax reflected, the x-ray results had been faxed to the physician. Resident #10's Physician's Telephone Order, 10/04/13, reflected to send her to to the emergency room due to femur fracture. Resident #10's "Cognitive/Behavior Collection," dated 10/04/13, reflected she required interventions 1-6 days per week for orientation and memory, resident exhibited attention seeking behaviors that required frequent redirection and/or verbal reassurance, resident was very forgetful, required frequent reminders concerning task at hand, and the outcome to these interventions had little effect. The "Fall Risk Assessment Algorithm," dated 10/04/13 reflected no additional services requested, discipline already ordered. When asked on 10/22/13 at 11:03 a.m., why there was no further recommendations made concerning Resident #10, LVN A replied the resident was already receiving Restorative Therapy and had been receiving it for some time. Interview on 10/21/13 at 2:20 p.m. with the DON revealed she only had one Incident/Accident Report for Resident #10, dated 10/04/13. She stated Resident #10 stood up and sat down in her room sometime around the first part of the month, but she did not fall, so an Incident Report was not completed. The facility's "Twenty-four Hour Report," dated 10/04/13, reflected LVN C documented Resident #10 had fallen, x-rays had been ordered, and neurological checks were in progress. Resident #10's Comprehensive Plan of Care, dated 10/07/13 while the resident was in the hospital, reflected a history of falls and a high risk for increased falls and fractures as evidenced by cognitive impairment and an unsteady gait. The goal of the Plan of Care was for Resident #10's dignity to be maintained, the incidences of falls to be reduced, and no injuries to occur over the next 90 days. The Plan of Care's Approaches were 1) Encourage resident to ask for assistance from staff. 2) Ensure call light is in reach, answer promptly 3) Therapy to eval and treat per orders 4) Anticipate needs, provide prompt assistance 5) Assure lighting is adequate and areas are free of clutter 6) Encourage socialization and activity attendance-as tolerated. Resident #10's Comprehensive Plan of Care, dated 10/07/13, while the resident was still in the hospital, reflected Resident #10 was noncompliant with care as evidenced by her failure to use the call light. The Approaches included the nurse physically seeing the residents per policy and procedure and frequently by nursing staff to ensure safety. Resident #10's MDS assessment, dated 10/16/13, reflected the resident was readmitted to the facility on [DATE]. Resident #10 required the extensive assistance (resident involved in activity, staff provide weight bearing support) of one person for transfers. Resident #10's range of motion in her lower extremity (hip, knee, ankle, foot) was impaired on one side. She was incontinent of bladder and incontinent of bowel. The MDS assessment also reflected [DIAGNOSES REDACTED]. Interview on 10/21/13 at 12:30 p.m. with Resident #10 revealed the staff had to use a lift now to get her up. She stated she wished her leg, which was bothering her, would get better. When asked what she meant, the resident replied she fell a time back out of her wheelchair. Resident #10 revealed she recalled leaning forward, but she did not remember anything else. She stated she broke her hip. Resident #10 said that was the only fall she had. When asked if she could walk prior to this happening, she replied she could not remember, but she thought she could. Resident #10 revealed she remembered falling. Interview on 10/22/13 at 9:15 a.m. with CNA E revealed she had been caring for Resident #10 for some time now. CNA E said Resident #10 was able to stand and pivot herself, but now with her broken hip, they had to use the Hoyer Lift. CNA E revealed Resident #10 could still propel her own wheelchair. She stated Resident #10 was forgetful and at times got upset with the staff because the resident thought the staff had forgotten to do "stuff" for her. CNA E stated Resident #10 got the scoop mattress after she returned from the hospital. CNA E also revealed since surveyor inquiry, Resident #10 was identified as a resident the CNAs take to the bathroom now, and then they placed an alarm on her chair. Resident #10's Comprehensive Care Plan, dated 10/07/13, did not address transfers or the need for Resident #10 to be transferred via Hoyer lift. Interview on 10/22/13 at 11:00 a.m. with the DON revealed she had communicated with the staff on 10/21/13 at 7:00 p.m., concerning the safety needs of Resident #10. She realized putting an alarm on her wheelchair would remind the resident to sit down and taking the resident to the bathroom would help keep the resident safer. Interview on 10/23/13 at 1:00 p.m. with Rehab Manager revealed Resident #10 had been on the Restorative Program for some time. The Rehab Manager said Resident #10 had been re-evaluated for services following her hospitalization for the fall and the fracture. The Rehab Manager stated he did not recall any discussion in the morning stand up meetings about Resident #10 falling. When asked if staff ever came to him about interventions for other residents, he replied they did at times, but he had never been asked about Resident #10. The Rehab Director said he noticed a chair alarm was placed on Resident #10, which he thought was a good idea. He stated he was going to speak to the surgeon concerning placing a positioning cushion to prevent Resident #10 from leaning forward in the chair, but wanted to make sure it would not affect the healing of the hip. The "Nursing Restorative Care Program" reflected Resident #10 had been on service from April 2013 through October 2013. The Restorative Plan included: range of motion and mobility goals. During this time there were no changes in goals or approaches. The Program reflected increasing and maintaining strength, range of motion to lower extremities, ambulation with rolling walker as tolerated, and stationary lower extremities peddler as tolerated. 2. Resident #3's most recent MDS assessment, dated 10/08/13, reflected the resident was a [AGE] year-old male, who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the MDS assessment, the resident required the extensive assistance of one person with transfers, bed mobility and dressing. Resident #3's admission orders [REDACTED]. Resident #3's Admission Care Plan, dated 10/01/13, addressed the problem of falls. The goal reflected he would remain free of injuries and falls. The Care Plan's interventions included keeping the call light in reach, encouraging the use of the call light, and a personal alarm if needed. Resident #3's Nurse's Notes, dated 10/03/13 at 2:15 p.m., reflected the resident was found on the floor, assessed and assisted to the chair. According to the Notes, Resident #3 had poor motor skills. The Notes reflected no injuries were sustained during the fall. An interview with LVN F on 10/22/13 at 3:30 p.m. revealed he was the author of the Nurse's Notes, dated 10/03/13 at 2:15 p.m. The nurse stated the resident was found on the floor of his room. According to the nurse, he had completed an Incident/Accident Report and placed it in the Twenty-four Hour Nurse's book. LVN F further stated the resident told him he had leaned too far over in the wheelchair and fell forward. LVN F stated he had worked in the facility for four years and nurses always placed the completed Incident/Accident Reports in the Twenty-four Hour Nurse's book. Additionally, LVN F stated when he returned to work the next day on 10/04/13 the Incident/Accident Report was gone. The facility's "Twenty-four Hour Reports," dated 10/03/13 and 10/04/13 reflected Resident #3 was listed as being in follow-up status due to a fall. According to the reports, neurological checks were in progress during the follow-up. The facility's Incident/Accident Reports for August 2013, September 2013 and October 2013 did not reflect Resident #3's fall. A safety assessment, dated 10/04/13, reflected Resident #3 was aware of safety needs but exhibited impaired decision making and had a history of [REDACTED]. Resident #3's Fall Risk Assessment, dated 10/05/13, reflected a score of 17, which indicated the resident was at high risk for falls. Resident #3's Admission Care Plan, dated 10/01/13, did not reflect an update or review regarding Resident #3's fall on 10/03/13 or that he was at high risk for falls. Resident #3 was initially observed sitting in a wheelchair in his room during rounds on 10/21/13 at 9:15 a.m. with Licensed Vocational Nurse (LVN) D. The nurse described the resident as being blind, continent of bowel/bladder and requiring assistance with eating. Resident #3's Comprehensive Plan of Care, dated 10/11/13, did not reflect the resident was at high risk for falls. There was no review or revision to address Resident #3's fall on 10/03/13. Interview on 10/21/13 at 2:20 p.m. with the DON revealed she was not aware Resident #3 had a fall. She stated she did not have an Incident/Accident Report for Resident #3. Interview on 10/21/13 at 3:45 p.m. with the DON revealed the nursing staff was required to complete an Incident/Accident Report anytime a resident had a fall, bruise, skin tear, or any unusual injury. The staff was required to call her about all incidents, if she was not in the facility. The DON revealed the staff placed the reports in a box at the Nurse's Station, and she picked them up every day and went over every report in the morning stand-up meeting. She stated after the meeting, she looked at the reports to see what all was reviewed such as therapy needs, medications, and a need for alarms. When asked if there was not an Incident/Accident Report how would she know a resident had an occurrence, the DON replied she reviewed "Twenty-Four Hour Reports" every day and if it was on there then she would know. The DON said they still had to call her with every incident. When asked again about an Incident/Accident Report for Resident #3, the DON replied there was not one. 3. The facility's current policy, Falls-Evaluation and Prevention, dated March 2012, reflected the policy was to evaluate residents' fall risk and develop interventions to prevent falls. The residents were to be assessed on admission/readmission, following any change of status that may affect balance, mobility, or safety, falling a fall and quarterly. The procedures included the nursing staff/interdisciplinary care team determining if a resident was at risk for falls and developing appropriate interventions based on the evaluation. The goal was to prevent falls if possible and avoid any injury related to falls. The care plan should only specify a few interventions at a time, so the staff could determine what interventions were not successful and needed to be changed. The policy also reflected after a fall, the resident's plan of care should be reviewed and interventions updated as appropriate, staff should be educated on fall prevention, providing a safe environment for residents, and the cause/risk factors for falls as well as the interventions to manage the risk. 4. An IJ was identified on 10/21/13. The Administrator, DON, and ADON were informed on 10/21/13 at 5:04 p.m. of the IJ, and a Plan of Removal was requested at that time. 5. Interview on 10/23/13 at 3:41 p.m. with the DON revealed she knew the IJ occurred because she did not have enough interventions in place for Resident #10 to ensure safety. The DON said she still did not think the fact that she had not put any interventions in place when the resident was standing up and sitting down was a part of the immediacy because she thought that was something the nurses saw and dealt with every day. She asked how was she supposed to know that would lead to the resident falling and breaking her hip. The DON said they now had systems of reporting, communicating, and follow-up concerning residents' changes and incidents. 6. The facility's Plan of Removal, dated and accepted on 10/22/13, reflected all residents would have fall risk assessments, and all fall risk assessments were redone on 10/21/13 for accuracy and following policy for all residents. Fall risk assessments would be completed upon admission/readmission, change of condition, and quarterly. Fall safety evaluations for fall prevention and recommendations from Therapy for prevention of falls were all started on 10/21/13 and completed on 10/22/13. Any resident with a score of "10" or higher who was identified as high fall risk or who had a fall was referred to therapy. Individualized Care Plans were updated on 10/21/13 reflecting interventions, and Aides' Care Plans were also updated to reflect interventions. The 43 residents, who were identified as "high risk" for falls, care plans were individualized on 10/21/13. The Safety Assessments by therapy for cognitive impairment, non-weight bearing, physical impairment, and unsteady gait were completed and provided to the DON/ADON and Admin for interventions to be placed and monitored by 10/22/13. The Restorative aide would monitor interventions, for placement and working order daily and a complete checklist that would be turned in daily to the ADON/DON, at which time they would notify Administration of any issues and also present to the Quality Assurance Committee fall prevention devices were in place for each resident. An in-service was initiated by the Administrator/Regional Clinical Director, DON, and ADON. The in-service would continue each shift to ensure all staff had the training. Arrangements were made with staff to attend individual training. In-services were related to: validating placement of alarms/fall mats/fall interventions and specialty equipment with a validation of training by a "Fall Care Basics" test with a passing score of 80% or higher. All staff with a lower score would be retrained and retested until a score of 80% or higher. Fall assessment and prevention would be part of the orientation process and ongoing in-service for all departments including the weekend staff. 7. Interviews conducted on 10/23/13 at 9:40 a.m. and 2:20 p.m. with LVNs D and F revealed they received training on 10/22/13 regarding fall prevention. The nurses stated training included nursing staff participating and implementing interventions for residents who fall and residents who were assessed to be at a high risk for falls. The nurses were able to explain when the fall risk assessment would be completed, on admission, readmission, changes in conditions, following a fall and quarterly. The nurses were able to explain the scoring system associated with the fall risk assessments and the therapy department referral process. On 10/23/13 at 10:45 a.m., Laundry Aide I was interviewed regarding falls and fall prevention. Laundry Aide I stated she recently had training regarding resident falls and actions to take. Laundry Aide I stated she was unable to physically assist a resident but would immediately notify the charge nurse if she found a resident after a fall. On 10/23/13 at 10:54 a.m. LVN B was interviewed regarding falls and fall prevention. LVN B stated training was held the afternoon of 10/22/13 and covered fall prevention such as removing clutter from a resident's room and ensuring that residents with visual impairment wear their glasses. LVN B stated that residents would be referred to therapy after a fall and fall assessments were to be completed after a resident's fall, significant change in status, readmission to the facility and upon admission. Interview on 10/23/13 at 11:28 a.m. with CNA H revealed the CNA received training regarding falls and fall prevention on the evening of 10/22/13. CNA H said following the in-service a test was given and staff had to make 80% on the test to pass it. CNA H understood trying to keep the residents safe and if a fall was witnessed, the charge nurse was to be notified. CNA H also revealed if staff thought something could cause a problem for the resident to report it to the nurse. On 10/23/13 at 12:36 p.m., CNA E was interviewed regarding falls and fall prevention. CNA E stated she had training on 10/22/13 along with a test given afterwards. CNA E stated if a resident had a fall, she would notify the nurse and then report the fall to the Administrator. CNA E also stated she would try and prevent resident falls by asking residents if they needed something before leaving their room and checking for environmental hazards. 8. The Administrator, RNC, and ADON were informed on 10/23/13 at 4:30 p.m. that the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of "pattern" because the facility was still in-servicing staff and monitoring the effectiveness of the Plan of Removal. 9. The facility's Form CMS-802, Roster/Sample Matrix provided on 10/21/13 by the DON reflected four residents had sustained falls out of the 43 residents identified by the facility as high risk for falls, following re-screening all residents for fall risk, provided by the DON on 10/22/13.

Based on observation, interview and record review, it was determined the facility failed to ensure all injuries of unknown origin were thoroughly investigated for one (Resident #1) of 11 residents, who were required to wear Wander Guards. On 12/17/10 Resident #1 eloped from the facility and was brought back by two unidentified males. The resident was sent to the hospital with multiple lacerations and contusions to the face and a fractured spine. The facility failed to thoroughly investigate the means by which the injuries occurred. An Immediate Jeopardy (IJ) was identified on 12/31/10. While the IJ was removed on 01/03/11, the facility remained out of compliance at a severity level of "Actual Harm that is not immediate jeopardy," and a scope of "Isolated," because staff were still being in-serviced, and the facility was still monitoring for implementation of the Plan of Removal. These failures could affect the 11 residents, who required Wander Guards and placed them at risk for leaving the facility without staff knowledge, and placing them at risk for being injured Findings included: 1) Record review of the Face Sheet dated 07/09/10 revealed Resident #1 was admitted to the facility on [DATE]. The admitting [DIAGNOSES REDACTED]. The Physician order [REDACTED]. There was an additional order to "Check wander guard q (every) shift for proper function." Resident #1's "Wandering Risk Assessment Tool" dated 12/01/10 and completed by the facility staff indicated the resident exhibited "High Risk" behavior for exiting and for wandering. Another "Wandering Risk Assessment Tool" dated 05/05/10 for Resident #1 indicated she would "follow others around. If someone exits the facility, resident will follow." The "Monthly Summary" completed by LVN F dated 11/12/10 also indicated she was ambulatory "alone" and had a history of [REDACTED]." The Care Plan dated 12/10/10 indicated she had been care planned for "Potential for elopement." Resident #1 had also been care planned for falls and fractures as evidenced by: "cognitive impairment, unsteady gait, and other - Stumbles while walking and speeds up while walking." Review of the Incident/Accident Report dated 12/17/10 revealed Resident #1 "had fallen outside" and was sent to the emergency room for treatment and evaluation. Record review of the facility's investigation report signed by the DON and dated 12/21/10 revealed "Incident Category...Missing Resident/Client...Description of Injury...Extent unknown. Was found outside facility premises face down. Blood noted on jaw and was transferred to the hospital...." The report reflected the resident had "pain & blood" on the jaw area. The facility notified the physician and family and the staff was in-serviced. Wander Guards and exit door alarms were checked for "functionality" and Wander Guard "assessments" were done. The facility "did not find any grounds for negligence on part of staff." The report's CONCLUSION AND INTERVENTIONS OF INCIDENT reflected potential contributing factors related to the occurrence were, "Wandering behavior, busy day as facility was hosting end of year/Christmas party for the residents/visitors & family." Review of the facility incident statements from the ADON and RA G dated 12/17/10 revealed their statements provided to the DON stated only, "did not see the resident fall." The incident report did not reflect the resident's severe injuries, nor if she had a Wander Guard in place, who the stranger was that brought her back into the facility, and what treatment had been given prior to 911 entering the facility. Witness statements completed by seven different staff members were attached to the investigation. Statements from ADON, MDS Coordinator, LVN E, LVN F, RA G, CNA R, and MA S revealed no one had witnessed any cause for Residents #1's injuries. Review of the forms used for the statements revealed the areas for contributing factors and areas for identification of injuries were not completed. This lack of documentation failed to make clear how the injury occurred. NOTE: Nowhere in the investigation packet provided by the facility was it indicated that Resident #1 was found by "strangers" or that facility staff was unaware the resident had exited the building or how the resident's injuries occurred. In an interview with the ADON on 12/30/10 at 10:40 AM, she stated she had been in her office (located near the front door of the facility) at the time of the incident. She looked up and saw RA G running past her door. She then went to her office door and saw Resident #1 being supported by a "soldier" as they turned the corner into the hallway from the front door entrance. She stated RA G grabbed a wheelchair and put the resident into it and pushed her back to her room. The paramedics were there almost immediately. The facility did not have a lot of visitors at that time. She talked with LVN F after the paramedics had taken the resident to the hospital. She stated she had not heard any alarms either prior to Resident #1's fall nor after she had been returned to the facility through the front door. When asked to provide documentation, she stated she did not document anything. On 12/30/10 at 11:00 AM, the ADON was again queried about the events on 12/17/10. The ADON stated she was in her office and observed RA G run past her door and she jumped up to see what was wrong. The ADON stated she followed her to the front door and observed a "young soldier was bringing her (Resident #1) in." When queried whether she heard any alarms, the ADON stated, "Not at that time." The ADON stated Resident #1 had a large amount of blood on her face around her mouth and jaw. The ADON added, "By the time we got her to her room, paramedics were here." On 12/30/10 at 12:23 PM interview with RA G revealed she did not know how Resident #1 had exited the building. When queried about the events of that day, RA G stated that Resident #1 had just finished eating in the dining room and walked away. RA G was in the dining room assisting other residents when she heard someone yelling for help and went running. RA G added when she saw Resident #1 with blood on her face she went running for a wheelchair. Review of the Nurses' Notes dated 12/17/10 at 1:30 PM revealed Resident #1 "was escorted to nurses' station via w/c, facial bleeding noted. Abrasions noted to left forehead. Resident's oral cavity with blood, spit out broken dentures, c/o pain to mouth, chin and neck areas. EMS (Emergency Medical Services) at facility. Resident sent to the local hospital." The Emergency Medical Record, from the local hospital, dated 12/17/10 reflected Resident #1 was "Positive for sharp pain...Positive for acute pain...Positive for bleeding gums, contusion to face, contusion to lip, dentures or partial plate, facial swelling, mouth bleeding, mouth swelling." The record also reflected Resident #1 appeared in acute distress, "...WITH A GROUND LEVEL FALL AND LANDED ON HER FACE WITH FRACTURE OF HER DENTURES, BILATERAL JAW PAIN, LIP LACERATION AND TONGUE LACERATION....THRU AND THRU LACERATION OF LOWER LIP, LACERATION TO CHIN, OBVIOUS MANDIBLE SWELLING AND DEFORMITY BILATERALLY." Her oxygen saturation was at 90%. The radiology section of this form reported findings of "Comminuted (multiple) mandibular (lower jaw) fractures" and "Compression fracture T 10 ([MEDICATION NAME] spine #10)." Resident #1 was transported to another hospital in another city. The CT (Computerized tomography) dated 12/17/10 reflected, "Impression: Comminuted fracture mandible." Review of the hospital Operative Report for placement of gastrostomy tube dated 12/25/10 for Resident #1 revealed due to her mandibular fracture repair she was to remain NPO for a period of six weeks and therefore needed alternate access for nutrition. In an interview with the DON on 12/31/10 at 10:00 AM, he stated he had talked with the staff on duty at the time of the accident. He stated he was not in the building at the time since he had worked the night before. He was called but arrived at the facility after the ambulance had taken Resident #1 to the hospital. He was unsure to any exact time. He stated, "No one had interviewed the two strangers who had brought her into the facility." He stated he did not know who in the facility had gotten to her first. He stated, "You will have to find that out in your interviews." He could not verify the exit door Resident #1 had used to leave the facility. In an interview with the ADM on 12/31/10 at 10:15 AM, she stated she did not remember where she was in the facility when she first heard about the accident. She immediately went to the resident's room and saw the paramedics working on her. She stated the MDS Coordinator brought Resident #1 to the nurses' station. LVN F pushed Resident #1 into her room. She stated she then went to the site where Resident #1 had fallen as indicated by the spilled blood on the pavement in front of the facility. At this time, the ADM was asked to show the surveyors the site. The surveyors and ADM exited the building. The site, as indicated by the ADM, was in the round-about driveway in front of the facility, where it joined the street. The ADM stated she was able to identify the exact spot of the incident by the blood on the driveway. She continued with her story by stating the "strangers had to have called 911, as the paramedics had gotten to the facility by the time the resident had been placed in her bed." She stated she had never seen the "strangers" before; they were not visitors. The "strangers" disappeared before anyone could talk with them. One of the "strangers" had been dressed in military uniform. In an interview with CNA P on 12/31/10 at 12:00 PM, she stated she had last seen Resident #1 walking to the dining room to eat lunch. She stated she had been the aide caring for Resident #1 on the day of the current accident. She stated after the accident, the resident was taken to her room in a wheelchair by LVN F, who had removed her broken crushed dentures from her mouth piece by piece. She stated she thought RA G removed the Wander Guard from the resident. CNA P stated that on the day of the accident and at the time of the accident, there were not many visitors in the building. She stated she saw the ADON, RA G, and LVN F working with the resident, but did not see the ADM or the DON. She stated she was not asked to write a statement for the incident report. On 12/31/10 at 1:30 PM, RA G was again interviewed regarding Resident #1 and walked through the scenario of that afternoon. As she described approaching the front entrance door she stated there were two people holding Resident #1 on either side. She stated one was definitely a man in a military uniform but could not describe the other person. She stated, "I took off running for a wheelchair; never heard an alarm. I don't know. I heard 'Help!', saw her and panicked...all that blood." 2) Review of the facility's current Policy and Procedure for Abuse dated January 2008 revealed: "It is the policy of this facility prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a resident's physicial or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person." The policy reflected, under Section IV, C., "All incident/accidents of unknown origin will be investigated." Under Section V. Investigation, B. the document reflected, "Ask any witness to wait for the Administrator or the person on-call to arrive at the facility." The Abuse Coordinator, unders Section V., D., will "Review all aspects of the investigation as soon as possible. Ensure that all reports are complete...." 3) An Immediate Jeopardy (IJ) was identified on 12/31/10. On 12/31/10 at 4:18 PM, the ADM and DON were notified an IJ was identified in the area of Resident Behavior and Facility Practice with Substandard Quality of Care (SQC). A Plan of Removal for the IJ was requested at that time. 4) During a meeting on 12/31/10 at 4:18 PM, DON was queried whether anyone had ever tried to locate the "strangers" who had found Resident #1 on the ground and assisted her into the building. The DON stated, "No, they left." DON replied "They (strangers) left, no one knew who they were." When queried whether he, or anyone had tried contacting emergency services and obtaining a call, report or contacting the responding paramedics. When queried "Isn't that the Emergency Administration Building across the street?" The DON did not answer. He was also requested to produce any further information he had concerning the facility's investigation. He could not produce anything further. 5) The following interviews were conducted with the 2:00 PM - 10:00 PM and 10:00 PM - 6:00 AM staff on 12/31/10 regarding the staff's training on the Wander Guard system and resident safety: At 9:00 PM, LVN B stated she had not had an in-service on Wander Guards, but a mandatory in-service was planned for 01/03/11 at 2:00 PM. The LVN referred to a notice hanging behind the nursing station. LVN B stated they checked residents with Wander Guards every shift. They take the resident to the doors to see if the alarm would sound. LVN B was uncertain if Resident #1 had been checked the evening of 12/16/10; At 9:20 PM, CNA J stated she had not received an in-service, was unable to explain how the Wander Guard functioned, until prompted by the DON; At 9:30 PM, CNA K stated the Wander Guard would alarm and that the door would open; At 9:45 PM, CNA L stated if the alarm went off, he would go out and get the resident back into the facility and have the charge nurse turn the alarm off. Again the DON attempted to prompt the CNA; At 10:00 PM, CNA O stated they did not check residents at night because they were sleeping. The CNA was asked if the resident got up in the early morning, what would she do. The CNA stated she thought the nurse checked the alarms; and Between 10:15 PM through 10:30 PM, CNAs M and N, and MA Q were interviewed. They all stated the ADON had talked to them about the Wander Guards and alarms when they came to work that evening. On 01/01/11 at 5:00 PM, an unidentified maintenance person was observed checking door alarms with a Wander Guard device. On 01/01/11 at approximately 5:30 PM, the ADON was observed providing staff with an in-service, in regards to the wander guard system and protocols. 6) On 01/03/11 at 10:07 AM, the facility incident statements were reviewed with the DON. The DON did not provide an explanation for the forms not being completed. His only explanation was that he was not in the building at the time of the incident. On 01/03/11 at 8:30 AM, the ADON, RA G and the ADM were interviewed. ADON and RA G were asked why, when completing Resident #1's Incident/Accident report, the resident's injuries and treatments were not documented and why they had not tried to locate and interview the unidentified male who brought the resident back into the facility. Both stated they gave the reports to the DON and he never asked them any questions. On 01/03/11 at 10:30 AM, the DON and ADM were interviewed. The DON was questioned in regards to the facility's incident report sent to State Office, stating, "small amount of blood was on the resident's face" and the fact the incident reports were not complete. The DON stated "that" was what was written down and he was not in the facility when it happened. The DON stated someone told him there was a small amount of blood, and he was not aware of the amount of blood until someone told him of the resident's injuries. The DON could not recall where he got his information. The DON stated when he got to the facility that afternoon, the ADM informed him of the incident and he began checking the doors and alarms. The DON was asked how he investigated the incident: who did he talk too; did he call the hospital to check on the resident; did he make any effort to contact the unidentified male; did he check with EMS, the police or 911 operator; and how did he determine who to interview in regards to this incident. The DON again stated he "reviewed the written statements and sent them to State Office." When asked how he would and/or did investigate this incident, the DON did not answer. 7) The Plan of Removal with Addendum was accepted on 01/03/11 at 4:00 PM and included: 1. All staff scheduled to work on 12/31/10 were in-serviced on the staff response to door alarms activated and all other staff would be in-serviced by 01/01/11; 2. Monitoring to prevent re-occurrence; 3. The facility Administrator and Director of Nurses had checked each resident at the time with an order for [REDACTED]. 4. The door alarms were to be checked by the facility maintenance to ensure proper working condition; 5. The door alarms were to be checked by the facility week-end Restorative Aide to ensure proper working condition; 6. The charge nurses would check placement of the wandering transmitter bracelet (Code Alert System) of each resident with an order each shift, everyday; 7. The Nurse Aide Care Plans would reflect those residents; 8. The facility front door was equipped with a Code Alert wandering system; 9. A QA (Quality Assurance) Meeting would be held on 01/01/11 at 11:00 AM with team members; 10. Facility staff not able to attend the first in-services were given the in-services; 11. A written Post Test was given to all facility staff; 12. The Code Alert Transmitter Tester System would be checked daily by the assigned restorative aide and documented; and 13. A back-up system was put in place including delegation of alternate staff for responsibility for checking door alarms and transmitter bracelets. 8) While the IJ was removed on 01/03/11, the facility remained out of compliance at a severity level of "Actual Harm that is not immediate jeopardy" and a scope of "Isolated," because staff were still being in-serviced, and the plan of removal was being monitored for implementation. 9) A list provided by facility administration on 12/30/10 reflected 11 residents required Wander Guards.

Based on observation, interview and record review, the facility failed to develop and implement written policies and procedures that rule out mistreatment, neglect and abuse of residents. The facility failed to thoroughly investigate injuries of unknown origin for one (Resident #1) of eleven residents reviewed for risk of injury. 1. On 12/17/10 Resident #1 eloped from the facility and was brought back by two unidentified males. The resident was sent to the hospital with multiple lacerations and contusions to the face and a fractured spine. The facility failed to implement the written policy to thoroughly investigate the injuries of unknown origin, including the means by which the resident left the building, who was with her while she was gone, and how the injuries occurred. An Immediate Jeopardy (IJ) was identified on 12/31/10. While the IJ was removed on 01/03/11, the facility remained out of compliance at a severity level of "Actual Harm that is not immediate jeopardy," and scope of "Isolated," because staff were still being in-serviced and the facility was still monitoring for implementation of the Plan of Removal. These failures could affect the 11 residents, who required Wander Guards and placed them at risk for leaving the facility without staff knowledge, and placing them at risk for injury. Findings included: 1) Review of the facility's current Policy and Procedure for Abuse dated January 2008 revealed: "It is the policy of this facility to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a resident's physicial or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person." The policy reflected, under Section IV, C., "All incident/accidents of unknown origin will be investigated." Under Section V. Investigation, B. the document reflected, "Ask any witness to wait for the Administrator or the person on-call to arrive at the facility." The Abuse Coordinator, unders Section V., D., will "Review all aspects of the investigation as soon as possible. Ensure that all reports are complete...." 2) Record review of the Face Sheet dated 07/09/10 revealed Resident #1 was admitted to the facility on [DATE]. The admitting [DIAGNOSES REDACTED]. The Physician order [REDACTED]. There was an additional order to "Check wander guard q (every) shift for proper function." Resident #1's "Wandering Risk Assessment Tool" dated 12/01/10 and completed by the facility staff indicated the resident exhibited "High Risk" behavior for exiting and for wandering. Another "Wandering Risk Assessment Tool" dated 05/05/10 for Resident #1 indicated she would "follow others around. If someone exits the facility, resident will follow." The "Monthly Summary" completed by LVN F dated 11/12/10 also indicated she was ambulatory "alone" and had a history of [REDACTED]." The Care Plan dated 12/10/10 indicated she had been care planned for "Potential for elopement." Resident #1 had also been care planned for falls and fractures as evidenced by: "cognitive impairment, unsteady gait, and other - Stumbles while walking and speeds up while walking." Review of the Incident/Accident Report dated 12/17/10 revealed Resident #1 "had fallen outside" and was sent to the emergency room for treatment and evaluation. Record review of the facility's investigation report signed by the DON and dated 12/21/10 revealed "Incident Category...Missing Resident/Client...Description of Injury...Extent unknown. Was found outside facility premises face down. Blood noted on jaw and was transferred to the hospital...." The report reflected the resident had "pain & blood" on the jaw area. The facility notified the physician and family and the staff was in-serviced. Wander Guards and exit door alarms were checked for "functionality" and Wander Guard "assessments" were done. The facility "did not find any grounds for negligence on part of staff." The report's CONCLUSION AND INTERVENTIONS OF INCIDENT reflected potential contributing factors related to the occurrence were, "Wandering behavior, busy day as facility was hosting end of year/Christmas party for the residents/visitors & family." Review of the facility incident statements from the ADON and RA G dated 12/17/10 revealed their statements provided to the DON stated only, "did not see the resident fall." The incident report did not reflect the resident's severe injuries, nor if she had a Wander Guard in place, who the stranger was that brought her back into the facility, and what treatment had been given prior to 911 entering the facility. Witness statements completed by seven different staff members were attached to the investigation. Statements from ADON, MDS Coordinator, LVN E, LVN F, RA G, CNA R, and MA S revealed no one had witnessed any cause for Residents #1's injuries. Review of the forms used for the statements revealed the areas for contributing factors and areas for identification of injuries were not completed. This lack of documentation failed to make clear how the injury occurred. NOTE: Nowhere in the investigation packet provided by the facility was it indicated that Resident #1 was found by "strangers" or that facility staff was unaware the resident had exited the building or how the resident's injuries occurred. In an interview with the ADON on 12/30/10 at 10:40 AM, she stated she had been in her office (located near the front door of the facility) at the time of the incident. She looked up and saw RA G running past her door. She then went to her office door and saw Resident #1 being supported by a "soldier" as they turned the corner into the hallway from the front door entrance. She stated RA G grabbed a wheelchair and put the resident into it and pushed her back to her room. The paramedics were there almost immediately. The facility did not have a lot of visitors at that time. She talked with LVN F after the paramedics had taken the resident to the hospital. She stated she had not heard any alarms either prior to Resident #1's fall nor after she had been returned to the facility through the front door. When asked to provide documentation, she stated she did not document anything. On 12/30/10 at 11:00 AM, the ADON was again queried about the events on 12/17/10. The ADON stated she was in her office and observed RA G run past her door and she jumped up to see what was wrong. The ADON stated she followed her to the front door and observed a "young soldier was bringing her (Resident #1) in." When queried whether she heard any alarms, the ADON stated, "Not at that time." The ADON stated Resident #1 had a large amount of blood on her face around her mouth and jaw. The ADON added, "By the time we got her to her room, paramedics were here." On 12/30/10 at 12:23 PM interview with RA G revealed she did not know how Resident #1 had exited the building. When queried about the events of that day, RA G stated that Resident #1 had just finished eating in the dining room and walked away. RA G was in the dining room assisting other residents when she heard someone yelling for help and went running. RA G added when she saw Resident #1 with blood on her face she went running for a wheelchair. Review of the Nurses' Notes dated 12/17/10 at 1:30 PM revealed Resident #1 "was escorted to nurses' station via w/c, facial bleeding noted. Abrasions noted to left forehead. Resident's oral cavity with blood, spit out broken dentures, c/o pain to mouth, chin and neck areas. EMS (Emergency Medical Services) at facility. Resident sent to the local hospital." The Emergency Medical Record, from the local hospital, dated 12/17/10 reflected Resident #1 was "Positive for sharp pain...Positive for acute pain...Positive for bleeding gums, contusion to face, contusion to lip, dentures or partial plate, facial swelling, mouth bleeding, mouth swelling." The record also reflected Resident #1 appeared in acute distress, "...WITH A GROUND LEVEL FALL AND LANDED ON HER FACE WITH FRACTURE OF HER DENTURES, BILATERAL JAW PAIN, LIP LACERATION AND TONGUE LACERATION....THRU AND THRU LACERATION OF LOWER LIP, LACERATION TO CHIN, OBVIOUS MANDIBLE SWELLING AND DEFORMITY BILATERALLY." Her oxygen saturation was at 90%. The radiology section of this form reported findings of "Comminuted (multiple) mandibular (lower jaw) fractures" and "Compression fracture T 10 ([MEDICATION NAME] spine #10)." Resident #1 was transported to another hospital in another city. The CT (Computerized tomography) dated 12/17/10 reflected, "Impression: Comminuted fracture mandible." Review of the hospital Operative Report for placement of gastrostomy tube dated 12/25/10 for Resident #1 revealed due to her mandibular fracture repair she was to remain NPO for a period of six weeks and therefore needed alternate access for nutrition. In an interview with the DON on 12/31/10 at 10:00 AM, he stated he had talked with the staff on duty at the time of the accident. He stated he was not in the building at the time since he had worked the night before. He was called but arrived at the facility after the ambulance had taken Resident #1 to the hospital. He was unsure to any exact time. He stated, "No one had interviewed the two strangers who had brought her into the facility." He stated he did not know who in the facility had gotten to her first. He stated, "You will have to find that out in your interviews." He could not verify the exit door Resident #1 had used to leave the facility. In an interview with the ADM on 12/31/10 at 10:15 AM, she stated she did not remember where she was in the facility when she first heard about the accident. She immediately went to the resident's room and saw the paramedics working on her. She stated the MDS Coordinator brought Resident #1 to the nurses' station. LVN F pushed Resident #1 into her room. She stated she then went to the site where Resident #1 had fallen as indicated by the spilled blood on the pavement in front of the facility. At this time, the ADM was asked to show the surveyors the site. The surveyors and ADM exited the building. The site, as indicated by the ADM, was in the round-about driveway in front of the facility, where it joined the street. The ADM stated she was able to identify the exact spot of the incident by the blood on the driveway. She continued with her story by stating the "strangers had to have called 911, as the paramedics had gotten to the facility by the time the resident had been placed in her bed." She stated she had never seen the "strangers" before; they were not visitors. The "strangers" disappeared before anyone could talk with them. One of the "strangers" had been dressed in military uniform. In an interview with CNA P on 12/31/10 at 12:00 PM, she stated she had last seen Resident #1 walking to the dining room to eat lunch. She stated she had been the aide caring for Resident #1 on the day of the current accident. She stated after the accident, the resident was taken to her room in a wheelchair by LVN F, who had removed her broken crushed dentures from her mouth piece by piece. She stated she thought RA G removed the Wander Guard from the resident. CNA P stated that on the day of the accident and at the time of the accident, there were not many visitors in the building. She stated she saw the ADON, RA G, and LVN F working with the resident, but did not see the ADM or the DON. She stated she was not asked to write a statement for the incident report. On 12/31/10 at 1:30 PM, RA G was again interviewed regarding Resident #1 and walked through the scenario of that afternoon. As she described approaching the front entrance door she stated there were two people holding Resident #1 on either side. She stated one was definitely a man in a military uniform but could not describe the other person. She stated, "I took off running for a wheelchair; never heard an alarm. I don't know. I heard 'Help!', saw her and panicked...all that blood." 3) An IJ was identified on 12/31/10. On 12/31/10 at 4:18 PM, the ADM and DON were notified an IJ was identified in the area of Resident Behavior and Facility Practice with Substandard Quality of Care (SQC). A Plan of Removal for the IJ was requested at that time. 4) During a meeting on 12/31/10 at 4:18 PM, DON was queried whether anyone had ever tried to locate the "strangers" who had found Resident #1 on the ground and assisted her into the building. The DON stated, "No, they left." DON replied "They (strangers) left, no one knew who they were." When queried whether he, or anyone had tried contacting emergency services and obtaining a call, report or contacting the responding paramedics. When queried "Isn't that the Emergency Administration Building across the street?" The DON did not answer. He was also requested to produce any further information he had concerning the facility's investigation. He could not produce anything further. 5) The following interviews were conducted with the 2:00 PM - 10:00 PM and 10:00 PM - 6:00 AM staff on 12/31/10 regarding the staff's training on the Wander Guard system and resident safety: At 9:00 PM, LVN B stated she had not had an in-service on Wander Guards, but a mandatory in-service was planned for 01/03/11 at 2:00 PM. The LVN referred to a notice hanging behind the nursing station. LVN B stated they checked residents with Wander Guards every shift. They take the resident to the doors to see if the alarm would sound. LVN B was uncertain if Resident #1 had been checked the evening of 12/16/10; At 9:20 PM, CNA J stated she had not received an in-service, was unable to explain how the Wander Guard functioned, until prompted by the DON; At 9:30 PM, CNA K stated the Wander Guard would alarm and that the door would open; At 9:45 PM, CNA L stated if the alarm went off, he would go out and get the resident back into the facility and have the charge nurse turn the alarm off. Again the DON attempted to prompt the CNA; At 10:00 PM, CNA O stated they did not check residents at night because they were sleeping. The CNA was asked if the resident got up in the early morning, what would she do. The CNA stated she thought the nurse checked the alarms; and Between 10:15 PM through 10:30 PM, CNAs M and N, and MA Q were interviewed. They all stated the ADON had talked to them about the Wander Guards and alarms when they came to work that evening. On 01/01/11 at 5:00 PM, an unidentified maintenance person was observed checking door alarms with a Wander Guard device. On 01/01/11 at approximately 5:30 PM, the ADON was observed providing staff with an in-service, in regards to the wander guard system and protocols. 6) On 01/03/11 at 10:07 AM, the facility incident statements were reviewed with the DON. The DON did not provide an explanation for the forms not being completed. His only explanation was that he was not in the building at the time of the incident. On 01/03/11 at 8:30 AM, the ADON, RA G and the ADM were interviewed. ADON and RA G were asked why, when completing Resident #1's Incident/Accident report, the resident's injuries and treatments were not documented and why they had not tried to locate and interview the unidentified male who brought the resident back into the facility. Both stated they gave the reports to the DON and he never asked them any questions. On 01/03/11 at 10:30 AM, the DON and ADM were interviewed. The DON was questioned in regards to the facility's incident report sent to State Office, stating, "small amount of blood was on the resident's face" and the fact the incident reports were not complete. The DON stated "that" was what was written down and he was not in the facility when it happened. The DON stated someone told him there was a small amount of blood, and he was not aware of the amount of blood until someone told him of the resident's injuries. The DON could not recall where he got his information. The DON stated when he got to the facility that afternoon, the ADM informed him of the incident and he began checking the doors and alarms. The DON was asked how he investigated the incident: who did he talk too; did he call the hospital to check on the resident; did he make any effort to contact the unidentified male; did he check with EMS, the police or 911 operator; and how did he determine who to interview in regards to this incident. The DON again stated he "reviewed the written statements and sent them to State Office." When asked how he would and/or did investigate this incident, the DON did not answer. 7) The Plan of Removal with Addendum was accepted on 01/03/11 at 4:00 PM and included: 1. All staff scheduled to work on 12/31/10 were in-serviced on the staff response to door alarms activated and all other staff would be in-serviced by 01/01/11; 2. Monitoring to prevent re-occurrence; 3. The facility Administrator and Director of Nurses had checked each resident at the time with an order for [REDACTED]. 4. The door alarms were to be checked by the facility maintenance to ensure proper working condition; 5. The door alarms were to be checked by the facility week-end Restorative Aide to ensure proper working condition; 6. The charge nurses would check placement of the wandering transmitter bracelet (Code Alert System) of each resident with an order each shift, everyday; 7. The Nurse Aide Care Plans would reflect those residents; 8. The facility front door was equipped with a Code Alert wandering system; 9. A QA (Quality Assurance) Meeting would be held on 01/01/11 at 11:00 AM with team members; 10. Facility staff not able to attend the first in-services were given the in-services; 11. A written Post Test was given to all facility staff; 12. The Code Alert Transmitter Tester System would be checked daily by the assigned restorative aide and documented; and 13. A back-up system was put in place including delegation of alternate staff for responsibility for checking door alarms and transmitter bracelets. 8) While the IJ was removed on 01/03/11, the facility remained out of compliance at a severity level of "Actual Harm that is not immediate jeopardy," and a scope of "Isolated," because staff were still being in-serviced, and the plan of removal was being monitored for implementation. 9) A list provided by facility administration on 12/30/10 reflected 11 residents required Wander Guards.

Based on observation, interview and record review, it was determined the facility failed to ensure two (Residents #1 and #2) of 11 residents who were required to wear Wander Guards received adequate supervision to prevent accidents. 1) On 12/17/09 Resident #1 eloped from the facility and was brought back by two unidentified males. The resident was sent to the hospital with multiple lacerations and contusions to the face and a fractured spine. The facility failed to determine the means by which the resident left the building, who was with her while she was gone, and how the injuries occurred. 2) Resident #2's family reported to CNA P the resident's Wander Guard alarm did not sound when they took the resident out of the building on 12/24/10. CNA P did not report this to anyone. An Immediate Jeopardy (IJ) was identified on 12/31/10. While the IJ was removed on 01/03/11 the facility remained out of compliance at a severity level of "Actual Harm that is not immediate jeopardy," and scope of "Isolated," because staff were still being in-serviced and the facility was still monitoring for implementation of the Plan of Removal. These failures could result in placed them at risk for leaving the facility without staff knowledge, and placing them at risk for injuries. These failures could affect the current 11 residents who required Wander Guards. Findings included: 1) Review of the Face Sheet dated 07/09/10 revealed Resident #1 was admitted to the facility on [DATE]. The admitting [DIAGNOSES REDACTED]. The Physician order [REDACTED]. There was an additional order to "Check wander guard q (every) shift for proper function." Resident #1's "Wandering Risk Assessment Tool" dated 12/01/10 and completed by the facility staff indicated the resident exhibited "High Risk" behavior for exiting and for wandering. Another "Wandering Risk Assessment Tool" dated 05/05/10 for Resident #1 indicated she would "follow others around. If someone exits the facility, resident will follow." The "Monthly Summary" completed by LVN F dated 11/12/10 also indicated she was ambulatory "alone" and had a history of [REDACTED]." The Care Plan dated 12/10/10 indicated she had been care planned for "Potential for elopement." Resident #1 had also been care planned for falls and fractures as evidenced by: "cognitive impairment, unsteady gait, and other - Stumbles while walking and speeds up while walking." Review of the Nurses' Notes dated 12/17/10 at 1:30 PM revealed Resident #1 "was escorted to nurses' station via w/c, facial bleeding noted. Abrasions noted to left forehead. Resident's oral cavity with blood, spit out broken dentures, c/o pain to mouth, chin and neck areas. EMS (Emergency Medical Services) at facility. Resident sent to the local hospital." Review of the facility incident statements from the ADON and RA G dated 12/17/10 revealed their statements provided to the DON stated only, "did not see the resident fall." The incident report did not reflect the resident's severe injuries, nor if she had a Wander Guard in place, who the stranger was that brought her back into the facility, and what treatment had been given prior to 911 entering the facility. Record review of the facility's investigation report signed by the DON and dated 12/21/10 revealed "Incident Category...Missing Resident/Client...Description of Injury...Extent unknown. Was found outside facility premises face down. Blood noted on jaw and was transferred to the hospital...." The report reflected the resident had "pain & blood" on the jaw area. The facility notified the physician and family and the staff was in-serviced. Wander Guards and exit door alarms were checked for "functionality" and Wander Guard "assessments" were done. However, there was no indication on the facility Incident report that the wander guard alarms were working. The facility "did not find any grounds for negligence on part of staff." (NOTE: there was no documentation in the report indicating the doors were functioning properly.) Witness statements completed by seven different staff members were attached to the investigation. Statements from ADON, MDS Coordinator, LVN E, LVN F, RA G, CNA R, and MA S revealed no one had witnessed any cause for Residents #1's injuries. Review of the forms used for the statements revealed areas for contributing factors and areas for identification of injuries were not completed. This lack of information failed to make clear how the injury occurred. NOTE: Nowhere in the investigation packet provided by the facility was it indicated that Resident #1 was found by "strangers" or that facility staff was unaware the resident had exited the building or how the resident's injuries occurred. The report's CONCLUSION AND INTERVENTIONS OF INCIDENT reflected potential contributing factors related to the occurrence were, "Wandering behavior, busy day as facility was hosting end of year/Christmas party for the residents/visitors & family." The report did not document how the incident occurred. On 12/30/10 at 8:37 AM, RA G was interviewed regarding the methods used by the facility to test the Wander Guard system. RA G stated she was responsible for testing the units every morning and demonstrated the procedure she followed. The surveyor observed RA G as she demonstrated the procedure. RA G obtained a current list of residents wearing Wander Guards and tested each unit using a tester box provided by the manufacturer. (This method was later confirmed as accurate per the Manufacturer's Manual.) RA G tested the front exit, the back exit by station two, and the exit by room 5 utilizing a Wander Guard unit as well as taking the residents to each of the three doors protected by the Wander Guard system. Three additional fire exits had key pad alarms and were tested . All units were functioning properly at that time. In an interview with Facility Maintenance on 12/30/10 at 8:45 AM, he stated, "That is the door she (Resident #1) left out of," pointing to the door by the nurses' station closest to the dining room. Facility Maintenance said the alarm would sound off in the presence of the Wander Guard, so that the residents wearing them could not go out the door without someone looking up and seeing what was going on. He did not state how he knew that was the door Resident #1 exited from on 12/17/10. In an interview with the ADON on 12/30/10 at 10:40 AM, she stated she had been in her office (located near the front door of the facility) at the time of the incident. She looked up and saw RA G running past her door. She then went to her office door and saw Resident #1 being supported by a "soldier" as they turned the corner into the hallway from the front door entrance. She stated RA G grabbed a wheelchair and put the resident into it and pushed her back to her room. The paramedics were there almost immediately. The facility did not have a lot of visitors at that time. She talked with LVN F after the paramedics had taken the resident to the hospital. She stated she had not heard any alarms either prior to Resident #1's fall nor after she had been returned to the facility through the front door. She stated she did not document anything. On 12/30/10 at 11:00 AM, the ADON was again queried about the events on 12/17/10. The ADON stated she was in her office and observed RA G run past her door and she jumped up to see what was wrong. The ADON stated she followed her to the front door and observed a "young soldier was bringing her (Resident #1) in." When queried whether she heard any alarms, the ADON stated, "Not at that time." The ADON stated Resident #1 had a large amount of blood on her face around her mouth and jaw. The ADON added, "By the time we got her to her room, paramedics were here." On 12/30/10 at 11:35 AM when the ADM was queried as to which door Resident #1 exited, she replied, "We don't know exactly." On 12/30/10 at 12:23 PM interview with RA G revealed she did not know how Resident #1 had exited the building. When queried about the events of that day, RA G stated that Resident #1 had just finished eating in the dining room and walked away. RA G was in the dining room assisting other residents when she heard someone yelling for help and went running. RA G added when she saw Resident #1 with blood on her face she went running for a wheelchair. When queried whether she heard an alarm, RA G stated she did not remember hearing one, only the cries for help. She denied re-setting an alarm, adding all she thought about was getting the resident to her room for assistance. The Emergency Medical Record, from the local hospital, dated 12/17/10 reflected Resident #1 was "Positive for sharp pain...Positive for acute pain...Positive for bleeding gums, contusion to face, contusion to lip, dentures or partial plate, facial swelling, mouth bleeding, mouth swelling." The record also reflected Resident #1 appeared in acute distress, "...WITH A GROUND LEVEL FALL AND LANDED ON HER FACE WITH FRACTURE OF HER DENTURES, BILATERAL JAW PAIN, LIP LACERATION AND TONGUE LACERATION....THRU AND THRU LACERATION OF LOWER LIP, LACERATION TO CHIN, OBVIOUS MANDIBLE SWELLING AND DEFORMITY BILATERALLY." (NOTE: the above portion appeared as written, in all capital letters on the Emergency Medical Record) Her oxygen saturation was at 90%. The radiology section of this form reported findings of "Comminuted (multiple) mandibular (lower jaw) fractures" and "Compression fracture T 10 (Thoracic spine #10)." Resident #1 was transported to another hospital in another city. The Chest X-ray dated 12/17/10 stated, "A moderately collapsed T10 compression fracture is present, age undetermined." The CT (Computerized tomography) dated 12/17/10 reflected, "Impression: Comminuted fracture mandible." Review of the hospital Operative Report for placement of gastrostomy tube dated 12/25/10 for Resident #1 revealed due to her mandibular fracture repair she was to remain NPO for a period of six weeks and therefore needed alternate access for nutrition. In an interview with the ADM on 12/30/10 at 2:40 PM, she said the restorative nurse aides were responsible for checking the functionality of the Wander Guards on a daily basis. She stated that no one particular person was responsible for watching the residents with Wander Guards, as all staff were responsible. She stated some residents signed themselves out, but the residents with Wander Guards were escorted by family. She stated that when a "call for 'help' is heard, everyone is responsible for checking on the situation." She stated the incident on 12/17/10 was the first time Resident #1 had wandered outside the facility. After the incident the Wander Guards were tested by their maintenance staff and by administrative staff and found to be working properly. When queried, ADM stated she was unable to provide any documentation of the testing. In an interview with the DON on 12/31/10 at 10:00 AM, he stated he had talked with the staff on duty at the time of the accident. He stated he was not in the building at the time since he had worked the night before. He was called but arrived at the facility after the ambulance had taken Resident #1 to the hospital. He was unsure to any exact time. He stated, "No one had interviewed the two strangers who had brought her into the facility." He stated he did not know who in the facility had gotten to her first. He stated, "You will have to find that out in your interviews." He could not verify the exit door Resident #1 had used to leave the facility. In an interview with the ADM on 12/31/10 at 10:15 AM, she stated she did not remember where she was in the facility when she first heard about the accident. She immediately went to the resident's room and saw the paramedics working on her. She stated the MDS Coordinator brought Resident #1 to the nurses' station. LVN F pushed Resident #1 into her room. She stated she then went to the site where Resident #1 had fallen as indicated by the spilled blood on the pavement in front of the facility. At this time, the ADM was asked to show the surveyors the site. The surveyors and ADM exited the building. The site, as indicated by the ADM, was in the round-about driveway in front of the facility, where it joined the street. The ADM stated she was able to identify the exact spot of the incident by the blood on the driveway. She continued with her story by stating the "strangers had to have called 911, as the paramedics had gotten to the facility by the time the resident had been placed in her bed." She stated she had never seen the "strangers" before; they were not visitors. The "strangers" disappeared before anyone could talk with them. One of the "strangers" had been dressed in military uniform. The ADM revealed CNA K reported seeing Resident #1, on the day of the incident, leaving the dining room and walking back to her room in her usual pattern/routine. The ADM explained the resident would have used the back hallway; she (resident) never went up into the front area of the facility. The ADM could not verify the exit Resident #1 had gone through to get outside the facility. She stated she believed the resident had followed a visitor outside the facility using the front door. In an interview with the MDS Coordinator on 12/31/10 at 11:00 AM, she stated the staff had been busy with decorating the facility for a Christmas Party scheduled for 2:00 PM that day. She stated the residents were getting finished with their lunch and the nurse aides were busy helping them back to their rooms. She stated she first saw Resident #1 coming down the hall from the front door and RA G was bringing her in a wheelchair. "I was following her (RA G) and told a nurse to call 911, later I learned someone else already had." (NOTE: This is a contradiction to the Administrator's statement that the MDS Coordinator brought Resident #1 to the nurses' station.) She stated she had not remembered any alarms sounding either prior to the fall nor after her entrance into the facility through the front door. She stated the Wander Guard was on the resident and it was "routine practice to remove it prior to going to the hospital." She stated Resident #1's Wander Guard was removed and given to Corporate Maintenance. She stated the Wander Guards were kept in the treatment carts at each nurses' station. The Wander Guards were not identified individually and assigned to specific residents. MDS Coordinator referenced a previous fall Resident #1 sustained on 12/10/10. She stated she witnessed her fall in the hallway. She stated she was returning some charts to the nurses station, observed Resident #1 ambulating in the hallway and suddenly speed up. She stated she dropped the charts and attempted to catch her but was unable to prevent her fall. (Resident #1 sustained an injury to her chin at that time requiring sutures.) In an interview with CNA I, on 12/31/10 at 11:50 AM, she stated Resident #1 had fallen on her face the previous week and required stitches on her chin. She stated the Wander Guards were checked every day by the RA G. She stated the aides were "not paying attention" because they were busy after lunch, taking the other residents back to their rooms and attending to the residents' needs. She stated she did not see the resident nor hear the alarm go off when the resident got out of the building. In an interview with CNA P on 12/31/10 at 12:00 PM, she stated she had last seen Resident #1 walking to the dining room to eat lunch. She stated she had been the aide caring for Resident #1 on the day of the "accident" on 12/17/10. She stated after the accident, the resident was taken to her room in a wheelchair by LVN F, who had removed her broken crushed dentures from her mouth piece by piece. She stated she thought RA G removed the Wander Guard from the resident. CNA P stated that on the day of the accident and at the time of the accident, there were not many visitors in the building. She stated she saw the ADON, RA G, and LVN F working with the resident, but did not see the ADM or the DON. She stated she had not received an in-service on Wander Guards after the incident . The last in-service she attended was on 12/29/10 and it was on gait belts. She stated she had been trained to check outside for residents with Wander Guards when the alarms went off and a resident with a Wander Guard was not inside the facility. She stated the RA G had been tasked with checking every resident with a Wander Guard everyday since the accident. She stated everyone was responsible for checking the residents with Wander Guards, to be sure they did not leave the exit doors without approval first. When the family took the resident with a Wander Guard, the alarm would have to be reset each time the resident left and returned. 2) Review of the Face Sheet dated 12/20/10 revealed Resident #2 was a [AGE] year-old female admitted to the facility 12/08/10 with [DIAGNOSES REDACTED]. Resident #2 was identified on a list provided by the facility of residents wearing a Wander Guard. Review of Nurses Notes dated 12/24/10 at 6:30 PM revealed Resident #2 left the facility with her daughter. An interview with CNA P on 12/31/10 at 12:00 PM revealed the weekend after Resident #1's accident, Resident #2 left the facility with her family through the front door. The resident was wearing the Wander Guard, but the alarm did not sound. She stated she was informed of this by the family upon their return to the facility. CNA P revealed the alarm did sound when the resident was brought back into the facility. CNA P stated she had not reported this incident to anyone. In an interview with Resident #2's family member on 12/31/10 at 1:30 PM, she confirmed she had taken her mother out of the building on 12/24/10 without the alarm sounding. The resident was wearing the Wander Guard. When she brought her mother back with her Wander Guard still on her person, the alarm did indeed sound. Review of the visitor log revealed Resident #2 was signed out for that date (12/24/10). 3) An IJ was identified on 12/31/10. On 12/31/10 at 4:18 PM, the ADM and DON were notified an IJ was identified in the area of Quality of Care with Substandard Quality of Care (SQC). A Plan of Removal for the IJ was requested at that time. 4) The following interviews were conducted with the 2:00 PM - 10:00 PM and 10:00 PM - 6:00 AM staff on 12/31/10 regarding the staff's training on the Wander Guard system and resident safety: At 9:00 PM, LVN B stated she had not had an in-service on Wander Guards, but a mandatory in-service was planned for 01/03/11 at 2:00 PM. The LVN referred to a notice hanging behind the nursing station. LVN B stated they checked residents with Wander Guards every shift. They take the resident to the doors to see if the alarm would sound. LVN B was uncertain if Resident #1 had been checked the evening of 12/16/10; At 9:20 PM, CNA J stated she had not received an in-service, was unable to explain how the Wander Guard functioned, until prompted by the DON; At 9:30 PM, CNA K stated the Wander Guard would alarm and that the door would open; At 9:45 PM, CNA L stated if the alarm went off, he would go out and get the resident back into the facility and have the charge nurse turn the alarm off. Again the DON attempted to prompt the CNA; At 10:00 PM, CNA O stated they did not check residents at night because they were sleeping. The CNA was asked if the resident got up in the early morning, what would she do. The CNA stated she thought the nurse checked the alarms; and Between 10:15 PM through 10:30 PM, CNAs M and N, and MA Q were interviewed. They all stated the ADON had talked to them about the Wander Guards and alarms when they came to work that evening. On 01/01/11 at 5:00 PM, an unidentified maintenance person was observed checking door alarms with a Wander Guard device. On 01/01/11 at approximately 5:30 PM, the ADON was observed providing staff with an in-service, in regards to the wander guard system and protocols. 5) The Plan of Removal was accepted on 01/03/11 at 4:00 PM and included: 1. All staff scheduled to work on 12/31/10 were in-serviced on the staff response to door alarms activated and all other staff would be in-serviced by 01/01/11; 2. Monitoring to prevent re-occurrence; 3. The facility Administrator and Director of Nurses had checked each resident at the time with an order for [REDACTED]. No issues were identified with the immediate inspection; 4. The door alarms were to be checked by the facility maintenance to ensure proper working condition; 5. The door alarms were to be checked by the facility week-end Restorative Aide to ensure proper working condition; 6. The charge nurses would check placement of the wandering transmitter bracelet (Code Alert System) of each resident with an order each shift, everyday; 7. The Nurse Aide Care Plans would reflect those residents; 8. The facility front door was equipped with a Code Alert wandering system; 9. A QA (Quality Assurance) Meeting would be held on 01/01/11 at 11:00 AM with team members; 10. Facility staff not able to attend the first in-services were given the in-services; 11. A written Post Test was given to all facility staff; 12. The Code Alert Transmitter Tester System would be checked daily by the assigned restorative aide and documented; and 13. A back-up system was put in place including delegation of alternate staff for responsibility for checking door alarms and transmitter bracelets. 6) While the IJ was removed on 01/03/11, the facility remained out of compliance at a severity level of "Actual Harm that is not immediate jeopardy," and a scope of "Isolated," because staff were still being in-serviced, and the plan of removal was being monitored for implementation. 7) A list provided by facility administration on 12/30/10 reflected 11 residents required Wander Guards.

Based on observation, interview and record review, the Administrator and the DON failed to use the facility's resources effectively and efficiently to attain or maintain the highest practicable physical well-being for two (Residentd #1 and #2) of 11 residents, who were required to wear Wander Guards. The Administrator and the DON failed to: a. Established the means that Resident #1 eloped from the facility and have established policies and procedures for the Wander Guards; b. Investigate the injuries that incurred to Resident #1; c. Investigate thoroughly the incident by interviewing all possible witnesses; d. Supervise residents assessed as a wandering risk; and e. Train all staff on adequate supervision of wandering residents and the equipment's (Wander Guard) use; and f. Ensure the Wander Guard system was functioning properly 1) On 12/17/10 Resident #1 eloped from the facility and was brought back by two unidentified males. The resident was sent to the hospital with multiple lacerations and contusions to the face and a fractured spine. The facility failed to thoroughly investigate the means by which the resident left the building; ie. who was with her while she was gone, and how the injuries occurred. 2) Resident #2's family reported to CNA P the resident's Wander Guard alarm did not sound when they took the resident out of the building. CNA P did not report this to anyone. An Immediate Jeopardy (IJ) was identified on 12/31/10. While the IJ was removed on 01/03/11, the facility remained out of compliance at a severity level of "Actual Harm that is not immediate jeopardy," and scope of "Isolated," because staff were still being in-serviced and the facility was still monitoring for implementation of the Plan of Removal. These failures could affect the 11 residents, who required Wander Guards and placed them at risk for leaving the facility without staff knowledge, and placing them at risk for injury. Findings included: 1) Record review of the Face Sheet dated 07/09/10 revealed Resident #1 was admitted to the facility on [DATE]. The admitting [DIAGNOSES REDACTED]. The Physician order [REDACTED]. There was an additional order to "Check wander guard q (every) shift for proper function." Resident #1's "Wandering Risk Assessment Tool" dated 12/01/10 and completed by the facility staff indicated the resident exhibited "High Risk" behavior for exiting and for wandering. Another "Wandering Risk Assessment Tool" dated 05/05/10 for Resident #1 indicated she would "follow others around. If someone exits the facility, resident will follow." The "Monthly Summary" completed by LVN F dated 11/12/10 also indicated she was ambulatory "alone" and had a history of [REDACTED]." The Care Plan dated 12/10/10 indicated she had been care planned for "Potential for elopement." Resident #1 had also been care planned for falls and fractures as evidenced by: "cognitive impairment, unsteady gait, and other - Stumbles while walking and speeds up while walking." Review of the Incident/Accident Report dated 12/17/10 revealed Resident #1 "had fallen outside" and was sent to the emergency room for treatment and evaluation. Review of the facility incident statements from the ADON and RA G dated 12/17/10 revealed their statements provided to the DON stated only, "did not see the resident fall." The incident report did not reflect the resident's severe injuries, nor if she had a Wander Guard in place, who the stranger was that brought her back into the facility, and what treatment had been given prior to 911 entering the facility. Record review of the facility's investigation report signed by the DON and dated 12/21/10 revealed "Incident Category...Missing Resident/Client...Description of Injury...Extent unknown. Was found outside facility premises face down. Blood noted on jaw and was transferred to the hospital...." The report reflected the resident had "pain & blood" on the jaw area. The facility notified the physician and family and the staff was in-serviced. Wander Guards and exit door alarms were checked for "functionality" and Wander Guard "assessments" were done. However, there was no indication on the facility Incident report that the wander guard alarms were working. The facility "did not find any grounds for negligence on part of staff." (NOTE: there was no documentation in the report indicating the doors were functioning properly.) The report's CONCLUSION AND INTERVENTIONS OF INCIDENT reflected potential contributing factors related to the occurrence were, "Wandering behavior, busy day as facility was hosting end of year/Christmas party for the residents/visitors & family." The report did not document how the incident occurred. Witness statements completed by seven different staff members were attached to the investigation. Statements from ADON, MDS Coordinator, LVN E, LVN F, RA G, CNA R, and MA S revealed no one had witnessed any cause for Residents #1's injuries. Review of the forms used for the statements revealed areas for contributing factors and areas for identification of injuries were not completed. This lack of information failed to make clear how the injury occurred. NOTE: Nowhere in the investigation packet provided by the facility was it indicated that Resident #1 was found by "strangers" or that facility staff was unaware the resident had exited the building or how the resident's injuries occurred. On 12/30/10 at 8:37 AM, RA G was interviewed regarding the methods used by the facility to test the Wander Guard system. RA G stated she was responsible for testing the units every morning and demonstrated the procedure she followed. The surveyor observed RA G as she demonstrated the procedure. RA G obtained a current list of residents wearing Wander Guards and tested each unit using a tester box provided by the manufacturer. (This method was later confirmed as accurate per the Manufacturer's Manual.) RA G tested the front exit, the back exit by station two, and the exit by room [ROOM NUMBER] utilizing a Wander Guard unit as well as taking the residents to each of the three doors protected by the Wander Guard system. Three additional fire exits had key pad alarms and were tested . All units were functioning properly at that time. In an interview with Facility Maintenance on 12/30/10 at 8:45 AM, he stated, "That is the door she (Resident #1) left out of," pointing to the door by the nurses' station closest to the dining room. Facility Maintenance said the alarm would sound off in the presence of the Wander Guard, so that the residents wearing them could not go out the door without someone looking up and seeing what was going on. He did not state how he knew that was the door Resident #1 exited from on 12/17/10. In an interview with the ADON on 12/30/10 at 10:40 AM, she stated she had been in her office (located near the front door of the facility) at the time of the incident. She looked up and saw RA G running past her door. She then went to her office door and saw Resident #1 being supported by a "soldier" as they turned the corner into the hallway from the front door entrance. She stated RA G grabbed a wheelchair and put the resident into it and pushed her back to her room. The paramedics were there almost immediately. The facility did not have a lot of visitors at that time. She talked with LVN F after the paramedics had taken the resident to the hospital. She stated she had not heard any alarms either prior to Resident #1's fall nor after she had been returned to the facility through the front door. She stated she did not document anything. On 12/30/10 at 11:00 AM, the ADON was again queried about the events on 12/17/10. The ADON stated she was in her office and observed RA G run past her door and she jumped up to see what was wrong. The ADON stated she followed her to the front door and observed a "young soldier was bringing her (Resident #1) in." When queried whether she heard any alarms, the ADON stated, "Not at that time." The ADON stated Resident #1 had a large amount of blood on her face around her mouth and jaw. The ADON added, "By the time we got her to her room, paramedics were here." On 12/30/10 at 11:35 AM when the ADM was queried as to which door Resident #1 exited, she replied, "We don't know exactly." On 12/30/10 at 12:23 PM interview with RA G revealed she did not know how Resident #1 had exited the building. When queried about the events of that day, RA G stated that Resident #1 had just finished eating in the dining room and walked away. RA G was in the dining room assisting other residents when she heard someone yelling for help and went running. RA G added when she saw Resident #1 with blood on her face she went running for a wheelchair. When queried whether she heard an alarm, RA G stated she did not remember hearing one, only the cries for help. She denied re-setting an alarm, adding all she thought about was getting the resident to her room for assistance. Review of the Nurses' Notes dated 12/17/10 at 1:30 PM revealed Resident #1 "was escorted to nurses' station via w/c, facial bleeding noted. Abrasions noted to left forehead. Resident's oral cavity with blood, spit out broken dentures, c/o pain to mouth, chin and neck areas. EMS (Emergency Medical Services) at facility. Resident sent to the local hospital." The Emergency Medical Record, from the local hospital, dated 12/17/10 reflected Resident #1 was "Positive for sharp pain...Positive for acute pain...Positive for bleeding gums, contusion to face, contusion to lip, dentures or partial plate, facial swelling, mouth bleeding, mouth swelling." The record also reflected Resident #1 appeared in acute distress, "...WITH A GROUND LEVEL FALL AND LANDED ON HER FACE WITH FRACTURE OF HER DENTURES, BILATERAL JAW PAIN, LIP LACERATION AND TONGUE LACERATION....THRU AND THRU LACERATION OF LOWER LIP, LACERATION TO CHIN, OBVIOUS MANDIBLE SWELLING AND DEFORMITY BILATERALLY." (NOTE: the above portion appeared as written, in all capital letters on the Emergency Medical Record) Her oxygen saturation was at 90%. The radiology section of this form reported findings of "Comminuted (multiple) mandibular (lower jaw) fractures" and "Compression fracture T 10 ([MEDICATION NAME] spine #10)." Resident #1 was transported to another hospital in another city. The CT (Computerized tomography) dated 12/17/10 reflected, "Impression: Comminuted fracture mandible." Review of the hospital Operative Report for placement of gastrostomy tube dated 12/25/10 for Resident #1 revealed due to her mandibular fracture repair she was to remain NPO for a period of six weeks and therefore needed alternate access for nutrition. In an interview with the ADM on 12/30/10 at 2:40 PM, she said the restorative nurse aides were responsible for checking the functionality of the Wander Guards on a daily basis. She stated that no one particular person was responsible for watching the residents with Wander Guards, as all staff were responsible. She stated some residents signed themselves out, but the residents with Wander Guards were escorted by family. She stated that when a "call for 'help' is heard, everyone is responsible for checking on the situation." She stated the incident on 12/17/10 was the first time Resident #1 had wandered outside the facility. After the incident the Wander Guards were tested by their maintenance staff and by administrative staff and found to be working properly. When queried, ADM stated she was unable to provide any documentation of the testing. In an interview with the DON on 12/31/10 at 10:00 AM, he stated he had talked with the staff on duty at the time of the accident. He stated he was not in the building at the time since he had worked the night before. He was called but arrived at the facility after the ambulance had taken Resident #1 to the hospital. He was unsure to any exact time. He stated, "No one had interviewed the two strangers who had brought her into the facility." He stated he did not know who in the facility had gotten to her first. He stated, "You will have to find that out in your interviews." He could not verify the exit door Resident #1 had used to leave the facility. In an interview with the ADM on 12/31/10 at 10:15 AM, she stated she did not remember where she was in the facility when she first heard about the accident. She immediately went to the resident's room and saw the paramedics working on her. She stated the MDS Coordinator brought Resident #1 to the nurses' station. LVN F pushed Resident #1 into her room. She stated she then went to the site where Resident #1 had fallen as indicated by the spilled blood on the pavement in front of the facility. At this time, the ADM was asked to show the surveyors the site. The surveyors and ADM exited the building. The site, as indicated by the ADM, was in the round-about driveway in front of the facility, where it joined the street. The ADM stated she was able to identify the exact spot of the incident by the blood on the driveway. She continued with her story by stating the "strangers had to have called 911, as the paramedics had gotten to the facility by the time the resident had been placed in her bed." She stated she had never seen the "strangers" before; they were not visitors. The "strangers" disappeared before anyone could talk with them. One of the "strangers" had been dressed in military uniform. The ADM revealed CNA K reported seeing Resident #1, on the day of the incident, leaving the dining room and walking back to her room in her usual pattern/routine. The ADM explained the resident would have used the back hallway; she (resident) never went up into the front area of the facility. The ADM could not verify the exit Resident #1 had gone through to get outside the facility. She stated she believed the resident had followed a visitor outside the facility using the front door. In an interview with the MDS Coordinator on 12/31/10 at 11:00 AM, she stated the staff had been busy with decorating the facility for a Christmas Party scheduled for 2:00 PM that day. She stated the residents were getting finished with their lunch and the nurse aides were busy helping them back to their rooms. She stated she first saw Resident #1 coming down the hall from the front door and RA G was bringing her in a wheelchair. "I was following her (RA G) and told a nurse to call 911, later I learned someone else already had." (NOTE: This is a contradiction to the Administrator's statement that the MDS Coordinator brought Resident #1 to the nurses' station.) She stated she had not remembered any alarms sounding either prior to the fall nor after her entrance into the facility through the front door. She stated the Wander Guard was on the resident and it was "routine practice to remove it prior to going to the hospital." She stated Resident #1's Wander Guard was removed and given to Corporate Maintenance. She stated the Wander Guards were kept in the treatment carts at each nurses' station. The Wander Guards were not identified individually and assigned to specific residents. MDS Coordinator referenced a previous fall Resident #1 sustained on 12/10/10. She stated she witnessed her fall in the hallway. She stated she was returning some charts to the nurses station, observed Resident #1 ambulating in the hallway and suddenly speed up. She stated she dropped the charts and attempted to catch her but was unable to prevent her fall. (Resident #1 sustained an injury to her chin at that time requiring sutures.) In an interview with CNA I, on 12/31/10 at 11:50 AM, she stated Resident #1 had fallen on her face the previous week and required stitches on her chin. She stated the Wander Guards were checked every day by the RA G. She stated the aides were "not paying attention" because they were busy after lunch, taking the other residents back to their rooms and attending to the residents' needs. She stated she did not see the resident nor hear the alarm go off when the resident got out of the building. In an interview with CNA P on 12/31/10 at 12:00 PM, she stated she had last seen Resident #1 walking to the dining room to eat lunch. She stated she had been the aide caring for Resident #1 on the day of the "accident" on 12/17/10. She stated after the accident, the resident was taken to her room in a wheelchair by LVN F, who had removed her broken crushed dentures from her mouth piece by piece. She stated she thought RA G removed the Wander Guard from the resident. CNA P stated that on the day of the accident and at the time of the accident, there were not many visitors in the building. She stated she saw the ADON, RA G, and LVN F working with the resident, but did not see the ADM or the DON. She stated she had not received an in-service on Wander Guards after the incident . The last in-service she attended was on 12/29/10 and it was on gait belts. She stated she had been trained to check outside for residents with Wander Guards when the alarms went off and a resident with a Wander Guard was not inside the facility. She stated the RA G had been tasked with checking every resident with a Wander Guard everyday since the accident. She stated everyone was responsible for checking the residents with Wander Guards, to be sure they did not leave the exit doors without approval first. When the family took the resident with a Wander Guard, the alarm would have to be reset each time the resident left and returned. 2) Record review of the Face Sheet dated 12/20/10 revealed Resident #2 was a [AGE] year-old female admitted to the facility 12/08/10 with [DIAGNOSES REDACTED]. Resident #2 was identified on a list provided by the facility of residents wearing a Wander Guard. Review of Nurses Notes dated 12/24/10 at 6:30 PM revealed Resident #2 left the facility with her daughter. An interview with CNA P on 12/31/10 at 12:00 PM revealed the weekend after Resident #1's accident, Resident #2 left the facility with her family through the front door. The resident was wearing the Wander Guard, but the alarm did not sound. She stated she was informed of this by the family upon their return to the facility. CNA P revealed the alarm did sound when the resident was brought back into the facility. CNA P stated she had not reported this incident to anyone. In an interview with Resident #2's family member on 12/31/10 at 1:30 PM, she confirmed she had taken her mother out of the building on 12/24/10 without the alarm sounding. The resident was wearing the Wander Guard. When she brought her mother back with her Wander Guard still on her person, the alarm did indeed sound. Review of the visitor log revealed Resident #2 was signed out for that date (12/24/10). 3) An IJ was identified on 12/31/10. On 12/31/10 at 4:18 PM, the ADM and DON were notified an IJ was identified in the area of Administration. A Plan of Removal for the IJ was requested at that time. 4) The following interviews were conducted with the 2:00 PM - 10:00 PM and 10:00 PM - 6:00 AM staff on 12/31/10 regarding the staff's training on the Wander Guard system and resident safety: At 9:00 PM, LVN B stated she had not had an in-service on Wander Guards, but a mandatory in-service was planned for 01/03/11 at 2:00 PM. The LVN referred to a notice hanging behind the nursing station. LVN B stated they checked residents with Wander Guards every shift. They take the resident to the doors to see if the alarm would sound. LVN B was uncertain if Resident #1 had been checked the evening of 12/16/10; At 9:20 PM, CNA J stated she had not received an in-service, was unable to explain how the Wander Guard functioned, until prompted by the DON; At 9:30 PM, CNA K stated the Wander Guard would alarm and that the door would open; At 9:45 PM, CNA L stated if the alarm went off, he would go out and get the resident back into the facility and have the charge nurse turn the alarm off. Again the DON attempted to prompt the CNA; At 10:00 PM, CNA O stated they did not check residents at night because they were sleeping. The CNA was asked if the resident got up in the early morning, what would she do. The CNA stated she thought the nurse checked the alarms; and Between 10:15 PM through 10:30 PM, CNAs M and N, and MA Q were interviewed. They all stated the ADON had talked to them about the Wander Guards and alarms when they came to work that evening. On 01/01/11 at 5:00 PM, an unidentified maintenance person was observed checking door alarms with a Wander Guard device. On 01/01/11 at approximately 5:30 PM, the ADON was observed providing staff with an in-service, in regards to the wander guard system and protocols. 5) On 01/03/11 at 10:07 AM, the facility incident statements were reviewed with the DON. The DON did not provide an explanation for the forms not being completed. His only explanation was that he was not in the building at the time of the incident. On 01/03/11 at 8:30 AM, the ADON, RA G and the ADM were interviewed. ADON and RA G were asked why, when completing Resident #1's Incident/Accident report, the resident's injuries and treatments were not documented and why they had not tried to locate and interview the unidentified male who brought the resident back into the facility. Both stated they gave the reports to the DON and he never asked them any questions. On 01/03/11 at 10:30 AM, the DON and ADM were interviewed. The DON was questioned in regards to the facility's incident report sent to State Office, stating, "small amount of blood was on the resident's face" and the fact the incident reports were not complete. The DON stated "that" was what was written down and he was not in the facility when it happened. The DON stated someone told him there was a small amount of blood, and he was not aware of the amount of blood until someone told him of the resident's injuries. The DON could not recall where he got his information. The DON stated when he got to the facility that afternoon, the ADM informed him of the incident and he began checking the doors and alarms. The DON was asked how he investigated the incident: who did he talk too; did he call the hospital to check on the resident; did he make any effort to contact the unidentified male; did he check with EMS, the police or 911 operator; and how did he determine who to interview in regards to this incident. The DON again stated he "reviewed the written statements and sent them to State Office." When asked how he would and/or did investigate this incident, the DON did not answer. 6) The Plan of Removal was accepted on 01/03/11 at 4:00 PM and included: 1. All staff scheduled to work on 12/31/10 were in-serviced on the staff response to door alarms activated and all other staff would be in-serviced by 01/01/11; 2. Monitoring to prevent re-occurrence; 3. The facility Administrator and Director of Nurses had checked each resident at the time with an order for [REDACTED]. 4. The door alarms were to be checked by the facility maintenance to ensure proper working condition; 5. The door alarms were to be checked by the facility week-end Restorative Aide to ensure proper working condition; 6. The charge nurses would check placement of the wandering transmitter bracelet (Code Alert System) of each resident with an order each shift, everyday; 7. The Nurse Aide Care Plans would reflect those residents; 8. The facility front door was equipped with a Code Alert wandering system; 9. A QA (Quality Assurance) Meeting would be held on 01/01/11 at 11:00 AM with team members; 10. Facility staff not able to attend the first in-services were given the in-services; 11. A written Post Test was given to all facility staff; 12. The Code Alert Transmitter Tester System would be checked daily by the assigned restorative aide and documented; and 13. A back-up system was put in place including delegation of alternate staff for responsibility for checking door alarms and transmitter bracelets. 7) While the IJ was removed on 01/03/11, the facility remained out of compliance at a severity level of "Actual Harm that is not immediate jeopardy," and a scope of "Isolated," because staff were still being in-serviced, and the plan of removal was being monitored for implementation. 8) A list provided by facility administration on 12/30/10 reflected 11 residents required Wander Guards.