Every finding on record at Avir at Pasadena

Based on interviews, and record review, the facility failed to protect the resident's right to be free from verbal abuse by CNA A for 1 (Resident #1) of 8 residents reviewed for verbal abuse. The facility failed to ensure Resident #1 was free from verbal abuse when CNA A used inappropriate language towards Resident #1. CNA A said, You old ugly lady, I don't have anything in my teeth bitch, I am taking you to court, Bitch why you hit me, You're nasty, to Resident #1 on unknown date and time. This failure could place residents at risk for not having their needs met to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings included: Record review of Resident #1's Care Plan, dated 08/17/2026, revealed Resident #1 was a [AGE] year-old female. Resident #1 was admitted to the facility on [DATE] and discharged on 08/05/2026. Resident #1 was diagnosed with Hypertension (High-Blood Pressure), Constipation (Difficulty passing hard stools), Transient Ischemic Attack (Stroke), Acute Embolism and Thrombosis (Blood Clot), Hyperlipidemia (High Cholesterol), Depression (Feelings of loss, sadness, or dread), Gastro-Esophageal Reflux Disease (Heartburn), Vitamin D Deficiency, Anemia (Low level of red blood cells), Osteoporosis (Bone disorder that causes thinner bones), Edema (Swelling), Vascular Dementia Unspecified Severity (cognitive impairment resulting from vascular disease), Psychotic Disturbance (experiencing hallucinations, delusions, or disorganized thinking), and Anxiety (frequent or nearly constant, nagging feelings of worry). Record review of Resident #1's Brief Interview Mental Status Assessment, dated 06/19/2026, revealed Resident #1 had a score of 14 indicating Resident #1's cognition was intact. Record review of Resident #1's Minimum Data Set, dated [DATE], revealed Resident #1 always required bowel and urinary incontinent care assistance. Resident #1 was dependent on facility staff with putting on/taking off footwear, lower body dressing, shower/bathing, toileting hygiene, toilet transfer, and shower/tub transfer. Resident #1 required substantial assistance with upper body dressing, sitting to lying, lying to sitting on side of bed, and sitting to stand. Resident #1 required partial assistance with personal hygiene, oral hygiene, rolling left and right, and chair/bed to chair transfer. Record review of audio recording, undated, provided by Family Member X, revealed that CNA A stated You old ugly lady, I don't have anything in my teeth, bitch, I am taking you to court, Bitch, why you hit me, You're nasty, You can never be a golden girl, to Resident #1. There was no video to accompany the audio recording. Resident #1 was heard telling CNA A to go away, leave me alone, bitch, and yelling help. CNA A stated that she was taking Resident #1 to court and would have her thrown in jail. Record review of an employee statement from CNA A, unknown date and time, revealed that on several occasions Resident #1 was combative towards her. She stated Resident #1 called her a black B word for changing her and told her that she was going to call the police while scratching her arm up while she changed her. She stated she was removed from working with Resident #1. She stated a nurse witnessed Resident #1 pulling and scratching her. She stated Resident #1 said all types of bad stuff towards her. Record review of an employee statement from CNA A, dated 08/21/2026, revealed that on 07/29/2026 she worked with Resident #1. CNA A stated that Resident #1 grabbed her arm and scratched her while she was providing incontinent care. She stated that she told Resident #1 that she was going to call the cops on her. Record review of an Employee Counseling with CNA A, dated 08/21/2026 at an unknown time, revealed the facility initiated an investigation on an allegation of verbal abuse based on audio recording that was brought to their attention on 08/21/2026. CNA A was suspended pending investigation. Record review of CNA A's Employee File, dated 03/04/2026, revealed CNA A received training on Dementia. The training revealed that dementia residents may have sudden mood swings without a known cause. The training stated that residents should be treated with respect. Training revealed that care staff should talk in a calm and reassuring manner and may need to be more tolerant of unusual behavior by reducing reactions to bizarre behaviors. Record review of CNA A's Employee File, dated 03/04/2026, revealed training on Resident Rights. The training revealed that a resident has a right to a dignified existence. The resident rights training stated that a resident may not be threatened, coerced, intimidated, or retaliated against because he or she chooses to exercise his/her rights. A resident has the right to be free from abuse and exploitation, treated with courtesy, consideration, and respect. Record review of CNA's Employee File, dated 03/04/2026, revealed training on Abuse, Neglect, Exploitation. The training revealed that a resident of the facility shall not be subject to abuse, neglect, or exploitation. Abuse was defined as the negligent willful infliction of injury, unreasonable confinement, intimidation, or cruel punishment. Record review of facility Abuse, Neglect, Resident Rights in-service training report, dated 08/21/2026, revealed that 30 of the facility staff signed on 08/21/2026. Record review of Resident Safe Survey for Resident #9, dated 08/21/2026, revealed that he had not witnessed verbal abuse. Resident #9 felt safe and had been treated with respect. Record review of Resident Safe Survey for Resident #10, dated 08/21/2026, revealed that she had not witnessed verbal abuse. Resident #10 felt safe and had been treated with respect. Interview on 08/20/2026 at 9:10 AM with DON D revealed Resident #1 had an issue with CNA A. She stated CNA A worked on the night shift. She stated that while on the overnight shift around 5:50 AM there was an incident between CNA A and Resident #1. She stated she did not remember the date. She stated LVN E walked into Resident #1's room and observed Resident #1 attacking CNA A. She stated this occurred during an incontinent care change. DON D stated two days after this incident occurred one of the staff members told her Family Member X was at the facility asking about the incident. She stated the staff member told her Family Member X was complaining about the incident. She stated she told the staff member that called her on the telephone that it was not true. She stated it was the resident who was attacking the CNA. She stated she was not aware of any staff members being inappropriate with Resident #1 and that it was the other way around. She stated she did not remember who it was that called her and asked about the incident. Interview on 08/20/2026 at 12:31 PM with ADON F revealed she had a conversation with Family Member X. She stated Family Member X asked her if there was anything going on with the staff on the overnight shift. She stated she called DON D to ask if she knew anything. She stated DON D said Resident #1 hit a CNA on the overnight shift. She stated DON D said it happened during incontinent care. She stated she only called DON D to find out if anything had happened. Interview on 08/20/2026 at 11:36 AM with Administrator B revealed she did not know about any verbal abuse allegations. She stated that Family Member X had not complained to her about verbal abuse involving Resident #1. She stated she was not told about CNA A being verbally abusive to Resident #1. She stated that Family Member X did not say anything about Resident #1 being called fresh meat by CNA A or that Resident #1 was told that the cops were going to be called on her by CNA A. Interview on 08/20/2026 at 1:05 PM with LVN E revealed she witnessed an incident between CNA A and Resident #1. She stated she walked into Resident #1's room and observed Resident #1 trying to hit CNA A. She stated she intervened. She stated Resident #1 did not have any bruising or injuries. She stated she did not know anything about verbal or physical abuse being done to Resident #1. She stated that she did not hear or see any verbal remarks. She stated it was the opposite. She stated Resident #1 was being verbally and physically abusive towards CNA A. Interview on 08/20/2026 at 1:30 PM with Family Member X revealed Family Member X informed Administrator B of verbal abuse on 08/29/2026. They stated they recorded the whole conversation. They stated they told Administrator B there was a CNA on the night shift who was threatening to call the cops on Resident #1. They stated the CNA told Resident #1 she was going to have her thrown in jail. They stated the CNA also told Resident #1 she was going to be fresh meat for the inmates in jail. They stated Administrator B identified the CNA but did not want to provide the name of the CNA. Interview on 08/21/2026 at 8:30 AM at the hospital with Resident #1 revealed CNA A was verbally abusive towards her. She stated she did not know the name of CNA A. She stated that she was not sad about what CNA A had said to her. She stated that she was not scared of what CNA A had said to her. She refused to answer any questions about what CNA A said to her. When asked what CNA A said to her, she stated, you don't want to know. When asked again she stated, you don't want to know. Interview on 08/21/2026 at 3:00 PM with Administrator B revealed that she did not think the facility staff followed the facility policies after listening to the audio recording. The audio recording was shared to Administrator B during the interview. She stated the staff members voice in the audio recording was CNA A. She stated that her expectations of her staff were to treat their residents with dignity and respect. She stated the residents have the right to be free from abuse and neglect. She stated CNA A was still an employee at the facility, but she would be suspended pending investigation immediately. She stated the facility would start abuse and neglect inservices immediately. She stated that safe surveys would also be performed to make sure residents felt safe. Interview on 08/21/2026 at 3:24 PM with DON D revealed that the staff member did not follow the facility policy during the audio recording. She stated the staff member in the audio recording was CNA A. She stated that after reviewing the audio recording that CNA A should have left Resident #1 alone once Resident #1 told her to leave her alone. She stated that CNA A and Resident #1 had already been separated because of the incident that was witnessed by LVN E. She stated that she did not know that there was verbal abuse occurring. She stated that she was not informed of verbal or physical abuse allegations. She stated that she knew Resident #1 was attacking CNA A but she did not know CNA A was being verbally abusive towards Resident #1. She stated that had she of known she would have already intervened and terminated CNA A. She stated she made rounds personally and never heard of any verbal abuse allegations occurring in the facility. She stated that once CNA A returned to work she would be terminated. Interview on 08/21/2026 at 3:30 PM with LVN E revealed that CNA A did not follow the facility policy during the audio recording. She stated that staff member in the audio recording was CNA A. She stated she was able to identify CNA A from her voice. Interview on 08/21/2026 at 3:45 PM with Resident # 2 revealed that she had not had any verbal abuse altercations with any of the facility staff. She stated that the staff treat her with dignity and respect. Interview on 08/21/2026 at 3:50 PM with Resident #9 revealed that he had not had any verbal abuse altercations with any of the facility staff. He stated that the staff treated him with dignity and respect. Interview on 08/21/2026 at 3:55 PM with Resident #10 revealed that she had not had any verbal abuse altercations with any of the facility staff. She stated that the staff treated her with dignity and respect. Interview on 09/01/2026 at 4:00 PM with CNA A revealed Resident #1 scratched her and called her a b word on the overnight shift. She stated that she did not intend to call Resident #1 ugly. She stated that she intended to tell Resident #1 that she was acting ugly because Resident #1 was being rude to her. She stated that it came out wrong. She stated that she called Resident #1 a bitch one time. She stated that she called Resident #1 a bitch because Resident #1 called her a bitch first. She stated that she did tell Resident #1 that she was going to call the police on her because Resident #1 scratched her. She stated that she remembered Golden Girls being on the television. She stated LVN E came into the room and witnessed the interaction. She stated that she believed this occurred on 07/29/2026. She stated that the reason she was in the room was because she was providing incontinent care for Resident #1. She stated she knew she should not have called Resident #1 a bitch because she was trained to disengage and walk away. Record review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation Policy Reporting and Investigating, dated, stated that all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Reporting Allegations to the Administrator and AuthoritiesIf 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.The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies:The state licensing/certification agency responsible for surveying/licensing the facility;The local/state ombudsman;The resident's representativeAdult protective services (where state law provides jurisdiction in long-term care)Immediately is defined as:Within two hours of an allegation involving abuse or result in serious bodily injury; orWithin 24 hours of an allegation that does not involve abuse or result in serious bodily injuryInvestigating Allegations 7. Allegations are thoroughly investigated. The administrator initiates investigations.Identifying Types of AbusesAs part of the abuse prevention strategy, volunteers, employees and contractors hired by this facility are expected to be able to identify the different types of abuse that may occur against residents.

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials, including to the State Survey Agency where state law provides for jurisdiction in long-term care facilities, in accordance with State law through established procedures for 1 of 8 residents (Resident #1) reviewed for reporting. The facility failed to follow their policy for reporting an allegation of abuse or neglect that was reported to Administrator B by Family Member X to the State Survey Agency. This failure could place residents at risk for not having incidents reported as required. Findings included: Record review of Resident #1's Care Plan, dated 08/17/2026, revealed Resident #1 was a [AGE] year-old female. Resident #1 was admitted to the facility on [DATE] and discharged on 08/05/2026. Resident #1 was diagnosed with Hypertension (High-Blood Pressure), Constipation (Difficulty passing hard stools), Transient Ischemic Attack (Stroke), Acute Embolism and Thrombosis (Blood Clot), Hyperlipidemia (High Cholesterol), Depression (Feelings of loss, sadness, or dread), Gastro-Esophageal Reflux Disease (Heartburn), Vitamin D Deficiency, Anemia (Low level of red blood cells), Osteoporosis (Bone disorder that causes thinner bones), Edema (Swelling), Vascular Dementia Unspecified Severity (cognitive impairment resulting from vascular disease), Psychotic Disturbance (experiencing hallucinations, delusions, or disorganized thinking), and Anxiety (frequent or nearly constant, nagging feelings of worry). Record review of Resident #1's Brief Interview Mental Status Assessment, dated 06/19/2026, revealed Resident #1 had a score of 14 indicating Resident #1's cognition was intact. Record review of Resident #1's Minimum Data Set, dated [DATE], revealed Resident #1 always required bowel and urinary incontinent care assistance. Resident #1 was dependent on facility staff with putting on/taking off footwear, lower body dressing, shower/bathing, toileting hygiene, toilet transfer, and shower/tub transfer. Resident #1 required substantial assistance with upper body dressing, sitting to lying, lying to sitting on side of bed, and sitting to stand. Resident #1 required partial assistance with personal hygiene, oral hygiene, rolling left and right, and chair/bed to chair transfer. Record review of audio recording, undated, of Family Member X and Administrator B revealed Family Member X told Administrator B that CNA A was telling Resident #1 that she was going to be thrown in jail and that she would be fresh meat for the inmates in jail. Family Member X stated that Resident #1 was living in fear of the police arriving to take her to jail. Administrator B thanked Family Member X for bringing the incident to her attention. Administrator B stated that she would investigate the incident and follow up. Family Member X stated that the date was 07/31/2026 and the time was 3:28 PM during the audio recording. Interview on 08/20/2026 at 11:36 AM with Administrator B revealed she did not know about any verbal abuse allegations. She stated Family Member X had not complained to her about verbal abuse. She stated that she was not told about CNA A being verbally abusive to Resident #1. She stated that Family Member X did not say anything about Resident #1 being called fresh meat by CNA A or that Resident #1 was told that the cops were going to be called on her by CNA A. Interview on 08/20/2026 at 2:30 PM with Administrator B revealed that she did not know about any verbal abuse allegations. She stated that Family Member X had not complained to her about verbal abuse. She stated she was not told about CNA A being verbally abusive to Resident #1. She stated that Family Member X did not say anything about Resident #1 being called fresh meat by CNA A or that Resident #1 was told that the cops were going to be called on her by CNA A. Interview on 08/21/2026 at 8:30 AM at the hospital with Resident #1 revealed CNA A was verbally abusive towards her. She stated she did not know the name of CNA A. She stated that she was not sad about what CNA A had said to her. She stated that she was not scared of what CNA A had said to her. She refused to answer any questions about what CNA A said to her. When asked what CNA A said to her, she stated, you don't want to know. When asked again she stated, you don't want to know. Interview on 08/21/2026 at 3:00 PM with Administrator B revealed that she remembered talking to Family Member X after she heard the audio recording of their conversation. She stated Family Member X's allegations were not reported to the Texas Health and Human Services Commission. She stated that Family Member X did not share with her all the statements made from CNA A towards Resident #1 or she would have reported it. She stated that by the time she talked to Family Member X she had already separated CNA A from Resident #1. Interview on 09/01/2026 at 4:00 PM with CNA A revealed Resident #1 scratched her and called her a b word on the overnight shift. She stated that she did not intend to call Resident #1 ugly. She stated that she intended to tell Resident #1 that she was acting ugly because Resident #1 was being rude to her. She stated that it came out wrong. She stated that she called Resident #1 a bitch one time. She stated that she called Resident #1 a bitch because Resident #1 called her a bitch first. She stated that she did tell Resident #1 that she was going to call the police on her because Resident #1 scratched her. She stated LVN E came into the room and witnessed the interaction. She stated that she believed this occurred on 07/29/2026. She stated that the reason she was in the room was because she was providing incontinent care for Resident #1. She stated she knew she should not have called Resident #1 a bitch because she was trained to disengage and walk away. Record review of Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigating Policy revealed that all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Reporting Allegations to the Administrator and AuthoritiesIf 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.The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies:The state licensing/certification agency responsible for surveying/licensing the facility;The local/state ombudsman;The resident's representativeAdult protective services (where state law provides jurisdiction in long-term care)Immediately is defined as:Within two hours of an allegation involving abuse or result in serious bodily injury; orWithin 24 hours of an allegation that does not involve abuse or result in serious bodily injuryInvestigating Allegations 7. Allegations are thoroughly investigated. The administrator initiates investigations.Identifying Types of AbusesAs part of the abuse prevention strategy, volunteers, employees and contractors hired by this facility are expected to be able to identify the different types of abuse that may occur against residents.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement in that: -Food items expired, and Food items not labeled or dated.These failures could affect residents who ate food from the facility kitchen and place them at risk of foodborne illness and disease.Findings include:Observation of the facility's kitchen and interview on 02/10/26 between 8:23 am and 8:30 am with Dietary [NAME] A revealed the following: A container of what appeared to be beans; it was not labeled or dated in the pantry A container of what appeared to be rice; it was not labeled or dated in the pantryApproximately 42 cups of tea in the refrigerator with no lidsA bag of what appeared to be cabbage that had brown residue in the refrigeratorIn an interview on 02/10/26 at 8:24AM with Dietary [NAME] A, she stated all items were supposed to be labeled with dates and name and she stated, I am about to label it now. When asked additional questions, she reported the dietary manager would be able to assist with additional questions.In an interview on 02/10/26 at 8:44AM with the Dietary Manager; she stated all items in the kitchen must be labeled with names and dates. She stated that when items were repackaged, they created labels for them. She stated the cooks and aides were responsible for labeling and dating the items in the kitchen, but they were to inform her of the items that needed to be removed and she discarded them. She stated when prepping drinks for lunch, the staff were supposed to cover the cups with saran wrap or a tray was placed on top of the drinks until they serve them. She stated the purpose of covering the drinks was to ensure that nothing gets inside of them. She stated she disposed of expired items on Tuesdays when the food truck arrives. She stated she planned to remove the items today (Tuesday) because the food truck was scheduled for today. She stated the risk of having expired items was food poison. Record review of the facility's Food Receiving and Storage policy revised November 2022, stated; .4. Dry foods that are stored in bins are removed from original packaging, labeled, and dated ( use by date). Such foods are rotated using a first in-first out system.7. Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded.

Based on observation, interview and record review, the facility failed to provide a safe, clean and comfortable homelike environment for 1 of 8 residents (Resident #11) reviewed for a homelike environment. The facility failed to ensure that Resident #11's room was a clean and comfortable homelike environment.The failure could place residents at risk for an uncomfortable, unhomelike environment, and a diminished quality of life. Findings included: Record review of Resident #11's face sheet dated 2/12/26, revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Parkinson's Disease (progressive neurological disorder that primarily affects movement) without Dyskinesia (uncontrollable and involuntary movements). Record review of Resident #11's quarterly MDS dated [DATE], section C revealed a BIMS was not conducted as Resident #11 was rarely or never understood. Observation on 2/10/26 at 9:47 a.m. revealed a brown substance on the bottom edge of the privacy curtain on A bed's side in the middle of Resident 11's room. The brown substance was 6 inches wide and 4 inches tall.Observation on 2/11/26 at 9:30 a.m. revealed the brown substance on the privacy curtain in Resident 11's room was unchanged from the previous observation. Observation on 2/11/26 at 1:29 p.m. revealed the brown substance on the privacy curtain in Resident 11's room was unchanged from the previous observations.During interview on 2/11/26 at 1:31 p.m., CNA H said they had not noticed the brown area on the privacy curtain in Resident 11's room. CNA H said she did not work yesterday and the brown substance was not on the privacy curtain when she last worked which was on 2/9/26. CNA H said the process regarding notifying regarding a situation like this was to notify the nurse and then the nurse would write a communication form to tell maintenance or housekeeping to take the curtain down. During interview on 2/11/26 at 2:02 p.m., Housekeeping A stated he was assigned to the orange hall where Resident #11's room was located and worked from 6 a.m. to 2 p.m. Housekeeping A stated he was off work yesterday. Housekeeping A stated he was cleaning Resident 11's room when he was called in to speak with surveyors. Housekeeping A stated that when the residents' privacy curtains were dirty, they would disinfect them and if they were not able to spot clean then they send them to laundry to be washed but most of the time the curtains do not get that dirty.During observation on 2/11/26 at 2:10 p.m., Housekeeper A accompanied the surveyor to Resident 11's room where they observed the brown spot on the privacy curtain. After observing the brown spot on the privacy curtain, Housekeeper A said the privacy curtain would have to be taken off the ceiling and sent out to the laundry. Regarding possible outcomes for the resident if the privacy curtain was dirty, Housekeeper A said he would not have the privacy curtain come in contact with the resident and mostly there was only food on the privacy curtains which wasn't hard to get rid of and he had cleaner for that kind of dirt and filth. During interview on 2/12/26 at 9:03 a.m., the DON said resident rooms should be cleaned every shift and as needed. The DON said areas in the resident rooms should be cleaned immediately if areas were observed to be dirty. The DON said they saw the area was in Resident 11's room after they were notified by the surveyor and they took the curtain down right away. The DON said she knew the area on the curtain in Resident 11's room was a stain but was unsure what the area on the curtain in Resident 11's room was. The DON said the resident in room with the stain was bedbound so she would not touch the area, but it would not be good to look at. The DON said an effect a resident could have if not bed bound was hard to say as they did not know what the substance was. Observation on 2/12/26 at 10:41 a.m. revealed a different color privacy curtain in Resident 11's room and the privacy curtain was clean. Interview on 2/12/26 at 11:11 a.m., the Administrator said her expectation was that the housekeeping staff should clean the resident rooms daily. The Administrator said dirty items like the privacy curtain in Resident 11's room should be cleaned. The Administrator said she did not know what the substance was on the privacy curtain in Resident 11's room. The Administrator said it was everybody's responsibility to make sure the residents' rooms were clean. The Administrator said regarding the substance on the privacy curtain in Resident 11's room she cannot say that there could be a negative outcome. During interview on 2/12/26 at 11:17 a.m., the Housekeeping Supervisor said they took care of the privacy curtain in Resident 11's room . The Housekeeping Supervisor said it was the expectation that the residents' rooms were cleaned daily and more if need be. The Housekeeping Supervisor said any of the staff should be observing for anything in the residents' rooms that were excessively dirty and was not limited to one department. The Housekeeping Supervisor said if the privacy curtains were dirty, the process was to take down the privacy curtain and clean them in the laundry and replace the privacy curtain. The Housekeeping Supervisor said as far as the privacy curtain being dirty, she did not know if there were any potential negative effects for the residents. The Housekeeping Supervisor said if there were hazardous materials or spills, then we immediately get that. The Housekeeping Supervisor said it could make anybody sick if they touched stool, but they do not let it get that far. The Housekeeping Supervisor said brand new housekeeping staff get three days of training including going through the job description of what they were supposed to do, show them how to deep clean which included moving the furniture, using correct PPE, how to clean bathroom, training on chemicals, potential hazards and what to do if it gets on them, to notify them if they see anything, if they see anything that was not right and to make room rounds. Record review of the facility's policy Homelike Environment revised February 2021 revealed the facility staff and management maximizes the characteristics of the facility that reflect a personalized, homelike setting which included the characteristics of a clean, sanitary and orderly environment.

49710 Based on interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible, and each resident received adequate supervision to prevent accidents for 1 of 18 residents (Resident #91) reviewed for accidents and supervision, in that: The facility failed to supervise Resident #91 on the secure unit, after he attempted to elope 20 minutes prior to eloping, out of the window on 12/31/23. An Immediate Jeopardy (IJ) was identified as past non-compliance on 11/21/24. The non-compliance began on 12/31/23 and ended on 1/2/24. The facility had corrected the non-compliance before the survey began on 11/19/24. This deficient practice could place residents who were elopement risks at-risk of harm, serious injury, or death. The findings included: Record review of Resident #91's undated face sheet revealed he was admitted to the facility on [DATE] and had a diagnosis of Alzheimer's disease. Record review of Resident #91's care plan revealed he was on a secure unit, was an elopement risk/wanderer and was at risk for possible injury related to his wandering and diagnosis of Alzheimer's Disease. The care plan also revealed Resident #91 eloped on 12/31/23 through his window in his room on the sercure unit. Record review of Resident #91's Admission Wandering Assessment performed on 12/1/23 by LVN E at 8:04 p.m., revealed a score of 8 which indicating the resident was a high risk for wandering. Record review of Resident #91's Physician Orders by MD C, revealed an order for Memantine HCl Oral Tablet 5 mg, 1 tablet by mouth a day, for memory r/t Dementia. Ordered on 12/1/23. Record review of Resident #91's December 2023 MAR-TAR revealed, RN A documented the resident was having wandering behaviors on 12/31/23 during the day. Record review of the facility's provider report on 11/21/2024 revealed, the charge nurse was notified that the resident was found on 12/31/23 at 3:05 pm. The report said a complete search of the facility was performed for the resident and it appeared he left via the window. The report said three teams went to search for the resident via cars. It also said the alarm system was tested and was working properly. The report revealed the resident had set off the alarm about 20 minutes prior but did not elope. Per the report, maintenance staff tested the alarm system, and it was working properly. The alarm company also did a test of the system, and everything was working properly. The provider report also revealed the facility staffed dedicated a person to monitor the alarm and the resident for 72 hours after the elopement. Record review of Resident #91's nurses note dated on 12/31/23 at 3:00 pm from RN A stated, Resident set off the alarm, and he was redirected back to his room and staff reset the alarm. About 20 minutes later writer left the Hall to go pick up diagnostic results off the fax for another resident when writer came back to the Hall, one of the CNA's was standing in front of the last room on the right side of the hall, and she said one of the residents in that room is pointing at the window and it's open. Writer did head count and noticed that resident was missing. The note went on to say, RN A last saw the resident at about 2:45 pm, but CNA B was the last person to see him and that was in the dining room. The note said, [at 4:00pm] the police told [RN A] that he has been found that someone dropped him off at the Fire station on [street]. The note said the resident was back at the facility at 4:15 pm and Q15 minute checks were started. Record review of Resident #91's Wandering Assessment performed on 12/31/24 at 4:15 pm by RN A revealed a score of 7 which was a moderate risk for wandering. Record review of Resident #91's nurse's note from 12/31/23 at 6:31 pm by LVN D said, Resident sitting on the hallway in company of a CNA, resident pleasant and talking with staff, Q15 minutes round sheet on progress per facility protocol. CR Record review of Resident #91's history and physical performed by MD C on 1/2/24 revealed, Patient left facility, found at Vista and [NAME] Road. Found by [good Samaritan]. Fire Department brought him back. No new orders. In observation on 11/19/24 at 10:31am resident #91 is observed playing ball in the dining room with other residents with staff supervision. On 11/20/24 at 9:25am observed the alarm monitor screen which indicated it was on. Reviewed alarm company records. In an observation and interview on 11/20/24 at 9:30am resident stated he's doing good. He just took a shower. He states his hair is still wet and requests a towel. Did not observe resident wandering, messing with the windows, or trying to exit. During observations he in the dining room with other residents under staff supervision. In an interview with CNA B on 11/21/24 at 11:01 am, she said she was on her 1 hour break when the elopement happened. She said she left for break after they had given snacks to the residents and then came back around 3 pm. She said when she came back, the resident was gone, and they went outside looking for the resident, but could not find him. She said the police found him at a fire station and a citizen had picked him up and dropped him off there. She said the resident came back close to dinner time and the only complaint was that he wanted water. CNA B said herself, an agency CNA, and one nurse were working on the Secure Unit that day. She said her schedule was Saturday-Sunday from 6am-10pm. She said the windows did not have locks but had alarms that would go off and were loud enough to be heard all through the Secure Unit and outside of the unit by the door. She said to reset the alarm all the windows had to be closed and the alarm panel was at the nurse's station. The CNA stated they were trained on elopement and to notify the nurse as soon as a resident is missing. They search the whole building and perform head counts. In an interview with the Administrator on 11/21/24 at 1:04 pm, he said, he was at the facility for the incident with Resident #91. He said there was no exact answer on how the resident got out. He said the facility partnered with the VA and sent them all the information he had, and they were not concerned . He said the incident happened on a weekend, on a Sunday, and the alarm went off earlier in the day. He said RN A reset the alarm and he thought Resident #91 must have disarmed the alarm because it was working earlier in the day, and no one heard an alarm go off. He said the alarm system worked very well and he had the alarm company come out and check it and it was fine. He said some one found Resident #91 on and took him to the fire station. The Administrator said the Police Department brought Resident #91 back to the facility. He said they performed a Missing Resident in service on how to search for the resident and an in-service on Abuse and Neglect. The Administrator also said Resident #91 was placed on Q15min checks for multiple days. In an interview with RN A on 11/21/24 at 4:12 pm, she said, earlier in the day, the alarm went off in the Secure Unit, but she was not sure why. She said another nurse re-set the alarm. She said she left the Secure Unit to grab an order off the fax and left an agency CNA on the Secure Unit to watch the residents while she left. She said when she got back, the CNA and another resident were pointing into a resident's room. RN A said she went to the room and the window was open and it was Resident #91's room. She said she immediately performed a head count and realized Resident #91 was missing. She said she had performed a head count right before she left the unit to get the lab order off the fax and seen Resident #91 in the dining room. She said CNA B had just left for break and she had seen him before she left. RN A said the facility had not had any other issues with the alarms before that day. She said the alarm that went off earlier in the day could have been from Resident #91's window but she could not remember. Record review reveals resident has not eloped since 12/31/23. Record review of facility's policy and procedure on Elopement (no revision date) read in part: Nursing personnel must report and investigate all reports of missing residents. It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the charge nurse as soon as practical. Determination of missing resident either by routine nursing rounds or door alarms: Note: A resident is determined missing when he/she leaves the facility without the staff knowledge .Should an employee observe a resident leaving the premises, he/she should: attempt to prevent the departure: obtain assistance from other staff members in the immediate vicinity, if necessary .Should an employee discover the resident is missing from the facility, he/she should: Report to the charge nurse, determine if the resident is out on an authorized leave or pass. If not; make a thorough search of the building(s) and premises .Provide search teams with resident identification information, Make an extensive search of the surrounding area . It was determined this failure placed Resident #91 in an IJ situation from 12/31/24 to 1/2/24. The Administrator was notified and provided with the IJ template on 11/21/24 at 5:34 p.m. The facility took the following action to correct the non-compliance on 1/2/24:. o The facility had Maintenance check the alarm system several times to ensure it was working properly. o The alarm company came out the next day on 1/2/24 at 9 a.m. - 11 a.m. and checked the whole alarm system and ensured it was working. o The alarm company replaced the sensor on Resident #91's window as a precaution. o An employee was placed on the unit who was dedicated to monitoring the alarm and the residents for 72 hrs from 12/31/23 to 1/3/24. o Maintenance tested the alarm system, daily, for 7 days after the incident . o In services on facility elopement, resetting the alarm system, and abuse/neglect were given on 1/2/24 and ongoing. o Rounds were done every 15-minute checks on Resident #91 on 12/31/23, 1/1/24, 1/2/24, 1/3/24. o The incident was brought to QAPI . unknown date. No other issues with elopement since 12/31/23. In an interview with RN A on 11/21/24 at 4:12 pm interviewee stated they had in services on elopement, which included performing a head count and searching the whole building for the resident. Then contacting the police as soon as possible. In an interview on 11/21/24 at 5:17 p.m. CNA B said they were trained on elopement and to notify the nurse as soon as a resident is missing. They search the whole building and perform head counts.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in 1 of 1 preparation kitchen. The facility did not ensure the dishwasher was above the appropriate sanitizing temperature of 120 degrees Fahrenheit. This failure could place residents who ate food from the kitchen at risk of foodborne illness. Findings included: In an observation on 11/20/24 at 1:30 pm, the low temperature dishwasher was observed at 115 degrees Fahrenheit during the rinse cycle, with 100 ppm. In an interview on 11/20/24 at 2:10 p.m., the Dietary Manager stated staff did not let her know the dishwasher was running low temperatures. Staff told her it was not for them to let her know . Maintenance came and looked at the water heater and he mixed up the heater with the laundry. There are two water heaters in the near closet located outside the kitchen. One is for the kitchen and the other one is for the laundry room. He raised it to 140 degrees Fahrenheit. She called corporate to ask where the temperature should be, and they stated between 120-140 degrees. They were checking the dishwasher temperatures multiple times a day so this could have been fixed sooner . She takes full responsibility. In an observation on 11/20/24 at 3:05 p.m., the dishwasher was observed running at 131 degrees Fahrenheit during rinse cycle. In an Interview on 11/20/24 at 3:10pm with the administrator. The interviewee states the dishwasher should be 120 degrees or above. He stated this was an older building and with the temperature dropping outside sometimes it takes longer for the water heaters to regulate. This old building is not as stable as it used to be. The Dietary Manager thought 115 degrees was okay. He stated he called three other facilities and spoke with them, and they thought 115 degrees would be sufficient since we use disinfectant solution as well and not relying on just the hot water. He stated it is the responsibility of the dietary staff to be checking the dishwasher daily. He stated he would be happy to have something in place for admin to be a backup for checking the temperature logs. Record review of an undated google document provided by the Administrator read in part, .Dishwashers that rely on chemicals to sanitize should reach a minimum of 120 degrees Fahrenheit, dated October 29, 2024 .

Based on observation, interview, and record review, the facility failed to provide, based on the comprehensive assessment and care plan, activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 1 of 6 residents (Residents #81) reviewed for activities, in that: The facility failed to ensure Resident #81 participated in one-on-one in-room activities since January 2024. This deficient practice could place residents at risk of decline in psychosocial well-being and their physical health. Findings included: Record review of Resident #81's Face Sheet dated 8/15/18 revealed she was an [AGE] year-old female admitted to the facility 2/24/23. Her diagnoses included cognitive communication deficit, ataxic gait (a walking abnormality that's characterized by an irregular, clumsy, and wide based walk), depression, muscle wasting and atrophy (loss of muscle mass and strength, often occurring due to lack of use, injury, malnutrition, or certain medical conditions, resulting in visible decrease in muscle size and function), and hyperthyroidism. Record review of Resident #81's MDS assessment dated [DATE] revealed a BIMS score of 6 indicating severe cognitive impairment. The activities rated as very important were listening to music and participating in religious services. Keeping up with the news, group activities, going outside, and doing favorite activities was rated as somewhat important. Record review of Resident #81's Care Plan dated 2/20/21 revealed she would attend socials and groups of interest. Resident would attend music, trivia, board games, Ice Cream Socials. Resident #81 required a rolling walker to attend. Interventions included inviting her to schedule activities and schedule medications, treatments, and ADL care around activities as able. Observation and interview on 11/19/2024 at 10:15 a.m., revealed Resident #81 lying in bed with the television on. A bed tray was hovering over her. She said she was tired of lying in bed. She said she had been at the facility for year and a half. She said they would come to visit her during mealtime. She said she never get out of bed unless it was to take a shower. In an interview on 11/20/2024 at 11:30 a.m., CNA A said she had been working at the facility since May 2024. She said she helped Resident #81 get up for showers. She said Resident #81 had a broken leg, broken hip, and whiplash. She said Resident #81 never wanted to get out bed. She said she tried to sit Resident #81 up to eat and sit her on the side of the bed, but she did not allow that to happen. She said Resident #81 refused food, therapy, and showers but would turn around and say staff had not done anything for her. She said when they tried to get Resident #81 out of bed, she would sometimes say she did not want to move her head. In an interview on 11/20/2024 at 11:36 a.m., the Activity Director said she always tried to do activities with Resident #81, but she refused. She said she had been working at the facility for [AGE] years. She said she had notes she could provide regarding Resident #81 refusal to participate in activities. The Activity Director tried looking for the refusal notes but could not find them. She said during the week, she would go into Resident #81's room and work with her. She said Resident #81 was an in-room patient. She said she had not done the books that keep logs of the resident's activties in a long time. She said she had not documented the weekly activities because she had not learned how to work the new software to document the activities that the residents participated in. She said she was going to call corporate because she did not understand the program. She said she should be documenting the activities that were usually done three times a week. She said it was important to have the activities documented to show the family and other staff at the facility what Resident #81 had been doing and what activities she participated in. She said she was out of work for 2 months and came back to the facility in September. She said the only activities she had to show for Resident #81 were progress notes of activities that were done every 90 days. In an interview on 11/21/2024 at 6:16 p.m., the Administrator said the Activity Director was not at the facility when the new system came about, and she was not able to save her documentation properly. He said it was important to have documentation of the resident's activities because it was a huge part of the resident's life. He said everyone should know what was being provided to the resident. He said it should all be captured. He said if daily activities were not provided to the residents, their mental capability could decline. He said everyone related well to stimulation. He said the activities with Resident #81 were done, but not documented in the system. Record review of the facility's policy titled Activity Program review date (not listed) read in part . Purpose: Provide a wide range of activities to enhance the lives of residents. Also, provide opportunities for residents and staff to interact on a social basis. Activities will be scheduled on a regular basis to enrich the lives of residents. Activities will include, but not be limited to: Social events, indoor and outdoor activities, activities away from the facility, religious programs, creative activities, intellectual and educational activities, exercise activities, individualized activities, in-room activities and community activities .

47722 Based on observations, interviews, and record reviews, 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 for 2 (Resident #67 and Resident #88) of 5 residents reviewed for infection control. 1. CNA F did not wear appropriate PPE when helping Resident #67, a resident on Enhanced Barrier Precautions, transfer from wheelchair to bed. 2. LVN G did not wear appropriate PPE when she was giving Resident #88, a resident on Enhanced Barrier Precautions, medications through his G-tube (tube into stomach for nutrition). These failures could place residents at risk for cross-contamination, and the spread of infection. Findings include: 1.Record review of Resident #67's undated face sheet revealed he was an [AGE] year-old male admitted on [DATE] with diagnoses of dementia (a decline in mental ability that affects a person's daily life), and retention of urine (unable to empty bladder). Record review of Resident #67's Admission MDS assessment dated [DATE] revealed a BIMS score of 14 out of 15, which indicated normal cognition. The resident used a wheelchair for mobility and required partial to moderate assistance (helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with chair to bed transfers. According to the MDS, the resident had an indwelling catheter (a tube into the bladder to drain urine). Record review of Resident #67's care plan dated 11/7/24, revealed a Focus: Resident has a foley catheter at risk for UTI, and other complications r/t urinary retention (Initiated: 11/7/24, Revised: 11/14/24). Goal: Foley catheter will remain patent through review date (Initiated: 11/14/24 Target: 11/20/24). Interventions: Change foley tubing and bag as ordered. Change foley catheter Q month and as needed. Catheter care per facility and PRN. Focus: Resident has an indwelling medical device. This places them at an increased risk of transmission of MDRO's (Initiated: 11/20/24, Revised: 11/20/24). Goal: Residents dignity and privacy will be maintained (Initiated: 11/20/24, Target: 11/20/24). Interventions: Change PPE before caring for other residents. PPE will be used for the following situations during resident care: dressing, bathing/showering, transferring, providing hygiene, changing linens, incontinent care, or assisting with toileting. Record review of Resident #67's Physician Orders revealed the following orders from MD C: - Change Foley catheter monthly on the 15th and PRN for occlusion/leaking. May flush with 30-60cc saline PRN occlusion. (16 Fr size and 10-30 balloon CC). Ordered on 11/7/24 at 2:00am. - Enhanced Barrier Precautions - gown and gloves required for high-contact activities: dressing, bathing, transfers, providing hygiene, changing linens, incontinent care, toileting, therapy, device care (catheter, central line [a tube inserted into a large vein], feeding tube or trach [opening into neck for an airway]), and wound care. Every day and night shift. Ordered on 11/7/24 at 11:30am. Record review of Resident #67's November 2024 MAR-TAR revealed staff signed off that the resident was on EBP for day and night shifts from 11/7/24-11/21/24. In an observation and interview on 11/20/24 at 9:12am, CNA F helped transfer Resident #67 from his wheelchair into his bed without any PPE on. Above the resident's bed was a sign with EBP on it. CNA F said the EBP meant they were supposed to wear the blue gowns with resident care. She said she was supposed to have worn the PPE, but she did not have any with her and that was why she did not put it on. She said she had just taken the resident from the dining room, and she did not have any PPE with her. She said they kept the PPE in the supply room. CNA F said she usually kept a couple gowns in her pocket, and they were not supposed to keep any in the room. The CNA said she was not from that hall but knew which of her residents were on EBP and so she would grab some PPE before going in their room. She said if the PPE was not worn it would cause infection control problems. In an interview on 11/20/24 at 9:20am with LVN G, she said they kept PPE in the supply closet. She said the staff knew which residents were on EBP so before going in the resident's room they grabbed PPE. The LVN said if they were in the room and figured out, they needed PPE, they could get some from the med cart or go to the supply room to grab some. She said they were unable to stock up on PPE at the beginning of the shift and keep it on them. She also said they were not allowed to keep any PPE in the resident's room. In an interview on 11/20/24 at 10:50am with LVN G, she said they could keep gowns in the drawers of the resident's rooms, they just could not have the gowns visible. 2.Record review of Resident #88's undated face sheet revealed he was a [AGE] year-old male originally admitted on [DATE], with the most recent admission being 10/23/24. He had diagnoses of dysphagia following cerebral infarction (trouble swallowing after a stroke) and gastrostomy status (opening into the stomach from the abdominal wall for nutrition). Record review of Resident #88's Significant Change MDS assessment from 10/25/24 revealed a BIMS score of 13 out of 15, which indicated normal cognition. The resident was dependent with all ADLs. The MDS revealed the resident was coughing or choking during meals or when swallowing medications and complained of difficulty or pain with swallowing. It also revealed he was on a feeding tube (tube into stomach for nutrition) on admission and while a resident. Record review of Resident #88's care plan dated 5/13/24 revealed a Focus: Resident is NPO and has a G-tube (tube into stomach for nutrition) for nutrition and hydration due to dx of dysphagia (Initiated: 5/14/24, Revised: 5/14/24). Goal: G-tube will remain patent through next review date (Initiated: 5/14/24, Target: 1/23/25). Interventions: Enhanced barrier precautions, gown and gloves required for high contact activities. Focus: Resident has indwelling medical devices. This places them at an increased risk of transmission of MDROs. Resident has the following indwelling medical device: feeding tube (Initiated: 5/22/24, Revised: 8/28/24). Goal: Residents dignity and privacy will be maintained (Initiated: 5/22/24, Target: 1/23/25). Interventions: PPE will be used for the following situations during resident care: .providing hygiene, transferring . Record review of Resident #88's Physician Orders revealed the following orders from MD C: - Enhanced Barrier Precautions - gown and gloves required for high-contact activities: dressing, bathing, transfers, providing hygiene, changing linens, incontinent care, toileting, therapy, device care (catheter, central line, feeding tube or trach), and wound care. Every day and night shift. Ordered on 10/23/24 at 10:02pm. - NPO-Tube feeding diet. Ordered on 10/23/24. - Enteral feed (feeding into the intestine), Jevity 1.5 (type of feeding) 55ml/hr x 22hours, off at 6am. Ordered on 11/11/24 at 8:09am. Record review of Resident #88's November 2024 MAR-TAR revealed staff signed off that the resident was on EBP for day and night shifts from 11/1/24-11/21/24. Record review of Resident #88's Kardex from 11/21/24 revealed he was on Enhanced Barrier Precautions and gown and gloves were required for high contact activities. An observation and interview on 11/20/24 at 3:01 p.m. in Resident #88's room revealed a sign above his bed that read EBP. LVN B washed her hands and donned gloves, but did not don a gown. She began the medication administration via g-tube for Resident #88 which included checking for placement and administering the medication and water flushes via feeding tube. After medication administration, LVN B said Resident #88 was on enhanced barrier precautions and said she needed to wear a gown for residents with g-tubes and wounds. She said she was trying to be perfect and putting on the gown slipped her mind. She said she was trained on EBP during orientation and the purpose was to protect the resident from infection. She said the resident could be at risk of transferring whatever was on the staff to them. In an interview with the DON on 11/21/24 at 10:20am, she said her expectations for staff and EBP was they were to wear a gown, gloves, and a face shield if needed. She said they should wear it with any resident care and could get the PPE from the supply room or from the drawers in the resident's room. The DON said the signs are above the resident's bed in their room. She said staff knew which residents are on EBP because they work the same halls and know their residents. She said staff are supposed to wear PPE to protect themselves and the residents from infection. The DON said if they did not wear PPE it was an infection control issue. She said the solution to having CNAs from other halls not knowing which residents were on EBP and needing PPE, was to have the PPE in the resident's drawers so they would not have to run out of the room to grab PPE. The DON said, or in the situation that happened earlier, they can grab PPE out of the resident's drawer and put it on quickly. Record review of the facility's undated policy and procedure on Enhanced Barrier Precautions reflected in part: .EBP refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. Guidance: EBP are indicated for residents .with chronic wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO .Indwelling medical device examples: central lines, urinary catheters, feeding tubes .Procedure: For resident for whom EBP are indicated should employ EBP during the following high-contact resident care activities: .transferring .device care or use: .feeding tube .

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety in 2 of 2 facility refrigerators and 1 of 1 dry food storage areas reviewed for food procurement in that: - The facility failed to label and date food items in the kitchen walk-in refrigerator and resident refrigerator located in the medical records room. - The facility failed to label and date all food items located in the dry food storage area. These failures could affect residents who ate food from the facility kitchen and place them at risk of foodborne illness. Findings include: Observed on 10/10/23 at 8:30 AM an unlabeled plastic gallon zip bag with cooked lima beans and corn and an unlabeled bag of French Fries in walk-in-refrigerator. Interview on 10/10/23 at 8:30 AM, the DM said the unlabeled and undated items in the walk-in refrigerator were items leftover from the previous night. She said the night cook must have forgotten to label them. The DM said that all food should be labeled with the name of the item and the date it was prepared or opened before it was put away. She said it was important to label and date so they knew when to discard items that could make residents sick. She said whoever was putting away the food should label it, but as the DM, it was ultimately her responsibility to make sure it was done. Observed on 10/10/23 at 8:35 AM an unlabeled plastic bag of shredded coconut in the dry storage area with no date or label. Interview on 10/10/23 at 8:35 AM, the DM repeated that all foods being stored should be labeled. Interview on 10/10/23 at 2:54 PM, the Administrator said his expectation is that all food being put away for storage should be labeled and dated to ensure it is safe and discarded as appropriate. Failure to do so could possibly make residents sick. The DM is responsible for making sure food stored in the kitchen is labeled and dated properly. Observed on 10/12/23 at 11:45 AM the unit refrigerator contained unlabeled food items with no discard dates. These items included a half of a meat and cheese sandwich wrapped in plastic wrap, a cut lemon in a biohazard bag, cheese and wrapped food item in a plastic container with a resident's initials. The freezer unit above the refrigerator contained a grocery bag with plastic containers. The contents of the plastic containers spilled out, and there was a brown liquid frozen in and around the plastic bag. Interview on 10/12/23 at 11:45 AM, LVN E said no particular person was responsible for clearing out the unit fridge, maybe housekeeping. She said that food placed into the refrigerator should have the resident's name and discard date to prevent giving residents old food that could make them sick. Interview on 10/12/23 at 11:47 AM, the HKS said that nursing was responsible for the unit refrigerator, and housekeeping had nothing to do with it. Interview on 10/12/23 at 11:50 AM, the DON said she stocked the unit fridge with supplements daily and did not see those items in the fridge. She said the food should be labeled and dated when placing in the refrigerator to know whether it is safe or needs to be discarded. Interview on 10/12/23 at 3:00 PM, the Administrator said all food stored in any refrigerator for resident consumption should be labeled and dated. He said the unit refrigerator did not have an assigned designee to discard unlabeled items, but it will be addressed. Record review of Food Safety policy (undated) read in part, . 2. Protein Salads and Sandwiches . Upon mixing, store in 2 inch depth containers, cover, date, and refrigerate until service . 5. Holding Cold Foods Cover and date foods after they have been cooled . Record review of Foods Brought by Family/Visitors policy (undated) read in part . 6. Perishable foods must be stored in re-sealable containers with tightly fitting lids in the refrigerator. Containers will be labeled with the resident's name, the item, and the use by date 7. The nursing staff (or designee) is responsible for discarding perishable foods on or before the use by date .

Based on interview and record review the facility failed to implement written policies and procedures that prohibit and prevent residents from abuse, neglect, exploitation, and misappropriation of resident property for 3 (the Administrator, Dietary A, and Housekeeping #A) out of 19 employees reviewed for annual EMR/NAR checks. The facility failed to ensure EMR/NAR checks were completed annually for the Administrator, Dietary A, and Housekeeping #A. The facility failed to keep a copy of the results of the initial and annual searches of the NAR and EMR in the employee's personnel file. This failure could place residents at risk of abuse, neglect, and/or misappropriation of personal property. Findings included: In an interview on 10/12/23 at 09:53 AM, the HR Director said she was responsible for organizing the employee's files and ensuring all the EMR/NAR checks were on the files. She said she completed EMR/NAR when hiring or rehiring an employee. She said she did not know she had to complete the EMR/NAR checks annually. She said she did not know the consequences of not checking the employee's EMR/NAR annually. In an interview on 10/12/23 at 10:01 AM, the Administrator said the HR Director was in charge of her department. He said she was responsible for checking EMR/NAR for all employees. He said the HR Director reports to her. He said he understood that not checking the EMR/NAR annually may cause the facility to have an employee who is not eligible to work there. The Administrator said he would do more research and provide the missing EMR/NAR checks. In an interview on 10/12/23 at 11:43 AM, the HR Director said she was sorry she could not find any EMR/NAR for the year 2022 for the Administrator, Dietary A, and Housekeeping #A. She provided EMR/NAR checks for the Administrator, Dietary A, and Housekeeping #A dated 10/12/2023. Administrator, Dietary A, and Housekeeping #A were eligible to continue employment. In an interview on 10/12/23 at 01:09 PM, the Administrator said that he contacted corporate and was told that the facility did not have an EMR/NAR check policy. A review of the facility's employees' files revealed that 7 (the Administrator, Dietary A, and Housekeeping #A) out of 19 employees did not have an annual EMR/NAR check. Further review showed the following: -The Administrator was hired on 08/01/2017, and last EMR/NAR search was conducted on 10/15/2021. -Dietary A was hired on 08/01/2017, and last EMR/NAR search was conducted on 10/15/2021. -Housekeeping A was hired on 01/28/2022, and last EMR/NAR search was conducted on 01/20/2022. A review of the facility Prevention and Reporting of Suspected Resident Abuse and Neglect dated 03/20/2023 read in part, . All potential employees and/or contractors will be screened for a history of abuse, neglect or mistreatment of residents during the hiring/contracting process. Screening will consist of, but not limited to: inquiries into state licensing authorities, Office of the Inspector General (State and Federal); inquiries into state nurse aide registry, reference checks from previous and/or current employees, and criminal background checks. Anyone prospective employee with a disciplinary history or action due to abuse, neglect, mistreatment, or misappropriation will not be hired. Record the results of the screening. File with other employee records .

Based on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review program (PASARR) to the maximum extent practicable for 1 of 6 residents reviewed for PASARR. -Resident #39 had a diagnosis of mental illness and the facility did not coordinate with the appropriate, State-designated authority. This failure could place residents at risk of not receiving needed care and services, causing a possible decline in mental health. Findings include: Review of Resident #39's face sheet, dated 10/11/23, revealed Resident #39 was a [AGE] year-old female, readmitted to the facility on [DATE] (original admission 05/10/2017), with the following diagnoses: Type 2 Diabetes Mellitus (impaired use of the body's blood sugar), bipolar disorder (a serious mental illness characterized by extreme mood swings), major depressive disorder, recurrent (episodes of depression), end stage renal disease on hemodialysis (loss of kidney function requiring kidney replacement therapy), and cerebral infarction (lack of oxygen to brain causing a cluster of brain cells to die). Review of Resident's 39's admission MDS assessment, dated 06/27/2023, revealed sections related to PASSR including Section A-1500 and Section A- 1510 was left blank which reflected that Resident #39 was not assessed for mental illness on her admission MDS. Section I- Active Diagnoses of the MDS, dated [DATE], revealed resident with bipolar disorder, major depressive disorder, and anxiety disorder. Review of Resident #39's PASARR Level I screening (PL1) dated 06/27/2023 revealed Resident #39 screened negative for Mental illness (MI) by the case manager of the acute care facility from which she transferred. Review of Resident #39's clinical records revealed there was no documented request to have Resident #39 further evaluated by local authorities for mental illness due to her diagnoses of bipolar disorder and major depressive disorder. Interview on 10/11/23 at 1:30 PM, LVN D and LVN M (MDS nurses) said that they shared the responsibilities of completing resident assessments and PASRR. They said Resident #39's PASRR level 1 was marked NO for mental illness, and they did not seek further evaluation for the resident. Both MDS nurses agreed that it was an oversight because they were aware major depressive disorder and bipolar disorder were both qualifying mental illnesses which the resident had and is recorded in her MDS assessment. They said the resident should have been re-evaluated. LVN M said failure to review PASRR level 1 screenings for accuracy and failure to re-evaluate residents with qualifying diagnoses could result in the resident potentially missing out on services. Interview on 10/ 11/23 at 2:54 PM, the Administrator said that he expected all PASRR documentation to be reviewed by the MDS nurses for accuracy. Failure to do so could result in a resident missing out on services that he or she might have been eligible. Record review of the facility's PASRR policy (undated) revealed in part: 1. The facility's designated staff will review all potential admission for possible positive PASRR conditions and ensure that CMS Preadmission guidelines are followed.

Based on interview and record review the facility failed to immediately consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 1 (CR #2) residents reviewed for notification of changes in that: The facility failed to notify the physician when CR #2 displayed a change in condition on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE] at 2:44pm. While the IJ was removed on [DATE] at 3:56pm the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their corrective systems. This failure could place residents at risk for a decline in health, and possible death. Findings include: CR #2's undated face sheet revealed she was an [AGE] year-old female readmitted on [DATE], with diagnoses of Alzheimer's Disease, major depression (extreme sadness, tearfulness), hypertension (high blood pressure), heart failure (heart does not pump blood efficiently), and dysphagia (trouble swallowing). CR #2 was sent to the hospital on [DATE] and expired on [DATE]. Record review of CR #2's Quarterly MDS dated [DATE], revealed a BIMS score of 3 out of 15, which indicated severely impaired cognition. CR #2 required extensive assistance with bed mobility, transferring, eating, and locomotion. CR #2 used a wheelchair and was always incontinent of bowel and bladder. No was answered to the question, Life expectancy of less than 6 months? According to the MDS, CR #2 required a mechanically altered diet (a change in texture of food or liquids like pureed foods, thickened liquids, Etc.). Record review of CR #2's care plan, revised [DATE], revealed Resident has DX of Alzheimer/Dementia. Resident has short- and long-term memory deficits. Needs moderate assistance with decisions-Resident will have no S/S of side effects to medications through next review date: Observe for change in mental status, increased behaviors, confusion, and notify MD. Observe for/document/report to MD and changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness .level of consciousness, mental status. The resident has ADL Self Care Performance deficits regarding .eating r/t cognitive deficits .and resisting care-The resident will remain clean, dry, odor free and appropriately dressed daily with interventions through next review date: Resident requires extensive assistance and verbal cue for eating. Provide physical assistance as needed. Encourage and assist as need to upright position for meals and PO intake. Record review of CR #2's lab results from [DATE] revealed potassium 5.2 (normal 3XXX,d+[DATE].2), BUN 31 (how well kidneys are functioning, normal ,d+[DATE]%), Creatinine 1.79 (how well kidneys are functioning, normal 0XXX,d+[DATE].11), and eGFR 28 (how well kidneys are working, normal >60). Record review of CR #2's medical record revealed a progress note from [DATE] by MD #1 that stated the reason for the appointment was for a sick visit. CR #2's Labs reviewed creatinine 1.79, potassium 5.2. No significant leg swelling, no shortness of breath. Discontinue Spironolactone. Record review of CR #2's medical record revealed one blood pressure recorded for [DATE] at 7:32am, and it was ,d+[DATE]. Record review of CR #2's MAR for [DATE] revealed an order to record the Side Effects to Hypnotic/Sedative Medication: (0)None, (1)Anxiety, (2)Blurred Vision, (3)Confusion, (4)Daytime Sedation, (5)Dizziness, (6)Fatigue, (7)Hallucinations, (8)Headache, (9)Mania, (10)Nightmares, (11)Syncope, (12)Urinary Retention, (13)Other, to be done Every day and night shift. The answer for Days on [DATE] by LVN #A was (0) or None. Record review of CR #2's medical record revealed she had the following medications ordered by MD A: - Amlodipine Besylate Tablet 5mg, 1 PO QD, started on [DATE] - Aspirin Tablet Chewable 81mg, 1 PO QD, started on [DATE] - Bupropion HCl ER Oral Tablet Extended Release 12 Hr 100mg, 1 PO QD, started on [DATE] - Lasix Tablet 20mg, 1 PO QD, started on [DATE] - Lisinopril Tablet 5mg, 1 PO QD, started on [DATE] - Multivitamin, 1 PO QD, started on [DATE] - Docusate Sodium 100mg, 1 PO BID, started on [DATE] - Memantine HCl Tablet 10mg, 1 PO BID, started on [DATE] - Depakote Sprinkles Capsule Delayed Release 125mg, 1 PO TID, started on [DATE] Record review of CR #2's medical record revealed she received the following medications on [DATE] by MA A: - amlodipine Besylate 5mg tab PO at 8:00am - aspirin 81mg chewable tab PO at 8:00am - bupropion HCL 100mg PO at 8:00am - Lasix 20mg PO at 8:00am - lisinopril 5mg PO at 8:00am - multivitamin PO at 8:00am - docusate sodium 100mg PO at 8:00am and 4:00pm - memantine 10mg PO at 8:00am and 4:00pm - Depakote sprinkles 125mg PO at 8:00am, 12:00pm, and 4:00pm. Record review of CR #2's medical record revealed a progress note from [DATE] at 5:20pm by LVN A that stated, [Family] in facility concerned about Resident not opening her eyes and not speaking throughout the day. Request for transfer to Patients ER for evaluation. On call Nurse notified of request. Called [name of EMS] and they stated they do not have units out today. On call notified and called 911. Upon arrival of EMS vs ,d+[DATE], HR-64, RR-20, 97%, glucose 74, 97.5 vs stable. Resident continues hard to arouse. [Family] request to continue with transfer to Patients ER. Resident leaves via stretcher and report called. No other notes were documented for [DATE]. Record review of CR #2's EMS report from [DATE] at 5:42pm revealed she was unresponsive and had weakness to her left and ride side. At 5:50pm it revealed CR #2's GCS (used to objectively describe extent of impaired consciousness) was E (best eye response) 2, V (best verbal response) 1, M (best motor response) 3 for a total score of 6 out of 15 which indicated severely impaired consciousness. The E/V/M were scored from 1 (no response) to 4 (normal response). At 6:12pm CR #2 was intubated (a tube in the throat to breathe for you). According to the EMS narrative it revealed, Patient is unconscious and only responsive to pain. It also stated, Facility was unable to obtain vitals. EMS left the facility at 6:07pm and arrived at the hospital at 6:20pm. Record review of CR #2's hospital record's from [DATE], revealed a patient registration form stating admitted was [DATE] at 10:16pm to ICU due to UTI, septic shock, and renal failure. Record review of CR #2's hospital records also revealed an H&P from [DATE] which indicated she had pyuria (infected urine), leukocytosis (elevated white blood cells) at 13.54, elevated lactic acid (indicator of systemic infection), and renal failure with BUN 79, creatinine 4.13, and GFR 10. According to the H&P, CR #2 was seen in room xxx and was obtunded (unconscious). The H&P also revealed CR #2 had a BP of ,d+[DATE] on [DATE] at 8:15pm, BP of ,d+[DATE] early in the morning of [DATE], and a BP of ,d+[DATE] on [DATE] at 1:00am. It was also revealed CR #2 had coarse rhonchi throughout her lungs and was on 2 L/min of O2 via NC. Her GCS was 7 with E(1), V(1), M(5). According to the assessment/plan from the H&P, CR #2 had a urinary tract infection with severe sepsis, aspiration pneumonia, acute renal failure with acute hyperkalemia, and acute metabolic encephalopathy. Record review of LVN A's statement from [DATE] at 2:30pm revealed on [DATE] CR #2 was fine and ate all 3 meals in her wheelchair. LVN A received in morning report on [DATE] that CR #2 did not sleep well through the night. LVN A got CR #2 out of bed for breakfast, into her wheelchair, and into the dining room. Per LVN A's statement, she did not wake up enough to eat breakfast, but she was able to wake her up to drink fluids. After breakfast, LVN A laid CR #2 back down in bed, changed her and took her vital signs, which were stable. LVN A's statement revealed before lunch, her and another staff member tried to get CR #2 up, but she was resisting and replied no when asked if she wanted to get up. The 2 staff members changed CR #2 and left her in bed with the HOB raised. Per the statement, when lunch came CR #2 did not wake up to eat, but LVN A checked her vitals, and they were stable (the only vital signs in the medical record were at 7:32am). LVN A's statement said, before dinner they changed CR #2, got her up into the wheelchair and took her to the dining room. Resident CR #2 still said no when asked if she wanted to get up, but since she did not eat lunch, LVN A got her up anyway. During dinner CR #2 did not eat, and her family member came and requested her to be sent to the hospital. LVN A stated her vital signs were stable (the only vital signs in the medical record were taken at 7:32am). EMS arrived and checked CR #2's vitals and they were stable. According to LVN A's statement, EMS asked what they wanted to do because the patient was ok with her eyes closed but was replying verbally very little and vitals were stable. EMS was told to take CR #2 to the hospital for further evaluation d/t sleeping throughout the day. In an interview with MA A on [DATE] at 11:01am she stated she remembered CR #2 and that she was sleepier on [DATE] then most days. She said it was normal for CR #2 be sleepy though, because sometimes she would stay up all night and then sleep during the day. She did not remember giving medications to CR #2, how awake she was when she took them, or how she took them because it was too long ago. She stated she made sure residents were awake enough before giving medications by ensuring they could open their eyes, say something, and take a sip of water first. In an interview with LVN A on [DATE] at 11:15am she stated it took 2 people to get CR #2 into a wheelchair on [DATE] because she was so sleepy, and she was not able to assist getting into the wheelchair. She also stated CR #2 resisted when they were changing her. LVN A stated CR #2 opened her mouth to drink when she asked her to, but never opened her eyes. She also said she did not feed CR #2 anything, and only gave her water to drink. LVN A stated she could not wake up CR #2 when tapping her shoulder or calling her name, but that was normal for her when she did not sleep at night. She stated she did not open her eyes, but she would say 1 word like no every now and then. When LVN A changed her, she said CR #2 pushed against them and resisted. LVN A stated her vital signs were normal so there was nothing wrong. She stated she did not feel the resident had a change in condition because she was sleepy like this sometimes during the day, when she stayed up all night. She stated she felt like it was okay for her to have gotten CR #2 into her wheelchair, even though she was sleepy, because she had the dining table in front of her so she could not have fallen. LVN A did not remember she documented 0 or none, for side effects to hypnotics/sedatives on [DATE]. LVN A said she did not understand how EMS could have scored CR #2 as a GCS of 6, because she was not. In an interview with the DON on [DATE] at 11:43am she stated she was not there the day the incident happened because it was a Sunday. She stated it was normal for CR #2 to sleep all day sometimes, if she stayed up all night, and was a heavy sleeper. She stated LVN A had worked with CR #2 for about 5yrs and knew the resident well. She also stated that she was told the family member left for about 3hrs, and if she was that concerned about CR #2, she would not have left. The DON stated the family member went to the facility more than any other family member and staff knew what the family wanted/expected and would not have left the resident like that. She also said if a family member wanted a resident to be sent to the hospital, there were no questions asked and they sent them right away. In an interview with CR #2's family member on [DATE] at 12:03pm, she revealed she arrived at the facility on [DATE] between 11:00am and 11:30am and found CR #2 unresponsive in her bed. The family member called out CR #2's name, patted her on the shoulder, and gave her a hug and she still did not respond. The family member went and spoke to LVN A, who stated CR #2 was just really sleepy from staying up the night before. The family member asked MA A why CR #2's food tray was still on her bedside table because she always ate in the dining room. MA A stated LVN A was unable to get CR #2 to eat, so she was going to try again later. The family member stated she told LVN A that CR #2 was not just sleepy and then went back to the resident's room. The family member stayed with CR #2 for a while and stated LVN A never came back into the room. The family member stated she left the facility for about 45min to get her phone charger and a change of clothes because she was going to send CR #2 to the hospital when she got back. The family member stated when she got back to the facility, LVN A told her she was able to get CR #2 to eat some cake and drink some water while she was gone. Then she saw CR #2 in the dining room in her wheelchair, slumped down in the chair with her head hanging back on the wheelchair. She tapped CR #2's arm and called her name, and she did not respond. The family member went back to LVN A and told her she wanted CR #2 transported to the hospital. The family member stated that LVN A said, You want her transported to the hospital? She is just sleepy. The family member said yes, and CR #2 was taken to her room to be changed. According to the family member, when EMS arrived LVN A told EMS She thought CR #2 was just sleepy, but the family member wanted her transferred. The family member stated CR #2 never opened her eyes the whole time she was there and never said one word. Also, the family member stated she last saw CR #2 on Friday, [DATE] and she was up in her wheelchair in the lobby, and they were laughing and having a good time. The family member also stated that CR #2 would be sleepy sometimes from staying up all night, but she could be woken up by calling her name or tapping her on the arm. She said she never had been in such a deep sleep that she could not have been woken up. In an interview with LVN B on [DATE] at 12:48pm she revealed she had worked with CR #2 for more than 5yrs and knew her and her family member well. She stated she worked with CR #2 on Friday [DATE] and she was awake, alert, and her usual self. She stated that CR #2 would sometimes be sleepy during the day but could be woken up by talking to her or tapping her shoulder. She also stated that it would be abnormal if CR #2 did not wake up or respond if she tried to wake her. LVN B stated she ensured residents were awake enough before giving them something to eat/drink by making sure their eyes were open, and they were talking first. She also stated on the days CR #2 was sleepy, she would not get her out of bed because she would be at risk of falling out of her wheelchair or hurting herself. She said she would not have gotten CR #2 out of bed, to her wheelchair, if she was that sleepy. She said she knew the family member really well and she did not feel that she was overreacting and would have believed that something was wrong. In an interview with MD A on [DATE] at 12:pm revealed, he was CR #2's doctor for many years, and he knew she was declining. He stated she had been diagnosed with heart failure, kidney failure, COPD, as well as dementia. He said he had been fine tuning her medications to allow for all her chronic conditions. He said she was always friendly when she saw him, but lately he could tell she was not feeling well and was slowly declining. He stated he always monitored her lactic acid levels with her chronic kidney disease and liver disease, and there was a decline from her normal baseline. MD A confirmed he was not called on [DATE] when CR #2 first displayed a change of condition. Regarding the change of condition in a resident, he said the nurses at the facility were familiar with the residents, and knew their baseline. He revealed he would expect them to call him, call the family, and call 911 if an emergency. Record review of the facility's policy and procedure on Change in Resident Condition, with no date, read in part: The facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status. 1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: . d. A significant change in the resident's physical/emotional/mental condition . i. Instructions to notify the Physician of changes in the resident's condition. 2. A significant change of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting) b. Impacts more than one area of the resident's health status . 3. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider. 4. Unless otherwise instructed by the resident, the Nurse Supervisor/Charge Nurse will notify the resident's family or representative when: . b. There is a significant change in the resident's physical, mental, or psychosocial status . 7. The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. The facility Administrator received the IJ template on [DATE] at 2:44pm. The Plan of Removal (POR) was accepted on [DATE] at 2:50pm and reflected: Immediate Action Taken (Initiated ([DATE]) (Completion [DATE]) 1. Resident #1 was discharged 911 to [Name of the Medical Center] on [DATE] and did not return to the facility. On [DATE] LVN A, B, and C on duty, the Director of Nurses, the ADON, Wound Care Nurse, and two MDS nurses did an immediate assessment of all 101 residents in the building. All vital signs and any concerns regarding residents' physical, mental, and psychosocial conditions were documented in {EMR system]. This immediate action was initiated at 1:00PM by all 8 nurses and completed by 3:00PM. The medical director was also in the facility while 100% of residents were assessed. No residents were found exhibiting a change of condition of an emergency nature. All on-going concerns were already being addressed by the physician and staff (Initiated [DATE]) (Completion [DATE]) 2. The three charge nurses, LVN A, charge nurse #1 and identified as Resident #1's charge nurse, LVN B, charge nurse #2, and LVN C, charge nurse #3 were the three charge nurses who were in the facility on [DATE] and helped conduct the initial assessments of 100 percent of the residents along with LVN D, wound care, RN A, ADON, LVN E, MDS and LVN F, MDS. All of the nurses on duty at that time were in-serviced by the Director Nurses, on the following on [DATE]. RN B and RN C were the other two charge nurses working the shift that was identified in the immediate jeopardy. Both of them are being in-serviced on [DATE] and are not scheduled to work for several days. a. Existing Change of Condition policy. No policy changes required. b. How to perform a complete resident assessment, including, vitals, other staff interviews, and concerns of a physical, mental, or psychosocial nature. c. How to properly document all findings in the EMR and on the 24 hour report. d. Emergency Change of Condition requiring 911. In the event of a medical emergency regarding change of condition, the charge nurse shall immediately call 911 for transport to the nearest local hospital. The judgement of the clinical staff and guidelines outlined in the Resident Assessment Instrument and 42 CFR 483.20 (b)(ii) shall be the guiding principle. e. Non-Emergencv Change of Condition requiring physician intervention, continued monitoring. The charge nurse shall notify the physician, nursing supervisor, and family (RP) of any significant change in the resident's physical, mental, and psychosocial status. The nurse will gather info on the resident and immediately contact the physician to obtain orders for the continued monitoring and treatment of the resident. All staff present on [DATE] were required to take a five (5) question test following the in-service. Any staff not making a 100 were required to be in-serviced again by the DON. Then, they were required to take the test again. Anyone not passing after three (3) consecutive times were not allowed to work their assigned shift on that day, until all in-service requirements were met. All nursing staff present passed on their first try. (Initiated ([DATE]) (Completion [DATE]) 3. A Quality Assurance Performance Improvement meeting was held on [DATE] at 12:00PM to review the allegations surrounding the Immediate Jeopardy and the plan moving forward related to the Plan of Removal. The Medical Director was notified and in attendance for the meeting on [DATE]. (Initiated [DATE]) Completion [DATE]) 4. The Medical Director was notified by phone of the additional IJ for Tag 580 - Notification to Physician. (Initiated [DATE]) (Completion [DATE]) 5. The Director of Nursing in-serviced all licensed nurses in the facility on [DATE] on notification of the physician when a change of condition occurs. The charge nurse, LVN A, who was identified as CR#2 's charge nurse and both other nurses who worked that specific shift on [DATE] received the in-service. All other licensed nurses in the facility, including two additional charge nurses, the ADON, wound care nurse, and two MDS nurses also received the training. All permanent nurses will be required to receive the same training prior to working any further shifts. Also, this in-service provision for any agency nurses or new hires will be on-going from [DATE]. Any agency and new hires will be required to receive the training before they will be allowed to work a shift. On-Going Training (Initiated ([DATE]) (Completion [DATE]) 1. While all staff present on [DATE] completed their in-service successfully, all other permanent, licensed nurses will be required to undergo the same in-service prior to working their assigned shift. (Initiated ([DATE]) (On-going) 2. If the facility requires the use of agency staff, they will be required to go through the same training as permanent staff. Each shift shall identify one charge nurse who has been properly trained in providing the in-service and training to the agency staff prior to their working their assigned shift. Agency staff [NAME] not be allowed to work unless they successfully pass the test per the above requirements. (Initiated ([DATE]) (On-going) 3. Newly hired staff will have this entire component of the same exact training and testing by the Director of Nurses built into their orientation process. No newly hired staff will be allowed to train on the floor until they successfully complete the training and pass the test in the same manner as all other staff. (Initiated ([DATE]) (On-going) 4. The DON and Administrator will review the 24 report daily for any changes in condition. They will also verify that the charge nurse notified the physician regarding that change of condition. From [DATE]-[DATE] a monitoring visit was conducted to ensure the facility was following it's POR. The visits revealed: On [DATE]-[DATE], the Director of Nursing began in-services with all nursing staff on change of condition and notification of physician. The Director of Nursing also had nurses perform assessments on all residents in the facility on [DATE], including vital signs. The DON also said she would monitor the 24hr report daily, for any change of condition reports. Record review of assessments performed by nurses on [DATE]-[DATE], revealed no concerns. Record review of in-services on [DATE] revealed nursing staff had a Change of Resident Condition in-service on [DATE] and [DATE], with a 5-question posttest. Record review of in-services on [DATE] also revealed nursing staff had a Notification of Physician, Family and Others in-service on [DATE] and [DATE]. Record review on [DATE] revealed a QAPI meeting was conducted on [DATE] to review the Plan of Removal and the plan moving forward on trainings. Record review of the facility's policy and procedure on Notification to Physician, Family and Others on [DATE] revealed facility will inform the resident's physician, and resident's representative of any changes in the resident's physical, mental, or psychological status, including in emergency or non-emergency changes in condition. Interviews with nursing staff on [DATE] revealed they had training on changes of resident condition with a post-test. Nursing staff were able to describe what to do in an emergency and non-emergency changes of condition, including notifying the physician. Nursing staff also confirmed they assessed the residents on [DATE]-[DATE]. Interviews with CNA's on [DATE] revealed they would let the charge nurse know about any change in condition in the resident, and they would stay with the resident. Observations and interviews with residents on [DATE] revealed they were satisfied with their care. They also confirmed that they had a nurse come and assess them in the last couple of days. Interview with the physician on [DATE] revealed he expected staff to call him, call the family, and call 911 if it was an emergency regarding change of condition. He stated the staff knew the resident's well and knew their baseline. The facility's ADM was notified the IJ was removed on [DATE] at 3:46 PM. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance due to the facility's need to evaluate the effectiveness of the Plan of Removal

Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for 1 of 1 resident (CR #2) reviewed for quality of care. -The facility failed to provide needed care and services resulting in a decline of CR #2's physical, mental, and psychosocial wellbeing on [DATE]. -CR #2 was identified as unresponsive at 11:00am on [DATE] by the family, and only at the request of the family was CR #2 sent out to the hospital. An Immediate Jeopardy (IJ) was identified on [DATE] at 2:44pm. While the IJ was removed on [DATE] at 3:56pm the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their corrective systems. These failures could place residents at risk for a decrease in their physical, mental, and psychosocial wellbeing. Findings include: CR #2's undated face sheet revealed she was an [AGE] year-old female readmitted on [DATE], with diagnoses of Alzheimer's Disease, major depression (extreme sadness, tearfulness), hypertension (high blood pressure), heart failure (heart does not pump blood efficiently), and dysphagia (trouble swallowing). CR #2 was sent to the hospital on [DATE] and expired on [DATE]. Record review of CR #2's Quarterly MDS dated [DATE], revealed a BIMS score of 3 out of 15, which indicated severely impaired cognition. CR #2 required extensive assistance with bed mobility, transferring, eating, and locomotion. CR #2 used a wheelchair and was always incontinent of bowel and bladder. No was answered to the question, Life expectancy of less than 6 months? According to the MDS, CR #2 required a mechanically altered diet (a change in texture of food or liquids like pureed foods, thickened liquids, Etc.). Record review of CR #2's care plan, revised [DATE], revealed Resident has DX of Alzheimer/Dementia. Resident has short- and long-term memory deficits. Needs moderate assistance with decisions-Resident will have no S/S of side effects to medications through next review date: Observe for change in mental status, increased behaviors, confusion, and notify MD. Observe for/document/report to MD and changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness .level of consciousness, mental status. The resident has ADL Self Care Performance deficits regarding .eating r/t cognitive deficits .and resisting care-The resident will remain clean, dry, odor free and appropriately dressed daily with interventions through next review date: Resident requires extensive assistance and verbal cue for eating. Provide physical assistance as needed. Encourage and assist as need to upright position for meals and PO intake. Record review of CR #2's medical record revealed a progress note from [DATE] at 5:20pm by LVN A that stated, [Family] in facility concerned about Resident not opening her eyes and not speaking throughout the day. Request for transfer to Patients ER for evaluation. On call Nurse notified of request. Called [name of EMS] and they stated they do not have units out today. On call notified and called 911. Upon arrival of EMS vs ,d+[DATE], 64, 20, 97%, glucose 74, 97.5 vs stable. Resident continues hard to arouse. [Family] request to continue with transfer to Patients ER. Resident leaves via stretcher and report called. No other notes were documented for [DATE]. Record review of CR #2's EMS report from [DATE] at 5:42pm revealed she was unresponsive and had weakness to her left and ride side. At 5:50pm it revealed CR #2's GCS (used to objectively describe extent of impaired consciousness) was E (best eye response) 2, V (best verbal response) 1, M (best motor response) 3, for a total score of 6 out of 15 which indicated severely impaired consciousness. The E/V/M were scored from 1 (no response) to 4 (normal response). At 6:12pm CR #2 was intubated (a tube in the throat to breathe for you). According to the EMS narrative it revealed, Patient is unconscious and only responsive to pain. It also stated, Facility was unable to obtain vitals. EMS left the facility at 6:07pm and arrived at the hospital at 6:20pm. On [DATE] at 9:26am the ICU progress note revealed CR #2 had an O2 saturation of 67%. A progress note from [DATE] at 4:50pm revealed CR #2's time of death was 4:50pm. Record review of CR #2's Certificate of Death issued [DATE], revealed the cause of death as aspiration pneumonia with severe sepsis. Record review of LVN As statement from [DATE] at 2:30pm revealed on [DATE] CR #2 was fine and ate all 3 meals in her wheelchair. LVN A received in morning report on [DATE] that CR #2 did not sleep well through the night. LVN A got CR #2 out of bed for breakfast, into her wheelchair, and into the dining room. Per LVN A's statement, she did not wake up enough to eat breakfast, but she was able to wake her up to drink fluids. After breakfast, LVN A laid CR #2 back down in bed, changed her and took her vital signs, which were stable. LVN A's statement revealed before lunch, her and another staff member tried to get CR #2 up, but she was resisting and replied no when asked if she wanted to get up. The 2 staff members changed CR #2 and left her in bed with the HOB raised. Per the statement, when lunch came CR #2 did not wake up to eat, but LVN A checked her vitals, and they were stable (the only vital signs in the medical record were at 7:32am). LVN A's statement said, before dinner they changed CR #2, got her up into the wheelchair and took her to the dining room. Resident CR #2 still said no when asked if she wanted to get up, but since she did not eat lunch, LVN A got her up anyway. During dinner CR #2 did not eat, and her family member came and requested her to be sent to the hospital. LVN A stated her vital signs were stable (the only vital signs in the medical record were taken at 7:32am). EMS arrived and checked CR #2's vitals and they were stable. According to LVN A's statement, EMS asked what they wanted to do because the patient was ok with her eyes closed but was replying verbally very little and vitals were stable. EMS was told to take CR #2 to the hospital for further evaluation d/t sleeping throughout the day. In an interview with MA A on [DATE] at 11:01am she stated she remembered CR #2 and that she was sleepier on [DATE] then most days. She said it was normal for CR #2 be sleepy though, because sometimes she would stay up all night and then sleep during the day. She did not remember giving medications to CR #2, how awake she was when she took them, or how she took them because it was too long ago. She stated she made sure residents were awake enough before giving medications by ensuring they could open their eyes, say something, and take a sip of water first. In an interview with LVN A on [DATE] at 11:15am she stated it took 2 people to get CR #2 into a wheelchair on [DATE] because she was so sleepy, and she was not able to assist getting into the wheelchair. She also stated CR #2 resisted when they were changing her. LVN A stated CR #2 opened her mouth to drink when she asked her to, but never opened her eyes. She also said she did not feed CR #2 anything, and only gave her water to drink. LVN A stated she could not wake up CR #2 when tapping her shoulder or calling her name, but that was normal for her when she did not sleep at night. She stated she did not open her eyes, but she would say 1 word like no every now and then. When LVN A changed her, she said CR #2 pushed against them and resisted. LVN A stated her vital signs were normal so there was nothing wrong. She stated she did not feel the resident had a change in condition because she was sleepy like this sometimes during the day, when she stayed up all night. She stated she felt like it was okay for her to have gotten CR #2 into her wheelchair, even though she was sleepy, because she had the dining table in front of her so she could not have fallen. LVN A did not remember she documented 0 or none, for side effects to hypnotics/sedatives on [DATE]. LVN A said she did not understand how EMS could have scored CR #2 as a GCS of 6, because she was not. In an interview with CR #2's family member on [DATE] at 12:03pm, she revealed she arrived at the facility on [DATE] between 11:00am and 11:30am and found CR #2 unresponsive in her bed. The family member called out CR #2's name, patted her on the shoulder, and gave her a hug and she still did not respond. The family member went and spoke to LVN A, who stated CR #2 was just really sleepy from staying up the night before. The family member asked MA A why CR #2's food tray was still on her bedside table because she always ate in the dining room. The MA A stated LVN A was unable to get CR #2 to eat, so she was going to try again later. The family member stated she told LVN A that CR #2 was not just sleepy and then went back to the resident's room. The family member stayed with CR #2 for a while and stated LVN A never came back into the room. The family member stated she left the facility for about 45min to get her phone charger and a change of clothes because she was going to send CR #2 to the hospital when she got back. The family member stated when she got back to the facility, LVN A told her she was able to get CR #2 to eat some cake and drink some water while she was gone. Then she saw CR #2 in the dining room in her wheelchair, slumped down in the chair with her head hanging back on the wheelchair. She tapped CR #2's arm and called her name, and she did not respond. The family member went back to LVN A and told her she wanted CR #2 transported to the hospital. The family member stated that LVN A said, You want her transported to the hospital? She is just sleepy. The family member said yes, and CR #2 was taken to her room to be changed. According to the family member, when EMS arrived LVN A told EMS She thought CR #2 was just sleepy, but the family member wanted her transferred. The family member stated CR #2 never opened her eyes the whole time she was there and never said one word. Also, the family member stated she last saw CR #2 on Friday, [DATE] and she was up in her wheelchair in the lobby, and they were laughing and having a good time. The family member also stated that CR #2 would be sleepy sometimes from staying up all night, but she could be woken up by calling her name or tapping her on the arm. She said she never had been in such a deep sleep that she could not have been woken up. In an interview with LVN B on [DATE] at 12:48pm she revealed she had worked with CR #2 for more than 5yrs and knew her and her family member well. She stated she worked with CR #2 on Friday [DATE] and she was awake, alert, and her usual self. She stated that CR #2 would sometimes be sleepy during the day but could be woken up by talking to her or tapping her shoulder. She also stated that it would be abnormal if CR #2 did not wake up or respond if she tried to wake her. LVN B stated she ensured residents were awake enough before giving them something to eat/drink by making sure their eyes were open, and they were talking first. She also stated on the days CR #2 was sleepy, she would not get her out of bed because she would be at risk of falling out of her wheelchair or hurting herself. She said she would not have gotten CR #2 out of bed, to her wheelchair, if she was that sleepy. She said she knew the family member really well and she did not feel that she was overreacting and would have believed that something was wrong. In an interview on [DATE] at 8:50am with the Activities Director she stated, the family member went to her office on [DATE] around lunch time and asked her to come look at CR #2. When the Activities Director got to the room and saw CR #2, she thought the resident was just sleeping. She said she saw the resident was not waking up when the family member was trying to wake her up. She stated that she whispered in the family member's ear to send her out to the hospital and was trying to convince her to call EMS. She said that she was only the Activity Director and did not want to step on anyone's shoes, so she stayed in her lane and could not tell the nurse's what to do. She said the incident happened before lunch and she did not see the family member anymore after that because she got busy with her activities, and she did not know what happened after that. In an interview with MD A on [DATE] at 12:pm revealed, he was CR #2's doctor for many years, and he knew she was declining. MD A confirmed he was not called on [DATE] when CR #2 first displayed a change of condition. Regarding the change of condition in a resident, he said the nurses at the facility were familiar with the residents, and knew their baseline. He revealed he would expect them to call him, call the family, and call 911 in an emergency if there was a decline from her baseline. The facility Administrator received the IJ template on [DATE] at 2:44pm. The Plan of Removal (POR) was accepted on [DATE] at 2:50pm and reflected: Immediate Action Taken (Initiated ([DATE]) (Completion [DATE]) 1. Resident #1 was discharged 911 to (Name of Medical Center) on [DATE] and did not return to the facility. On [DATE] three charge nurses on duty, the Director of Nurses, the ADON, Wound Care Nurse, and two MDS nurses did an immediate assessment of all 101 residents in the building. All vital signs and any concerns regarding residents' physical, mental, and psychosocial conditions were documented in (name of EMR). This immediate action was initiated at 1:00PM by all 8 nurses and completed by 3:00PM. The medical director was also in the facility while 100% of residents were assessed. No residents were found exhibiting a change of condition of an emergency nature. All on-going concerns were already being addressed by the physician and staff (Initiated [DATE]) (Completion [DATE]) 2. The three charge nurses, LVN A, charge nurse #1 and identified as Resident #1's charge nurse, LVN B, charge nurse #2, and LVN C, charge nurse #3 were the three charge nurses who were in the facility on [DATE] and helped conduct the initial assessments of 100 percent of the residents along with LVN D, wound care, RN A, ADON, LVN E, MDS and LVN F, MDS. All of the nurses on duty at that time were in-serviced by the Director Nurses, on the following on [DATE]. RN B and RN C were the other two charge nurses working the shift that was identified in the immediate jeopardy. Both of them are being in-serviced on [DATE] and are not scheduled to work for several days. a. Existing Change of Condition policy. No policy changes required. b. How to perform a complete resident assessment, including, vitals, other staff interviews, and concerns of a physical, mental, or psychosocial nature. c. How to properly document all findings in (name of EMR) and on the 24 hour report. d. Emergency Change of Condition requiring 911. In the event of a medical emergency regarding change of condition, the charge nurse shall immediately call 911 for transport to the nearest local hospital. The judgement of the clinical staff and guidelines outlined in the Resident Assessment Instrument and 42 CFR 483.20 (b)(ii) shall be the guiding principle. e. Non-Emergencv Change of Condition requiring physician intervention, continued monitoring. The charge nurse shall notify the physician, nursing supervisor, and family (RP) of any significant change in the resident's physical, mental, and psychosocial status. The nurse will gather info on the resident and immediately contact the physician to obtain orders for the continued monitoring and treatment of the resident. All staff present on [DATE] were required to take a five (5) question test following the in-service. Any staff not making a 100 were required to be in-serviced again by the DON. Then, they were required to take the test again. Anyone not passing after three (3) consecutive times were not allowed to work their assigned shift on that day, until all in-service requirements were met. All nursing staff present passed on their first try. (Initiated ([DATE]) (Completion [DATE]) 3. A Quality Assurance Performance Improvement meeting was held on [DATE] at 12:00PM to review the allegations surrounding the Immediate Jeopardy and the plan moving forward related to the Plan of Removal. The Medical Director was notified and in attendance for the meeting on [DATE]. (Initiated [DATE]) Completion [DATE]) 4. The Medical Director was notified by phone of the additional IJ for Tag 684. On-Going Training (Initiated ([DATE]) (Completion [DATE]) 1. While all staff present on [DATE] completed their in-service successfully, all other permanent, licensed nurses will be required to undergo the same in-service prior to working their assigned shift. (Initiated ([DATE]) (On-going) 2. If the facility requires the use of agency staff, they will be required to go through the same training as permanent staff. Each shift shall identify one charge nurse who has been properly trained in providing the in-service and training to the agency staff prior to their working their assigned shift. Agency staff [NAME] not be allowed to work unless they successfully pass the test per the above requirements. (Initiated ([DATE]) (On-going) 3. Newly hired staff will have this entire component of the same exact training and testing by the Director of Nurses built into their orientation process. No newly hired staff will be allowed to train on the floor until they successfully complete the training and pass the test in the same manner as all other staff. (Initiated ([DATE]) (On-going) 4. The DON and Administrator will review the 24 report daily for any changes in condition. They will also verify that any non-emergency physician orders are being administered and that any resident who experienced an emergency change in condition was transported to the nearest hospital via 911. From [DATE]-[DATE] a monitoring visit was conducted to ensure the facility was following it's POR. The visits revealed: On [DATE]-[DATE], the Director of Nursing began in-services with all nursing staff on change of condition and notification of physician. The Director of Nursing also had nurses perform assessments on all residents in the facility on [DATE], including vital signs. The DON also said she would monitor the 24hr report daily, for any change of condition reports. Record review of assessments performed by nurses on [DATE]-[DATE], revealed no concerns. Record review of in-services on [DATE] revealed nursing staff had a Change of Resident Condition in-service on [DATE] and [DATE], with a 5-question posttest. Record review of in-services on [DATE] also revealed nursing staff had a Notification of Physician, Family and Others in-service on [DATE] and [DATE]. Record review on [DATE] revealed a QAPI meeting was conducted on [DATE] to review the Plan of Removal and the plan moving forward on trainings. Record review of the facility's policy and procedure on Notification to Physician, Family and Others on [DATE] revealed facility will inform the resident's physician, and resident's representative of any changes in the resident's physical, mental, or psychological status, including in emergency or non-emergency changes in condition. Interviews with nursing staff on [DATE] revealed they had training on changes of resident condition with a post-test. Nursing staff were able to describe what to do in an emergency and non-emergency changes of condition, including notifying the physician. Nursing staff also confirmed they assessed the residents on [DATE]-[DATE]. Interviews with CNA's on [DATE] revealed they would let the charge nurse know about any change in condition in the resident, and they would stay with the resident. Observations and interviews with residents on [DATE] revealed they were satisfied with their care. They also confirmed that they had a nurse come and assess them in the last couple of days. Interview with the physician on [DATE] revealed he expected staff to call him, call the family, and call 911 if it was an emergency regarding change of condition. He stated the staff knew the resident's well and knew their baseline. The facility's ADM was notified the IJ was removed on [DATE] at 3:46 PM. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance due to the facility's need to evaluate the effectiveness of the Plan of Removal.

Based on interview and record review the facility failed to ensure licensed nurses had the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 1 of 1 nurse (LVN A) reviewed for nursing services. LVN A failed to identify CR #2 was unresponsive on [DATE]. LVN A got CR #2 into her wheelchair and attempted to give her water to drink, when she was unresponsive. An Immediate Jeopardy (IJ) was identified on [DATE] at 2:44pm. While the IJ was removed on [DATE] at 3:56pm the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their corrective systems. These failures could place all residents at risk for inadequate or delayed treatment and interventions, based on inaccurate assessments. Findings include: CR #2's undated face sheet revealed she was an [AGE] year-old female readmitted on [DATE], with diagnoses of Alzheimer's Disease, major depression (extreme sadness, tearfulness), hypertension (high blood pressure), heart failure (heart does not pump blood efficiently), and dysphagia (trouble swallowing). CR #2 was sent to the hospital on [DATE] and expired on [DATE]. Record review of CR #2's Quarterly MDS dated [DATE], revealed a BIMS score of 3 out of 15, which indicated severely impaired cognition. CR #2 required extensive assistance with bed mobility, transferring, eating, and locomotion. CR #2 used a wheelchair and was always incontinent of bowel and bladder. No was answered to the question, Life expectancy of less than 6 months? According to the MDS, CR #2 required a mechanically altered diet (a change in texture of food or liquids like pureed foods, thickened liquids, Etc.). Record review of CR #2's care plan, revised [DATE], revealed Resident has DX of Alzheimer/Dementia. Resident has short- and long-term memory deficits. Needs moderate assistance with decisions-Resident will have no S/S of side effects to medications through next review date: Observe for change in mental status, increased behaviors, confusion, and notify MD. Observe for/document/report to MD and changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness .level of consciousness, mental status. The resident has ADL Self Care Performance deficits regarding .eating r/t cognitive deficits .and resisting care-The resident will remain clean, dry, odor free and appropriately dressed daily with interventions through next review date: Resident requires extensive assistance and verbal cue for eating. Provide physical assistance as needed. Encourage and assist as need to upright position for meals and PO intake. Record review of CR #2's lab results from [DATE] revealed potassium 5.2 (normal 3XXX,d+[DATE].2), BUN 31 (how well kidneys are functioning, normal ,d+[DATE]%), Creatinine 1.79 (how well kidneys are functioning, normal 0XXX,d+[DATE].11), and eGFR 28 (how well kidneys are working, normal >60). Record review of CR #2's medical record revealed a progress note from [DATE] by MD A that stated the reason for the appointment was for a sick visit. CR #2's Labs reviewed creatinine 1.79, potassium 5.2. No significant leg swelling, no shortness of breath. Discontinue Spironolactone. Record review of CR #2's medical record revealed one blood pressure recorded for [DATE] at 7:32am, ,d+[DATE]. Record review of CR #2's MAR for [DATE] revealed an order to record the Side Effects to Hypnotic/Sedative Medication: (0)None, (1)Anxiety, (2)Blurred Vision, (3)Confusion, (4)Daytime Sedation, (5)Dizziness, (6)Fatigue, (7)Hallucinations, (8)Headache, (9)Mania, (10)Nightmares, (11)Syncope, (12)Urinary Retention, (13)Other, to be done Every day and night shift. The answer for Days on [DATE] by LVN A was (0) or None. Record review of CR #2's medical record revealed she had the following medications ordered by MD A: - Amlodipine Besylate Tablet 5mg, 1 PO QD, started on [DATE] - Aspirin Tablet Chewable 81mg, 1 PO QD, started on [DATE] - Bupropion HCl ER Oral Tablet Extended Release 12 Hr 100mg, 1 PO QD, started on [DATE] - Lasix Tablet 20mg, 1 PO QD, started on [DATE] - Lisinopril Tablet 5mg, 1 PO QD, started on [DATE] - Multivitamin, 1 PO QD, started on [DATE] - Docusate Sodium 100mg, 1 PO BID, started on [DATE] - Memantine HCl Tablet 10mg, 1 PO BID, started on [DATE] - Depakote Sprinkles Capsule Delayed Release 125mg, 1 PO TID, started on [DATE] Record review of CR #2's medical record revealed she received the following medications on [DATE] by MA A: - amlodipine Besylate 5mg tab PO at 8:00am - aspirin 81mg chewable tab PO at 8:00am - bupropion HCL 100mg PO at 8:00am - Lasix 20mg PO at 8:00am - lisinopril 5mg PO at 8:00am - multivitamin PO at 8:00am - docusate sodium 100mg PO at 8:00am and 4:00pm - memantine 10mg PO at 8:00am and 4:00pm - Depakote sprinkles 125mg PO at 8:00am, 12:00pm, and 4:00pm. Record review of CR #2's medical record revealed a progress note from [DATE] at 5:20pm by LVN A that stated, [Family] in facility concerned about Resident not opening her eyes and not speaking throughout the day. Request for transfer to Patients ER for evaluation. On call Nurse notified of request. Called [name of EMS] and they stated they do not have units out today. On call notified and called 911. Upon arrival of EMS vs ,d+[DATE], 64, 20, 97%, glucose 74, 97.5 vs stable. Resident continues hard to arouse. [Family] request to continue with transfer to Patients ER. Resident leaves via stretcher and report called. No other notes were documented for [DATE]. Record review of CR #2's EMS report from [DATE] at 5:42pm revealed she was unresponsive and had weakness to her left and ride side. At 5:50pm it revealed CR #2's GCS (used to objectively describe extent of impaired consciousness) was E (best eye response) 2, V (best verbal response) 1, M (best motor response) 3, for a total score of 6 out of 15 which indicated severely impaired consciousness. The E/V/M were scored from 1 (no response) to 4 (normal response). At 6:12pm CR #2 was intubated (a tube in the throat to breathe for you). According to the EMS narrative it revealed, Patient is unconscious and only responsive to pain. It also stated, Facility was unable to obtain vitals. EMS left the facility at 6:07pm and arrived at the hospital at 6:20pm. Record review of CR #2's hospital record's from [DATE], revealed a patient registration form stating admitted was [DATE] at 10:16pm to ICU. Record review of CR #2's hospital records revealed an H&P from [DATE] which revealed CR #2 had a BP of ,d+[DATE] on [DATE] at 8:15pm, BP of ,d+[DATE] early in the morning of [DATE], and a BP of ,d+[DATE] on [DATE] at 1:00am. It was also revealed CR #2 had coarse rhonchi throughout her lungs and was on 2 L/min of O2 via NC. According to the labs from [DATE] she had pyuria (infected urine), leukocytosis (elevated white blood cells) at 13.54, elevated lactic acid (indicator of systemic infection), and renal failure with BUN 79, creatinine 4.13, and GFR 10. Her GCS was 7 (severe) with E(1), V(1), M(5). According to the assessment/plan from the H&P, CR #2 had a urinary tract infection with severe sepsis, aspiration pneumonia, acute renal failure with acute hyperkalemia, and acute metabolic encephalopathy. Record review of CR #2's ICU progress notes from [DATE] revealed she was still unconscious, had a foley catheter, and was on 4 L/min of O2 via NC. The ICU progress note from [DATE] revealed CR #2's urine culture came back positive for an MDRO-E. Coli. It also revealed CR #2 had to be switched to a NRBM at 4 L/min of O2. It also stated CR #2's ABG revealed hypoxia and her chest x-ray was worse than the previous one. On [DATE] at 9:26am the ICU progress note revealed CR #2 had an O2 saturation of 67%. A progress note from [DATE] at 4:50pm revealed CR #2's time of death was 4:50pm. Record review of CR #2's Certificate of Death issued [DATE], revealed the cause of death as aspiration pneumonia with severe sepsis. Record review of LVN As statement from [DATE] at 2:30pm revealed on [DATE] CR #2 was fine and ate all 3 meals in her wheelchair. LVN A received in morning report on [DATE] that CR #2 did not sleep well through the night. LVN A got CR #2 out of bed for breakfast, into her wheelchair, and into the dining room. Per LVN A's statement, she did not wake up enough to eat breakfast, but she was able to wake her up to drink fluids. After breakfast, LVN A laid CR #2 back down in bed, changed her and took her vital signs, which were stable. LVN A's statement revealed before lunch, her and another staff member tried to get CR #2 up, but she was resisting and replied no when asked if she wanted to get up. The 2 staff members changed CR #2 and left her in bed with the HOB raised. Per the statement, when lunch came CR #2 did not wake up to eat, but LVN A checked her vitals, and they were stable (the only vital signs in the medical record were at 7:32am). LVN A's statement said, before dinner they changed CR #2, got her up into the wheelchair and took her to the dining room. Resident CR #2 still said no when asked if she wanted to get up, but since she did not eat lunch, LVN A got her up anyway. During dinner CR #2 did not eat, and her family member came and requested her to be sent to the hospital. LVN A stated her vital signs were stable (the only vital signs in the medical record were taken at 7:32am). EMS arrived and checked CR #2's vitals and they were stable. According to LVN A's statement, EMS asked what they wanted to do because the patient was ok with her eyes closed but was replying verbally very little and vitals were stable. EMS was told to take CR #2 to the hospital for further evaluation d/t sleeping throughout the day. In an interview with MA A on [DATE] at 11:01am she stated she remembered CR #2 and that she was sleepier on [DATE] then most days. She said it was normal for CR #2 be sleepy though, because sometimes she would stay up all night and then sleep during the day. She did not remember giving medications to CR #2, how awake she was when she took them, or how she took them because it was too long ago. She stated she made sure residents were awake enough before giving medications by ensuring they could open their eyes, say something, and take a sip of water first. In an interview with LVN A on [DATE] at 11:15am she stated it took 2 people to get CR #2 into a wheelchair on [DATE] because she was so sleepy, and she was not able to assist getting into the wheelchair. She also stated CR #2 resisted when they were changing her. LVN A stated CR #2 opened her mouth to drink when she asked her to, but never opened her eyes. She also said she did not feed CR #2 anything, and only gave her water to drink. LVN A stated she could not wake up CR #2 when tapping her shoulder or calling her name, but that was normal for her when she did not sleep at night. She stated she did not open her eyes, but she would say 1 word like no every now and then. When LVN A changed her, she said CR #2 pushed against them and resisted. LVN A stated her vital signs were normal so there was nothing wrong. She stated she did not feel the resident had a change in condition because she was sleepy like this sometimes during the day, when she stayed up all night. She stated she felt like it was okay for her to have gotten CR #2 into her wheelchair, even though she was sleepy, because she had the dining table in front of her so she could not have fallen. LVN A did not remember she documented 0 or none, for side effects to hypnotics/sedatives on [DATE]. LVN A said she did not understand how EMS could have scored CR #2 as a GCS of 6, because she was not. In an interview with the DON on [DATE] at 11:43am she stated she was not there the day the incident happened because it was a Sunday. She stated it was normal for CR #2 to sleep all day sometimes, if she stayed up all night, and was a heavy sleeper. She stated LVN A had worked with CR #2 for about 5yrs and knew the resident well. She also stated that she was told the family member left for about 3hrs, and if she was that concerned about CR #2, she would not have left. The DON stated the family member went to the facility more than any other family member and staff knew what the family wanted/expected and would not have left the resident like that. She also said if a family member wanted a resident to be sent to the hospital, there were no questions asked and they sent them right away. In an interview with CR #2's family member on [DATE] at 12:03pm, she revealed she arrived at the facility on [DATE] between 11:00am and 11:30am and found CR #2 unresponsive in her bed. The family member called out CR #2's name, patted her on the shoulder, and gave her a hug and she still did not respond. The family member went and spoke to LVN A, who stated CR #2 was just really sleepy from staying up the night before. The family member asked MA A why CR #2's food tray was still on her bedside table because she always ate in the dining room. The MA A stated LVN A was unable to get CR #2 to eat, so she was going to try again later. The family member stated she told LVN A that CR #2 was not just sleepy and then went back to the resident's room. The family member stayed with CR #2 for a while and stated LVN A never came back into the room. The family member stated she left the facility for about 45min to get her phone charger and a change of clothes because she was going to send CR #2 to the hospital when she got back. The family member stated when she got back to the facility, LVN A told her she was able to get CR #2 to eat some cake and drink some water while she was gone. Then she saw CR #2 in the dining room in her wheelchair, slumped down in the chair with her head hanging back on the wheelchair. She tapped CR #2's arm and called her name, and she did not respond. The family member went back to LVN A and told her she wanted CR #2 transported to the hospital. The family member stated that LVN A said, You want her transported to the hospital? She is just sleepy. The family member said yes, and CR #2 was taken to her room to be changed. According to the family member, when EMS arrived LVN A told EMS She thought CR #2 was just sleepy, but the family member wanted her transferred. The family member stated CR #2 never opened her eyes the whole time she was there and never said one word. Also, the family member stated she last saw CR #2 on Friday, [DATE] and she was up in her wheelchair in the lobby, and they were laughing and having a good time. The family member also stated that CR #2 would be sleepy sometimes from staying up all night, but she could be woken up by calling her name or tapping her on the arm. She said she never had been in such a deep sleep that she could not have been woken up. In an interview with LVN B on [DATE] at 12:48pm she revealed she had worked with CR #2 for more than 5yrs and knew her and her family member well. She stated she worked with CR #2 on Friday [DATE] and she was awake, alert, and her usual self. She stated that CR #2 would sometimes be sleepy during the day but could be woken up by talking to her or tapping her shoulder. She also stated that it would be abnormal if CR #2 did not wake up or respond if she tried to wake her. LVN B stated she ensured residents were awake enough before giving them something to eat/drink by making sure their eyes were open, and they were talking first. She also stated on the days CR #2 was sleepy, she would not get her out of bed because she would be at risk of falling out of her wheelchair or hurting herself. She said she would not have gotten CR #2 out of bed, to her wheelchair, if she was that sleepy. She said she knew the family member really well and she did not feel that she was overreacting and would have believed that something was wrong. In an interview on [DATE] at 8:50am with the Activities Director she stated, the family member went to her office on [DATE] around lunch time and asked her to come look at CR #2. When the Activities Director got to the room and saw CR #2, she thought the resident was just sleeping. She said she saw the resident was not waking up when the family member was trying to wake her up. She stated that she whispered in the family member's ear to send her out to the hospital and was trying to convince her to call EMS. She said that she was only the Activity Director and did not want to step on anyone's shoes, so she stayed in her lane and could not tell the nurse's what to do. She said the incident happened before lunch and she did not see the family member anymore after that because she got busy with her activities, and she did not know what happened after that. Record review of the facility's policy and procedure on Change in Resident Condition, with no date, read in part: The facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status. 1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: . d. A significant change in the resident's physical/emotional/mental condition . i. Instructions to notify the Physician of changes in the resident's condition. 2. A significant change of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting) b. Impacts more than one area of the resident's health status . 3. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider. 4. Unless otherwise instructed by the resident, the Nurse Supervisor/Charge Nurse will notify the resident's family or representative when: . b. There is a significant change in the resident's physical, mental, or psychosocial status . 7. The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. The facility Administrator received the IJ template on [DATE] at 2:44pm. The Plan of Removal (POR) was accepted on [DATE] at 2:50pm and reflected: Immediate Action Taken (Initiated ([DATE]) (Completion [DATE]) Resident #1 was discharged 911 to (Name of Medical Center) on [DATE] and did not return to the facility. On [DATE] three charge nurses on duty, the Director of Nurses, the ADON, Wound Care Nurse, and two MDS nurses did an immediate assessment of all 101 residents in the building. All vital signs and any concerns regarding residents' physical, mental, and psychosocial conditions were documented in (name of EMR). This immediate action was initiated at 1:00PM by all 8 nurses and completed by 3:00PM. The medical director was also in the facility while 100% of residents were assessed. No residents were found exhibiting a change of condition of an emergency nature. All on-going concerns were already being addressed by the physician and staff (Initiated [DATE]) (Completion [DATE]) 1. The three charge nurses, LVN A, charge nurse #1 and identified as Resident #1's charge nurse, LVN B, charge nurse #2, and LVN C, charge nurse #3 were the three charge nurses who were in the facility on [DATE] and helped conduct the initial assessments of 100 percent of the residents along with LVN D, wound care, RN A, ADON, LVN E, MDS and LVN F, MDS. All of the nurses on duty at that time were in-serviced by the Director Nurses on the following on [DATE]. RN B and RN C were the other two charge nurses working the shift that was identified in the immediate jeopardy. Both of them are being in-serviced on [DATE] and are not scheduled to work for several days. a. Existing Change of Condition policy. No policy changes required. b. How to perform a complete resident assessment, including, vitals, other staff interviews, and concerns of a physical, mental, or psychosocial nature. c. How to properly document all findings in (name of EMR) and on the 24 hour report. d. Emergency Change of Condition requiring 911. In the event of a medical emergency regarding change of condition, the charge nurse shall immediately call 911 for transport to the nearest local hospital. The judgement of the clinical staff and guidelines outlined in the Resident Assessment Instrument and 42 CFR 483.20 (b)(ii) shall be the guiding principle. e. Non-Emergencv Change of Condition requiring physician intervention, continued monitoring. The charge nurse shall notify the physician, nursing supervisor, and family (RP) of any significant change in the resident's physical, mental, and psychosocial status. The nurse will gather info on the resident and immediately contact the physician to obtain orders for the continued monitoring and treatment of the resident. All staff present on [DATE] were required to take a five (5) question test following the in-service. Any staff not making a 100 were required to be in-serviced again by the DON. Then, they were required to take the test again. Anyone not passing after three (3) consecutive times were not allowed to work their assigned shift on that day, until all in-service requirements were met. All nursing staff present passed on their first try. Plan of Removal - [DATE] (Initiated ([DATE]) (Completion [DATE]) 3. A Quality Assurance Performance Improvement meeting was held on [DATE] at 12:00PM to review the allegations surrounding the Immediate Jeopardy and the plan moving forward related to the Plan of Removal. The Medical Director was notified and in attendance for the meeting on [DATE] On-Going Training (Initiated ([DATE]) (Completion [DATE]) 1. While all staff present on [DATE] completed their in-service successfully, all other permanent, licensed nurses will be required to undergo the same in-service prior to working their assigned shift. (Initiated ([DATE]) (On-going) 2. If the facility requires the use of agency staff, they will be required to go through the same training as permanent staff. Each shift shall identify one charge nurse who has been properly trained in providing the in-service and training to the agency staff prior to their working their assigned shift. Agency staff [NAME] not be allowed to work unless they successfully pass the test per the above requirements. (Initiated ([DATE]) (On-going) 3. Newly hired staff will have this entire component of the same exact training and testing by the Director of Nurses built into their orientation process. No newly hired staff will be allowed to train on the floor until they successfully complete the training and pass the test in the same manner as all other staff. (Initiated ([DATE]) (On-going) 4. The DON and Administrator will review the 24 report daily for any changes in condition. From [DATE]-[DATE] a monitoring visit was conducted to ensure the facility was following it's POR. The visits revealed: On [DATE]-[DATE], the Director of Nursing began in-services with all nursing staff on change of condition and notification of physician. The Director of Nursing also had nurses perform assessments on all residents in the facility on [DATE], including vital signs. The DON also said she would monitor the 24hr report daily, for any change of condition reports. Record review of assessments performed by nurses on [DATE]-[DATE], revealed no concerns. Record review of in-services on [DATE] revealed nursing staff had a Change of Resident Condition in-service on [DATE] and [DATE], with a 5-question posttest. Record review of in-services on [DATE] also revealed nursing staff had a Notification of Physician, Family and Others in-service on [DATE] and [DATE]. Record review on [DATE] revealed a QAPI meeting was conducted on [DATE] to review the Plan of Removal and the plan moving forward on trainings. Record review of the facility's policy and procedure on Notification to Physician, Family and Others on [DATE] revealed facility will inform the resident's physician, and resident's representative of any changes in the resident's physical, mental, or psychological status, including in emergency or non-emergency changes in condition. Interviews with nursing staff on [DATE] revealed they had training on changes of resident condition with a post-test. Nursing staff were able to describe what to do in an emergency and non-emergency changes of condition, including notifying the physician. Nursing staff also confirmed they assessed the residents on [DATE]-[DATE]. Interviews with CNA's on [DATE] revealed they would let the charge nurse know about any change in condition in the resident, and they would stay with the resident. Observations and interviews with residents on [DATE] revealed they were satisfied with their care. They also confirmed that they had a nurse come and assess them in the last couple of days. Interview with the physician on [DATE] revealed he expected staff to call him, call the family, and call 911 if it was an emergency regarding change of condition. He stated the staff knew the resident's well and knew their baseline. The facility's ADM was notified the IJ was removed on [DATE] at 3:46 PM. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance due to the facility's need to evaluate the effectiveness of the Plan of Removal.

Based on observation, record review and interview, the facility failed to follow written policies on permitting residents to return to the facility after they were hospitalized or placed on therapeutic leave for 1 of 2 closed Records (CR #1) reviewed. 1. The facility failed to readmit CR #1 after he was hospitalized . This failure could place residents, who transfer to the hospital, at risk of being denied readmission to the facility. Findings include: Observation of the facility on 06/26/23 at 12:15PM, revealed CR #1 was not in the facility. Record review of CR #1's undated face sheet revealed he was [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included, heart disease, essential hypertension (High blood pressure), lack of coordination cerebral infarction, dementia, psychotic disturbance, mood disturbance, and anxiety. Record review of CR #1's nurse note dated 1/2023 read in part- : 1200- transportation EMS transportation scheduled for resident to go to Local Hospital ER. ETA 1 hour. Resident was notified that he would be going to the local Hospital when transportation arrived. Resident stated, Good, I have friends there. I like their food better. 1250- EMS transportation arrived at facility to transport resident. CR #1 was assisted onto stretcher. While on stretcher, resident yelling using explicit and being verbally abusive. Resident kicked female paramedic in the leg and hit her in stomach. Resident rolling on stretcher trying to get off and attempting to hit any staff close to him. Stretcher moved away from desk to prevent resident from hitting his head or any other body parts on desk. Resident stating, he was going to put himself on the ground and tried to slide himself off stretcher. At this time, paramedics denied transport stating they will not take him while he is being combative and aggressive. This nurse asked resident if he would get onto the stretcher peacefully because this nurse did not want to call police to help. Resident replied with, Call them. 911 called and awaiting arrival. EMS called to have another ambulance sent. This nurse, CNAs, staff, and administration present. 1:10PM - Police arrived. Resident was friendly and cooperative with police and stated that he will get on the stretcher for safety to be transported to the local Hospital. This nurse, CNAs, staff, and administration present . In a telephone interview on 06/23/23 at 9:20AM, CR #1's RP said she got a five-day discharge letter from the facility that CR #1 was discharged to the hospital and would only be readmitted back for few days. She said she was supposed to get a 30- day letter. She said she felt CR #1 was not treated fairly. She said she would not send CR #1 back to the facility. She sent the letter but was not assessable. CR #1's RP was contacted but did not respond. In an interview with the facility Administrator and DON on 06/27/23 at 1:00PM, the Administrator said CR#1 was not present at the facility. He said CR #1 was sent out due to behavior. He said CR#1 threatened another resident that he was going to beat him and cut his head off. The Administrator said CR#1 was cursing and yelling at every one on his way and the facility staff could not get him to calm down. The DON said CR#1 was very aggressive during transfer that he kicked the first ambulance driver that came to pick him up to go to the hospital. She said all was documented on the nurse's notes. She said the police had to be called and he finally slowed down when the police appeared. The Administrator said CR #1 said he was not going anywhere unless he had all his belonging, and his belongings were given to him before leaving the facility. The Administrator said he had a conversation with the hospital case worker that he would take CR #1 back for few days and assist CR # 1 in locating a suitable facility that could manage his behavior. He said he was willing to accept CR #1 back but never received a call back from the local hospital that CR #1 was ready to come back to the facility. He provided a telephone # to hospital case worker. During an interview with the Hospital Case worker on 07/07/23 at 11:30AM, hospital CW said, during a phone conversation, the Facility Administrator told her that he would only admit CR #1 for a few days and assist in discharging him to a more appropriate facility. The Hospital CW said after that conversation she did not reach out to the facility. The Hospital CW said she decided to find a placement for CR #1. Interview with the Administrator on 07/26/23 at 9:40AM, he said he did not refuse to take CR #1 back but would discharge him if his behavior continued and the facility would assist CR #1 to locate a safe place where his behavior could be managed. Record review of a facility's provided letter to local Hospital dated 06/02/23 at 11:11AM read in part As you are aware, CR #1 was sent to the hospital on Wednesday for behaviors. Wednesday was incredibly difficult day for him behavior wise, as was the week before. After sending him to the hospital, we notify them that we will still help so that he has a safe discharge to another facility . In an interview on 07/26/23, the Administrator said CR # 1's discharge was an emergency discharge and for the safety of other residents. He said he would have taken CR #1 back if the local hospital CW reached out for CR #1's return but the local hospital did not. He said he issue the 5 days letter since no one reached out to him. Record review of the facility's policy/procedure related to admission, transfer, and discharge undated did not address emergency discharge. permitting residents to return to the facility after being sent out to hospital for evaluation. The policy read in part, Emergency discharge.

Based on interview and record review, the facility failed to ensure the Pre-Admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for two (Resident #60 and Resident #33) of six residents reviewed for PASRR Screenings. 1. The facility failed to ensure the accuracy of the PASRR Level 1 screen for Resident #60. The resident did not receive a PASRR Level II assessment Evaluation. 2. The facility failed to ensure the accuracy of the PASRR Level 1 screen for Resident #33. The resident did not receive a PASRR Level II assessment Evaluation. This failure could place residents who had a mental illness at risk of not receiving individualized specialized service to meet their needs. Findings included: 1. Review of Resident #60's face sheet, dated 06-29-22, reflected she was a [AGE] year-old female with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #60's PASRR Level 1 screen dated 02-01-22, reflected, .C0100. Mental Illness: Is there evidence or an indicator this is an individual that has a mental illness? No. 2. Review of Resident #33's face sheet, dated 06-29-22, reflected she was a [AGE] year-old female with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #33's PASRR Level 1 screen dated 04-26-21, reflected, .C0100. Mental Illness: Is there evidence or an indicator this is an individual that has a mental illness? No. Interviews on 06/28/22 at 3:01 PM and 06/29/22 at 2:42 PM with the MDS Nurse revealed she had been completing PASRR evaluations for a few months. She said she was not employed at the time the PASRR Level 1 screens were completed for Residents #33 and #60. She said they did not have a positive PASRR Level 1 screen because they both had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] An interview on 06/29/22 at 1:36 PM with the DON revealed she did not monitor the facility PASRR process, and that the SW was supposed to, but she was still a new employee. She said if a resident did not receive the appropriate PASRR Level 1 screen they could be denied services. An interview on 06/29/22 at 1:42 PM with the SW revealed she did not monitor the facility PASRR process. She said if a resident did not receive an accurate PASRR Level 1 screen screening the resident might not receive services that PASRR could provide. An interview on 06/29/22 at 3:06 PM with the Administrator revealed no one was double-checking PASRR assessments . The Administrator said the facility needed more PASRR training. Review of the facility's policy and procedure Preadmission Screening and Resident Review (PASRR), not dated, reflected, Procedure: 1. The facilities designated staff will review all potential admission for possible positive PASRR conditions and ensure CMS preadmission guidelines are followed.

Based on observation, interview, and record review, the facility failed to ensure that each resident who was incontinent of bowel/bladder and each resident with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections, for 1 (Resident #1) of one residents reviewed for incontinent care and for indwelling urinary catheters. - Failed to prevent Resident #1's catheter tubing from resting on the floor. These failures could place residents with urinary catheters at risk for infections and injuries. The findings included: Resident #1 Record review of Resident #1's Face Sheet dated 12/22/2021 revealed a [AGE] year-old male admitted on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] [CONDITION(S)] (enlarged prostate) with lower urinary tract symptoms, Type 2 diabetes mellitus without complications, [CONDITION(S)] (fat build up in arteries), hypertension (high blood pressure). Record review of Resident #1's progress note dated 12//15/2021 revealed Resident #1 was admitted to the facility with a foley catheter and noted nephrostomy tube (nephrostomy tube is a thin catheter placed into your kidney to drain urine). A record review of Resident #1's MDS was not reviewed because the MDS had not been completed. A record review of Resident #1's care plan was not reviewed because the care plan was not completed. Record review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 12/22/2021 at 9:30 a.m. of Resident #1 lying in bed revealed the tubing of his nephrostomy catheter was coiled on the floor. Observation on 12/22/2021 at 12:20 p.m. of Resident #1 lying in bed revealed the tubing of his nephrostomy catheter was coiled on the floor. Interview on 12/22/2021 at 12:25 p.m. with CNA A said Resident #1's tubing from the catheter should not be on the floor. CNA A said the floor is not clean there for potential bacteria can be cross contaminated and cause an infection for the resident. CNA A said he could was trained and has had skills checks on catheter care. CNA A said he was responsible to ensure the catheter tubing was not on the floor. Interview on 12/22/2021 at 12:30 p.m. with CNA B said Resident #1's tubing from the catheter should not be on the floor. CNA B said she took Resident #1 to be weighed earlier that morning but could not remember if she ensured his tubing was not placed on the floor. CNA B said Resident #1's tubing being on the floor could cause cross contamination and possible infection. CNA B said she had catheter care training but could not remember when. Interview on 12/22/2021 at 12:35 p.m. with the DON said, Resident #1's catheter tubing should not be on the floor. The DON said the tubing being on the floor could cause an infection. The DON said the aides should complete rounds at least every 2 hours or as needed to ensure the residents' needs are met. The DON said it was all staff (aides, nurses) to make sure infection control protocols were followed for catheter tubing. Interview on 12/22/2021 at 1:59 p.m. with the ADMIN said his expectation was for staff to have ensured Resident #1's catheter tubing was kept off the floor to prevent infection. The ADMIN said it was the responsibility of nurses, aides and DON to ensure the tubing was kept off the floor. Record review of facility policy Urinary Catheter Care dated 2018 revealed the following in part: Perform catheter care and maintenance: .catheter care is very important to prevent infection and other complications . -Do not place . on the floor .

Based on interview and record review the facility failed to ensure that allegations involving abuse and neglect, including injuries of unknown source, are reported immediately to the state agency for 2 of 22 residents (Resident #42 and Resident #50) reviewed for abuse and neglect reporting. The facility failed to report Resident #42's and Resident #50's injury of unknown source. This failure affected two residents and placed them at risk of abuse and neglect. Findings include: Resident #42 Record review of Resident #42's face sheet revealed an [AGE] year-old female with an admission date of [DATE]. [DIAGNOSES REDACTED]. Record review of Resident #42's Quarterly MDS dated [DATE] revealed a BIMS score of 2 indicating cognition was severely impaired. Record review of Resident #42's incident report dated 7/22/19 revealed resident was found on the floor in dayroom laying on her left side. This was un-witnessed. LVN D was in the hallway when she heard a yell and found resident on the floor. She was assessed, and no injury was noted. She was limping when put into bed and said she was hurting. Pain medications were given, and she was observed. Further review revealed resident continued to have pain and an x-ray was ordered on [DATE]. It was discovered she had an acute non-displaced [MEDICAL CONDITION] neck and [MEDICAL CONDITION]. She was sent to the hospital. Interview on 01/08/20 at 2:15 PM CNA 1 said she was in the hallway when Resident #42 fell . The resident was ambulatory and walking at the time. She said there were other residents in the room, so she could have tripped over them, but she just heard her yell out. Resident #50 Record review of Resident #50's face sheet revealed a [AGE] year-old male with an admission date of [DATE]. [DIAGNOSES REDACTED]. Record review of Resident #50's Quarterly MDS dated [DATE] revealed a staff assessment for mental status indicating cognition was severely impaired. Record review of Resident #50's incident report dated 9/4/19 revealed resident was found on the floor with face down on the floor. Resident was bleeding from the nose and mouth and right eye was swollen and bruised. This was un-witnessed but was believed resident tripped and fell . Resident was assessed, and no other injuries were noted. Resident was sent out to the hospital. Resident returned on 9/5/19. Record review of Resident #50's nurses' notes stated resident returned on 9/5/19 via EMS with a [DIAGNOSES REDACTED]. Record review of Resident #50's hospital record dated 9/5/19 revealed resident had a contusion and [MEDICAL CONDITION]. Interview on 01/09/20 at 9:45 AM, DON said they were supposed to report unwitnessed falls with injury and an incident that could be of abuse or neglect to the state. She said they did not report Resident #42's fall because they knew what happened. The DON admitted that it was unwitnessed. She said Resident #50's incident was not witnessed but he had no major injury. She said they sent him to the hospital, but he did not have a fracture. The DON said she was not sure why the hospital said he did. Interview on 01/09/20 at 11:10 AM, Administrator said they try to follow the matrix that the state sent when they call in incident reports. He said he reported incidents within 2 hours if something was abusive in nature or injury of unknown origin. He said the falls involving Resident #42 and Resident #50 did not fit the criteria in his mind. Record review of facility policy Prevention and Reporting of Suspected Resident Abuse and Neglect undated read in part, .Notify Texas Department of Human Services according to state law as required by state; state specific guidelines will be followed

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistenent with resident's medical, nursing and mental and psychosocial needs that are identified for 1 of 22 residents (Resident #42) reviewed for comprehensive care plans in that: -The facility failed to care plan Resident #42's need for a pommel cushion. This failure affected one resident and placed her at risk of inappropriate care or not having her needs met. Findings include: Resident #42 Record review of Resident #42's face sheet revealed an [AGE] year-old female with an admission date of [DATE]. [DIAGNOSES REDACTED]. Record review of Resident #42's Quarterly MDS dated [DATE] revealed a BIMS score of 2, indicating cognition was severely impaired. Further review revealed her transfer ability and locomotion was one person assist with extensive assistance. Record review of Resident #42's physician orders [REDACTED]. Record review of Resident #42's care plan dated 11/22/19 revealed a fall on 7/22/19 but no interventions that mention a pommel cushion. Record review of Resident #42's clinical record revealed no progress notes or assessments completed for a pommel cushion. There were no notes from therapy for a recommendation or need for a pommel cushion. Observation on 01/07/20 at 9:00 AM found Resident #42 sitting in a black desk chair with wheels, asleep. Next to the resident was her wheelchair with a pommel cushion in the seat. Interview on 01/08/20 at 12:40 PM, LVN D said Resident #42 occassionally got up on her own and will fall so the family brought the pommel cushion for her to use. Interview on 01/08/20 at 12:45 PM, DON said Resident #42's family brought the pommel cushion in since she was falling. Interview on 01/09/20 at 9:40 AM, LVN D said Resident #42 used a pommel cushion and said she was not sure if they had the paperwork. She was not sure of when the cushion was started. Interview on 01/09/20 at 9:45 AM, DON said the pommel cushion keeps Resident #42 from sliding out of the chair. She said she believed therapy ordered it and they should still have all the correct paperwork.

Based on interview and record review, the facility failed to maintain clinical records that were complete and/or accurately documented, in accordance with accepted professional standards and practices, for 1 of 22 residents (Resident #84) reviewed for clinical records. - The facility failed to accurately document blood sugar levels on Resident #84's Medication Administration Record. This failure affected 1 resident and placed him at risk for having inaccurate treatment or inaccurate medical records. Findings included: Record review of Resident # 84 's clinical record revealed a [AGE] years old male admitted on [DATE], with [DIAGNOSES REDACTED]. Record review of Resident #84 's Care Plan dated 11/21/19 revealed diagnosed with [REDACTED]. Accu-checks conducted before meals and bedtime. Further noted assess reports of [DIAGNOSES REDACTED] / [MEDICAL CONDITION], implement ordered interventions and notify MD if not effective. Record review of Resident #84's Physician order [REDACTED]. Insulin [MEDICATION NAME] 10 units subcutaneously to administer before meals. Record review of the MARs for Resident #84 dated (MONTH) 2019 revealed to administer Insulin [MEDICATION NAME] 10 units subcutaneously before meals for DM. Further noted on 12/4/19 at 11:00am, a blood sugar value of 10 ug/dl was documented and [MEDICATION NAME]10 units was administered. Record review of Resident #84's nurses' progress notes revealed late entry dated 01/09/20, indicated on 12/04/19 data entry blood sugar of 10, correct blood sugar is 110. In an interview on 1/8/20 at 1:30 pm. LVN K stated she was the assigned nurse to Resident #84. LVN K acknowledged the documented BS 10 was a data entry error on 12/04/19. Record review of Resident #84 's nurses progress notes dated 12/04/19, indicated as per Pharmacist review report [MEDICATION NAME] noted blood glucose documented as 24 on 12/01/19, but [MEDICATION NAME] was administered anyway despite such low blood sugar. In an interview on 01/08/20 at 2:00 pm, when asked about Resident #84, the DON stated the documented blood sugar 24 was also an entry error on 12/01/19. DON stated they verified with the nurse and noted there was a glitch with the Keyboard and the blood sugar value was 246. DON stated glucometer also verified the blood sugar of 246 on 12/01/19. In an interview on 01/09/20 10:10 am Administrator stated there was a glitch with the keyboard related to the keys sticking on the computer in pink and yellow hall. He further stated they just replaced the keyboard and threw away the old keyboard. Record review of facility provided policy on clinical records undated, revealed documentation will occur when an activity, event or incident that is not usual for the resident or change in level of assistance occurs.

Based on observation, interview and record review, the facility failed to develop and implement policies and procedures that prohibit neglect for two, Closed Record (CR) #1 and Resident #5, of ten residents reviewed for neglect. · The facility failed to provide supervision for CR #1 when her delusional behaviors increased and she walked out of the facility into the road where she sustained a laceration to her chin and was transferred to the hospital. · The facility failed to supervise Resident #5, who had severe cognitive impairment, when he left the facility via the side door in the main dining room that led to the back parking lot. An IJ was identified on [DATE] at 1:36 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of actual harm due to the facility needing more time to monitor the plan of removal for effectiveness. These failures affected two residents and placed70 residents whose care was compromised due to staff neglecting to adequately monitor residents who have a [DIAGNOSES REDACTED]. # 0 Findings include: CR #1 Record review of CR #1's clinical record revealed an admission date of [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR #1's Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment. CR #1 was assessed as feeling depressed nearly every day, required supervision for bed mobility, transfer, locomotion on and off unit, dressing, eating, toilet use, and personal hygiene. Her active [DIAGNOSES REDACTED]. Record review of CR #1's Care Plans dated [DATE] with a review date of [DATE] revealed she had the following care plans: -History of [MEDICAL CONDITION] and was being treated with an antipsychotic. Approaches included: administering the medication as ordered by my doctor. Monitor and document my behaviors daily. Observe for side effects of medication such as [MEDICAL CONDITION], rhinitis, [MEDICAL CONDITION], increased confusion, palpitations, [MEDICAL CONDITION], tongue [MEDICAL CONDITION], vomiting. [MEDICATION NAME] as ordered. -[DIAGNOSES REDACTED]. Help me with dressing, grooming and showers, so I can feel good about the way I look. Develop a trusting relationship with me so I am prompted to accept direction. Monitor me for signs and symptoms of anxiety levels in relation to situation. Avoid challenging illogical thinking because I may become defensive as a result. Display clocks, calendars, personal items, seasonal decorations to assist me with reality oriented environment, remind of your names if I cannot remember. Notify my physician and family of any significant changes in my condition. Allow me to choose activities I wish to attend. Some days I may be able to do more than others. Record review of Incident Investigation Worksheet dated [DATE] for CR #1 revealed that the Administrator first learned of the incident on [DATE] at 7:00 a.m. On [DATE] at 7:00 a.m., staff reported CR #1 was standing in the road with a bystander. The bystander said the resident fell . The bystander was on the phone with 911. The resident sustained [REDACTED]. The resident was sent to the hospital. The resident was still in the hospital but she did not sustain any fractures due to the fall. She will be placed in a psychiatric hospital. There are no witnesses to the incident. No alleged perpetrators. No staff suspended pending the outcome of the facility's investigation. To prevent a similar incident/or to protect the resident the facility initiated and investigation and interviewed staff. The physician and family were notified of the incident. The resident had had an increase in [MEDICAL CONDITION]-type behavior. The incident was still under investigation. Record review of Provider Investigation Report dated [DATE] for CR #1 read in part . Incident Category was marked as other, psychotic behavior resulting in harm . Incident date and time-[DATE] at 7:00 a.m. with location documented as street in front of facility . CR #1 had with minimal functional ability, level of supervision was documented as other-24 hour service, independent in ambulation, not interviewable, does not have the capacity to make informed decisions .verbal aggression .other pertinent history was dementia and history of psychotic symptoms .witnesses were present . The incident was described as follows: Resident was last seen 5 to 10 minutes before incident. Resident walked outside of building and seen with a bystander. Bystander stated resident had fallen. resident sustained [REDACTED]. The injury was described as a laceration on the chin and a bruise with swelling on the right elbow. The ambulance arrived before staff could measure laceration. Resident was in an upset delusion state . She was very upset and told staff that someone had died in her family and she was going to them .Provider Response . Resident has been at the facility since 2013 .Resident had been showing signs of delusions, hallucinations and anxiety. Evaluation ordered by primary physician to assess resident for current psychiatric medication regimen and psychotic symptoms on [DATE].Investigation Summary . On ,[DATE] -[MEDICATION NAME] increased to 50 mg. ,[DATE]- Resident put on antibiotic for urinary tract infection, seen by psychiatric services on ,[DATE] (no year provided) and [DATE]. ,[DATE] [MEDICATION NAME] 25 mg at 8:00 a.m., [MEDICATION NAME] 25 mg at 1:00 p.m. and 50 mg at bedtime . Record review of Physician order [REDACTED].>1. Discontinue [MEDICATION NAME] 25 mg by mouth at bedtime. 2. Start [MEDICATION NAME] 50 mg by mouth at bedtime. 3. Start [MEDICATION NAME] 25 mg by mouth daily. The [DIAGNOSES REDACTED].>Record review of Physician order [REDACTED].>1. [MEDICATION NAME] 25 mg by mouth in the morning. 2. [MEDICATION NAME] 25 mg by mouth at 1:00 p.m. 3. [MEDICATION NAME] 50 mg by mouth at bedtime. [DIAGNOSES REDACTED].>In an interview with ADON (Assistant Director of Nurses) on [DATE] at 11:30 a.m. she said she was on vacation and not at the facility when CR #1's incident occurred. ADON said CR #1 was not residing in the secure unit but instead in a regular hall. ADON revealed that CR #1 had been delusional in the past. When asked how her care was revised for the delusional behavior she said the staff were to redirect her when she exhibited the behaviors. When asked by surveyor if staff had been in-serviced she said she was not aware of an in-service for elopement/wandering. In an interview with MDS Nurse on [DATE] at 11:56 a.m. she revealed that she was driving to work on [DATE] at 7:11 a.m., and, as she pulled into the facility parking lot, she noticed CR #1 in the middle of the road, which is a busy street. MDS Nurse said CR #1 was in the middle of the 2 lanes of the road that move East. MDS Nurse said 2 cars were blocking traffic so oncoming traffic could not harm her. She said CR #1 had a laceration on her chin and said, I'm guessing it was 2 centimeters in width. MDS Nurse said that it was difficult to see injury on CR #1's chin because of the amount of blood. MDS Nurse said that CR #1 said, All my family is dead and no one will tell me what happened to them, I have to go find them. MDS nurse said that while she was with CR #1, the nurse came outside and then went back in to get a wheelchair. The nurse then returned with someone from restorative and a wheelchair. MDS Nurse said that CR #1 had good range of motion and the nurse and restorative person were able to get CR #1 into the wheelchair with use of a gait belt after a full assessment. MDS Nurse said that the bystander was outside on the phone with the police and told the police that CR #1 was trying to kill herself. Emergency Medical System (EMS) arrived and took resident to hospital for evaluation. MDS Nurse said someone in the facility took the bystander's information, but she was unsure of the person's identity. MDS Nurse said CR #1 was not belligerent or hostile and that she was just looking for her family. When asked if CR #1 had ever left facility unsupervised before that time, she said that she was not sure if CR #1 had ever wandered before. In an interview with Certified Nurse Aide (CNA) A, on [DATE] at 12:11 p.m., she revealed she was moving things around in CR #1's room on [DATE] between 7:00 a.m. and 7:30 a.m. because the floor was going to be waxed. CNA A said CR #1 said, Who died in my family, everyone is lying to me. CNA A told her that no one in her family died and CNA A continued moving things in CR #1's room so the floor could be waxed. CNA A said that CR #1 went to CNA B who then took CR #1 to RN C. CNA A said that she has worked with CR #1 for 4 years and CR #1 started getting really confused approximately 2 months ago. CNA A said CR #1 was always saying someone died in her family or she was being kicked by someone. In an interview with CNA D on [DATE] at 1:04 p.m. she said that she had arrived to work at 6:00 a.m. on [DATE] and CR #1 was already up. CNA D said CR #1 stopped her in the hall and was crying and said that someone in her family died and no one would tell her anything. CNA D said she redirected CR #1 back to her room and she calmed down when she started fiddling with items on her bedside table. CNA D said she then left the room to go assist other residents in getting ready for breakfast and then went to dining room. Because there was no nurse to check trays, CNA D said she left the dining room to get a nurse to check trays when she heard that a resident left the building. CNA D said someone told her that a resident got out of the facility but was not sure what resident and then she saw staff wheel CR #1 into the facility and CR #1's shirt and face were bloody. CNA D said EMS arrived quickly and she was not sure who called 911. CNA D said that CR #1 had been confused with more anxiety for at least a week and a half. CNA D said staff were in-serviced on [DATE] regarding wandering/elopement of residents. In an interview with the Administrator on [DATE] at 1:02 p.m., she said that 2 bystanders found CR #1 in the street in front of the facility. Administrator said one bystander worked across the street at the surgery center but she was not sure of her name or how to reach her. Administrator said she thought staff got information from the bystander and would get it to the surveyor. In an interview with Licensed Vocational Nurse (LVN) C on [DATE] at 1:50 p.m. she said that at the start of her shift on [DATE] at approximately 7:00 a.m. she had a new admission that did not have any medications and she needed to go into medication room to get medications for the new admit. LVN C said that Medication Aide (MA) E said that CR #1 was complaining that her family was dead and was going into another resident's room. LVN C said that MA E redirected CR #1 and then she (LVN C) went into the medication room to get the medications for the new admit. LVN C said she was in the medication room for approximately 5 minutes and thought CR #1 had went to the dining room. LVN C said when she left medication room she gave medication to the new admission and then was told by office staff and MDS nurse that CR #1 was found outside. LVN C said CR #1 had a laceration under her chin and she notified the physician and responsible party. LVN C said the bystander had already called 911 so the facility did not call. LVN C said ambulance arrived quickly and there was no time for vitals, or wound measurement. When asked by surveyor which ambulance or EMS picked up CR #1, she said she did not know because it happened so fast. All they documented in the charts was when a resident was picked up and not what ambulance service. LVN C said that each resident had an elopement risk scale and it instructed staff to keep a greater eye on high risk residents. LVN C said she was not sure of the elopement policy or if there is one. In a telephone interview on [DATE] at 12:00 p.m. with Responsible Party (RP) #1, she said that the facility had been decreasing CR #1's medications since [DATE]. She said that CR #1 began hearing voices in [DATE] and thought people were trying to hurt her. Responsible Party #1 said that she had told staff several times of CR #1's hallucinations and behavior and was told by the facility that CR #1 has matching clothes and her nails are painted and that it was going to be fine. Responsible Party #1 said that CR #1 had exhibited these behaviors in the past and had informed the facility of previous behaviors. Responsible Party #1 said that she had informed the facility that CR #1 had once ran down the beltway way tearing off her clothes. The facility told us it would be fine and they would watch her and not let her leave the facility. When asked if it was possible to visit CR #1 at the hospital, RP #1 said that the psychiatric unit at the hospital was limiting visitors and limiting visiting hours for CR #1. In an interview with CR #1's Responsible Party #2 on [DATE] 12:15 p.m., she said that CR #1 has been hearing a male voice for over a month. Responsible Party #2 said that CR #1 has had auditory hallucinations for years. Responsible Party #2 said that the facility has been cutting back on CR #1's medication and when she asked why, she was told that someone outside the facility said they needed to cut back on CR #1's medication but did not tell her who made the recommendation. Responsible Party #2 said that she had informed the facility starting [DATE] that CR #1's hallucinations were increasing and that every time it was mentioned that the facility never documented anything that she told them. Record review of nurses' notes dated [DATE] at 12:00 a.m. revealed CR #1 was standing in the hallway and motioned to nurse to come into her room. CR #1 spoke in a whisper voice and said, I don't want anyone else to here (sic) this. CR #1 spoke to the nurse at length about money being taken out of different bank accounts without the owner's permission. CR #1 spoke of hearing running water over her bed and two men taking money from others to buy a club. Nurse spent time with CR #1; assured her these issues would be addressed by supervisors. The interventions included in this nurses' note were: Tylenol given for pain to bilateral knees and Will continue to monitor. Record review of nurse ' s note dated [DATE] at 12:46 p.m. revealed CR #1 was upset and notified the nurse that she felt that staff members were talking about her and she began to cry. Record review of CR #1's nurses note dated [DATE] at 4:30am revealed CR #1 stated she knew people were talking about her and they think she steals things. Record review of CR #1's nurses note dated [DATE] 5:00pm read in part: received new order from psycdoctor (sic), start [MEDICATION NAME] mg by mouth daily for depression . Record review of CR #1's nurses note dated [DATE] at 10:29am read in part .at 7:19am (CR #1) asked the nurse if someone was going to be giving her drugs and a purse .CR #1 stated someone said last night she would be given a bunch of drugs in a purse. Record review of CR #1's nurses note dated [DATE] read in part .CR #1 asked the Nurse Are they selling books here. Because I saw them putting them into the attic yesterday and someone said the man is coming back today to take more naked pictures of the girls for the books. When the Nurse told her that would not happen at the facility CR #1 stated, Yes they are I heard them talking about the girls coming back up here today to take more pictures . Record review of CR #1's physician order [REDACTED]. Record review of CR #1 ' s Behavior-Intervention form dated [DATE]-[DATE] revealed the following: [DATE]- Date of service was [DATE], Chief Complaint was documented as referred by primary care physician (PCP) for [MEDICAL CONDITION] review and patient having hallucinations and delusional thoughts. Psychiatric history .anxiety .depression .[MEDICAL CONDITION] .Other Pertinent information .follow up (f/u) on auditory hallucinations, delusional thoughts, anxiety, mood, [MEDICATION NAME] does increased to 25mg at 1:00pm daily and continue 50mg of [MEDICATION NAME] every night .Current Psych Meds: were listed as [MEDICATION NAME] 50mg every night, start date [DATE] for [MEDICAL CONDITION]; [MEDICATION NAME] 25mg daily, with start date of [DATE] for [MEDICAL CONDITION] and Klonazepam 0.5mg twice a day with a start date of [DATE] for anxiety .Mood was listed as anxious, though process was scattered, affect was [MEDICATION NAME], delusions were paranoid and hallucinations were auditory .orientation was to time only .insight was assessed as poor, judgment was poor, speech was repetitive, memory was assessed as having short-term memory impairment, attention span was easily distracted .Knowledge .general awareness, details lacking .Language was lacking content .Clinical Status and Impressions: She report (sic)she is sad because she lost her husband last year. She is having delusional thoughts and having auditory hallucinations. [MEDICATION NAME] was previously GDR (Gradual Dose Reduction) but recently increase due to exacerbation in psychiatric behavior. She report (sic) anxiety and stated is related to her diarrhea .abdominal pain .depressed mood which she stated was related to loosing (sic) her husband for (sic) before Christmas. I will adjust [MEDICATION NAME] today as listed below to help her delusional thoughts and hallucinations. Will monitor patient and reevaluate in future visits . Treatment Plan .Medication Change .Discontinue (D/C) [MEDICATION NAME] 25mg every day, start [MEDICATION NAME] 25 mg every morning, [MEDICATION NAME] 25mg at 1:00pm and continue 50mg of [MEDICATION NAME] at bedtime. [DATE]-Reason for visit: Follow up on [MEDICATION NAME] dose increase, hallucinations and delusional thoughts . Review of Systems: was marked as unreliable/ unable to participate due to conditions/dementia .Additional information . F/U on auditory hallucinations, delusional thoughts, anxiety, mood F/U on [MEDICATION NAME] 20mg every day initiated on [DATE], consider cognitive testing .Mood/Affect .Anxious, Depressed .Flat .Thought process was scattered .Abnormal Psychotic thoughts .auditory hallucinations and reference delusions (where person believes everything is about them even when it is not.) .Orientation was to person and situation .Attention and Concentration was described as easily distracted and short, awake and alert .Memory: short-term memory impairment .speech was repetitive .language was lacking content and knowledge was assessed as general awareness, details lacking .Insight/Judgment was assessed as poor .Clinical Status and Impression read in part . (CR #1) reported she was depressed in mood and appeared very anxious during the visit . Med changes were to add [MEDICATION NAME] 20mg by mouth everyday . [DATE]-CR #1 had three episodes of anxiety, depression, hallucinations/paranoid/delusions, and mood changes and was restless, redirection was provided with an outcome of no change in her behavior. [DATE]-CR #1 had one episode of anxiety, depression, hallucinations/paranoid/delusions, and mood changes and was restless, redirection was provided and the behavior improved. [DATE]- CR #1 had three episodes of anxiety, depression, hallucinations/paranoid/delusions, and mood changes and was restless, redirection was provided with an outcome of no change in behavior. Record review of CR #1's Physician order [REDACTED]. Physician order [REDACTED]. -Klonopin 0.5 mg: 1 tablet by mouth twice daily for anxiety. Start date [DATE]. -[MEDICATION NAME] 25 mg: Take 1 tablet by mouth at bedtime for Delusional Disorder. -[MEDICATION NAME] 20 mg: 1 tab by mouth once daily for depression. In an interview with the Physician and Administrator on [DATE] at 11:00 a.m. physician said that he did not understand how CR #1 leaving the facility was an Immediate Jeopardy situation. The physician said he was doing all he could for CR #1 and he was adjusting her medications. The Surveyor informed the Physician that staff knew that CR #1 was delusional and exit seeking the morning of [DATE] and did not supervise her. She was able to leave facility and wander into the street. The Administrator said that the facility had no way of knowing that CR #1 would leave the facility and did not agree with the Immediate Jeopardy. Record review of Physician order [REDACTED].#1 to Behavioral Health Services to evaluate and treat. Record review of Physician order [REDACTED].#1's [DIAGNOSES REDACTED]. Record review of Physician order [REDACTED]. Observation on [DATE] at 10:30 a.m. revealed no staff at sign-in desk at the main entrance. Office doors near the main entrance were closed. Observation on [DATE] at 11:30 a.m. revealed no staff at sign-in desk at main entrance. There were two residents sitting near the main entrance door. No staff were located in the area and office doors were closed. Observation on [DATE] at 12:30 p.m. there was no one at the desk at the main entrance. Observation on [DATE] at 3:00 p.m. revealed no staff were at sign-in desk by the main entrance and no staff were in the area. In an interview with Administrator on [DATE] at 1:31 p.m., she said that the facility had a full time staff member that worked at the reception desk located at the main entrance near the door. The Administrator said the receptionist monitored who entered and exited the facility and sometimes assisted residents back to their rooms if needed. The Administrator revealed that there was no one to monitor the door from 6:00am-9:00am and when the receptionist went to lunch that she told the staff so they could monitor the door. Surveyor informed Administrator the dates and times that there had not been staff at the main entrance desk to monitor the door and the Administrator had no response. In an interview with the Receptionist on [DATE] at 2:22 p.m., she said that she worked at the front desk Monday through Friday from 9:00 a.m. until 6:00 p.m. The Receptionist said her lunch break was between 12:30 p.m. and 1:30 p.m. and she did not have to report that she was going to lunch because that was her normal schedule. The Receptionist said that staff did not monitor the desk during her lunch time or when she took a break and that no one monitored the desk after 6:00 p.m. Monday through Friday or on the weekends. Observation on [DATE] at 3:00pm revealed the door to the main entrance could not be seen from the Nurses ' station and all office doors located near the front door were closed. Resident #5 Record review Resident #5's face sheet revealed he was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #5's Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. Resident #5 required extensive from one person for bed mobility, dressing, and personal hygiene. Resident #5 was totally dependent on 2 people for transfer and toilet use. Record review of Resident #5's Care Plans dated [DATE] revealed care plans for: -Confusion related to short and/or long term memory loss and my daily decision making abilities may be compromised. Resident has cognitive impairment secondary to [DIAGNOSES REDACTED]. Use simple commands, one word commands if possible. Pleasant interaction which reassures resident when confused. Provide cuing and prompting for personal care. Attempt to have the resident imitate the activity you want them to perform. Use eye contact and use commands such as Do and Lets. Try to not use words such as Don't. Plan frequent rest periods. Observe for signs of frustration and anxiety and change activity. -Risk for falls. The approaches included: Staff to report all falls immediately to the charge nurse. Charge staff to assess resident before resident is moved from the floor. At risk sign on wall. Call light within reach. Record review of Resident #5's Monthly Summary signed by nurse and physician dated [DATE] revealed his mental status was Alert, Confused, Poor Memory. His emotional assessment Friendly, Cooperative. Record review of Resident #5's Monthly Summary dated [DATE] revealed his mental status was Alert, Confused, Poor Memory. His emotional assessment was friendly, cooperative. Record review of Resident #5's Monthly summary report dated [DATE] revelaled his mental status was Alert, Confused, and Poor Memory. His emotional assessment was Friendly, Cooperative. Record review of Elopement Risk Assessment with dates of [DATE], [DATE] and [DATE] read: Resident is at risk for elopement if the total score is 9 points or higher. If Resident total score is 9 points or higher a wander guard will be issued to resident. If Resident total score is greater than 15 a 1:1 will be assigned and discharge process to a secure unit will be initiated. -Resident #5's Elopement Risk assessment of 3 on [DATE]. -Resident #5's Elopement Risk Assessment of 6 on [DATE]. -Resident #5's Elopement Risk Assessment of 6 on [DATE]. Record review of Resident #5's nurses' note dated [DATE] at 12:55 p.m. read: Resident went out the side door in the dining room going towards the laundry room. Resident states, I am going to get myself a Beer. Staff asked are you really going to get a Beer. Resident states, No I'm Not. Will continue to monitor. Record review of Resident #5's nurses' notes dated [DATE] at 5:00 p.m. read: Staff reported to this nurse that the resident was outside the facility by the laundry room going down the ramp. He was found lying on his right side, he flipped his wheelchair. Abrasions on both knees, right elbow, skin tear on the right hand 2 cm x 0.5 cm. The responsible party and physician were notified. Will continue to monitor. In an interview on [DATE] at 1:00 p.m. with the Dietary supervisor, she said that Resident #5 tried to get out of the facility to go to the freeway through the dining room door that leads outside to the staff parking lot. The Dietary Supervisor said she offered Resident #5 cookies and was able to convince him to return to the facility. The Dietary Supervisor said that she tried to watch the residents when she is out in the dining room so they would not exit the door leading to the parking lot. The Dietary Supervisor said there is no lock or alarm on door. Observation and interview on [DATE] at 11:24 a.m. revealed Resident #5 wheeling self in wheelchair to dining room. Resident # 5 said he still goes outside and on outings. He said his friends take him places. In an interview with DON on [DATE] at 1:36 p.m. regarding Immediate Jeopardy she said she did not understand why it was an Immediate Jeopardy and said it could not have been prevented because there were no signs that CR #1 was a risk. In an interview with Administrator on [DATE] at 11:27 a.m. regarding Immediate Jeopardy (IJ) she said that she uses nursing assessments, care plans, MDS, and standard nursing practice to make sure the residents needs are being met. When Administrator was asked about how to ensure competency of staff, she said that she observes staff, morning meeting, 24 hour report, random follow-ups and she expects staff to follow policy and procedures. When Administrator was asked by surveyor on how she thought IJ came about and what corrective measures would be used and she said that she was aware of the incident an d based on investigation, resident had increased confusion and psych and physician was involved. Administrator said that Resident #8 was not previously and elopement risk. When asked by surveyor about what resources are available to facility and staff, Administrator said nurse consultant was very involved. In an interview with Nurse Consultant on [DATE] at 8:22 a.m. she revealed that a new form was created for residents to log in and out of at the main entrance with the receptionist. Nurse consultant said that she agreed that there was a failure regarding CR #1 and she agreed that there were warning signs, the door wasn't monitored and the resident left the facility without anyone noticing. Record review of in-services provided by facility did not reveal that an in-service had been performed regarding wandering and elopement prior to the incident on [DATE]. Record review of in-services revealed an in-service was provided to staff on [DATE] regarding elopement risk assessment. Record review of policy and procedure regarding Abuse and Neglect dated [DATE] by the National Center for Elder Abuse and provided by facility Administrator revealed, Neglect was defined as the refusal or failure to fulfill any part of a person's obligations or duties to an elder. Neglect may also include failure of a person who has fiduciary responsibilities to provide care for an elder or failure on the part of in-home service provider to provide necessary care. Neglect typically means the refusal or failure to provide an elderly person with such life necessities as food, water, clothing, shelter, personal hygiene, medicine, comfort, personal safety, and other essentials included in an implied or agreed-upon responsibility to an elder. Record review of the undated facility policy on Elopement: Missing Resident policy and procedure revealed, To protect the resident from elopement and if elopement occurs to ensure that the resident was found quickly and then monitored for adverse outcomes. An Immediate Jeopardy (IJ) was identified on [DATE] at 1:36 p.m. The Administrator and the Director of Nurses were informed at that time. A Plan of Removal (PoR) was requested at that time. The first PoR was received on [DATE] at 9:13 p.m. After several revisions, it was accepted on [DATE]. The POR included in part: Immediate Action 1. All resident medical records were audited, and Licensed personnel completed an elopement risk assessment form for 100% of the residents. This was completed by 4:30 p.m. on [DATE]. Director of Nursing reviewed the findings and found no resident in the general population of facility, was at a high risk for elopement. This was completed on [DATE] at 4:40 p.m. 2. All new residents will be assessed for being at risk for elopement on admission. All resident will have an elopement risk completed quarterly and after an incident. These assessments will be done by the Charge Nurse. Residents found to be as an elopement risk will be assessed for admiss

Based on observation, interview and record review, the facility failed to ensure that each resident had the required supervision to prevent accidents for two(CR #1, Resident #5) of 10 residents reviewed for supervision and elopement. The facility failed to provide supervision for CR #1 when her delusional behaviors increased and she walked out of the facility into the road where she sustained a laceration to her chin and was transferred to the hospital. · The facility failed to supervise Resident #5, who had severe cognitive impairment, when he left the facility via the side door in the main dining room that led to the back parking lot. An IJ was identified on [DATE] at 1:36 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of actual harm due to the facility needing more time to monitor the plan of removal for effectiveness. These failures affected two residents and placed70 residents whose care was compromised due to staff neglecting to adequately monitor residents who have a [DIAGNOSES REDACTED]. # 0 Findings include: CR #1 Record review of CR #1's clinical record revealed an admission date of [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR #1's Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment. CR #1 was assessed as feeling depressed nearly every day, required supervision for bed mobility, transfer, locomotion on and off unit, dressing, eating, toilet use, and personal hygiene. Her active [DIAGNOSES REDACTED]. Record review of CR #1's Care Plans dated [DATE] with a review date of [DATE] revealed she had the following care plans: -History of psychosis and was being treated with an antipsychotic. Approaches included: administering the medication as ordered by my doctor. Monitor and document my behaviors daily. Observe for side effects of medication such as seizures, rhinitis, atrial fibrillation, increased confusion, palpitations, syncope, tongue edema, vomiting. Seroquel as ordered. -[DIAGNOSES REDACTED]. Help me with dressing, grooming and showers, so I can feel good about the way I look. Develop a trusting relationship with me so I am prompted to accept direction. Monitor me for signs and symptoms of anxiety levels in relation to situation. Avoid challenging illogical thinking because I may become defensive as a result. Display clocks, calendars, personal items, seasonal decorations to assist me with reality oriented environment, remind of your names if I cannot remember. Notify my physician and family of any significant changes in my condition. Allow me to choose activities I wish to attend. Some days I may be able to do more than others. Record review of Incident Investigation Worksheet dated [DATE] for CR #1 revealed that the Administrator first learned of the incident on [DATE] at 7:00 a.m. On [DATE] at 7:00 a.m., staff reported CR #1 was standing in the road with a bystander. The bystander said the resident fell . The bystander was on the phone with 911. The resident sustained [REDACTED]. The resident was sent to the hospital. The resident was still in the hospital but she did not sustain any fractures due to the fall. She will be placed in a psychiatric hospital. There are no witnesses to the incident. No alleged perpetrators. No staff suspended pending the outcome of the facility's investigation. To prevent a similar incident/or to protect the resident the facility initiated and investigation and interviewed staff. The physician and family were notified of the incident. The resident had had an increase in psychosis-type behavior. The incident was still under investigation. Record review of Provider Investigation Report dated [DATE] for CR #1 read in part . Incident Category was marked as other, psychotic behavior resulting in harm . Incident date and time-[DATE] at 7:00 a.m. with location documented as street in front of facility . CR #1 had with minimal functional ability, level of supervision was documented as other-24 hour service, independent in ambulation, not interviewable, does not have the capacity to make informed decisions .verbal aggression .other pertinent history was dementia and history of psychotic symptoms .witnesses were present . The incident was described as follows: Resident was last seen 5 to 10 minutes before incident. Resident walked outside of building and seen with a bystander. Bystander stated resident had fallen. resident sustained [REDACTED]. The injury was described as a laceration on the chin and a bruise with swelling on the right elbow. The ambulance arrived before staff could measure laceration. Resident was in an upset delusion state . She was very upset and told staff that someone had died in her family and she was going to them .Provider Response . Resident has been at the facility since 2013 .Resident had been showing signs of delusions, hallucinations and anxiety. Evaluation ordered by primary physician to assess resident for current psychiatric medication regimen and psychotic symptoms on [DATE].Investigation Summary . On ,[DATE] -Seroquel increased to 50 mg. ,[DATE]- Resident put on antibiotic for urinary tract infection, seen by psychiatric services on ,[DATE] (no year provided) and [DATE]. ,[DATE] Seroquel 25 mg at 8:00 a.m., Seroquel 25 mg at 1:00 p.m. and 50 mg at bedtime . Record review of Physician order [REDACTED]. 1. Discontinue Seroquel 25 mg by mouth at bedtime. 2. Start Seroquel 50 mg by mouth at bedtime. 3. Start Seroquel 25 mg by mouth daily. The [DIAGNOSES REDACTED].>Record review of Physician order [REDACTED]. 1. Seroquel 25 mg by mouth in the morning. 2. Seroquel 25 mg by mouth at 1:00 p.m. 3. Seroquel 50 mg by mouth at bedtime. [DIAGNOSES REDACTED].>In an interview with ADON (Assistant Director of Nurses) on [DATE] at 11:30 a.m. she said she was on vacation and not at the facility when CR #1's incident occurred. ADON said CR #1 was not residing in the secure unit but instead in a regular hall. ADON revealed that CR #1 had been delusional in the past. When asked how her care was revised for the delusional behavior she said the staff were to redirect her when she exhibited the behaviors. When asked by surveyor if staff had been in-serviced she said she was not aware of an in-service for elopement/wandering. In an interview with MDS Nurse on [DATE] at 11:56 a.m. she revealed that she was driving to work on [DATE] at 7:11 a.m., and, as she pulled into the facility parking lot, she noticed CR #1 in the middle of the road, which is a busy street. MDS Nurse said CR #1 was in the middle of the 2 lanes of the road that move East. MDS Nurse said 2 cars were blocking traffic so oncoming traffic could not harm her. She said CR #1 had a laceration on her chin and said, I'm guessing it was 2 centimeters in width. MDS Nurse said that it was difficult to see injury on CR #1's chin because of the amount of blood. MDS Nurse said that CR #1 said, All my family is dead and no one will tell me what happened to them, I have to go find them. MDS nurse said that while she was with CR #1, the nurse came outside and then went back in to get a wheelchair. The nurse then returned with someone from restorative and a wheelchair. MDS Nurse said that CR #1 had good range of motion and the nurse and restorative person were able to get CR #1 into the wheelchair with use of a gait belt after a full assessment. MDS Nurse said that the bystander was outside on the phone with the police and told the police that CR #1 was trying to kill herself. Emergency Medical System (EMS) arrived and took resident to hospital for evaluation. MDS Nurse said someone in the facility took the bystander's information, but she was unsure of the person's identity. MDS Nurse said CR #1 was not belligerent or hostile and that she was just looking for her family. When asked if CR #1 had ever left facility unsupervised before that time, she said that she was not sure if CR #1 had ever wandered before. In an interview with Certified Nurse Aide (CNA) A, on [DATE] at 12:11 p.m., she revealed she was moving things around in CR #1's room on [DATE] between 7:00 a.m. and 7:30 a.m. because the floor was going to be waxed. CNA A said CR #1 said, Who died in my family, everyone is lying to me. CNA A told her that no one in her family died and CNA A continued moving things in CR #1's room so the floor could be waxed. CNA A said that CR #1 went to CNA B who then took CR #1 to RN C. CNA A said that she has worked with CR #1 for 4 years and CR #1 started getting really confused approximately 2 months ago. CNA A said CR #1 was always saying someone died in her family or she was being kicked by someone. In an interview with CNA D on [DATE] at 1:04 p.m. she said that she had arrived to work at 6:00 a.m. on [DATE] and CR #1 was already up. CNA D said CR #1 stopped her in the hall and was crying and said that someone in her family died and no one would tell her anything. CNA D said she redirected CR #1 back to her room and she calmed down when she started fiddling with items on her bedside table. CNA D said she then left the room to go assist other residents in getting ready for breakfast and then went to dining room. Because there was no nurse to check trays, CNA D said she left the dining room to get a nurse to check trays when she heard that a resident left the building. CNA D said someone told her that a resident got out of the facility but was not sure what resident and then she saw staff wheel CR #1 into the facility and CR #1's shirt and face were bloody. CNA D said EMS arrived quickly and she was not sure who called 911. CNA D said that CR #1 had been confused with more anxiety for at least a week and a half. CNA D said staff were in-serviced on [DATE] regarding wandering/elopement of residents. In an interview with the Administrator on [DATE] at 1:02 p.m., she said that 2 bystanders found CR #1 in the street in front of the facility. Administrator said one bystander worked across the street at the surgery center but she was not sure of her name or how to reach her. Administrator said she thought staff got information from the bystander and would get it to the surveyor. In an interview with Licensed Vocational Nurse (LVN) C on [DATE] at 1:50 p.m. she said that at the start of her shift on [DATE] at approximately 7:00 a.m. she had a new admission that did not have any medications and she needed to go into medication room to get medications for the new admit. LVN C said that Medication Aide (MA) E said that CR #1 was complaining that her family was dead and was going into another resident's room. LVN C said that MA E redirected CR #1 and then she (LVN C) went into the medication room to get the medications for the new admit. LVN C said she was in the medication room for approximately 5 minutes and thought CR #1 had went to the dining room. LVN C said when she left medication room she gave medication to the new admission and then was told by office staff and MDS nurse that CR #1 was found outside. LVN C said CR #1 had a laceration under her chin and she notified the physician and responsible party. LVN C said the bystander had already called 911 so the facility did not call. LVN C said ambulance arrived quickly and there was no time for vitals, or wound measurement. When asked by surveyor which ambulance or EMS picked up CR #1, she said she did not know because it happened so fast. All they documented in the charts was when a resident was picked up and not what ambulance service. LVN C said that each resident had an elopement risk scale and it instructed staff to keep a greater eye on high risk residents. LVN C said she was not sure of the elopement policy or if there is one. In a telephone interview on [DATE] at 12:00 p.m. with Responsible Party (RP) #1, she said that the facility had been decreasing CR #1's medications since [DATE]. She said that CR #1 began hearing voices in [DATE] and thought people were trying to hurt her. Responsible Party #1 said that she had told staff several times of CR #1's hallucinations and behavior and was told by the facility that CR #1 has matching clothes and her nails are painted and that it was going to be fine. Responsible Party #1 said that CR #1 had exhibited these behaviors in the past and had informed the facility of previous behaviors. Responsible Party #1 said that she had informed the facility that CR #1 had once ran down the beltway way tearing off her clothes. The facility told us it would be fine and they would watch her and not let her leave the facility. When asked if it was possible to visit CR #1 at the hospital, RP #1 said that the psychiatric unit at the hospital was limiting visitors and limiting visiting hours for CR #1. In an interview with CR #1's Responsible Party #2 on [DATE] 12:15 p.m., she said that CR #1 has been hearing a male voice for over a month. Responsible Party #2 said that CR #1 has had auditory hallucinations for years. Responsible Party #2 said that the facility has been cutting back on CR #1's medication and when she asked why, she was told that someone outside the facility said they needed to cut back on CR #1's medication but did not tell her who made the recommendation. Responsible Party #2 said that she had informed the facility starting [DATE] that CR #1's hallucinations were increasing and that every time it was mentioned that the facility never documented anything that she told them. Record review of nurses' notes dated [DATE] at 12:00 a.m. revealed CR #1 was standing in the hallway and motioned to nurse to come into her room. CR #1 spoke in a whisper voice and said, I don't want anyone else to here (sic) this. CR #1 spoke to the nurse at length about money being taken out of different bank accounts without the owner's permission. CR #1 spoke of hearing running water over her bed and two men taking money from others to buy a club. Nurse spent time with CR #1; assured her these issues would be addressed by supervisors. The interventions included in this nurses' note were: Tylenol given for pain to bilateral knees and Will continue to monitor. Record review of nurse ' s note dated [DATE] at 12:46 p.m. revealed CR #1 was upset and notified the nurse that she felt that staff members were talking about her and she began to cry. Record review of CR #1's nurses note dated [DATE] at 4:30am revealed CR #1 stated she knew people were talking about her and they think she steals things. Record review of CR #1's nurses note dated [DATE] 5:00pm read in part: received new order from psycdoctor (sic), start Paxil20 mg by mouth daily for depression . Record review of CR #1's nurses note dated [DATE] at 10:29am read in part .at 7:19am (CR #1) asked the nurse if someone was going to be giving her drugs and a purse .CR #1 stated someone said last night she would be given a bunch of drugs in a purse. Record review of CR #1's nurses note dated [DATE] read in part .CR #1 asked the Nurse Are they selling books here. Because I saw them putting them into the attic yesterday and someone said the man is coming back today to take more naked pictures of the girls for the books. When the Nurse told her that would not happen at the facility CR #1 stated, Yes they are I heard them talking about the girls coming back up here today to take more pictures . Record review of CR #1's physician order [REDACTED]. Record review of CR #1 ' s Behavior-Intervention form dated [DATE]-[DATE] revealed the following: [DATE]- Date of service was [DATE], Chief Complaint was documented as referred by primary care physician (PCP) for psychotropic review and patient having hallucinations and delusional thoughts. Psychiatric history .anxiety .depression .psychosis .Other Pertinent information .follow up (f/u) on auditory hallucinations, delusional thoughts, anxiety, mood, Seroquel does increased to 25mg at 1:00pm daily and continue 50mg of Seroquel every night .Current Psych Meds: were listed as Seroquel 50mg every night, start date [DATE] for psychosis; Seroquel 25mg daily, with start date of [DATE] for Psychosis and Klonazepam 0.5mg twice a day with a start date of [DATE] for anxiety .Mood was listed as anxious, though process was scattered, affect was blunted, delusions were paranoid and hallucinations were auditory .orientation was to time only .insight was assessed as poor, judgment was poor, speech was repetitive, memory was assessed as having short-term memory impairment, attention span was easily distracted .Knowledge .general awareness, details lacking .Language was lacking content .Clinical Status and Impressions: She report (sic)she is sad because she lost her husband last year. She is having delusional thoughts and having auditory hallucinations. Seroquel was previously GDR (Gradual Dose Reduction) but recently increase due to exacerbation in psychiatric behavior. She report (sic) anxiety and stated is related to her diarrhea .abdominal pain .depressed mood which she stated was related to loosing (sic) her husband for (sic) before Christmas. I will adjust Seroquel today as listed below to help her delusional thoughts and hallucinations. Will monitor patient and reevaluate in future visits . Treatment Plan .Medication Change .Discontinue (D/C) Seroquel 25mg every day, start Seroquel 25 mg every morning, Seroquel 25mg at 1:00pm and continue 50mg of Seroquel at bedtime. [DATE]-Reason for visit: Follow up on Seroquel dose increase, hallucinations and delusional thoughts . Review of Systems: was marked as unreliable/ unable to participate due to conditions/dementia .Additional information . F/U on auditory hallucinations, delusional thoughts, anxiety, mood F/U on Paxil 20mg every day initiated on [DATE], consider cognitive testing .Mood/Affect .Anxious, Depressed .Flat .Thought process was scattered .Abnormal Psychotic thoughts .auditory hallucinations and reference delusions (where person believes everything is about them even when it is not.) .Orientation was to person and situation .Attention and Concentration was described as easily distracted and short, awake and alert .Memory: short-term memory impairment .speech was repetitive .language was lacking content and knowledge was assessed as general awareness, details lacking .Insight/Judgment was assessed as poor .Clinical Status and Impression read in part . (CR #1) reported she was depressed in mood and appeared very anxious during the visit . Med changes were to add Paxil 20mg by mouth everyday . [DATE]-CR #1 had three episodes of anxiety, depression, hallucinations/paranoid/delusions, and mood changes and was restless, redirection was provided with an outcome of no change in her behavior. [DATE]-CR #1 had one episode of anxiety, depression, hallucinations/paranoid/delusions, and mood changes and was restless, redirection was provided and the behavior improved. [DATE]- CR #1 had three episodes of anxiety, depression, hallucinations/paranoid/delusions, and mood changes and was restless, redirection was provided with an outcome of no change in behavior. Record review of CR #1's Physician order [REDACTED]. Physician order [REDACTED]. -Klonopin 0.5 mg: 1 tablet by mouth twice daily for anxiety. Start date [DATE]. -Seroquel 25 mg: Take 1 tablet by mouth at bedtime for Delusional Disorder. -Paxil 20 mg: 1 tab by mouth once daily for depression. In an interview with the Physician and Administrator on [DATE] at 11:00 a.m. physician said that he did not understand how CR #1 leaving the facility was an Immediate Jeopardy situation. The physician said he was doing all he could for CR #1 and he was adjusting her medications. The Surveyor informed the Physician that staff knew that CR #1 was delusional and exit seeking the morning of [DATE] and did not supervise her. She was able to leave facility and wander into the street. The Administrator said that the facility had no way of knowing that CR #1 would leave the facility and did not agree with the Immediate Jeopardy. Record review of Physician order [REDACTED].#1 to Behavioral Health Services to evaluate and treat. Record review of Physician order [REDACTED].#1's [DIAGNOSES REDACTED]. Record review of Physician order [REDACTED]. Observation on [DATE] at 10:30 a.m. revealed no staff at sign-in desk at the main entrance. Office doors near the main entrance were closed. Observation on [DATE] at 11:30 a.m. revealed no staff at sign-in desk at main entrance. There were two residents sitting near the main entrance door. No staff were located in the area and office doors were closed. Observation on [DATE] at 12:30 p.m. there was no one at the desk at the main entrance. Observation on [DATE] at 3:00 p.m. revealed no staff were at sign-in desk by the main entrance and no staff were in the area. In an interview with Administrator on [DATE] at 1:31 p.m., she said that the facility had a full time staff member that worked at the reception desk located at the main entrance near the door. The Administrator said the receptionist monitored who entered and exited the facility and sometimes assisted residents back to their rooms if needed. The Administrator revealed that there was no one to monitor the door from 6:00am-9:00am and when the receptionist went to lunch that she told the staff so they could monitor the door. Surveyor informed Administrator the dates and times that there had not been staff at the main entrance desk to monitor the door and the Administrator had no response. In an interview with the Receptionist on [DATE] at 2:22 p.m., she said that she worked at the front desk Monday through Friday from 9:00 a.m. until 6:00 p.m. The Receptionist said her lunch break was between 12:30 p.m. and 1:30 p.m. and she did not have to report that she was going to lunch because that was her normal schedule. The Receptionist said that staff did not monitor the desk during her lunch time or when she took a break and that no one monitored the desk after 6:00 p.m. Monday through Friday or on the weekends. Observation on [DATE] at 3:00pm revealed the door to the main entrance could not be seen from the Nurses ' station and all office doors located near the front door were closed. Resident #5 Record review Resident #5's face sheet revealed he was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #5's Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. Resident #5 required extensive from one person for bed mobility, dressing, and personal hygiene. Resident #5 was totally dependent on 2 people for transfer and toilet use. Record review of Resident #5's Care Plans dated [DATE] revealed care plans for: -Confusion related to short and/or long term memory loss and my daily decision making abilities may be compromised. Resident has cognitive impairment secondary to [DIAGNOSES REDACTED]. Use simple commands, one word commands if possible. Pleasant interaction which reassures resident when confused. Provide cuing and prompting for personal care. Attempt to have the resident imitate the activity you want them to perform. Use eye contact and use commands such as Do and Lets. Try to not use words such as Don't. Plan frequent rest periods. Observe for signs of frustration and anxiety and change activity. -Risk for falls. The approaches included: Staff to report all falls immediately to the charge nurse. Charge staff to assess resident before resident is moved from the floor. At risk sign on wall. Call light within reach. Record review of Resident #5's Monthly Summary signed by nurse and physician dated [DATE] revealed his mental status was Alert, Confused, Poor Memory. His emotional assessment Friendly, Cooperative. Record review of Resident #5's Monthly Summary dated [DATE] revealed his mental status was Alert, Confused, Poor Memory. His emotional assessment was friendly, cooperative. Record review of Resident #5's Monthly summary report dated [DATE] revelaled his mental status was Alert, Confused, and Poor Memory. His emotional assessment was Friendly, Cooperative. Record review of Elopement Risk Assessment with dates of [DATE], [DATE] and [DATE] read: Resident is at risk for elopement if the total score is 9 points or higher. If Resident total score is 9 points or higher a wander guard will be issued to resident. If Resident total score is greater than 15 a 1:1 will be assigned and discharge process to a secure unit will be initiated. -Resident #5's Elopement Risk assessment of 3 on [DATE]. -Resident #5's Elopement Risk Assessment of 6 on [DATE]. -Resident #5's Elopement Risk Assessment of 6 on [DATE]. Record review of Resident #5's nurses' note dated [DATE] at 12:55 p.m. read: Resident went out the side door in the dining room going towards the laundry room. Resident states, I am going to get myself a Beer. Staff asked are you really going to get a Beer. Resident states, No I'm Not. Will continue to monitor. Record review of Resident #5's nurses' notes dated [DATE] at 5:00 p.m. read: Staff reported to this nurse that the resident was outside the facility by the laundry room going down the ramp. He was found lying on his right side, he flipped his wheelchair. Abrasions on both knees, right elbow, skin tear on the right hand 2 cm x 0.5 cm. The responsible party and physician were notified. Will continue to monitor. In an interview on [DATE] at 1:00 p.m. with the Dietary supervisor, she said that Resident #5 tried to get out of the facility to go to the freeway through the dining room door that leads outside to the staff parking lot. The Dietary Supervisor said she offered Resident #5 cookies and was able to convince him to return to the facility. The Dietary Supervisor said that she tried to watch the residents when she is out in the dining room so they would not exit the door leading to the parking lot. The Dietary Supervisor said there is no lock or alarm on door. Observation and interview on [DATE] at 11:24 a.m. revealed Resident #5 wheeling self in wheelchair to dining room. Resident # 5 said he still goes outside and on outings. He said his friends take him places. In an interview with DON on [DATE] at 1:36 p.m. regarding Immediate Jeopardy she said she did not understand why it was an Immediate Jeopardy and said it could not have been prevented because there were no signs that CR #1 was a risk. In an interview with Administrator on [DATE] at 11:27 a.m. regarding Immediate Jeopardy (IJ) she said that she uses nursing assessments, care plans, MDS, and standard nursing practice to make sure the residents needs are being met. When Administrator was asked about how to ensure competency of staff, she said that she observes staff, morning meeting, 24 hour report, random follow-ups and she expects staff to follow policy and procedures. When Administrator was asked by surveyor on how she thought IJ came about and what corrective measures would be used and she said that she was aware of the incident an d based on investigation, resident had increased confusion and psych and physician was involved. Administrator said that Resident #8 was not previously and elopement risk. When asked by surveyor about what resources are available to facility and staff, Administrator said nurse consultant was very involved. In an interview with Nurse Consultant on [DATE] at 8:22 a.m. she revealed that a new form was created for residents to log in and out of at the main entrance with the receptionist. Nurse consultant said that she agreed that there was a failure regarding CR #1 and she agreed that there were warning signs, the door wasn't monitored and the resident left the facility without anyone noticing. Record review of in-services provided by facility did not reveal that an in-service had been performed regarding wandering and elopement prior to the incident on [DATE]. Record review of in-services revealed an in-service was provided to staff on [DATE] regarding elopement risk assessment. Record review of policy and procedure regarding Abuse and Neglect dated [DATE] by the National Center for Elder Abuse and provided by facility Administrator revealed, Neglect was defined as the refusal or failure to fulfill any part of a person's obligations or duties to an elder. Neglect may also include failure of a person who has fiduciary responsibilities to provide care for an elder or failure on the part of in-home service provider to provide necessary care. Neglect typically means the refusal or failure to provide an elderly person with such life necessities as food, water, clothing, shelter, personal hygiene, medicine, comfort, personal safety, and other essentials included in an implied or agreed-upon responsibility to an elder. Record review of the undated facility policy on Elopement: Missing Resident policy and procedure revealed, To protect the resident from elopement and if elopement occurs to ensure that the resident was found quickly and then monitored for adverse outcomes. An Immediate Jeopardy (IJ) was identified on [DATE] at 1:36 p.m. The Administrator and the Director of Nurses were informed at that time. A Plan of Removal (PoR) was requested at that time. The first PoR was received on [DATE] at 9:13 p.m. After several revisions, it was accepted on [DATE]. The POR included in part: Immediate Action 1. All resident medical records were audited, and Licensed personnel completed an elopement risk assessment form for 100% of the residents. This was completed by 4:30 p.m. on [DATE]. Director of Nursing reviewed the findings and found no resident in the general population of facility, was at a high risk for elopement. This was completed on [DATE] at 4:40 p.m. 2. All new residents will be assessed for being at risk for elopement on admission. All resident will have an elopement risk completed quarterly and after an incident. These assessments will be done by the Charge Nurse. Residents found to be as an elopement risk will be assessed for admission into the w

Based on observation, interview and record review the facility administration failed to administer the facility in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practical physical, mental and psychosocial well-being for two of 10 (CR #1 and Resident #5) reviewed for neglect. The Administrator failed to: -To implement the facility ' s policy and procedure on abuse and neglect. -To implement the facility ' s policy on residents with behaviors and were at risk for elopement or safety issues. -Supervise the DON to ensure nursing staff were trained and monitored in supervision or residents with behaviors. -Supervise the DON to ensure nursing staff conducted accurate assessments of residents, when they had a change in condition or behaviors. The DON failed to: -Train and monitor nursing staff in supervision of residents with behaviors. -Train and monitor nursing staff regarding accurate assessments of residents when they have a change in health or mental status. An IJ was identified on [DATE] at 1:36 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility needing more time to monitor the plan of removal for effectiveness. These failures affected two residents and placed 113 residents whose care was compromised due to staff neglecting to adequately monitor residents who have a [DIAGNOSES REDACTED]. # 0 Findings include: CR #1 Record review of CR #1's clinical record revealed an admission date of [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR #1's Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment. CR #1 was assessed as feeling depressed nearly every day, required supervision for bed mobility, transfer, locomotion on and off unit, dressing, eating, toilet use, and personal hygiene. Her active [DIAGNOSES REDACTED]. Record review of CR #1's Care Plans dated [DATE] with a review date of [DATE] revealed she had the following care plans: -History of [MEDICAL CONDITION] and was being treated with an antipsychotic. Approaches included: administering the medication as ordered by my doctor. Monitor and document my behaviors daily. Observe for side effects of medication such as [MEDICAL CONDITION], rhinitis, [MEDICAL CONDITION], increased confusion, palpitations, [MEDICAL CONDITION], tongue [MEDICAL CONDITION], vomiting. [MEDICATION NAME] as ordered. -[DIAGNOSES REDACTED]. Help me with dressing, grooming and showers, so I can feel good about the way I look. Develop a trusting relationship with me so I am prompted to accept direction. Monitor me for signs and symptoms of anxiety levels in relation to situation. Avoid challenging illogical thinking because I may become defensive as a result. Display clocks, calendars, personal items, seasonal decorations to assist me with reality oriented environment, remind of your names if I cannot remember. Notify my physician and family of any significant changes in my condition. Allow me to choose activities I wish to attend. Some days I may be able to do more than others. Record review of Incident Investigation Worksheet dated [DATE] for CR #1 revealed that the Administrator first learned of the incident on [DATE] at 7:00 a.m. On [DATE] at 7:00 a.m., staff reported CR #1 was standing in the road with a bystander. The bystander said the resident fell . The bystander was on the phone with 911. The resident sustained [REDACTED]. The resident was sent to the hospital. The resident was still in the hospital but she did not sustain any fractures due to the fall. She will be placed in a psychiatric hospital. There are no witnesses to the incident. No alleged perpetrators. No staff suspended pending the outcome of the facility's investigation. To prevent a similar incident/or to protect the resident the facility initiated and investigation and interviewed staff. The physician and family were notified of the incident. The resident had had an increase in [MEDICAL CONDITION]-type behavior. The incident was still under investigation. Record review of Provider Investigation Report dated [DATE] for CR #1 read in part . Incident Category was marked as other, psychotic behavior resulting in harm . Incident date and time-[DATE] at 7:00 a.m. with location documented as street in front of facility . CR #1 had with minimal functional ability, level of supervision was documented as other-24 hour service, independent in ambulation, not interviewable, does not have the capacity to make informed decisions .verbal aggression .other pertinent history was dementia and history of psychotic symptoms .witnesses were present . The incident was described as follows: Resident was last seen 5 to 10 minutes before incident. Resident walked outside of building and seen with a bystander. Bystander stated resident had fallen. resident sustained [REDACTED]. The injury was described as a laceration on the chin and a bruise with swelling on the right elbow. The ambulance arrived before staff could measure laceration. Resident was in an upset delusion state . She was very upset and told staff that someone had died in her family and she was going to them .Provider Response . Resident has been at the facility since 2013 .Resident had been showing signs of delusions, hallucinations and anxiety. Evaluation ordered by primary physician to assess resident for current psychiatric medication regimen and psychotic symptoms on [DATE].Investigation Summary . On ,[DATE] (no year provided) [MEDICATION NAME] increased to 50 mg. ,[DATE] (no year provided) Resident put on antibiotic for urinary tract infection, seen by psychiatric services on ,[DATE] (no year provided) and [DATE]. ,[DATE] (no year provided) [MEDICATION NAME] 25 mg at 8:00 a.m., [MEDICATION NAME] 25 mg at 1:00 p.m. and 50 mg (drug name not provided) at bedtime . In an interview with ADON (Assistant Director of Nurses) on [DATE] at 11:30 a.m. she said she was on vacation and not at the facility when CR #1's incident occurred. ADON said CR #1 was not residing in the secure unit but instead in a regular hall. ADON revealed that CR #1 had been delusional in the past. When asked how her care was revised for the delusional behavior she said the staff were to redirect her when she exhibited the behaviors. When asked by surveyor if staff had been in-serviced on Residents at Risk for Elopement/Wandering, she said she was not aware of an in-service for elopement/wandering. In an interview with MDS Nurse on [DATE] at 11:56 a.m. she revealed that she was driving to work on [DATE] at 7:11 a.m., and, as she pulled into the facility parking lot, she noticed CR #1 in the middle of the road, which is a busy street. MDS Nurse said CR #1 was in the middle of the 2 lanes of the road that move East. MDS Nurse said 2 cars were blocking traffic so oncoming traffic could not harm her. She said CR #1 had a laceration on her chin and said, I'm guessing it was 2 centimeters in width. MDS Nurse said that it was difficult to see injury on CR #1's chin because of the amount of blood. MDS Nurse said that CR #1 said, All my family is dead and no one will tell me what happened to them, I have to go find them. MDS nurse said that while she was with CR #1, the nurse came outside and then went back in to get a wheelchair. The nurse then returned with someone from restorative and a wheelchair. MDS Nurse said that CR #1 had good range of motion and the nurse and restorative person were able to get CR #1 into the wheelchair with use of a gait belt after a full assessment. MDS Nurse said that the bystander was outside on the phone with the police and told the police that CR #1 was trying to kill herself. Emergency Medical System (EMS) arrived and took resident to hospital for evaluation. MDS Nurse said someone in the facility took the bystander's information, but she was unsure of the person's identity. MDS Nurse said CR #1 was not belligerent or hostile and that she was just looking for her family. When asked if CR #1 had ever left facility unsupervised before that time, she said that she was not sure if CR #1 had ever wandered before. In an interview with Certified Nurse Aide (CNA) A, on [DATE] at 12:11 p.m., she revealed she was moving things around in CR #1's room on [DATE] between 7:00 a.m. and 7:30 a.m. because the floor was going to be waxed. CNA A said CR #1 said, Who died in my family, everyone is lying to me. CNA A told her that no one in her family died and CNA A continued moving things in CR #1's room so the floor could be waxed. CNA A said that CR #1 went to CNA B who then took CR #1 to RN C. CNA A said that she has worked with CR #1 for 4 years and CR #1 started getting really confused approximately 2 months ago. CNA A said CR #1 was always saying someone died in her family or she was being kicked by someone. In an interview with CNA D on [DATE] at 1:04 p.m. she said that she had arrived to work at 6:00 a.m. on [DATE] and CR #1 was already up. CNA D said CR #1 stopped her in the hall and was crying and said that someone in her family died and no one would tell her anything. CNA D said she redirected CR #1 back to her room and she calmed down when she started fiddling with items on her bedside table. CNA D said she then left the room to go assist other residents in getting ready for breakfast and then went to dining room. Because there was no nurse to check trays, CNA D said she left the dining room to get a nurse to check trays when she heard that a resident left the building. CNA D said someone told her that a resident got out of the facility but was not sure what resident and then she saw staff wheel CR #1 into the facility and CR #1's shirt and face were bloody. CNA D said EMS arrived quickly and she was not sure who called 911. CNA D said that CR #1 had been confused with more anxiety for at least a week and a half. CNA D said staff were in-serviced on [DATE] regarding wandering/elopement of residents. In an interview with the Administrator on [DATE] at 1:02 p.m., she said that 2 bystanders found CR #1 in the street in front of the facility. Administrator said one bystander worked across the street at the surgery center but she was not sure of her name or how to reach her. Administrator said she thought staff got information from the bystander and would get it to the surveyor. In an interview with Licensed Vocational Nurse (LVN) C on [DATE] at 1:50 p.m. she said that at the start of her shift on [DATE] at approximately 7:00 a.m. she had a new admission that did not have any medications and she needed to go into medication room to get medications for the new admit. LVN C said that Medication Aide (MA) E said that CR #1 was complaining that her family was dead and was going into another resident's room. LVN C said that MA E redirected CR #1 and then she (LVN C) went into the medication room to get the medications for the new admit. LVN C said she was in the medication room for approximately 5 minutes and thought CR #1 had went to the dining room. LVN C said when she left medication room she gave medication to the new admission and then was told by office staff and MDS nurse that CR #1 was found outside. LVN C said CR #1 had a laceration under her chin and she notified the physician and responsible party. LVN C said the bystander had already called 911 so the facility did not call. LVN C said ambulance arrived quickly and there was no time for vitals, or wound measurement. When asked by surveyor which ambulance or EMS picked up CR #1, she said she did not know because it happened so fast. All they documented in the charts was when a resident was picked up and not what ambulance service. LVN C said that each resident had an elopement risk scale and it instructed staff to keep a greater eye on high risk residents. LVN C said she was not sure of the elopement policy or if there is one. In an interview on [DATE] at 1:36pm the Administrator and DON both said they did not understand why it was an IJ and said the incident with CR #1 could not have been prevented because there were no signs. In an interview on [DATE] at 11:27am the Administrator said the procedures put in place to make sure the residents ' needs were met was as follows: nursing assessments were done, care plans and MDS Assessments were completed and standard nursing practice was followed. She said that she monitored the DON and other nursing staff by observation, morning meetings, reviewing the 24 hour reports with random follow-ups. She said she expected the staff to follow policy and procedures of the facility. When asked how she thought they IJ occurred she said she was aware of the incident with CR #1 and based on investigation the resident had increased confusion. She said that the resources available for staff were their consultant who was very involved in the facility. In a telephone interview on [DATE] at 12:00 p.m. with Responsible Party (RP) #1, she said that the facility had been decreasing CR #1's medications since [DATE]. She said that CR #1 began hearing voices in [DATE] and thought people were trying to hurt her. Responsible Party #1 said that she had told staff several times of CR #1's hallucinations and behavior and was told by the facility that CR #1 has matching clothes and her nails are painted and that it was going to be fine. Responsible Party #1 said that CR #1 had exhibited these behaviors in the past and had informed the facility of previous behaviors. Responsible Party #1 said that she had informed the facility that CR #1 had once ran down the beltway way tearing off her clothes. The facility told us it would be fine and they would watch her and not let her leave the facility. When asked if it was possible to visit CR #1 at the hospital, RP #1 said that the psychiatric unit at the hospital was limiting visitors and limiting visiting hours for CR #1. In an interview with CR #1's Responsible Party #2 on [DATE] 12:15 p.m., she said that CR #1 has been hearing a male voice for over a month. Responsible Party #2 said that CR #1 has had auditory hallucinations for years. Responsible Party #2 said that the facility has been cutting back on CR #1's medication and when she asked why, she was told that someone outside the facility said they needed to cut back on CR #1's medication but did not tell her who made the recommendation. Responsible Party #2 said that she had informed the facility starting [DATE] that CR #1's hallucinations were increasing and that every time it was mentioned that the facility never documented anything that she told them. Record review of nurses' notes dated [DATE] at 12:00 a.m. revealed CR #1 was standing in the hallway and motioned to nurse to come into her room. CR #1 spoke in a whisper voice and said, I don't want anyone else to here (sic) this. CR #1 spoke to the nurse at length about money being taken out of different bank accounts without the owner's permission. CR #1 spoke of hearing running water over her bed and two men taking money from others to buy club. Nurse spent time with CR #1; assured her these issues would be addressed by supervisors. The interventions included in this nurses' note were: Tylenol given for pain to bilateral knees and Will continue to monitor. Record review of nurse ' s note dated [DATE] at 12:46 p.m. revealed CR #1 was upset and notified the nurse that she felt that staff members were talking about her and she began to cry. Record review of CR #1's nurses note dated [DATE] at 4:30am revealed CR #1 stated she knew people were talking about her and they think she steals things. Record review of CR #1's nurses note dated [DATE] 5:00pm read in part: received new order from psycdoctor (sic), start [MEDICATION NAME] mg by mouth daily for depression . Record review of CR #1's nurses note dated [DATE] at 10:29am read in part .at 7:19am (CR #1) asked the nurse if someone was going to be giving her drugs and a purse .CR #1 stated someone said last night she would be given a bunch of drugs in a purse. Record review of CR #1's nurses note dated [DATE] read in part .CR #1 asked the Nurse Are they selling books here. Because I saw them putting them into the attic yesterday and someone said the man is coming back today to take more naked pictures of the girls for the books. When the Nurse told her that would not happen at the facility CR #1 stated, Yes they are I heard them talking about the girls coming back up here today to take more pictures . Record review of CR #1's nurses note dated [DATE] read in part Record review of CR #1's monthly summary sheet signed by a nurse and physician dated [DATE] revealed that her mental status was alert, oriented, poor memory. Her emotional assessment was friendly, quiet. Record review of CR #1's monthly summary sheet signed by a nurse and physician dated [DATE] revealed that her mental status was alert, oriented, poor memory. Her emotional assessment was friendly, quiet. Record review of CR #1's monthly summary sheet signed by a nurse and physician dated [DATE] revealed her mental status was alert, confused, poor memory. Her emotional assessment was friendly, anxious, and cooperative. Record review of CR #1's physician order [REDACTED]. Record review of CR #1 ' s Behavior-Intervention form dated [DATE]-[DATE] revealed the following: [DATE]- Date of service was [DATE], Chief Complaint was documented as referred by primary care physician (PCP) for [MEDICAL CONDITION] review and patient having hallucinations and delusional thoughts. Psychiatric history .anxiety .depression .[MEDICAL CONDITION] .Other Pertinent information .follow up (f/u) on auditory hallucinations, delusional thoughts, anxiety, mood, [MEDICATION NAME] does increased to 25mg at 1:00pm daily and continue 50mg of [MEDICATION NAME] every night .Current Psych Meds: were listed as [MEDICATION NAME] 50mg every night, start date [DATE] for [MEDICAL CONDITION]; [MEDICATION NAME] 25mg daily, with start date of [DATE] for [MEDICAL CONDITION] and Klonazepam 0.5mg twice a day with a start date of [DATE] for anxiety .Mood was listed as anxious, though process was scattered, affect was [MEDICATION NAME], delusions were paranoid and hallucinations were auditory .orientation was to time only .insight was assessed as poor, judgment was poor, speech was repetitive, memory was assessed as having short-term memory impairment, attention span was easily distracted .Knowledge .general awareness, details lacking .Language was lacking content .Clinical Status and Impressions: She report (sic)she is sad because she lost her husband last year. She is having delusional thoughts and having auditory hallucinations. [MEDICATION NAME] was previously GDR (Gradual Dose Reduction) but recently increase due to exacerbation in psychiatric behavior. She report (sic) anxiety and stated is related to her diarrhea .abdominal pain .depressed mood which she stated was related to loosing (sic) her husband for (sic) before Christmas. I will adjust [MEDICATION NAME] today as listed below to help her delusional thoughts and hallucinations. Will monitor patient and reevaluate in future visits . Treatment Plan .Medication Change .Discontinue (D/C) [MEDICATION NAME] 25mg every day, start [MEDICATION NAME] 25 mg every morning, [MEDICATION NAME] 25mg at 1:00pm and continue 50mg of [MEDICATION NAME] at bedtime. [DATE]-Reason for visit: Follow up on [MEDICATION NAME] dose increase, hallucinations and delusional thoughts . Review of Systems: was marked as unreliable/ unable to participate due to conditions/dementia .Additional information . F/U on auditory hallucinations, delusional thoughts, anxiety, mood F/U on [MEDICATION NAME] 20mg every day initiated on [DATE], consider cognitive testing .Mood/Affect .Anxious, Depressed .Flat .Thought process was scattered .Abnormal Psychotic thoughts .auditory hallucinations and reference delusions (where person believes everything is about them even when it is not.) .Orientation was to person and situation .Attention and Concentration was described as easily distracted and short, awake and alert .Memory: short-term memory impairment .speech was repetitive .language was lacking content and knowledge was assessed as general awareness, details lacking .Insight/Judgment was assessed as poor .Clinical Status and Impression read in part . (CR #1) reported she was depressed in mood and appeared very anxious during the visit . Med changes were to add [MEDICATION NAME] 20mg by mouth everyday . [DATE]-CR #1 had three episodes of anxiety, depression, hallucinations/paranoid/delusions, and mood changes and was restless, redirection was provided with an outcome of no change in her behavior. [DATE]-CR #1 had one episode of anxiety, depression, hallucinations/paranoid/delusions, and mood changes and was restless, redirection was provided and the behavior improved. [DATE]- CR #1 had three episodes of anxiety, depression, hallucinations/paranoid/delusions, and mood changes and was restless, redirection was provided with an outcome of no change in behavior. Record review of CR #1's Physician order [REDACTED]. Physician order [REDACTED]. -Klonopin 0.5 mg: 1 tablet by mouth twice daily for anxiety. Start date [DATE]. -[MEDICATION NAME] 25 mg: Take 1 tablet by mouth at bedtime for Delusional Disorder. -[MEDICATION NAME] 20 mg: 1 tab by mouth once daily for depression. Record review of Physician order [REDACTED].>1. Discontinue [MEDICATION NAME] 25 mg by mouth at bedtime. 2. Start [MEDICATION NAME] 50 mg by mouth at bedtime. 3. Start [MEDICATION NAME] 25 mg by mouth daily. The [DIAGNOSES REDACTED].>Record review of Physician order [REDACTED].>1. [MEDICATION NAME] 25 mg by mouth in the morning. 2. [MEDICATION NAME] 25 mg by mouth at 1:00 p.m. 3. [MEDICATION NAME] 50 mg by mouth at bedtime. [DIAGNOSES REDACTED].>In an interview with the Physician and Administrator on [DATE] at 11:00 a.m. physician said that he did not understand how CR #1 leaving the facility was an Immediate Jeopardy situation. The physician said he was doing all he could for CR #1 and he was adjusting her medications. The Surveyor informed the Physician that staff knew that CR #1 was delusional and exit seeking the morning of [DATE] and did not supervise her. She was able to leave facility and wander into the street. The Administrator said that the facility had no way of knowing that CR #1 would leave the facility and did not agree with the Immediate Jeopardy. Record review of Physician order [REDACTED].#1 to Behavioral Health Services to evaluate and treat. Record review of Physician order [REDACTED].#1's [DIAGNOSES REDACTED]. Record review of Physician order [REDACTED]. Observation on [DATE] at 10:30 a.m. revealed no staff at sign-in desk at the main entrance. Office doors near the main entrance were closed. Observation on [DATE] at 11:30 a.m. revealed no staff at sign-in desk at main entrance. There were two residents sitting near the main entrance door. No staff were located in the area and office doors were closed. Observation on [DATE] at 12:30 p.m. there was no one at the desk at the main entrance. Observation on [DATE] at 3:00 p.m. revealed no staff were at sign-in desk by the main entrance and no staff were in the area. In an interview with Administrator on [DATE] at 1:31 p.m., she said that the facility had a full time staff member that worked at the reception desk located at the main entrance near the door. The Administrator said the receptionist monitored who entered and exited the facility and sometimes assisted residents back to their rooms if needed. The Administrator revealed that there was no one to monitor the door from 6:00am-9:00am and when the receptionist went to lunch that she told the staff so they could monitor the door. Surveyor informed Administrator the dates and times that there had not been staff at the main entrance desk to monitor the door and the Administrator had no response. In an interview with the Receptionist on [DATE] at 2:22 p.m., she said that she worked at the front desk Monday through Friday from 9:00 a.m. until 6:00 p.m. The Receptionist said her lunch break was between 12:30 p.m. and 1:30 p.m. and she did not have to report that she was going to lunch because that was her normal schedule. The Receptionist said that staff did not monitor the desk during her lunch time or when she took a break and that no one monitored the desk after 6:00 p.m. Monday through Friday or on the weekends. Observation on [DATE] at 3:00pm revealed the door to the main entrance could not be seen from the Nurses ' station and all office doors located near the front door were closed. Resident #5 Record review Resident #5's face sheet revealed he was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #5's Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. Resident #5 required extensive from one person for bed mobility, dressing, and personal hygiene. Resident #5 was totally dependent on 2 people for transfer and toilet use. Record review of Resident #5's Care Plans dated [DATE] revealed care plans for: -Confusion related to short and/or long term memory loss and my daily decision making abilities may be compromised. Resident has cognitive impairment secondary to [DIAGNOSES REDACTED]. Use simple commands, one word commands if possible. Pleasant interaction which reassures resident when confused. Provide cuing and prompting for personal care. Attempt to have the resident imitate the activity you want them to perform. Use eye contact and use commands such as Do and Lets. Try to not use words such as Don't. Plan frequent rest periods. Observe for signs of frustration and anxiety and change activity. -Risk for falls. The approaches included: Staff to report all falls immediately to the charge nurse. Charge staff to assess resident before resident is moved from the floor. At risk sign on wall. Call light within reach. Record review of Resident #5's Monthly Summary signed by nurse and physician dated [DATE] revealed his mental status was Alert, Confused, Poor Memory. His emotional assessment Friendly, Cooperative. Record review of Resident #5's Monthly Summary dated [DATE] revealed his mental status was Alert, Confused, Poor Memory. His emotional assessment was friendly, cooperative. Record review of Resident #5's Monthly summary report dated [DATE] revelaled his mental status was Alert, Confused, and Poor Memory. His emotional assessment was Friendly, Cooperative. Record review of Elopement Risk Assessment with dates of [DATE], [DATE] and [DATE] read: Resident is at risk for elopement if the total score is 9 points or higher. If Resident total score is 9 points or higher a wander guard will be issued to resident. If Resident total score is greater than 15 a 1:1 will be assigned and discharge process to a secure unit will be initiated. -Resident #5's Elopement Risk assessment of 3 on [DATE]. -Resident #5's Elopement Risk Assessment of 6 on [DATE]. -Resident #5's Elopement Risk Assessment of 6 on [DATE]. Record review of Resident #5's nurses' note dated [DATE] at 12:55 p.m. read: Resident went out the side door in the dining room going towards the laundry room. Resident states, I am going to get myself a Beer. Staff asked are you really going to get a Beer. Resident states, No I'm Not. Will continue to monitor. Record review of Resident #5's nurses' notes dated [DATE] at 5:00 p.m. read: Staff reported to this nurse that the resident was outside the facility by the laundry room going down the ramp. He was found lying on his right side, he flipped his wheelchair. Abrasions on both knees, right elbow, skin tear on the right hand 2 cm x 0.5 cm. The responsible party and physician were notified. Will continue to monitor. In an interview on [DATE] at 1:00 p.m. with the Dietary supervisor, she said that Resident #5 tried to get out of the facility to go to the freeway through the dining room door that leads outside to the staff parking lot. The Dietary Supervisor said she offered Resident #5 cookies and was able to convince him to return to the facility. The Dietary Supervisor said that she tried to watch the residents when she is out in the dining room so they would not exit the door leading to the parking lot. The Dietary Supervisor said there is no lock or alarm on door. Observation and interview on [DATE] at 11:24 a.m. revealed Resident #5 wheeling self in wheelchair to dining room. Resident # 5 said he still goes outside and on outings. He said his friends take him places. In an interview with DON on [DATE] at 1:36 p.m. regarding Immediate Jeopardy she said she did not understand why it was an Immediate Jeopardy and said it could not have been prevented because there were no signs that CR #1 was a risk. In an interview with Administrator on [DATE] at 11:27 a.m. regarding Immediate Jeopardy (IJ) she said that she uses nursing assessments, care plans, MDS, and standard nursing practice to make sure the residents needs are being met. When Administrator was asked about how to ensure competency of staff, she said that she observes staff, morning meeting, 24 hour report, random follow-ups and she expects staff to follow policy and procedures. When Administrator was asked by surveyor on how she thought IJ came about and what corrective measures would be used and she said that she was aware of the incident an d based on investigation, resident had increased confusion and psych and physician was involved. Administrator said that Resident #8 was not previously and elopement risk. When asked by surveyor about what resources are available to facility and staff, Administrator said nurse consultant was very involved. In an interview with Nurse Consultant on [DATE] at 8:22 a.m. she revealed that a new form was created for residents to log in and out of at the main entrance with the receptionist. Nurse consultant said that she agreed that there was a failure regarding CR #1 and she agreed that there were warning signs, the door wasn't monitored and the resident left the facility without anyone noticing. Record review of in-services provided by facility did not reveal that an in-service had been performed regar