Every finding on record at Brighton Place West

The facility identified a census of 50 residents. The sample included three residents. Based on observation, record review, and interview, the facility failed to provide the necessary behavioral care and services for Resident (R) 1, who had moderate cognitive impairment as well as schizophrenia (mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and a history of violence and substance abuse. On 07/07/25, R1 began refusing to take his mental health medications and demonstrated increased behaviors. On 07/10/25, around 11:06 AM, the Social Worker spoke with R1's parental guardian, who shared concerns with R1's history of medication noncompliance, erratic behaviors, and history of substance abuse. At around 03:58 PM, after asking Administrative Nurse D and Administrative Nurse E a question, R1 began kicking the door, stating he wanted to leave the facility, and made threats to kill the staff. The staff provided R1 with an Against Medical Advice (AMA) form (a document signed by a patient who is choosing to leave a healthcare facility against their physician's recommendation), which R1 signed, and allowed R1 to leave the facility. The staff did not involve R1's physician, guardians, emergency services, or law enforcement in an attempt to de-escalate or address the mental health crisis. R1 was gone from the facility, with his whereabouts unknown, for seven days before law enforcement picked him up for attempting to procure alcohol without payment and for erratic behaviors. R1 admitted to the acute hospital with sunburn and dehydration. The facility's failure to provide adequate and appropriate services, including physician and guardian involvement to treat a behavioral health crisis, placed R1 in immediate jeopardy. Findings included: - R2's Electronic Medical Record (EMR) documented diagnoses of need for assistance with personal care, difficulty in walking, muscle wasting and atrophy (wasting or decrease in size of a part of the body), and age-related physical debility. The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderate cognitive impairment. The MDS documented R1 required supervision or touching assistance for hygiene, showers or bathing, dressing, and moving from seated to standing position. The MDS documented R1 required supervision or touching assistance for chair or bed, shower or tub, and toilet transfers. The MDS further documented R1 required supervision or touching assistance for walking. The MDS documented R1 required partial or moderate assistance for car transfers, picking up objects, and going up curbs and steps. The Cognitive Loss / Dementia Care Area Assessment (CAA), dated 07/03/25, directed staff to monitor for signs and symptoms of acute mental status changes to help treat the underlying condition.The Falls CAA, dated 07/03/25, directed staff to anticipate and meet R1's care needs so R1 did not attempt to unsafely perform Activities of Daily Living (ADL) cares without staff assistance. R1's Care Plan revealed the following with their initiated dates:06/27/25, R1 needed assistance with ADLs related to schizophrenia and weakness from recent hospitalization. 07/06/25, R1 had impaired cognitive function or dementia, or impaired thought processes related to psychotropic (alters mood or thought) drug use. 07/06/25, directed staff to monitor, document, and report any changes in cognitive function, specifically changes in decision-making ability, memory, recall, general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status. 07/06/25, R1 was at risk for falls related to impaired mobility. 07/07/25, R1 would work to express and manage his emotions and behaviors. 07/07/25, directed staff to encourage R1 to discuss feelings and monitor his progression or decompensation for continued stabilization.R1's Guardianship documents, dated 01/26/22, recorded By clear and convincing evidence, [R1] is an adult with impairments and lacks the capacity to meet essential needs for physical health, safety or welfare, should not be permitted to make any decisions which affect his person, and the Co-Guardians herein appointed shall be possessed of all the powers and duties of a Guardian as set out in K.S.A. $59-3075 and the Letters of Guardianship to be issued herein shall so state. An Acute Care admission Psychiatric Evaluation dated 05/28/25, recorded R1 had diagnoses of schizophrenia and schizoaffective disorder, bipolar type (a condition that combines symptoms of schizophrenia and bipolar disorder [major mental illness that causes people to have episodes of severe high and low moods]). The document further recorded the hospital requested screening due to R1's behaviors and R1 not stabilizing. The document recorded R1 had not cleared the signs and symptoms of psychosis (any major mental disorder characterized by a gross impairment in reality perception) since 05/01/25. The document recorded R1 repeatedly physically attacked staff and peers; R1 was irritable, delusional, and had not taken medication consistently; R1's parents were his guardians. R1's Kansas Preadmission Screening and Resident Review (PASRR) dated 06/24/25, documented R1 had a history of substance use. The PASRR recommended the following specialized services for R1: community psychiatric support and treatment, crisis services, substance use services, behavioral support services, peer support, and case management.R1's Medication Administration Record (MAR) dated 07/01/25 through 07/31/25, documented R1 refused the following five medications: 1. Divalproex Sodium (medication used to treat bipolar disorder) 500 milligrams (mg), give one tablet two times a day, for hallucinations and delusions. R1 refused the evening dose on 07/07/25, the morning and evening doses on 07/08/25 and 07/09/25, and the morning dose 07/10/25. 2. Haloperidol (medication used to treat various psychiatric and behavioral disorders) 10 mg, give two tablets by mouth two times a day, for schizophrenia. R1 refused the evening dose on 07/07/25, the morning and evening doses on 07/08/25 and 07/09/25, and the morning dose on 07/10/25. 3. Oxcarbazepine (medication used to treat bipolar disorder) 300 mg, give one tablet two times a day, for mood stabilizer. R1 refused the evening dose on 07/07/25, morning and evening doses on 07/08/25 and 07/09/25, and the morning dose on 07/10/25.4. Ziprasidone (medication used to treat schizophrenia) give 80 mg, twice a day, related to schizophrenia. R1 refused the evening dose on 07/07/25, the morning and evening doses on 07/08/25 and 07/09/25, and the morning dose on 07/10/25.5. Buspirone (Buspar) 30 mg, give one tablet by mouth three times a day, for pacing and agitation related to anxiety disorder. R1 refused morning and mid-day dose on 07/10/25.On 07/07/25 at 11:26 AM, a Social Service Note documented R1 approached the Social Worker and insisted staff did not meet with him for an assessment. After a while, he was able to recall meeting with the Social Worker. R1 was asked, What can we help you with at this time? and he responded that he continued to have hallucinations and demanded a change in his medications (would like his Buspar and Haldol increased). The Social Worker informed him it would be passed along to the nurse, and he replied angrily, You need to just call my mom. R1 was supported and reassured that the Social Worker would follow up with the proper staff about his concerns. R1's EMR lacked evidence of follow-up from the social worker. On 07/07/25 at 04:19 PM, a Nurse's Note documented R1 refused all evening medications except Risperdal (medication used to treat schizophrenia). The note documented notifications were sent to R1's doctor and the Advanced Practice Registered Nurse (APRN).On 07/07/25 at 10:30 PM, an Administration Note documented R1 refused all medications but Buspar 30 MG and documented a notification to the charge nurse. On 07/08/25 at 10:19 PM, an Administration Note documented R1 refused all medications except Buspar and documented a notification to the charge nurse. On 07/09/25 at 09:43 AM, a Behavior Note documented R1 was heard yelling at and cursing at staff members this morning about not wanting to take his medications. R1 struck a door with no apparent injury to himself. Staff told R1 to take his medications, and then he could go out to smoke. R1 went inside, and when he went back out, he lied to staff about taking his medications to get a cigarette, as R1 still had not taken medications. On 07/09/25 at 09:56 AM, a Behavior Note documented the nurse heard a huge boom sound. When the nurse got up to investigate, R1 was coming back into the building after punching the outside patio door. The nurse asked the resident what the issue was, and R1 stated, I will talk to you about it in a minute after I get my meds. The note documented the nurse approached and informed the staff it was policy the resident be medication compliant before going out for a smoke break. The staff told the nurse R1 lied about taking his medications before he smoked. R1 then approached the nurse and asked if he could speak again. R1 was agitated and said he was not getting enough nicotine, and he needed extra smoke breaks or a nicotine patch. The nurse informed R1 that smoke breaks were at certain times, per facility policy. R1 asked about a nicotine patch and the nurse told R1 he would not be able to smoke with a nicotine patch. R1 became more agitated and said he wanted to beat up every nurse in the facility because they were all worthless. The nurse asked R1 if he would take his medications. R1 was still extremely agitated and said he would take Buspar, but he would not take any other medications because he was not schizophrenic. The note documented R1 then told the nurse to get his Buspar because the staff were making his anxiety high. A medication aide approached R1 to provide medication and R1 became rude and spiteful with the medication aide and said, Shut up and do your job, or you will get hurt. R1 picked out his Buspar and cursed at the medication aide. R1 walked away from the medication cart, swinging his fists in the air with a fast, long-stride pace in the hallway and gave evil looks at the other residents that were walking around him. The nurse also visualized R1 talking to unseen others and muttering under his breath. The nurse let R1 have some personal space for about 20 minutes and then went out to the patio and tried to educate the importance of taking his physician-prescribed medications. R1 then laughed sinisterly and stated again he was not mentally ill and only had an anxiety problem that everybody was making worse, and he just wanted to hurt people. The note documented R1, then walked off the patio into the facility, only to come into the office doorway. The note documented R1 wanted to apologize, and then his mood swung again to being rude and hateful. The staff offered an injection of anxiety medication, to help R1 relax, and he refused.On 07/09/25 at 09:54 PM, an Administration Note documented R1 refused all medications except Buspar, and documented notification to the charge nurse. On 07/09/25 at 11:11 PM, a Behavior Note documented R1 refused all medications except Buspar on the 02:00 PM to 10:00 PM shift, after three attempts to offer medications. The note documented notification to the physician. The EMR lacked evidence of follow-up after the physician notification. On 07/10/25 at 10:09 AM, a Behavior Note documented the nurse asked R1 if he wanted to switch to a different room, but R1 kept ignoring the nurse and walked away. When the nurse once again attempted to get R1's attention to ask, R1 told the nurse writer to shut up, not to talk, and just work. The note documented R1 further told the nurse that was what he paid them for, and then walked away.On 07/10/25 at 10:15 AM, a Behavior Note documented R1 was pacing in the hallway, talking to himself and other residents. The note documented R1 told others to wake up and made expletive remarks insulting their appearance. The note documented R1 made expletive remarks about staff, stated he was in charge and to watch those fingers or he would cut another one off, asking staff which one they wanted to lose.On 07/10/25 at 10:30 AM, a Behavior Note documented multiple staff members reported R1 was verbally aggressive towards them, calling them names, and using slurs.On 07/10/25 at 10:30 AM, a Nurse's Note documented speaking with the psychiatric provider about R1's behaviors and refusal of medications, and was awaiting further orders. The EMR lacked evidence of follow-up related to the note. On 07/10/25 at 11:06 AM, a Social Services Note documented the Social Worker made contact with R1's mother and Guardian and provided her with copies of the admission paperwork as requested. R1's mother expressed concerns about feeling pressured by a previous psychiatric hospital's Social Worker. The note documented R1's mother felt this other social worker rushed to discharge R1 and found placement prior to R1 being stabilized, especially since R1 had been non-compliant with his medications. R1's mother reported she dealt with R1's mental state and aggression since he was the age of 12 and reported feeling fearful of R1 due to his erratic behaviors. The note further documented R1's mother inquired about the steps that would need to be taken if R1 returned to the psychiatric hospital or was discharged from the facility. R1's mother reported R1 did not have access to a home he previously rented. R1's mother reported concerns about his substance use, concerns when R1 was unstable, and reported that R1 only agreed to come to the facility due to his ability to smoke cigarettes. On 07/10/25 at 03:45 PM, a Behavior Note documented R1 continued to have escalating behaviors and delusions throughout the shift. Staff were unable to redirect R1 as staff intervention caused further escalation of behaviors. R1 continued to be verbally abusive and intimidating towards staff, cursing and using slurs, threatening violence, and making delusional statements. On 07/10/25 at 03:58 PM, a Behavior Note documented R1 knocked on the door to the office of the Administrative Nurse D and Administrative Nurse E. The nurse answered the door, and the resident asked what they were doing. The nurse told the resident they were working. R1 asked why the staff were wasting his time. The nurse tried to close the door, and R1 pushed on the door trying to get in. The nurse got the door closed, and R1 started kicking the door multiple times, threatening bodily harm. After kicking stopped, the nurses opened the door and saw R1 down the hallway putting his middle finger up in the air. R1 cursed and said he wanted to get out of the facility, and if the staff did not let him out, he was going to kill everyone. The staff informed R1 he would have to sign out AMA if he wanted to leave. R1 told the staff to give him the paper. The staff returned his two packs of cigarettes and lighter. R1 signed AMA paperwork, and the staff let R1 leave.A Request for Discharge Against Medical Advice dated 07/10/25, recorded I hereby request to be discharged from the facility. I have been fully informed by my physician and the facility of the consequences of this action and understand that it is against my best medical interest to be discharged from the facility. I have further been fully informed by my physician, health care providers, and the facility of the risks inherent in the discharge from the facility against medical advice and they have explained the alternatives to me. After considering the alternatives, the risks involved, and the prognosis of my condition, I have requested that I be discharged from the facility, and I understand that it is against medical advice from my physician and the facility. The document further recorded Furthermore, my family members and next of kin have had an opportunity to discuss this matter with R1's provider and the representative of the facility and have been advised and are fully aware of the risks and dangers to my health if I am discharged from the facility. I understand the full import of this declaration and I am emotionally and mentally competent to make this declaration. The document was signed by R1 on 07/10/25. The document contained no other signatures. On 07/10/25 at 04:03 PM, a Nurse's Note documented R1 discharged AMA at 03:55 PM on 07/10/25 and was released from the facility. The staff notified R1's mother, psychiatric provider, and primary care provider. On 07/10/25 at 04:06 PM, a Social Service Note documented R1 left the facility against staff advice due to his altered mental status, delusional thoughts, hallucinations, refusing medications, and becoming increasingly more verbally aggressive. The Social Worker completed an Adult Protective Services (APS) report.On 07/10/25 at 04:15 PM a Communication - with Family, Next of Kin (NOK), Power of Attorney (POA) note documented staff spoke to R1's mother regarding R1 leaving the facility AMA. R1's mother understood R1 was being aggressive with staff, other residents, and chose to sign out against medical advice. R1's mother indicated this was R1's pattern. R1 stopped taking his medication and quickly became paranoid and aggressive. R1's mother also indicated she felt the previous psychiatric hospital discharged R1 before he was stable on his medication. The staff spoke to R1's mother about the facility's obligation to call APS and make a report that R1 was no longer at the facility, he signed out AMA and was having unmedicated mental health issues. R1's mother indicated she would come to the facility to pick up his property and his money within the next 30 days. The Social Worker notified APS. On 08/28/25 at 09:19 AM, R1's Representative stated she thought the facility called her to let her know R1 stopped taking his medications, but she was unsure if it was the day before R1 left AMA or the day he left. R1's Representative stated they told her R1 had not taken his medications for four days. R1's Representative stated her understanding was, for R1 to stay in the facility, he had to be medication compliant and thought he would be sent back to the state psychiatric hospital if he was not. R1's Representative stated the facility staff told her they would have a team meeting and would call her back, but she never heard back from them. R1's Representative stated that around 04:00 PM on 07/10/25, staff called to tell her R1 was no longer in the facility. R1's Representative stated she thought that meant R1 was sent back to the state hospital, but then staff told her R1 was let out of the building. R1's Representative stated she did not understand how this could happen at a locked facility, and she believed the facility let R1 go because R1 was too much trouble. She stated the facility did not call her to let her know about his behaviors or demanding to leave on 07/10/25. R1's Representative stated she did not understand how R1 could have signed himself out because she is R1's legal guardian. R1's Representative stated she spoke to the facility administrator and told her if R1 were to return to the facility, to call her. R1's Representative further stated she later found out R1 had returned to the facility the next day to pick up some cigarettes, but the facility did not contact her as requested. R1's Representative stated the administrator told her, after R1 had come and gone, that R1 came back to pick up his cigarettes the following day. R1's Representative stated the administrator told her she forgot to call when R1 came back. R1's Representative stated R1 was out in the community for about a week before the police picked him up and took him to a local hospital. She stated R1 was not from the area, did not know where he was, had no identification with him, and no phone. R1's Representative stated the police told her R1 was found walking down the middle of a freeway after he left AMA. The police told R1 he could not do that and was let go. She stated R1's second encounter with police was when R1 was kicked out of a bar after taking alcohol he could not pay for. R1's Representative stated the third time she was able to get a missing person report, the police found R1 and brought him to a local hospital. R1's Representative stated he was dehydrated and had a sunburn when he was picked up and taken to the hospital. R1's Representative stated she did not give permission for R1 to leave the facility and would not have given them permission to let him go AMA. R1's Representative stated there was no way R1 was ready to transition to the community, as he was not tracking well and was not compliant with his medications. On 08/27/25 at 01:49 PM, Administrative Staff A stated R1 was admitted to the facility from a psychiatric facility to stabilize on his medications. Administrative Staff A stated R1 took his medications initially, but started refusing to take them, became aggressive, and started hitting walls. Administrative Staff A stated R1 was being aggressive and stated he wanted out of the facility, so staff discussed the AMA paperwork with R1. Administrative Staff A stated staff attempted to explain to R1 that the doctor thought he needed to stay, but R1 wanted to leave, and staff could not hold him down. She stated R1 should have been taking his medications, but staff could not force him to take them. Administrative Staff A stated she believed staff contacted R1's guardian right after R1 left the facility and was unsure if anyone had contacted the guardian prior to R1 leaving AMA. Administrative Staff A stated that no one came to pick R1 up from the facility, he just left on his own. She reported R1 came back the next day to get his cigarettes but was not sure where he went after. She stated she was told R1 eventually ended up at a local hospital. Administrative Staff A stated staff told R1's guardian that R1 had refused his medications at one point during his stay, because the guardian went down to talk to R1 to get him to take them. Administrative Staff A further stated that beyond that one time, she was unable to recall if staff had updated the guardian of the refusals in the days prior to R1 leaving AMA. Administrative Staff A stated staff did not contact law enforcement when R1 wanted to leave AMA. On 08/28/25 at 10:25 AM, Administrative Nurse E stated he was at the facility the day R1 left AMA. Administrative Nurse E stated he could not remember how many days R1 was in the facility, but stated R1 was not compliant with taking his medications. Administrative Nurse E stated R1 tried to intimidate other residents and staff by cursing and calling them names. Administrative Nurse E stated R1 would refuse as-needed medications when offered and would become more agitated. Administrative Nurse E stated in the days leading up to 07/10/25, he was unsure if there were any new orders from the doctor when staff reported R1 was not taking his medications. Administrative Nurse E stated on 07/10/25, Administrative Nurse E was in a meeting with Administrative Nurse D, and R1 came to the door and asked what they were doing. Administrative Nurse E stated he told R1 they were working, and R1 became more agitated and threatened the staff. Administrative Nurse E stated he attempted to close the door, and R1 began kicking it several times. Administrative Nurse E stated when he opened the door up R1 was down the hall yelling that he wanted to leave the facility. Administrative Nurse E stated Administrative Staff A informed him he could sign out AMA. Administrative Nurse E said R1 did sign out AMA and was let out of the facility. He stated he was not sure if the guardian was contacted before or after, as he did not make those phone calls, but he was told the family was contacted. Administrative Nurse E stated the resident came back the next day to get his cigarettes, and the resident told him he slept outside behind a gas station. Administrative Nurse E stated staff went back inside, and when they came out again, R1 was walking down the street. Administrative Nurse E stated that if things were done by the book, then no, R1 should not have signed himself out due to having a guardian. Administrative Nurse E stated maybe the police should have been called, but R1 was so agitated all staff and residents were afraid of him. Administrative Nurse E stated when R1 signed out, there was no stopping him. Administrative Nurse E stated the staff probably should have called the guardian first.On 08/28/25 at 10:50 AM, Administrative Nurse D stated she was in the office the day R1 left AMA on 07/10/25. Administrative Nurse D stated R1 paced the halls and made threats to staff. Administrative Nurse D stated R1 continued to escalate and asked them, What are you going to do? Administrative Nurse D stated that Administrative Nurse E got up to shut the door, and R1 began kicking it repeatedly. Administrative Nurse D stated that when they finally came out of the room, R1 was down the hall talking to Administrative Staff A. She stated she could not hear all of the conversation, but wanted to stay away as Administrative Nurse E and herself were the targets of R1's aggression at that time, and she did not want to make it worse. Administrative Nurse D stated R1 was given AMA paperwork, signed out, and left the facility. Administrative Nurse D stated the guardian was called after R1 left the facility. Administrative Nurse D stated they were trying to make the environment safe first and then tried to follow the correct steps. Administrative Nurse D stated she knew staff had talked to the family prior, but it was not charted. Administrative Nurse D stated the guardian was not upset that day when they made contact, and R1 came back the next day. Administrative Nurse D stated she knows the policy, and if a resident has a guardian, and the guardian says the resident cannot leave, then they have to deal with them. Administrative Nurse D stated if a resident had a guardian, they had to notify them before they are allowed to leave. Administrative Nurse D stated looking back, the policy was not followed. Administrative Nurse D stated she had never been that scared, and at some point, they have to protect the other residents and staff. Administrative Nurse D stated when staff contacted the physician about R1 not taking his medications, she believed the provider had not seen R1 yet, and the response was to continue to encourage R1 to take his medications. Administrative Nurse D stated they could have contacted law enforcement when R1 became aggressive, but they did not have a good history with the local police department, they often took a long time to show up, and had a history of not doing anything. Administrative Nurse D stated that it all happened so fast, but they should have called the police. On 08/28/25 at 11:00 AM, Administrative Staff A stated on 07/10/25, R1 was aggressive, threatening staff, and kicking the door. Administrative Staff A stated R1 was yelling that he wanted out and they could not keep him at the facility. Administrative Staff A stated she knew R1 had a guardian, but if R1 refused to stay, she would have the nurse read the AMA document to R1, explain it, and let him sign out. Administrative Staff A stated after R1 signed, they let him out the door. Administrative Staff A stated they called the guardian, the provider, and made a report to APS after R1 left AMA. Administrative Staff A stated R1 came back the next morning to pick up his cigarettes. Administrative Staff A stated she told R1's guardian he said he would be back the next day, and the guardian just said Okay. Administrative Staff A stated the guardian did not ask Administrative Staff A to call her the next day if R1 came back to the facility. Administrative Staff A stated the guardian understood the resident was being aggressive, and the guardian said R1 had been that way for a while. Administrative Staff A stated they have called the police at times when residents became aggressive, but because of the mental illness, the police just talk to them and leave. She stated the police would not take them away, and they could not press charges. Administrative Staff A stated she was not aware they needed to contact the guardian first before a resident left AMA. Administrative Staff A stated she knew they had to contact the guardian if they left, she just did not know it had to be before the person left. She stated based on the wording in R1's guardianship papers, R1 should not have been able to sign himself out. The facility's undated Transfer and Discharge (Including AMA) policy, documented AMA only applied when a resident expressed their wishes to be discharged earlier than outlined in the care plan. These situations did not apply if the facility offered to discharge a resident to a location that did not meet their health and or safety needs, and the resident agreed. The resident and family/legal representative should be informed of the risks involved, the benefits of staying at the facility, and the alternative to both. Under no circumstances would the facility force, pressure, or intimidate a resident into leaving AMA. The physician should be notified of the intended AMA discharge and be encouraged to speak with the resident to encourage them to stay at the facility. Documentation of this notification should be entered in the nurse's notes by the nursing department. The social services designee should document any discussion held with the resident/family in the social service program notes, if present, notify Adult Protective Services (APS), or other entity as appropriate, if self-neglect is suspected, and document accordingly. On 08/28/25 at 03:15 PM, Administrative Staff A was provided the IJ template and notified the facility's failure to provide adequate and appropriate services, including physician and guardian involvement to treat a behavioral health crisis, placed R1 in immediate jeopardy.The facility submitted an acceptable IJ removal plan on 08/28/25, which included the following: 1. Administrative Nurse D re-educated staff that administered medication on facility Notification of Changes policy to include notification to physician and guardian/responsible party upon refusal of medications.2. The facility began an audit process for refusal of medications for appropriate notifications to the physician and guardian/responsible party daily for 4 weeks, starting on 08/28/25.3. The Regional Nurse Consultant re-educated IDT and professional nursing staff on facility Transfer and Discharge policy including Against Medical Advice Process.4. The Regional [NAME] President and/or Regional Nurse Consultant would be notified prior to any resident leaving Against Medical Advice to ensure facility processes were followed, starting 08/28/25.On 08/28/25 at 04:41 PM, the surveyor verified the above corrective actions were implemented. The scope and severity remained at G to reflect the serious adverse outcome, including dehydration and exposure.

The facility identified a census of 48 residents. The sample included 13 residents with five residents reviewed for significant medication errors. Based on record review, observation, and interview, the facility failed to ensure Resident (R) 21 remained free of significant medication errors. On 12/28/24 the facility received an order from R21's psychiatric provider to discontinue Clozaril (an antipsychotic medication used to treat major mental conditions that cause a break from reality) 25 milligrams (mg) in the morning. Licensed Nurse (LN) G discontinued both the 25 mg dose of Clozaril scheduled in the morning and the 500 mg dose of Clozaril at bedtime creating an abrupt discontinuation of the medication. This deficient practice resulted in increased auditory and visual hallucinations (sensing things while awake that appear to be real, but the mind created) for R21, which caused her significant psychosocial distress. Findings include: - R21's Electronic Medical Record (EMR) documented R21 had diagnoses of disorganized schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), extrapyramidal and movement disorder (movement disorders as a result of taking certain medications), and hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R21 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R21 had indicators of psychosis (any major mental disorder characterized by a gross impairment in reality perception) including delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue) but no hallucinations. The MDS documented R21 took antipsychotic medication during her stay at the facility. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 04/14/24, documented staff were to monitor for signs and symptoms of acute mental status changes to treat underlying conditions. The CAA documented staff were to use short simple sentences and allow adequate time for R21 to understand and communicate her needs. The CAA directed staff to approach R21 in a non-threatening manner to help R21 feel calm and unhurried. The Psychotropic Drug Use CAA, dated 04/14/24, documented psychotropic (altering mood or thought) medications would be addressed in R21's plan of care. The CAA directed staff to monitor for any adverse side effects of medication usage to help prevent or minimize risks of the current medication regimen. The CAA directed staff to administer medications as ordered to help prevent any side complications. R21's Care Plan directed staff R21 had a diagnosis of schizophrenia and this illness was first documented when she was a teen. R21 had many psychiatric hospitalization s over the years and had been in facilities for years. The care plan documented R21 had poor insight, depression, agitation, hallucinations, and delusions. The care plan directed staff to monitor R21 for acute major changes in her cognition. The care plan documented R21 was on Clozaril and staff were to administer medications as ordered, and to obtain monthly complete blood counts (CBC-blood laboratory test). The Prescriber Order Note, dated 12/28/23, directed staff to discontinue R21's Clozaril 25 mg every day and to keep the night dose as ordered, 500 mg every night, for the diagnosis of schizophrenia. The Psychiatric Consultation Progress Note, dated 12/28/23, documented R21 was seen on a routine basis to reduce the risk of decompensation of her psychiatric stability. The plan documented that R21's morning dose of Clozaril would be discontinued. The note directed staff to monitor for any return of behaviors and to monitor R21 closely for any changes in her psychiatric stability. The Behavioral Monitoring Note, dated 12/20/24, documented R21 had occasional pacing in the hallway. The Behavioral Monitoring Note, dated 12/22/24, documented R21 had no behaviors. The Order Note, dated 12/28/24, documented the facility received an order to discontinue R21's morning dose of Clozaril. The December Medication Administration Record, dated December 2023, documented R21's Clozaril 25 mg daily in the morning and Clozaril 500 mg at bedtime were discontinued on 12/28/23. The Medication Review Report, dated 12/31/23 and signed by the physician, documented that R21's Clozaril 25 mg was discontinued on 12/28/23 and R21's Clozaril 500 mg was discontinued on 12/28/24. The Behavior Note, dated 12/31/24, documented R21 maintained a persistent delusion that the nurse was giving her injections. The nurse told R21 the nurse had never given R21 an injection besides her flu shot. R21 called the nurse a liar. The Behavioral Monitoring Note, documented that R21 was not acting her usual self. When spoken to, R21 would stare blankly and not talk. R21 was hanging out at the front door, walked out the first door, and had to be re-directed back inside. R21 would not eat her meals. An order was received to obtain a stat (immediate) complete metabolic panel (CMP-laboratory blood test)and a urine sample, start Seroquel (antipsychotic medication) 25 mg every night, and give Ativan (antianxiety medication) every six hours as needed for fourteen days. The Behavioral Monitoring Note, dated 01/06/24, documented R21 yelled out for Mommy, pounded her fists on the walls, ran out the front door, sobbed, yelled, and stayed awake for hours and would not sit down or lay down. The Order Note, dated 01/06/24, documented to restart Clozaril 25 mg every evening. The eAdmin Record - Hour of Administration Level Note, dated 01/07/24, documented R21 was on one-to-one. R21 was more cooperative with care. R21 cried out often, refused to eat, and drank small amounts of water. The eInteract SBAR Summary for Providers Note, dated 01/07/24, documented R21 had a change in condition: abdominal pain, altered mental status, fluid and food intake decreased or unable to eat or drink adequate amounts, and functional decline. R21 was documented as talking less, being tired weak, and confused. R21 had the following medication changes in the past week: restarted Clozaril 25 mg and Seroquel 25 mg at bedtime. Nursing observations included that R21 was nonverbal. R21 yelled out when touched. R21 was weak and unable to support her body weight without assistance. R21 had difficulty standing and transferring. R21's abdomen was distended and firm. R21 did not have any intake, refused her medication, and would not open her mouth. Staff received a new order received to send R21 to the emergency room . The Hospital Nurse's Note, dated 01/11/24, documented that R21 remained confused, hallucinated, and was restless and agitated. The noted documented R21 was confused, disoriented times four, and unable to follow commands; she had poor safety awareness, and poor attention and concentration. R21 responded to auditory hallucinations and made irrelevant and incomprehensible statements. The psychiatric review documented R21 had anxiety, concentration difficulties, delusions, disorientation, hallucinations, and memory difficulties. The note documented R21's cognition was impaired due to psychosis. R21 remained psychotic but unfortunately due to medical conditions, R21 was not tolerating antipsychotics well. The plan documented to try to titrate up the dose of Seroquel to help control psychosis and mood. The History and Physical, dated 01/11/24, documented R21 admitted to the hospital with altered mental status (lethargy, hallucinations). R21 was found to have a urinary tract infection. Initially, there had been concern for a small bowel obstruction, but R21 was negative for obstruction or ileus (obstruction of the intestines, caused by immobility of the bowel). The Discharge Summary, dated 01/11/24, documented R21 discharged from the hospital on Clozaril 75 mg at bedtime and Seroquel 25 mg at bedtime. The Interdisciplinary Team Note, dated 01/11/24 documented R21 and R21's responsible party attended her care plan meeting. The note documented R21 had not had any medication changes that quarter and was stable on her medications. The Progress Note, dated 01/11/24, documented R21 admitted back to the facility from the hospital. The Behavior Note, dated 01/11/24, documented R21 was found in her bed crying with a torn gift bag wrapped around her hand and pieces thrown all over the bed and floor. R21 pulled the call light up around her neck, cried, and stated she needed to go see her angel. Staff took the call light away from R21 and tried to calm R21 down. The charge nurse was notified and stated she would look into an as-needed medication to give R21. Staff remained in the room to monitor R21 until the charge nurse could check on medication. The Nurse's Note, dated 01/12/24, documented R21 was unable to hold her posture upright when in her wheelchair. R21 leaned back in the wheelchair with her bilateral lower extremities straight out. R21 is unable to follow directions. R21 was assisted from the wheelchair to the bed by two staff. The Nurse's Note, dated 01/12/24, documented R21's psychiatric provider was notified of the change of dose of Clozaril from the hospital. Staff received a new order to keep R21's Clozaril at the previous dose of 500 mg at bedtime. The Psychiatric Order Note, dated 01/23/24, documented the provider had received a message from the facility regarding R21. Staff reported R21 was out of control, removing her clothes, and spitting out her pills and meals on her wheelchair since returning from the hospital. The note documented that while at the hospital, R21's Clozaril was decreased from 500 mg to 175 mg and Seroquel was increased to three times a day when R21 was previously only on Seroquel at bedtime. The note documented the plan for R21 was to return to the previous dosing of Clozaril and Seroquel and start Ativan to be given every four hours as needed. The orders directed staff to discontinue all (current) Seroquel, start Seroquel 25 mg at bedtime, discontinue all (current} Clozaril, start Clozaril 500 mg at bedtime, and start Ativan 2 mg every four hours as needed for anxiety and agitation. On 10/15/24 at 10:30 AM, R21 lay in her bed in pajamas. R21 had a flat affect. On 10/15/24 at 10:30 AM, R21 stated she did not remember being sick or having any medication changes at the end of December and the beginning of January. R21 did not want to talk. On 10/15/24 at 11:30 AM, Administrative Nurse D stated she realized the facility had a problem with medication orders that were connected together in the EMR in October and put in a Performance Improvement Plan (PIP) to go through all of the orders and ensure that orders that were connected together, were separated into separate orders, so if one was changed or discontinued the other order would not be affected. Administrative Nurse D stated R21's Clozaril orders should not have been connected together, but rather two separate orders should have been placed in the EMR; one for Clozaril 25 mg in the morning and one order for Clozaril 500 mg at bedtime. When LN G discontinued the 25 mg dose of Clozaril the EMR discontinued both orders. Administrative Nurse D stated part of the problem was LN G was an agency nurse and did not know the resident and her routine and the medication aides at the time were agency and did not realize R21 normally took 500 mg of Clozaril every night. Administrative Nurse D stated in the review of medications that were connected, R21's Clozaril dose had been missed. On 10/15/24 at 02:30 PM, LN H stated he had been in a nursing meeting when R21's Clozaril dose was brought up as being discontinued and he immediately knew something was wrong because R21 required Clozaril 500 mg for psychiatric stability. LN H stated as soon as the meeting was over he reviewed R21's medications and realized she was not on Clozaril 500 mg and contacted the psychiatric provider immediately to get the Clozaril 500 mg restarted. LN H stated R21 did have a decline after the Clozaril was discontinued. The facility's Use of Psychotropic Drugs Policy, dated 01/01/20, documented that residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record and the medication is beneficial to the resident as demonstrated by monitoring and documentation of the resident's response to the medications. A psychotropic drug is any medication that affects brain activities associated with mental processes and behavior. The indications for initiating, withdrawing, or withholding medications, as well as the use of non-pharmacological approaches, will be determined by assessing the resident's underlying condition, current signs, symptoms, expressions, preferences, and goals for treatment, and identifying underlying causes. The attending physician will assume leadership in medication management by developing, monitoring, and modifying the medication regime in collaboration with residents, their families, and/or representatives, other professionals, and the interdisciplinary team. Residents who receive psychotropic medications shall receive gradual dose reductions. The facility failed to ensure R21 remained free of significant medication errors. This deficient practice caused R21 significant psychosocial harm as evidenced by R21 having increased auditory and visual hallucinations that caused her significant distress.

The facility had a census of 48 residents. The sample included 13 residents. Based on observation, record review, and interview the facility failed to prepare, store, distribute, and serve food under sanitary conditions for the 48 residents in the facility, who received their meals from the kitchen. This placed the residents at risk of foodborne illness. Findings included: - On 10/14/24 at 8:00 AM, during the initial tour, observations revealed the following: The refrigerator had an opened, undated half-full 2.5 pounds container of deli turkey meat, an undated peanut butter sandwich, and two plastic bags of shredded lettuce dated 09/29/24 (15 days). Observation revealed five 12-inch by three-foot fluorescent lights located above the food preparation area. Two of the plastic light covers had a brownish substance in the cover, one florescent light fixture was pulled down and not adhered to the ceiling, and three florescent light covers were cracked. One four feet by three feet ceiling mounted air conditioning unit, located on the exterior wall/ceiling of the kitchen blew air directly across the food preparation area. The air vent grills, water and condensation pipes were covered with a brown greasy substance and a gray fuzzy substance. On 10/14/24 at 12:30 PM, Dietary Staff (DS) BB verified the undated food in the refrigerator, the overhead fluorescent light fixtures with the brownish substance in the covers, the cracked covers and the fixture separating from the ceiling as well as the dirty air conditioner. DS BB verified the facility did not presently have any maintenance department staff and they would be the ones to complete any task that requires climbing a ladder. The facility's Kitchen Preventative Maintenance policy, dated 10/25/2019, documented that the facility would maintain a schedule of maintenance services to ensure that the building, grounds, and equipment are maintained in a safe and operable manner. The facility failed to prepare, store, distribute and serve food under sanitary conditions for the 48 residents residing in the facility, who received meals from the kitchen.

The facility had a census of 48 residents. The sample included 13 residents. Based on record review and interview the facility failed to deliver mail to facility residents on Saturdays. Findings included: - On 10/14/24 at 01:00 PM during the resident council meeting, a resident verbalized there was no mail delivery on Saturdays. On 10/14/24 at 02:00 PM, Administrative Staff verified the Activity Director would get the mail during the week from the mailbox in front of the facility, then deliver to the residents. Administrative Staff A verified the key to the mailbox was kept in the Activity Directors office and said there was another key kept in the medication cart. Administrative Staff A verified that on the weekends the medication aide would get the mail and deliver the residents' personal mail and the business mail would be kept in the office. Administrative Staff said that Certified Medication Aides knew they were to get the mail on Saturdays. On 10/14/24 at 02:15 PM, Certified Medication Aide (CMA) R looked through both the facility medication carts, and the medication room, and could not find the mailbox key. CMA R said he was unaware that the CMAs were supposed to get the mail and deliver it to the residents on Saturdays. On 10/14/24 at 2:25 PM, Administrative Staff A verified the mailbox key was not in the medication carts and stated she would have to do some in-servicing to the weekend staff regarding the mail. The facility's Resident Right to Privacy in Communication, dated 08/08/2019 documented residents are to have a right to privacy in communications with entities within and external to the facility. The policy documented they would honor the resident's right to privacy in written communication including the right to send and promptly receive mail unopened. Promptly means delivery of mail or other material to the resident within 24 hours of delivery by the postal service (including a post office box) and delivery of outgoing mail to the postal service within 24 hours, except when there is no regularly scheduled postal delivery and pick-up service. The facility failed to deliver mail to the residents in the facility on Saturday.

The facility had a census of 48 residents. The sample included 13 residents with three reviewed for discharge. Based on observation, interview, and record review the facility failed to provide written notice for facility-initiated transfers for Residents (R) 22, R23, and R20 or their representative when they were transferred to the hospital. The facility also failed to notify the Office of the Long-Term Care Ombudsman (LTCO-a public official who works to resolve resident issues in nursing facilities) of R22, R23, and R20's discharge. This placed the residents at risk of uninformed care choices. Findings included: - R22's Electronic Medical Record documented diagnoses of anxiety disorder (mental or emotional disorder characterized by apprehension, uncertainty, and irrational fear), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to insulin), and hypertension (elevated blood pressure). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R22 required supervision for activities of daily living. R22's Care Plan dated 09/08/24 directed staff to observe the resident daily for safety. The plan recorded the resident was taking anti-anxiety medications which are associated with an increased risk of confusion, loss of balance, and cognitive impairment and increase the risk of falls. The Progress Note, dated 05/07/24 at 09:22 AM, documented R22 ambulated with an unsteady gait and staff helped R22 to a chair. R22 was drooling and unable to form a sentence and when asked to smile his right side drooped a bit. The physician ordered staff to send R22 to the emergency room . The Progress Note, dated 05/08/24 at 06:43 PM, documented R22 returned from the hospital. R22's medical record lacked documentation of written notice to R22 or his representative. On 10/14/24 at 04:15 PM, observation revealed R22 sat in a chair at the dining table reading a book with his walker beside him. On 10/15/24 at 10:55 AM, Social Services X verified he had not sent any discharge notices to the state ombudsman office. He stated he was not aware the mental health facilities were to send the notices. On 10/17/24 at 10:00 AM, Administrative Nurse D verified the facility had not provided written notice to the resident or their representative of the reason for the discharge. The facility's undated Bed Hold Policy, documented at the time of transfer for hospitalization or therapeutic leave, the facility would provide to the resident or representative written notice that specifies the duration of the bed hold policy and addresses information explaining the return of the resident to the next available bed. The facility failed to provide written notice of a facility-initiated transfer to R22 or their representative when they were transferred to the hospital and also failed to notify the Office of the Long-Term Care Ombudsman of the discharge. This placed R22 at risk of uninformed care choices and impaired resident rights. - R23's Electronic Medical Record documented diagnoses of urinary tract infection (UTI-an infection in any part of the urinary system), schizoaffective (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), chronic respiratory failure with hypoxia (inadequate supply of oxygen), and hypertension (HTN-elevated blood pressure). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 99, indicating severely impaired cognition. The MDS documented R23 required supervision with some activities of daily living. The Progress Note, dated 09/25/24 at 05:37 PM, documented R23 was seen by her nurse practitioner and new orders included Rocephin (antibiotic), 1 milligram (mg) for UTI and continued Macrobid (antibiotic) as ordered. The Progress Note, dated 09/25/24 at 09:29 PM, documented a change in R23's condition and the physician ordered staff to send R23 to the hospital. On 10/15/24 at 10:02 AM, observation revealed R23 ambulated to the dining room and received a chocolate supplement drink. R23 poured it into the trash and went outside to sit. On 10/15/24 at 10:55 AM, Social Service X verified he had not sent any discharge notices to the state ombudsman office. He stated he was not aware the mental health facilities were supposed to send the notices. On 10/17/24 at 10:00 AM, Administrative Nurse D verified the facility had not provided written notice to the resident or their representative of the reason for the discharge. The facility's undated Bed Hold Policy, documented at the time of transfer for hospitalization or therapeutic leave, the facility would provide to the resident or representative written notice that specifies the duration of the bed hold policy and addresses information explaining the return of the resident to the next available bed. The facility failed to provide written notice of a facility initiated transfer to R23 or their representative when they were transferred to the hospital and failed to notify the Office of the Long-Term Care Ombudsman of the discharge. This placed R23 at risk of uninformed care choices and impaired rights. 32358 - R20's Electronic Medical Record (EMR) documented that R20 had a diagnosis of overactive bladder (a condition that causes sudden urges to urinate that may be hard to control). R20's Quarterly Minimum Data Set (MDS), dated [DATE], documented that R20 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R20 required staff supervision for toileting hygiene. R20's Care Plan, revised 10/01/24-, documented R20 was independent with toileting. The Progress Note, dated 12/23/23 at 04:15 PM, documented R20 was admitted to the hospital. A review of R20's clinical record lacked evidence that the resident or representative was provided written notice when she was transferred to the hospital or of notification to the Office of the Long-Term Care Ombudsman (LTCO-a public official who works to resolve resident issues in nursing facilities) of R20's discharge. On 10/14/24 at 12:30 PM, observation revealed that R20 sat in a wheelchair by the medication cart and visited with staff. On 10/15/24 at 01:03 PM, Social Service X stated he was responsible for providing the bed hold policy to residents but was unaware he was supposed to provide notice when a resident was transferred to the hospital. Social Service X stated nursing was responsible for providing written notice to the resident or his representative when R20 was transferred to the hospital. On 10/15/24 at 01:03 PM, Licensed Nurse (LN) I stated nursing notifies the resident's representative by phone but does not give them a written notice when a resident is transferred to the hospital. On 10/17/24 at 10:00 AM, Administrative Nurse D verified the facility had not provided written notice to the resident or their representative which included the reason for the discharge when R20 was transferred to the hospital. The facility's undated Bed Hold Policy, documented at the time of transfer for hospitalization or therapeutic leave, the facility would provide to the resident or representative written notice that specifies the duration of the bed hold policy and addresses information explaining the return of the resident to the next available bed. The facility failed to provide R20 or his representative with written notice regarding R20's facility-initiated transfer to the hospital and did not notify the LTCO. This placed the resident and/or her representative at risk of uninformed care choices and impaired rights.

The facility identified a census of 49 residents. The sample included 13 residents. Based on record review and interviews, the facility failed to ensure sufficient Licensed Nurse (LN) coverage and adequate weekend staffing. This placed the facility residents at risk for a decline and inadequate resident cares being completed. Findings included: - A review of the Facility assessment dated [DATE] indicated the facility should have a one LN, one Certified Medication Aide (CMA), and three Certified Nurse's Aides (CNA) for morning (06:00AM to 02:00PM) and day (02:00PM to 10:00PM) shifts. The assessment indicated the facility needed one LN and two CNAs for night shift (10:00PM to 06:00AM). The assessment indicated the facility will provide recreational activities from a certified activity coordinator. A review of the facility's Payroll-Based Journal (PBJ -Staffing Data Report) from 01/01/22 through 12/31/22 indicated the facility failed to have 24/7 licensed nurse coverage in the facility for 1/1, 1/2, 1/3, 1/8, 1/9, 1/15, 1/16, 1/22, 1/23, 1/29, 1/30, 2/2, 2/5, 2/12, 2/13, 2/19, 2/20, 2/26, 2/27, 3/5, 3/19, 3/26, 4/2, 4/3, 4/9, 4/10, 4/16, 4/17, 4/23, 4/24, 5/7, 5/8, 5/14, 5/15, 5/21, 5/22, 5/28, 5/29, 5/30, 6/4, 6/5, 6/11, 6/12, 6/19, 6/25, 6/26, 7/2, 7/3, 7/10, 7/17, 7/23, 7/24, 7/29, 8/6, 8/7, 8/9, 8/13, 8/14, 9/4, 9/5, 9/6, 9/7, 9/9, 9/10, 9/17, 9/18, 9/22, 9/23, 9/24, 9/25, 10/1, 10/16, 11/19, 11/20, 12/4, 12/10, 12/11, 12/17, 12/18, 12/25, and 12/26. The PBJ Report indicated the facility triggered for excessively low weekend staffing (submitted weekend staffing data was excessively low) for Fiscal Year (FY) Quarter Two 2022 (January 1, 2022 - March 31, 2022), FY Quarter Three 2022 (April 1, 2022 - June 30, 2022), FY Quarter Four 2022(July 1, 2022 - September 30, 2022), and FY Quarter One 2023 (October 1, 2022 to December 31, 2022). A review of the provided documentation revealed staff coverage (nursing and direct care staff) between 01/01/22 and 07/31/22 (53 reported dates) could not be verified due to lack of facility documentation. The review could not rule out sufficient staffing concerns related to excessively low weekend staffing or licensed nurse coverage. On 05/11/23 at 11:01AM, Resident Council members reported the activities coordinator worked Sunday through Thursday. The council reported activities would often be missed on Saturdays due to not having an activities person and staff too busy to complete activity groups and personal pass mail. (Refer to F576 and F679) On 05/11/23 at 02:20PM Administrative Staff A stated that Activity Coordinator (AC) Z was on vacation, but the staff were covering the activities for the week. She stated she forgot that AC Z was not certified to provide activity. She stated the facility had not had a certified activities coordinator since October 2022. (Refer to F680) On 05/15/23 at 04:41PM Licensed Nurse G reported that activities on Saturdays often get missed due to staff being too busy. She stated direct care staff would try and sit with the residents at times to run groups but sometimes would not happen due to staff being too busy to hold the groups. On 05/15/23 at 04:45PM Administrative Staff A provided the facility's working schedules for 08/2022 - 01/2023 but could not access the schedules for 01/2022 to 07/2022 due to the facility's recent ownership changeover. Administrative Staff A reported she would continue to contact the previous company to retrieve the records needed for review. . On 05/15/23 at 04:45PM Administrative Nurse D reported the facility utilized working schedules with the company's previous ownership and agency staff to support the care staff. She reported Administrative Nurse E and herself would come in to assist call-offs, low staffing, or add extra support to the facility. She reported Administrative Staff B would come in sometimes on her days off to complete activities. The facility did not provide a policy related to staffing as requested on 05/16/2023. The facility failed to ensure sufficient licensed nurse coverage and adequate weekend staffing. This placed the facility residents at risk for a decline and inadequate resident cares being completed.

The facility identified a census of 49 residents. The sample include 13 residents. Based on record review and interviews, the facility failed to provide activities consistently on Saturdays. This deficient practice placed the affected residents at risk for decreased psychosocial wellbeing. Findings Included: - A review of the facility's Activity Calendar on Saturdays for April and May of 2023 revealed that on 4/1, 4/8, 4/15, 4/22, 4/29, 5/6, 5/13, 5/20, and 5/27 the schedule remained the same (10:00AM - Coloring, 01:30PM-Quiet Time, 03:00PM-Puzzles, and 06:00PM- Nightly News). On 05/11/23 at 11:01AM, Resident Council members reported the activities coordinator worked Sunday through Thursday. The council reported activities would often be missed on Saturdays due to low staffing. The council reported staff were busy and often not able to hold groups some weekends. On 05/15/23 at 04:15PM Administrative Staff B stated she was the activity director until July 2022 and transition to another role in the facility. She stated Activity Coordinator (AC) Z took over activities. She stated that AC Z trained with her before assuming the role but was not certified. She stated staff should be providing activities scheduled on the calendars. On 05/15/23 at 04:41PM Licensed Nurse G reported that activities on Saturdays often get missed due to staff being too busy. She stated direct care staff would try and sit with the residents at times to run groups but sometimes would not happen. A review of the facility's Activities implemented 08/2019 indicated the facility will provide ongoing activities to support residents in the choice of activities. The policy indicated scheduled activities are posted and encouraged for all residents. The policy lacked documentation related to training or certification requirements for the AC. The facility failed to provide activities consistently on Saturdays. This deficient practice placed the affected residents at risk for decreased psychosocial wellbeing

The facility identified a census of 49 residents. The sample include 14 residents. Based on observation, record review, and interviews, the facility failed to provide a certified activity professional. This deficient practice placed the affected residents at risk for decreased psychosocial wellbeing. Findings Included: - Upon request, the facility was unable to provide evidence the Activity Coordinator was certified. On 05/11/23 at 02:20PM Administrative Staff A stated that Activity Coordinator (AC) Z was on vacation, but the staff were covering the activities for the week. She stated she forgot that AC Z was not certified to provide activity. She stated the facility had not had a certified activities coordinator since October 2022. On 05/15/23 at 04:15PM Administrative Staff B stated she was the activity director until July 2022 and transition to another role in the facility. She stated Activity Coordinator (AC) Z took over activities. She stated that AC Z trained with her before assuming the role but was not certified. She stated staff should be providing activities scheduled on the calendars. A review of the facility's Activities policy implemented 08/2019 indicated the facility will provide ongoing activities to support residents in the choice of activities. The policy indicated scheduled activities are posted and encouraged for all residents. The policy lacked documentation related to training or certification requirements for the AC. The facility failed to provide a certified activity professional. This deficient practice placed the affected residents at risk for decreased psychosocial wellbeing.

The facility identified a census of 49 residents. The sample included 13 residents. Based on record review, and interviews, the facility failed to obtain pneumococcal (pneumonia infection that inflames air sacs in one or both lungs which may fill with fluid) vaccination consents, declinations, or administration information for Residents (R)10, R29, R9 and R27. This deficient practice placed the residents at increased risk for pneumonia, and related complications. Findings included: - Review of the Electronic Medical Record (EMR) for R10, R29, R9 and R27 revealed the clinical record lacked documentation indicating the residents listed had been offered, consented, refused, or had received the pneumonia vaccination. On 05/15/23 at 04:22 PM Licensed Nurse (LN) G stated that residents are not usually offered or asked about past immunizations at the time of admission. LN G stated she thought it was social services responsibility to ask the resident about current immunization status. On 05/15/23 at 04:44 PM Administrative Nurse D stated that assistant director of nursing assisted her with tracking resident immunizations and offers residents the opportunity to sign a consent or declination for immunizations. On 05/15/23 at 05:02 PM Administrative Nurse E stated questions about immunization was on the admission checklist for the admitting nurse to ask at the time off admission. The facility's Pneumococcal Vaccine (Series) policy dated 11/01/19, documented that it is the facilities policy to offer their residents, staff, and volunteer workers immunization against pneumococcal disease in accordance with the Centers for Disease Control and Prevention (CDC) guidelines and recommendations. The facility failed to provide pneumococcal vaccinations and or informed refusals for R10, R29, R9 and R27. This deficient practice placed the residents at risk for complications related to pneumonia.

The facility identified a census of 49 residents. The sample included 13 residents with two reviewed for dignity. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 33 and R41 were treated in a dignified manner. This deficient practice placed the residents at risk for decreased psychosocial well-being. Findings included: - On 05/11/23 at 09:00AM R41 was assisted to the smoking area by staff. Upon opening the exit door to the smoking area, a staff member yelled out, Make sure [R41] is not wet, he was wet this morning. The staff member pushing R41 yelled back, No, he's not wet. I just checked him. On 05/11/23 at 12:30PM R33 had an incontinent episode during lunch and sat down on the couch in front of the visitor's restroom. An unidentified staff walked up to R33 and made her get out off the couch. The staff member stated loudly Why did you sit on the couch if you know your pants were wet? as other residents were eating lunch within ten feet of R33. The staff member removed the seat cushion and told R33 to go to her room and wait for assistance. On 05/15/23 at 04:02 PM Certified Nurse Aide (CNA) M stated that she would ask the resident to come with her and take them to their room before asking if they needed to use the bathroom or to check them for incontinence. CNA M stated that it would not be okay to ask a resident if they were incontinent in front of others. On 05/15/23 at 04:44 PM Administrative Nurse D stated that staff should not discuss a residents' incontinence in front of others. The facility's Promoting/Maintaining Resident Dignity policy dated 01/01/20, directed staff to speak respectfully to residents and avoid discussions about residents that may be overheard. The facility failed to ensure R33 and R41 were treated in a dignified manner. This deficient practice placed the residents at risk for decreased psychosocial well-being.

The facility identified a census of 49 residents with 13 residents included in the sample. Based on interview and record review the facility failed to issue CMS (Center for Medicare/Medicaid Services) Skilled Nursing Facility Advance Beneficiary Notification (SNF ABN) form 10055 (the form used to notify Medicare A participants of potential financial liability when a Medicare Part A episode ends) and Notification of Medicare Non-Coverage (NOMNC- the form used to notify Medicare A participants of their rights to appeal and the last covered date of service) form 10123 which contained the required information for Resident (R) 32 and R99. This failure placed the residents at risk for decreased autonomy and impaired right to appeal. Findings included: - Review of R32's Electronic Medical Record (EMR) documented the Medicare Part A episode began on 02/02/23 and ended on 04/08/23. R32 remained in the facility for custodial care. The facility did not issue the SNF ABN 10055 to R32. Review of R99's EMR documented the Medicare Part A episode began on 01/31/23 and ended on 02/14/23. R99 remained in the facility for custodial care. The facility did not issue the NOMNC 10123 to R99. On 05/15/23 at 03:12 PM Administrative Staff B stated she was new to the position, and she did not know both forms were required to be given to the residents. Administrative Staff B stated she did not have the missing forms for R32 and R99. The facility's Advance Beneficiary Notices policy dated 11/01/19 documented that the facility shall inform Medicare beneficiaries of his or her potential liability for payment. The policy further documented that the NOMNC form 10123 shall be issued to the resident/representative when Medicare covered service(s) are ending, no matter if the resident is leaving the facility or remaining in the facility. The facility failed to issue the SNF ABN form 10055 and the NOMNC form 10123, which contained the required information for R32 and R99. This failure placed the resident at risk for decreased autonomy and impaired right to appeal.

The facility identified a census of 49. The sample included 13 residents. Based on observation, record review and interview, the facility failed to provide written notice of transfer with the required information to Resident (R)32 and/or to their family/durable power of attorney (DPOA- legal document that named a person to make healthcare decisions when the resident was no longer able to) in a practicable amount of time. This deficient practice had the risk of miscommunication between facility and resident/family and possible missed opportunity for healthcare service for R32. Findings included: - The Electronic Medical Record (EMR) for R32 documented diagnoses of schizophrenia (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), and neuromuscular dysfunction of bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system). The Significant Change Minimum Data Set (MDS) dated [DATE], documented R32 had a Brief Interview for Mental Status (BIMS) score of eight which indicates moderately impaired cognition. The Care Plan with an intervention dated 04/10/23, directed staff to review R32's living will, ensure it is followed and involve R32's family in discussion. A Nurses' Note dated 01/28/23 at 10:01 AM documented that R32 was lethargic, weak, and diaphoretic (sweaty). R32's primary care provider (PCP) was notified of R32's condition and orders were received for Rocephin (antibiotic- medication that inhibits or destroys microorganism that cause infections) injection, Tylenol and directed staff to continue to monitor. A Nurses' Note dated 01/28/23 at 03:02 PM documented that R32 became more alert for a few hours after receiving the Rocephin injection, but again became weak, lethargic, and unable to hold his head up or sit in his wheelchair. R32's PCP was notified, and order was received to send him to the emergency room for evaluation. A General Nursing Note dated 01/30/23 at 08:52 PM documented that R32 was admitted to the hospital. R32's clinical record lacked evidence the facility provided a written notification of transfer/discharge which contained the required information to R32 or representative. On 05/15/23 at 01:04 PM R32 slept on his bed. On 05/15/23 at 04:33 PM Licensed Nurse (LN) G stated she would call their family/DPOA to notify them of the resident's transfer/ admission to the hospital. LN G stated she had never sent a written notification. On 05/15/23 at 04:45 PM Administrative Nurse D stated the charge nurse would notify the family or DPOA by phone, the facility did not send written notification of transfer/admission to the hospital. The facility's undated Discharge Summary and Plan of Care policy documented that discharge planning process is in place which addresses each resident's discharge goals and needs, including caregiver support and referral to local contact agencies. The facility failed to provide written notice of transfer with the required information to R32 and/or to their representative in a practicable amount of time. This deficient practice had the risk of miscommunication between facility and resident/family and possible missed opportunity for healthcare service for R32.

The facility identified a census of 49 residents. The sample included 13 residents with one resident reviewed for quality of care. Based on observation, record review, and interviews, the facility failed to implement a physician order for daily weights to monitor for congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid) for Resident (R) 29. This deficient practice placed R29 at risk of delayed treatment and untreated illness. Findings included: - R29's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hypertension (elevated blood pressure), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), congestive heart failure, and atrial fibrillation (rapid, irregular heartbeat). The Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 14 which indicated intact cognition. The MDS documented that R29 required set up assistance for activities of daily living (ADLs). The MDS documented R29 had received anticoagulant (class of medications used to prevent the formation of blood clots) and diuretic (medication to promote the formation and excretion of urine) for seven days during the look back period. The Quarterly MDS dated [DATE] documented a BIMS score of 15 which indicated intact cognition. The MDS documented that R29 required set up assistance for ADLs. The MDS documented R29 received anticoagulant and diuretic medication for seven days during the look back period. R29's Psychotropic Drug Use Care Area Assessment (CAA) dated 02/02/23 documented staff would monitor for any adverse side effects of medication usage to help prevent or minimize risks of current medication regimen. Staff would administer medications as ordered to help prevent any side effect complications. R29's Care Plan dated 04/04/22 documented staff would observe/document/report as needed any changes in lung sounds, edema and changes in weight. Review of the EMR under Orders tab revealed physician orders: Daily weight on day shift for CHF dated 04/21/23. Review of the EMR under Treatment Administrative Record (TAR) reviewed from 04/22/23 to 05/09/23 (17 days) lacked documentation on 04/26/23 and 04/27/23. The clinical record lacked documentation of refusal and/or physician notification. On 05/15/23 at 02:56 PM R29 sat in the wheelchair in her room and looked outside her window. On 05/15/23 at 04:03 PM Certified Nurse Aide (CNA) M stated everyone worked together to do the weights. CNA M stated she had never worked a dayshift and was not sure how the daily weight was communicated to the day shit. On 05/15/23 at 04:33 PM Licensed Nurse (LN) G stated she usually grabbed the resident in the morning on their way to breakfast and weighed them unless they refused. LN G stated R29 did not usually refuse. On 05/15/23 at 04:45 PM Administrative Nurse D stated she expected the nursing staff to follow the physician orders. The facility's Provision of Quality Care policy dated 02/01/20 documented based on the comprehensive assessments, the facility would ensure that residents received treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person centered care plans, and the residents' choices. Each resident would be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. The facility failed to follow a physician order for daily weights to monitor weight gain for CHF for R29. This deficient practice placed R29 at risk of adverse side effects for unnecessary medication or complications related to CHF.

The facility had a census of 49 residents. The sample included 13 residents with four residents reviewed for accidents. Based on observation, record review and interview, the facility failed to ensure chemicals were stored in a safe, secure manner. This deficient practice placed three cognitively impaired independently mobile residents at risk for preventable accidents and injuries. Findings Included: - On 05/10/2023 at 07:04AM an inspection of the facility revealed the laundry room door (right side) was propped open by a hanger. The room contained two bottles of disinfectant spray and a bottle of lemon scented furniture polish with the warning Caution- Keep Out of Reach for Children label indicating a poison ingestion risk. On 05/16/23 at 04:15PM Certified Nurse's Aide (CNA) M stated the laundry room should always be locked. She stated staff should not be leaving the door unsecured or allowing residents inside the room. On 05/15/23 at 04:35PM Licensed Nurse (LN) G reported staff should never prop or leave the laundry room unsecured. She reported that room had tools and chemicals stored they could injure or harm themselves or others. She reported frequently checked the doors during rounds to ensure it was secured. On 05/15/23 at 04:44PM Administrative Nurse D stated staff were expected to ensure the door always remained locked. She stated resident should never have access to chemicals due to safety concerns. A review of the facility's policy revised 11/2017 indicated the facility must ensure the residnet's safety. The policy indicated staff must ensure all hazards within the enviriment are idnetified and assessed to prevent accidents or injuries. The facility failed to ensure chemicals were stored in a safe, secure manner. This deficient practice placed three cognitively impaired independently mobile residents at risk for preventable accidents and injuries.

The facility identified a census of 49 residents. The sample included 13 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities for monitoring hypertensive medication (class of medication used to treat high blood pressure) for Resident (R) 33 for failure to monitor heart rate and R29 for failure to administer as needed antihypertensive medication as ordered. This deficient practice had the potential of unnecessary medication administration thus leading to possible harmful side effects or harmful consequences. Findings included: - R33's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of edema (swelling resulting from an excessive accumulation of fluid in the body tissues) and hypertension (elevated blood pressure). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented that R33 required supervision and set up assistance for activities of daily living (ADLs). The MDS documented R33 had received insulin (medication to regulate blood sugar), diuretic (medication to promote the formation and excretion of urine) for seven days and opioid (a class of medication used to treat pain) for four days during the look back period. The Quarterly MDS dated [DATE] documented a BIMS score of 15 which indicated intact cognition. The MDS documented that R33 required limited assistance of one staff member for ADLs. The MDS documented R33 had received insulin, diuretic medication for seven days and opioid medication for four days during the look back period. R33's Psychotropic Drug Use Care Area Assessment (CAA) dated 01/17/23 documented staff would monitor for any adverse side effects of medication usage to help prevent or minimize risks of current medication regimen. Staff would administer medications as ordered to help prevent any side effect complications. R33's Care Plan dated 08/15/22 documented staff would administer medication as ordered, observe for any side effects, and notify the physician as needed. Review of the EMR under Orders tab revealed physician orders: Losartan potassium (antihypertensive) oral tablet 50 milligrams (mg) give 50mg by mouth in the evening for hypertension. Hold if systolic blood pressure (SBP-relating to the phase of the heartbeat when the heart muscle contracts and pumps blood from the chambers into the arteries) less (<) than 100 millimeters of mercury (mmHg). and/or heart rate < 60 beats dated 02/17/23. Review of the Medication Administration Record (MAR) from 02/18/23 to 05/09/23 (81 days) lacked documentation of heart rate for losartan administration as physician ordered. Review of the Monthly Medication Review (MMR) from February 2023 to April 2023 lacked notification of the failure to obtain heart rate monitoring for antihypertensive medication as ordered by the physician. On 05/10/23 at 11:29 AM R33 walked down the south hallway with a walker, using a slow steady gait. On 05/15/23 at 04:33 PM Licensed Nurse (LN) G stated once the MMR were reviewed by the physicians, she makes the changes if any new orders were given. LN G stated once the new orders were entered into the resident's clinical record the MMR were sent to medical records where they were scanned into the residents EMR under the Miscellaneous tab. LN G stated the medication aides were good at notification to the nurse if a medication order lacked a blood pressure or heart rate for monitoring. On 05/15/23 at 04:45 PM Administrative Nurse D stated the MMRs were emailed to the assistant director of nursing. On 05/15/23 at 05:02 PM Administrative Nurse E stated the MMRs were emailed to her by the CP. Administrative Nurse E stated she had the physicians review the MMR's and once they have been returned, the charge nurse made the changes in the resident's clinical record. Administrative Nurse E stated once the charge nurse noted the new orders the MMRs were sent to medical records to be scanned into the resident's EMR. On 05//16/23 at 12:40 PM CP GG stated he reviewed the clinical record of each resident monthly and emailed the recommendations monthly to the facility. CP GG stated he would make a recommendation for the facility to follow the physician order to monitor the heart rate as ordered. The facility's Medication Regimen Review dated 01/01/20 documented the drug regimen of each resident would be reviewed at least once a month by a licensed pharmacist and includes a review of the resident's medical chart. The facility staff would act upon all recommendations according to procedures for addressing medication regimen review irregularities. The facility failed to ensure the CP identified and reported irregularities for monitoring hypertensive medication R33 who had hypertension, for failure to monitor physician ordered heart rate. This deficient practice had the potential of unnecessary medication administration thus leading to possible harmful side effects or harmful consequences. - R29's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hypertension (elevated blood pressure), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), and atrial fibrillation (rapid, irregular heartbeat). The Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 14 which indicated intact cognition. The MDS documented that R29 required set up assistance for activities of daily living (ADLs). The MDS documented R29 had received anticoagulant (class of medications used to prevent the formation of blood clots) and diuretic (medication to promote the formation and excretion of urine) for seven days during the look back period. The Quarterly MDS dated [DATE] documented a BIMS score of 15 which indicated intact cognition. The MDS documented that R29 required set up assistance for ADLs. The MDS documented R29 had received anticoagulant and diuretic medication for seven days during the look back period. R29's Psychotropic Drug Use Care Area Assessment (CAA) dated 02/02/23 documented staff would monitor for any adverse side effects of medication usage to help prevent or minimize risks of current medication regimen. Staff would administer medications as ordered to help prevent any side effect complications. R29's Care Plan dated 06/13/22 documented staff would administer medication as ordered, observe for any side effects, and notify the physician as needed. Review of the EMR under Orders tab revealed physician orders: Clonidine tablet (antihypertensive) 0.1 milligram (mg) give one tablet by mouth as needed for hypertension. Give for systolic blood pressure (SBP-relating to the phase of the heartbeat when the heart muscle contracts and pumps blood from the chambers into the arteries) greater (>) than 160 millimeters of mercury (mmHg) or > than diastolic blood pressure (DBP-minimum level of blood pressure measured between contractions of the heart; the bottom number of a blood pressure reading) 100mmHg. Recheck blood pressure in 30 minutes and if not decreasing then call physician for instructions dated 08/25/22 and then discontinued 03/21/23. Review of the Medication Administration Record (MAR) from 01/28/23 to 02/23/23 (27 days) revealed as needed clonidine was not administered on the following three dates 01/28/23, 02/04/23, and 02/19/23. The clinical record lacked documentation of physician notification of elevated blood pressure. Review of the Monthly Medication Review (MMR) from February 2023 to April 2023 lacked evidence the CP identified the as needed antihypertensive medication order was not followed. On 05/15/23 at 02:56 PM R29 sat in the wheelchair in her room and looked outside her window. On 05/15/23 at 04:33 PM Licensed Nurse (LN) G stated once the MMR were reviewed by the physicians, she makes the changes if any new orders were given. LN G stated once the new orders were entered into the resident's clinical record the MMR were sent to medical records where they were scanned into the residents EMR under the Miscellaneous tab. LN G stated the medication aides were good at notification to the nurse if a medication order lacked a blood pressure or heart rate for monitoring. On 05/15/23 at 04:45 PM Administrative Nurse D stated the MMRs were emailed to the assistant director of nursing. On 05/15/23 at 05:02 PM Administrative Nurse E stated the MMRs were emailed to her by the CP. Administrative Nurse E stated she had the physicians review the MMR's and once they have been returned, the charge nurse made the changes in the resident's clinical record. Administrative Nurse E stated once the charge nurse noted the new orders the MMRs were sent to medical records to be scanned into the resident's EMR. On 05/16/23 at 12:40 PM CP GG stated he reviewed the clinical record of each resident monthly and emailed the recommendations to the facility. CP GG stated he would make a recommendation for the as needed antihypertensive medication should be administered as ordered when blood pressure was outside the ordered parameters. The facility's Medication Regimen Review dated 01/01/20 documented the drug regimen of each resident would be reviewed at least once a month by a licensed pharmacist and includes a review of the resident's medical chart. The facility staff would act upon all recommendations according to procedures for addressing medication regimen review irregularities. The facility failed to ensure the CP identified and reported the failure to administer physician ordered as needed antihypertensive medication for R29. This deficient practice had the potential of unnecessary medication administration thus leading to possible harmful side effects or harmful consequences.

The facility identified a census of 49 residents. The sample included 13 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to follow a physician order for monitoring of hypertensive medication (class of medication used to treat high blood pressure) for Resident (R) 33 for failure to monitor heart rate and R29 for failure to administer as needed antihypertensive medication as ordered. This deficient practice had the potential of unnecessary medication administration thus leading to possible harmful side effects or harmful consequences. Findings included: - R33's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of edema (swelling resulting from an excessive accumulation of fluid in the body tissues) and hypertension (elevated blood pressure). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented that R33 required supervision and set up assistance for activities of daily living (ADLs). The MDS documented R33 had received insulin (medication to regulate blood sugar), diuretic (medication to promote the formation and excretion of urine) for seven days and opioid (a class of medication used to treat pain) for four days during the look back period. The Quarterly MDS dated [DATE] documented a BIMS score of 15 which indicated intact cognition. The MDS documented that R33 required limited assistance of one staff member for ADLs. The MDS documented R33 had received insulin, diuretic medication for seven days and opioid medication for four days during the look back period. R33's Psychotropic Drug Use Care Area Assessment (CAA) dated 01/17/23 documented staff would monitor for any adverse side effects of medication usage to help prevent or minimize risks of current medication regimen. Staff would administer medications as ordered to help prevent any side effect complications. R33's Care Plan dated 08/15/22 documented staff would administer medication as ordered, observe for any side effects, and notify the physician as needed. Review of the EMR under Orders tab revealed physician orders: Losartan potassium (antihypertensive) oral tablet 50 milligrams (mg) give 50mg by mouth in the evening for hypertension. Hold if systolic blood pressure (SBP-relating to the phase of the heartbeat when the heart muscle contracts and pumps blood from the chambers into the arteries) less (<) than 100 millimeters of mercury (mmHg). and/or heart rate < 60 beats dated 02/17/23. Review of the Medication Administration Record (MAR) from 02/18/23 to 05/09/23 (81 days) lacked documentation of heart rate for losartan administration as physician ordered. On 05/10/23 at 11:29 AM R33 walked down the south hallway with a walker, using a slow steady gait. On 05/15/23 at 04:33 PM Licensed Nurse (LN) G stated the medication aides were good at notification to the nurse if a medication order lacked a blood pressure or heart rate for monitoring. On 05/15/23 at 04:45 PM Administrative Nurse D stated she excepted the nursing staff to follow the physician orders for medication administration. On 05/15/23 at 05:02 PM Administrative Nurse E stated she would not usually follow physician orders if the nurse had signed off. The facility was unable to provide a policy related to medication administration. The facility failed to follow a physician order for monitoring hypertensive medication for R33 who had hypertension, for failure to monitor heart rate. This deficient practice had the potential of unnecessary medication administration thus leading to possible harmful side effects or harmful consequences. - R29's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hypertension (elevated blood pressure), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), and atrial fibrillation (rapid, irregular heartbeat). The Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 14 which indicated intact cognition. The MDS documented that R29 required set up assistance for activities of daily living (ADLs). The MDS documented R29 had received anticoagulant (class of medications used to prevent the formation of blood clots) and diuretic (medication to promote the formation and excretion of urine) for seven days during the look back period. The Quarterly MDS dated [DATE] documented a BIMS score of 15 which indicated intact cognition. The MDS documented that R29 required set up assistance for ADLs. The MDS documented R29 had received anticoagulant and diuretic medication for seven days during the look back period. R29's Psychotropic Drug Use Care Area Assessment (CAA) dated 02/02/23 documented staff would monitor for any adverse side effects of medication usage to help prevent or minimize risks of current medication regimen. Staff would administer medications as ordered to help prevent any side effect complications. R29's Care Plan dated 06/13/22 documented staff would administer medication as ordered, observe for any side effects, and notify the physician as needed. Review of the EMR under Orders tab revealed physician orders: Clonidine tablet (antihypertensive) 0.1 milligram (mg) give one tablet by mouth as needed for hypertension. Give for systolic blood pressure (SBP-relating to the phase of the heartbeat when the heart muscle contracts and pumps blood from the chambers into the arteries) greater (>) than 160 millimeters of mercury (mmHg) or > than diastolic blood pressure (DBP-minimum level of blood pressure measured between contractions of the heart; the bottom number of a blood pressure reading) 100mmHg. Recheck blood pressure in 30 minutes and if not decreasing then call physician for instructions dated 08/25/22 and then discontinued 03/21/23. Review of the Medication Administration Record (MAR) from 01/28/23 to 02/23/23 (27 days) revealed as needed clonidine was not administered on the following three dates 01/28/23, 02/04/23, and 02/19/23. The clinical record lacked documentation of physician notification of elevated blood pressure. On 05/15/23 at 02:56 PM R29 sat in the wheelchair in her room and looked outside her window. On 05/15/23 at 04:33 PM Licensed Nurse (LN) G stated the medication aides were good at notification to the nurse if a resident's vital signs were outside the physician ordered parameters or elevated. On 05/15/23 at 04:45 PM Administrative Nurse D stated she excepted the nursing staff to follow the physician orders for medication administration. On 05/15/23 at 05:02 PM Administrative Nurse E stated she would not usually follow physician orders if the nurse had signed off. The facility was unable to provide a policy related to medication administration. The facility failed to ensure the physician ordered as needed antihypertensive medication was administered as ordered for R29. This deficient practice had the potential of unnecessary medication administration thus leading to possible harmful side effects or harmful consequences.

The facility identified a census of 49 residents. The sample include 13 residents. Based on observation, record review, and interviews, the facility failed to provide a system to ensure mail was consistently delivered on Saturdays for the residents. This deficient practice placed 49 residents at risk for decreased psychosocial wellbeing. Findings Included: - On 05/11/23 at 11:01AM, Resident Council members reported the facility often would not pass mail on Saturdays due to staff were not aware they were supposed to check the mailboxes and hand it out. The council reported mail would often be locked up until the following Monday. On 05/16/23 at 04:15PM Administrative Staff B stated mail should be collected on Saturdays by the charge nurse and secured in the administrative office until delivery to the residents. She stated the charge nurses should have a key to the mailbox. She stated direct care staff should have passed it out to the residents. On 05/15/23 at 04:41PM Licensed Nurse G reported mail delivery would often be inconsistent due to some nurses not having access to the mailboxes. She reported that some weekends she was not able to unlock the area the mail was locked up. She stated staff received no specific instructions on who was responsible for passing the mail on Saturdays. A review of the facility's Resident Rights policy revised 08/2019 indicated the facility will respect and maintian the services offered by the facility to maintain indepednence and communication with outside services. The facility failed to provide a system to ensure mail was consistently delivered on Saturdays for the residents. This deficient practice placed 49 residents at risk for decreased psychosocial wellbeing.

The facility identified a census of 43 residents. The sample included 14 residents. Based on observation and interviews, the facility failed to provide a home like environment in the facility. This increased the risk for an institutionalized experience for affected residents. Findings included: - On 11/29/21 at 07:57 AM during initial tour of the facility, staff used the overhead intercom system to page residents and staff to the phone and/or activities. The women's hallway had empty carts, soiled linen carts, a fan, a beauty shop chair, mechanical lift, and an empty wheelchair along the hallway. On 11/29/21 at 09:23 AM, during an interview with R93, the floor next to her bed was scuffed and damaged so that the wooden floor material underneath was exposed. R93 stated that the floor was like that when she arrived to the facility on [DATE]. On 11/29/21 at 03:23 PM soiled linen carts, fan, a beauty shop chair, and empty cart remain in the women's hallway. On 11/30/21 at 07:05 AM soiled linen carts, a fan, a beauty shop chair, mechanical lift, empty wheelchair, and empty cart remained in the women's hallway. On 11/30/21 at 11:48 AM phone call for nurse was announced on the overhead intercom system during lunch. On 11/30/21 at 03:26 PM phone call for a resident was announced on overheard intercom system. On 11/30/21 at 04:12 PM soiled linen carts, a fan, a beauty shop chair, mechanical lift, and empty cart remain in the women's hallway. On 12/01/21 at 07:14 AM soiled linen carts, fan, a beauty shop chair, mechanical lift, an empty wheelchair, and empty cart, remained in the women's hallway. On 12/01/21 at 09:01 AM phone call for a resident was announced on overheard intercom system. On 12/01/21 at 10:30 AM phone call for nurse was announced on the overhead intercom system. On 12/01/21 at 10:52 AM phone call for a resident was announced on overheard intercom system -. On 12/01/21 at 11:36 AM phone call for nurse was announced on the overhead intercom system. On 12/01/21 at 02:24 PM soiled linen carts, fan, a beauty shop chair, mechanical lift, an empty wheelchair, and empty cart remained in the women's hallway. On 12/01/21 at 01:33 PM in an interview, Certified Nurse's Aide (CNA) M stated if anything needed repaired, staff filled out a work order form. The maintenance director picked up the work order forms from the desk. Staff also informed the maintence director verbally if they saw him. CNA M stated she was not aware of any policies or reasons related to overhead intercom system related to hours of use or type of use. On 12/01/21 at 01:42 PM in an interview, Licensed Nurse (LN) G stated staff report items that needed repair or replaced by filling a work order form. LN G stated R93's flooring was damaged from a recliner that had been in that room from a previous resident. LN G stated there was not any set times the intercom system was restricted to try to allow for resident comfort. On 12/01/21 at 01:54 PM in an interview, Administrative Nurse D stated workorders have been repaired pretty quickly. Administrative Nurse D stated she was sure maintence director was aware of the floor, since he did all the room transfers. Administrative Nurse D stated that she was not aware of a policy or procedure related to the approved use of the overhead intercom system. On 12/01/21at 02:11 PM in an interview, Maintenance Director V stated he was aware of R93's scuffed floor. He had received a work order and was a list to be repaired, he tracked the workorders of the date received the order and date it was completed. The facility did not provide a policy related to environment. The facility failed to provide a homelike environment for the 43 residents living at the facility a clean and homelike environment which placed the resident at risk for impaired health and wellness.

The facility identified a census of 43 residents. Based on observation, record review, and interview, the facility failed to ensure laundry staff failed to cover clothing racks when transporting clean linen/clothing through the facility as to prevent the spread of infection, and failed to ensure that facility staff measured and recorded water temperatures for the washing machine. This placed residents at risk of contaminants on clothing, and at risk for infection due to laundry not being laundered at appropriate water temperatures to clean and disinfect clothing. Finding included: - Observation on 11/29/21 at 12:12 PM showed a laundry staff member pushed an uncovered portable wheeled clothing rack with clean residents' clothing down the hallways to be delivered to each resident. Observation on 11/30/21 at 12:49 PM showed laundry staff member pushed an uncovered portable wheeled clothing rack with clean residents' clothing down the hallways to be delivered to each resident. On 12/01/21 maintenance staff failed to provide water temperature logs for the washing machine. In an interview of Housekeeping/Laundry Staff U on 12/01/21 at 08:00 AM, she stated that she was a new employee and was not certain if the clothing racks should be covered when they are taken out of the laundry area to be delivered to residents' rooms. She stated she would guess that the rack should be covered with a sheet or something. In an interview with Maintenance Staff V on 12/01/21 at 08:23 AM, he stated that he had worked at the facility for two years and was not aware that the facility should check and record the water temperature on the wash cycle. In an interview with Housekeeping Manager W, on 12/01/21 at 10:09 AM, she stated that clean laundry should be on a covered rack when being stored or transported from the laundry area to the resident's rooms. Administration had been made aware of that specific rack not having a cover and they were working on resolving that issue. Housekeeping Manager W stated there should be daily water temperature logs for the washer. The facility policy The Laundry Process Infection Control: Disinfection in the Laundry Process revised 1/30/13 documented: Most detergent and bleach cycles call for 140 to 160 degrees Fahrenheit (F), which is far above the comfort zone for bacteria. In addition to the water temperature in the wash cycles, the temperature in the dryers provides substantial sanitization. Laundry that is being washed in water temperatures above 160 degrees F must be washed for a minimum of 25 minutes, and wash in water temperatures below 160 degrees F must have 125 parts per million of chemical dispersed. The facility failed to ensure that the wheeled rack with the residents clean clothing items were transported from the laundry room area to the resident's rooms had a covering over it. The facility failed to maintain and document water temperature logs for the washing machine. These deficient practices placed the residents at risk for the potential for exposure to harmful contaminants during transfer, and at risk for micro-organism growth when there was no record of water temperatures to ensure a proper temperature was reached during laundering.

The facility identified a census of 43 residents. The sample included 14 residents, with five residents reviewed for unnecessary medication. Based on observation, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) recommendations were acknowledged and/or followed up for Resident (R) 20 and R10. This deficit practice had the potential for unnecessary medication use and possible unwarranted side effects. Findings included: - R20's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of hypertension (elevated blood pressure) and [CONDITION(S)] (rapid, irregular heartbeat). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented that R20 was independent with her activities of daily living (ADL's). The MDS documented R20 had received antipsychotic medication (class of medications used to treat [CONDITION(S)] (any major mental disorder characterized by a gross impairment in reality testing) and other mental emotional conditions), antidepressant medication (class of medications used to treat mood disorders and relieve symptoms of depression ( abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), for seven days and opioid medication (a class of medication used to treat pain) for one day during look back period. The Quarterly MDS dated [DATE] documented a BIMS score of 13 which indicated intact cognition. The MDS documented that R20 was independent with her ADL's. The MDS documented R20 had received antipsychotic medication, antidepressant medication, anticoagulant medication (class of medications used to prevent the formation of blood clots), diuretic medication (medication to promote the formation and excretion of urine), for seven days and opioid medication for two days. R20's [CONDITION(S)] Drug Use Care Area Assessment (CAA) dated 01/22/21 documented that received antipsychotic and antidepressant medication. She was followed by the pharmacy. R20 's Care Plan dated 02/17/16 documented to give hypertensive medication (class of medication used to treat hypertension as ordered and observe for any side effects as [CONDITION(S)] (blood pressure dropping with change of position) and [CONDITION(S)] (rapid heartbeat greater than 100 beats per minute) and the effectiveness of the medication. Review of the EMR under Orders tab documented: [MEDICATION(S)] (antihypertensive medication) 10 milligrams (mg) one tablet by mouth in the morning for hypertension. Hold medication if systolic blood pressure ( SBP) is less (<) 100mmHg or diastolic blood pressure (DBP < 50mmHg dated 10/08/19. [MEDICATION(S)] (antihypertensive) tablet 25mg, give one tablet by mouth in the morning for hypertension. Hold medication for heart rate < 55 beats and /or SBP , 100mmgh and/or DBP < 50mmHg dated 06/21/19. [MEDICATION(S)] tablet 25mg, give two tablets by mouth at bedtime for hypertension. Hold medication for heart rate < 55 beats and /or SBP , 100mmgh and/or DBP < 50mmHg dated 06/21/19. Review of November 2021 Medication Administration Record (MAR) revealed heart for the bedtime hypertensive was not monitored from November 1,2021 thru November 30,2021. Review of the Monthly Medication Review (MMR) reviewed November 2020 through October 2021 revealed the CP made a recommendation to monitor the heart rate for the hypertensive medication given at bedtime: December 2020; January 2021; March 2021; June 2021; August 2021 and October 2021. On 11/30/21 at 08:42 AM R20 sat on chair at the nurses station as the Certified Medication Aide (CMA) administrated her morning medication. No behavior noted . On 12/1/2021 at 02:10 PM in an interview with Licenses Nurse (LN) G, she stated that parameters are documented on hypertensive medications and should be indicated in the orders for what parameters should be followed. She said usually the medication aides are very good about following that. On 12/1/2021 at 02:30 PM in an interview, Administrative Nurse D stated that the pharmacy review reports should be review by the physician and responses sent back to the pharmacy. She stated that the review reports should be in the charts for nursing staff to review. On 12/02/21 at 02:37 PM in an interview, CP GG stated when a pharmacy recommendation had not been addressed from the previous month, he allowed another month for the facility to address the recommendation. CP GG stated if the recommendation was not addressed he would readdress the recommendation that following month. CP GG stated if the facility was monitoring the vital signs for medication administration in some way and no abnormal vital sign monitoring was noted, he would consider that to be a major concern, for the facility not monitoring R20 pulse on the bedtime administration pf her hypertensive medication. A review of the facilities Medication Administration Policy dated 06/2008 indicated that medications should be administered in accordance with the written physician's orders. Irregularities or discrepancies that are found should be reported to the physician. If applicable and/or prescribed, take vital signs or tests prior to administration of the doses. A review of the facilities Drug Regimen Review dated 6/27/2012 noted the individual reviews communicated to the prescribe shall remain on the clinical record for at least three months after the prescribe review, so it is easily accessible to other disciplines. If a time acute issue is found during the drug regimen review that should be addressed prior submission of the report, the information shall be relayed verbally directly to the Director of Nursing, appropriate nurse, or prescribe. The facility failed to ensure CP recommendations had been addressed for R20 's hypertensive medication. This deficit practice placed her risk of adverse side effects of [CONDITION(S)] and [CONDITION(S)]. Findings Include: -The electronic medical record review (EMR) documented the following diagnoses for R10: [CONDITION(S)] (condition characterized by decreased activity of the [CONDITION(S)]), [CONDITION(S)] (sudden severe confusion, disorientation and restlessness), [CONDITION(S)] (gradual loss of kidney function), hypertension (elevated blood pressure), [CONDITION(S)] with behaviors (progressive mental disorder characterized by failing memory, confusion), type-two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), [CONDITION(S)] disorder(psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), and [CONDITION(S)] disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). R10's Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The Care Area Assessment (CAA) dated 07/08/2021 triggered for R10 included: [CONDITION(S)] drug use related to medication compliance, side effects monitored by using the Abnormal Involuntary Movement Scale (AIMS), [CONDITION(S)] monitoring, independence performing activities of daily living (ADL's), and management of aggression related to cognitive loss while allowing him to makes his own decision directed towards his daily routines. A review of R10's Care Plan dated 8/5/2019 indicated a Black Box Warning for R10's prescribed [MEDICATION(S)] documented side effect risks for severe [CONDITION(S)] (chest pain), [CONDITION(S)] (heart attack), and arrhythmias (abnormal heart rhythms) after abrupt discontinuation of the medication. The Care Plan directed R10's hypertensive medications should be administered as ordered. A review of the Medication Administration Report (MAR) indicated an order for 10 milligrams (mg) [MEDICATION(S)] [MEDICATION(S)] to be administered by mouth at 08:00 AM and 08:00 PM daily for [CONDITION(S)] (rapid heartbeat greater than 100 beats per minute). The order stated to hold the medication if the heart rate was below 60 beats per minute. The ordered was started on 02/11/2021. A review of the Drug Regimen Review (DRR) provided by the facility on 11/30/2021 recommended that pulse readings for [MEDICATION(S)] be charted. The pharmacist noted this in his reports for March, June, October, and November of 2021. A review of the resident's MAR revealed that the charting for the pulse readings had not been completed from February through November 2021. On 11/29/2021 at 09:15 AM R10 rested in his bed watching television. He reported feeling good with no concerns or complaints. He reported that he is taking his medication and insulin. The client appeared calm and comfortable. No concerns or issues observed. On 12/01/2021 at 02:10 PM in an interview with Licenses Nurse (LN) G, she stated that parameters are documented on hypertensive medications and should be indicated in the orders for what parameters should be followed. She said usually the medication aides were very good about following the orders. On 12/01/2021 at 02:30 PM in an interview with Administrative Nurse D, she stated that the pharmacy review reports should be reviewed by the physician and responses sent back to the pharmacy. She stated that the review reports should be in the charts for nursing staff to review. A review of the facilities Medication Administration Policy dated 06/2008 indicated that medications should be administered in accordance with the written physician's orders. Irregularities or discrepancies that are found should be reported to the physician. If applicable and/or prescribed, take vital signs or tests prior to administration of the doses. A review of the facilities Drug Regimen Review dated 6/27/2012 noted the individual reviews communicated to the prescriber shall remain on the clinical record for at least three months after the prescriber review, so it is easily accessible to other disciplines. If a time acute issue is found during the drug regimen review that should be addressed prior submission of the report, the information shall be relayed verbally directly to the Director of Nursing, appropriate nurse, or prescriber. The facility failed to implement and/or acknowledge the pharmacy recommendations to chart R10's twice a day pulse parameter for his [MEDICATION(S)] medication for the months of February through October 2021. This deficient practice placed the resident at risk for ineffective treatment and unnecessary complications.

The facility identified a census of 41 residents. The sample included four residents identified at risk for elopement (when a resident with poor safety awareness, leaves the facility without staff knowledge). Based on record review, observation, and interview the facility failed to provide adequate supervision and appropriate interventions to prevent an elopement. Resident (R1), who ambulated independently and was identified at high risk for elopement, was not checked for approximately 3.5 hours and during that time, exited the facility (between 04:30 A.M. and 08:05 AM) on 10/18/21. A day long search was unable to locate the resident. The deficient practice placed R1 in Immediate Jeopardy. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnosis tab, included a diagnosis of paranoid [CONDITION(S)] (a long-term mental disorder, characterized by delusions and hallucinations that blurs the line between what is real and what is not, making it difficult for the person to lead a typical life). The Annual Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status score of 15, which indicated R1's cognition (orientation to self, time and place) was intact. The MDS documented R1 had delusions and hallucinations during the seven-day assessment period and received anti-psychotic medication (medication to aide with symptoms of mental illness). The MDS documented R1 as independent with most activities of daily living (ADL's) and ambulated without the use of assistive devices. The 07/25/21 Behavior Care Area Assessment (CAA) recorded when delusions were increased, R1 yelled out and become verbally and physically aggressive. The CAA recorded R1 was easily distracted and directed staff to have R1 call family to help de-escalate behaviors. R1's Elopement Risk assessment dated [DATE] documented a score of 12, which placed R1 at high risk for elopement. The Elopement Care Plan initiated on 06/24/21 and revised on 10/07/21 recorded R1's elopement status was elevated to high, due to R1's impaired safety awareness, aimless wandering behavior, and verbalization of wanting to leave the facility. The Care Plan directed staff to distract the resident with diversions like structured activities, offering food, engage in conversation, television, and books. The Care Plan further directed staff to identify any patterns of wandering to determine if R1's wandering was purposeful, aimless, or escapist, or if R1 was looking for something. The Care Plan lacked documentation to address R1's night-time alertness and/or activities such as pacing the halls and showering at night. A Nurses Progress Note dated 04/27/21 at 12:39 AM and 12:41 AM documented R1 spoke loudly in the halls about issues with the constitution and the government and his need to leave the country. A Nurses Progress Note dated 06/21/21 at 09:29 AM documented a nurse counseled R1 that going to the hospital [06/18/21] to get out of the facility was not the correct way. R1 stated he needed help, the military was after him. Staff administered an as needed (PRN) anti-anxiety medication that was ineffective, prior to going to the hospital. R1 stated I wanted the hospital to admit me to a psychiatric hospital to get out of here. A Nurses Progress Note dated 06/24/21 at 11:27 AM documented R1 was added as an elopement risk due to R1 asked to go to the hospital because R1 wanted to go to the convenience store. R1 walked from the hospital emergency room back to the facility. Review of the undated Facility Investigation documented the night shift staff reported R1 was restless on the night of 10/17/21, but R1 made no mention of leaving the facility. R1 showered at 01:30 AM and staff observed R1 in bed, covered up, at 04:30 AM. On 10/18/21 at 08:05 AM R1 was not in his room. The facility initiated the elopement protocol. Staff notified Administrative Staff A. Staff performed a search of all rooms, facility grounds, and local neighborhoods. Staff notified police that R1 was missing. The investigation uncovered R1 pushed a bedroom window, breaking both L brackets (brackets that allowed only 3-4-inch opening of the windows). R1 crawled out the window on the facility's east side, left the window open and closed the curtains, so the open window was not immediately noticed. The investigation recorded R1's heavy coat and tennis shoes were missing from his room and the temperature was 46 degrees Fahrenheit on 10/18/21 in the early morning. On 10/20/21 at 10:00 AM observation of the areas around the facility revealed numerous hazards such as changing slopes, portioned off neighborhood housing, grassy areas with fencing, undeveloped wooded areas, and asphalt side streets, with varying speed limits and minimal lighting. The facility was located on a side street that intersected with a highly trafficked street (0.25 miles from the facility) which had four lanes of traffic moving at 40 miles per hour. Access to an interstate with four lanes of traffic moving at 70 miles per hour was 1.3 miles from the facility. Interviewed on 10/20/21 at 2:02 PM Administrative Nurse D stated R1 experienced a normal level of restlessness the evening of 10/17/21 and nursing staff counseled the resident. R1 would often pace and sometimes yell down the halls, but that was not the case that evening. Administrative Nurse D stated the facility protocol was to check residents every two hours. On 10/18/21, there were newer less experienced staff who documented on the report sheet that Certified Nurse Aid N checked on R1 at 06:30 A.M without seeing him . Review of the facility's Elopement Management policy revised July 2017 recorded: The goal of the elopement management system is to identify residents with potential exiting behaviors to assure the Care Plan and Kardex reflect effective and consistent interventions and safety measures, and to assure staff are educated regarding the Elopement Management System and resident specific interventions. This same policy recorded: If a resident who was at risk for elopement exhibited exit seeking behavior, the behaviors must be documented on the 24-hour report and the resident must be assessed for additional interventions. The facility failed to provide adequate supervision and appropriate interventions to prevent R1, identified at high risk for elopement and with diagnosed mental illness, from exiting the facility in the early morning on 10/18/21. R1 went unchecked for at least 3.5 hours and eloped from the facility during that time. This deficient practice placed R1 in immediate jeopardy for potential accidents and/or life threating injury. The facility implemented and completed the following corrective actions on 10/18/21, prior to the survey: In-services were immediately initiated and completed on 10/18/21 on the following topics: supervision of residents occurs every two hours using two-hour physical checks and ensuring residents are visualized by staff when they are checked, and then their whereabouts are logged. An immediate audit was performed on all resident rooms to make sure that 2 L brackets are present on every window that residents have access to. Any brackets that were bent at all have been replaced and windows are secured so that they only are able to be raised approximately three inches. for fresh air. Social Services X, with assistance of the Interdisciplinary Team (IDT), updated the Elopement Book which identified residents as Very High, High, Medium, or Low elopement risk. The book will be updated with each admission and discharge and will be reviewed monthly at quality assurance and performance improvement activities to verify its accuracy. The deficient practice was cited as past noncompliance.

The facility reported a census of 44 residents with three residents sampled for advance directives. Based on interviews and record reviews, the facility failed to provide Basic Life Support (BLS) which included notification to emergency services (911) and cardiopulmonary resuscitation (CPR-full code, a life-saving medical procedure that consists of chest compressions to allow [MEDICATION NAME] blood to circulate to vital organs, such as the brain and heart and artificial ventilation) to Resident (R)1, whose Care Plan and physician orders [REDACTED]. This deficient practice placed R1 in immediate jeopardy . Findings included: - The [DIAGNOSES REDACTED]. R1's Significant Change Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 11 which indicated moderate cognitive impairment. He required extensive staff assistance with his Activities of Daily Living (ADLs). The Care Area Assessment (CAA) for cognition dated [DATE] documented R1 was able to make his needs known with clear speech. He had difficulty finding words at times. R1's Care Plan revised [DATE] documented R1chose to have CPR preformed. An intervention dated [DATE] directed staff to provide CPR. The physician's orders [REDACTED].>Under the Progress Note tab, an Administration Note dated [DATE] at 01:36 PM documented R1 had vomited. Under the Progress Note tab, an Administration Note dated [DATE] at 12:00 AM documented R1 had one episode of vomiting. The EMR documented a Nurse Note under the Progress Notes tab dated [DATE] at 02:33 AM which recorded, during resident rounds at 11:50 PM, R1 was found lying on his bed in a supine (lying on the back) position, unresponsive, and with no audible nor visible respirations. R1 was void of pulse. His eyes were open and pupils fixed. All vital signs were absent. A call was placed to Consultant Physician GG's pager. At 12:15 AM Consultant Physician GG returned the call and staff notified Physician GG of the resident's status. Staff placed a call to R1's responsible party at 12:17 AM and a voicemail message was left. At 12:20 AM, staff placed a call to notify R1's Power of Attorney (POA) of Healthcare. At 12:33 AM the facility received a call from R1's POA which directed the facility on how to disperse R1's belongings and verified the preferred funeral home. At 12:35 AM, the facility received a call from the funeral home, who requested the facility nurse to call Consultant Physician GG to ask if he would sign the death certificate in order to determine if the coroner needed notification. Staff called Consultant Physician GG's pager at 12:40 AM to inquire of Consultant Physician GG's willingness to sign the death certificate. Consultant Physician GG agreed. The EMR lacked documentation nursing or facility staff notified 911 upon finding R1 unresponsive and lacked documentation CPR was attempted, per R1's wishes, during the 25 minutes between staff identification and physician communication On [DATE] at 02:00 PM Administrative Nurse D stated when she entered R1's room, he was laying on his back, arm to the side of the bed, eyes open, with his head at the foot of the bed. He was white, not stiff yet, was cold, but still flexible. The Certified Nurses Aids (CNAs) saw him between 10:00 PM and 11:00 PM when night shift did change of shift rounds. She said R1 was a full code. Consultant Physician GG stated under the circumstances of his decline and since the family was okay with the condition, he was okay with facility calling it and he would sign the death certificate. Administrative Nurse D stated if staff found someone unresponsive, nursing should assess them for their need, and perform CPR if they were a full code status, if they were arresting at that time. Administrative Nurse D stated R1 was gone, he had been gone for a while and was beyond resuscitation. She stated staff knew the resident's code status by checking the electronic medical record. On [DATE] at 03:24 PM Administrative Nurse D stated they did not call 911 and called Consultant Physician GG first since it had been over an hour since last time someone saw R1. In an interview with Consultant Physician GG on [DATE] at 9:00 AM he stated he received a call around 12:30 AM. He said, obviously CPR would be the first thing they would do normally before a phone call, but they called me first. Consultant Physician GG said he told them not to do CPR because the report he received was R1 was cool to the touch and rigor mortis had started to set in. He further stated normally when taking care of people who die unexpectedly, he asked if they were just awake recently and he would have them start CPR and call 911. He went on to say R1 was outside the normal resuscitation and it would not have made a difference to his life. He said R1 had been declining and they had not yet got him on hospice. Consultant Physician GG stated he felt that at the time calling off the resuscitation was the correct call. In an interview on [DATE] at 09:50 AM CNA N stated she and CNA O were getting ready to pass out denture cups, urinals, and stuff. They went to R1's room first and that's when they saw him on the bed. It was obvious he was dead. CNA N went and got Administrative Nurse D. They entered R1's room about 11:,[DATE]:45 PM. CNA O said she saw him sitting up about 20 minutes before that. When they touched him to clean him up, his body was warm. Administrative Nurse D listened to R1 with the stethoscope. He was laying with head at foot of the bed with his right arm hanging off the bed. They got him up on the bed, took his t-shirt off. He had fluid coming out of his mouth. They cleaned him up, put a hospital gown on him, covered him up and waited for the funeral home to pick him up. CNA N stated she honestly could not say what R1's code status was. She thought he was a DNR (DNR-Do Not Resuscitate). She said the code status is found in the chart. She stated when a resident is a full code, staff were supposed to start CPR. The facility's Medical Emergency Management policy, last revised February 2017, documented once a medical emergency was identified, qualified staff assessed the resident, initiated the appropriate emergency procedures in accordance with physician's orders [REDACTED]. The staff continued to provide care and monitor the resident until the emergency personnel arrive. The facility failed to provide resuscitative measures, including calling 911 and providing CPR, to R1 whose advance directives and physician's orders [REDACTED]. These failures resulted in the non-adherence to R1's wish for resuscitative measures and R1 was pronounced dead in the facility. This deficient practice placed R1, who desired a full code, in immediate jeopardy. The facility removed the immediate jeopardy when it implemented the following: An audit was performed on all resident files to make sure that the code status sticker in the front of the chart matched the code status order in the file. In-services were immediately initiated on the following topics: CPR regulation, Guidelines for initiating CPR, distinguishing between clinical death (lack of vital signs) and irreversible death (as defined by the State Operation Manual) and initiation of emergency response to include but not limited to initiating CPR, calling 911, notifying the Primary Care Physician. All licensed nurses will also participate in a mock code with return demonstration to verify that they understand the policy and procedure and that they are able to perform CPR appropriately. This deficient practice remained at the scope and severity of a D.

The facility identified a census of 49 residents. The sample included 3 residents reviewed for accidents. Based on observation, record review and interview, the facility failed to ensure 1 resident (#1) received adequate supervision and appropriate interventions to prevent two elopements after staff identified the resident was at risk for elopement. Resident #1 exited the facility on 2 separate occasions when he/she used unsecured splintering, wooden pallets to climb over a fence in the locked facility courtyard. The facility further failed to ensure this resident's safety when he/she ingested razor blades and required hospitalization on two separate occasions. These deficient practices placed resident #1 in immediate jeopardy. Findings included: - The physician's orders [REDACTED].#1 included [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident's cognition was intact, and he/she had no behaviors and/or rejection of cares during the assessment period. The resident was independent with activities of daily living (ADLs) such as ambulation, dressing and toileting, and received anti-psychotic medications (major tranquilizers, a class of medication primarily used to manage mental illness), and anti-depressant medications. The 1/27/17 care area assessment (CAA) for behavior did not trigger. The CAA for Activities of Daily Living (ADLs) documented the facility would develop a care plan to maintain the resident's ADL independence. The CAA also indicated a care plan would be developed to address the resident's mood and psychotropic medication use. The CAA lacked narrative documentation or analysis for all triggered areas. The resident's initial care plan dated 1/23/17 (4 days after admission) did not address the resident's risk for elopement from the facility. The initial care plan care plan dated 1/23/17 documented the resident had a potential for self-harm and directed staff to refer the resident to his/her safety plan when he/she expressed an urge to harm him/herself, initiate safety checks as indicated, administer medications as ordered, observe and document for side effects and effectiveness, allow choices within his/her decision making ability, provide the opportunity for a positive interaction, attention and stop and talk with him/her when passing by. The care plan and safety plan lacked documentation of any new interventions to prevent future elopements after the resident exited the facility on 1/22/17 after 5:15 A.M. and returned to the facility at 8:50 A.M. (3 hours and 35 minutes). The care plan and safety plan lacked documentation of any new interventions after the resident exited a local hospital (without facility knowledge) on 1/30/17 at 10: 40 P.M. and returned to the facility on [DATE] at 8:35 A.M. (9 hours and 55 minutes). The care plan and safety plan lacked documentation of any new interventions after the resident exited the facility again on 1/31/17 at approximately 5:45 P.M. (the medical record does not note a return time to the facility). The care plan recorded the resident had a history of [REDACTED]. The care plan directed staff to have the resident avoid activities that involve bending or lifting, discuss with the resident or family any concerns related to stomach distress, give medications as ordered and observe/document side effects and effectiveness, obtain and observe lab work as ordered and report the results to the physician. The care plan update on 1/31/17 documented staff placed the resident on 15 minute checks. The care plan lacked direction to staff with safety measures to prevent access to harmful items the resident could ingest. The care plan also lacked documentation of any new interventions after the resident received treatment for [REDACTED]. Review of the resident's admission personal inventory log dated 1/19/17 failed to document the resident had any razor blades. Review of the nurse's progress note dated 1/22/17 at 7:22 A.M. documented at 2:50 A.M. the resident requested to go to a local crisis center for a screening. Staff explained the crisis center could not provide a screening at this time. The resident's behavior escalated and he/she barricaded his/herself in the bathroom and made a very small superficial mark on his/her wrist. He/she became argumentative with staff, conversed on his/her cell phone and sometime after 5:15 A.M., he/she exited the facility through the patio door, climbed over the fence, and left with his/her significant other. The resident returned to the facility on [DATE] at 8:50 A.M. after he/she received medical attention at a local hospital for his/her right hand. The resident stated he/she hit the wall a couple of times and called his/her significant other to take him/her to the hospital. The resident provided paperwork from the hospital for treatment of [REDACTED]. He/she had a splint on, with an ace wrap and an ice pack. There were no new physician orders. Review of the nurse's progress note dated 1/23/17 at 9:50 P.M. documented the resident reported to staff he/she swallowed 2 razor blades. He/she showed a broken blue safety razor with two blades missing. Staff activated emergency medical services and resident was transported to the hospital. The nurse notes documented a follow-up call to the emergency room documented the resident had in fact swallowed razor blades and the objects were removed by a tube placed to remove a foreign object. The resident returned to the facility on [DATE] at 3:30 P.M The facility submitted an investigation of the incidents to the State Agency on 1/24/17 at 11:10 A.M. (3 days after a first incident/accident of exiting the facility) The investigation lacked documentation of how the resident exited the facility on 1/22/17, where he/she went, how long he/she was treated in the hospital emergency room and how he/she returned to the facility. The nurse's note dated 1/30/17 at 9:10 P.M. documented the resident presented at the nursing station requesting hospitalization for right hand swelling, which was two times the normal size. The resident said he/she hit it against the wall. The resident transported to the emergency room for treatment. The nurse's note dated 1/31/17 at 2:28 A.M. documented a phone call placed to the hospital emergency room revealed the resident had been discharged at 10:40 P.M. on 1/30/17. The nurse's note dated 1/31/17 at 7:35 A.M. documented the resident returned to the facility. He/she stated he/she returned by public transportation. The nurse's note dated 1/31/17 at 8:46 P.M. documented the resident exited the building at 5:30 P.M. for a local crisis center and refused to come back to the facility. The resident returned to the facility escorted by the police department at 8:28 P.M Shortly after the police left the facility, the resident ran out of the facility office onto the patio and jumped the fence. The electronic medical record lacked documentation the resident returned to the facility after his/her exit on 1/31/17 at 8:28 P.M The nurse's note dated 2/1/17 at 1:10 P.M. documented the facility received a call from a police officer who stated at approximately 1:05 A.M. he/she received a phone call from the resident. The resident stated he/she swallowed 4 razor blades. At this time, the resident confirmed to facility staff he/she swallowed the blades. The resident was transported to the hospital. The nurse's note dated 2/1/17 at 4:11 A.M. documented the hospital confirmed evidence of razor blades in the resident's stomach and at present, hospital staff was discussing the resident's course of treatment. On 2/2/17 at 10:20 A.M. the resident laid in the bed at the hospital. On 2/2/17 at 11:20 A.M., two broken wooden pallets were stacked in the facility courtyard. Smaller boards were stacked at the base of the east side of the fence. On 2/2/17 at 11:45 A.M., a disposable blue razor, 4 plastic blade covers, and a razor 6 pack multipack wrapper laid in a trash can in the facility's gender specific bathing/shower room. On 2/2/17 at 10:20 A.M., the resident stated he/she had a history of [REDACTED]. The resident stated he/she did not like it at the facility, as he/she had no one the same age to associate with. The resident stated he/she used the boards from the pallets to stand on and climbed over the fence in the courtyard when he/she left the facility. The resident stated the facility did do an inventory when he/she arrived, but staff only inventoried what the resident wanted them to. He/she stated the first time he/she swallowed the razor blades, he/she had them with his/her belongings, and the second time he/she swallowed the razor blades, he/she found them in an unattended, unlocked drawer in the gender specific shower room at the facility. On 2/2/17 at 3:20 P.M. administrative licensed nurse E stated he/she received a call on 1/22/17 at 5:10 A.M. from facility staff the resident punched a wall and then jumped the fence. Staff E stated staff interviewed the resident after the first incident, but an investigation was not completed. The resident was not considered an elopement risk after this incident, because Staff E felt the resident did not elope, due to staff witnessed the resident leave the facility. Staff E stated the facility did not place any new interventions or report the incident, because staff did not anticipate the resident to elope again. Administrative nursing staff E further stated he/she was presented with a blue broken razor on 2/1/17 by the resident. The resident stated he/she swallowed the blades, but it was not the same brand as the facility used. Staff E further reported staff searched the resident's room after the resident swallowed the razor blades and found nothing. On 2/2/17 at 1:20 P.M. administrative staff D stated he/she watched the resident run from his/her office on 1/31/16 at 5:30 P.M. and climb over the fence. Staff D stated he/she expected the facility razors to be kept in a locked cabinet in the bathing/shower rooms, and the overstock of razors was stored in a room behind the nurse's station. The facility policy titled Resident Elopement, revised 5/5/16, documented the facility would provide a safe environment and preventative measures for elopement. Nursing personnel must report and investigate all reports of missing residents. The facility did not provide a policy related to the resident's safety from self harm. The facility failed to ensure this resident received adequate supervision and appropriate interventions to prevent an elopement after staff identified the resident was at risk for elopement. The resident exited the facility on 2 separate occasions when he/she used unsecured splintering, wooden pallets to climb over a fence in the facility courtyard. The facility further failed to ensure this resident's safety when (on two separate occasions) he/she ingested razor blades and required hospitalization . These deficient practices placed resident #1 in immediate jeopardy. The facility abated the immediate jeopardy on 2/4/17 at 10:00 P.M. when it implemented the following: Immediate Action Taken: The resident identified was no longer in the building. Upon resident's return, resident will be limited to a set amount of personal belongings, any item that was deemed unsafe would need to be checked out from the nurse. Staff will monitor him/her while using it and then the item will be returned to lock up. At this time, the resident's significant other was not allowed on the campus due to his/her behavior and the possibility of him/her bringing the resident unsafe personal items. The resident's guardian was made aware of these actions and had approved of them. The care plan would be updated and staff education would be completed by 2/4/17 at 10:00 P.M Identification of Others: Audits were completed on 2/2/17 by 10:00 P.M. to identify if any other residents were at risk for self-harm. Two residents were identified as potential for self-harm, and both had existing care plans in place. All care plans were reviewed by the interdisciplinary team (IDT) on 2/2/17 at 10:00 P.M Systemic Changes: All rooms would be searched for objects deemed unsafe by IDT and removed by staff on or before 2/3/17 at 12:00 P.M Education would be given to staff about any residents identified to be at risk for self-harm by the social worker or the director of nursing (DON). Education would be provided to all new staff upon hire. Staff education would be completed by 2/4/17 at 10:00 P.M All new admissions and residents with change of condition or behavior would be assessed for self-harm. Facility staff would be educated on proper disposal of used razors. All razors will be locked in the nurse's station where the charge nurse has the only key. The razors and sharps container would be taken by staff during shaves and returned to charge nurse for proper lock up. Monitoring: The administrator or DON would monitor ongoing staff education and residents identified at risk for self-harm. All rooms would be monitored 3 times a week, with high risk rooms (rooms with resident determined to have self-harm behaviors and shower rooms) would be monitored daily for 30 days. Random rooms would be monitored weekly for 60 days, with high risk rooms continuing to be monitored daily. Any identified trends or concerns from room monitoring, residents identified at risk for self-harm or safety issues would be reported to the Quality Assurance (QA) Committee by the administrator or DON. Immediate Action Taken: Staff removed the wooden pallets from the fence area, and the fence was checked for any other possible areas of concern, and none were noted. Systemic Changes: All residents would be reassessed using the elopement risk assessment and would be added to the elopement book at the nurse's station. All residents who were deemed to be unsafe to leave the facility unsupervised would not leave under any circumstance without staff. If a transported by ambulance out of the facility, staff would supervise the resident while at the emergency room . The resident would be escorted back to the facility by facility staff. All staff will be educated on this new system by 2/4/17 at 10:00 P.M The facility's door lock system would be added to the patio door. The door would remain open during smoking hours and locked from 1:00 A.M. to 6:30 A.M The door would not open except by the staff key. All staff would be educated on the new lock on the patio door by 2/4/17 at 10:00 P.M Staff will be in attendance with all residents who require assistance with smoking and would monitor the residents on the patio through the facility's camera. Monitoring: The administrator or DON would monitor the fence area daily for possible areas residents could climb over the fence. Staff would be educated on residents who were identified as elopement risks, and new staff would receive training in orientation regarding the elopement policy and high risk residents. Any identified trends or concerns or residents determined as elopement risk or safety issues would be reported to the QA Committee by the administrator DON. This deficient practice remained at the scope and severity of a G.

The facility identified a census of 48 residents. The sample included 3 residents. Based on observation, interview, and record review, the facility failed to provide supervision for resident #1, a cognitively impaired independently mobility resident assessed as an elopement risk, to prevent the resident from leaving the facility without the facility staff knowledge for approximately 30 minutes. The resident was found approximately 0.6 miles from the facility. This deficient practice placed the resident in immediate jeopardy. Findings included: - Resident #1 had [DIAGNOSES REDACTED]., social or interpersonal functioning), convulsions (involuntary series of contractions of a group of muscles), and anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The annual Minimal Data Set (MDS) assessment, dated 9/22/15, documented the resident with a Brief Interview for Mental Status (BIMS) score of (9), which identified the resident had moderately impaired cognition. The resident experienced indicators of delirium, disorganized thinking, hallucinations, and delusions. The resident exhibited wandering behaviors during 1 to 3 days of the assessment period, which placed the resident at significant risk of getting to a potentially dangerous place and significantly intruded on the privacy or activities of others. The resident was independent with all his/her activities of daily living. The Care Area Assessment (CAA) for cognition, dated 10/5/15, documented the resident with the [DIAGNOSES REDACTED]. The resident often made poor decisions because of his/her delusions, which affected his/her cognitive status. The resident often wandered through and made attempts to leave the facility. The CAA for behaviors, dated 10/5/15, documented the resident frequently wandered and made attempts to leave the facility. Staff assessed the resident was an elopement risk and required supervision while outside of the facility. The resident made poor decisions and put him/herself in danger. The quarterly ((MDS) dated [DATE], documented the resident with a (BIMS) score of (9), which identified the resident with moderately impaired cognition. The resident experienced indicators of delirium, disorganized thinking, hallucinations, and delusions. The elopement assessment, dated 10/13/15, recorded the resident was at risk for elopement. The resident's plan of care for elopement, dated 10/28/15, documented the resident was an elopement risk, had previously attempted to leave the facility and staff observed the resident's location at regular and frequent intervals. The care plan directed the staff documented wandering behavior and attempted diversional interventions. The staff redirected the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and a book. The care plan for impaired cognitive function, dated 1/17/16, documented the resident had difficulty expressing him/herself which put him/her at risk for safety issues due to poor decision-making and insight, and a history of attempts to leave the facility due to his/her delusional beliefs. The care plan directed staff to discourage the resident from yelling out whoohoo and other loud verbalizations. This behavior was a good indication that the resident would attempt to leave the building. A hand-written care plan intervention, dated (2/26/16), (sic) directed staff to provide 15-minute visual checks of the resident and one to one observation if the resident seemed to be exit seeking. During an interview, on 3/15/16 at 3:55 P.M., with administrative A confirmed administrative nursing staff D misdated the intervention, which was actually initiated on 2/27/16 in response to the resident's elopement. A nursing behavior note, dated 1/31/16 at 2:22 P.M., documented the resident exited out the south door of the facility and staff brought the resident back into the building without difficulty. A nursing note dated 2/27/16 at 12:21 P.M., documented at 10:05 A.M., staff received a phone call from licensed nursing staff H, reporting he/she was near a convenient store and bringing the resident back to the facility. Review of the facility provided investigation, dated 3/4/16, documented on 2/27/16 between 9:15 A.M. and 9:30 A.M., the resident exited the front door of the building without facility staff knowledge. The investigation documented the assumption the resident followed licensed nursing staff H out the front door when he/she left the facility in his/her car, at approximately 9:15 A.M. At approximately 9:30 A.M., from his/her vehicle, licensed nursing staff H observed the unattended resident at the corner of a main intersection (according to Google maps, approximately 0.6 miles from the facility) and staff called the facility at 9:43 A.M. to report he/she had the resident. At approximately 10:00 A.M., licensed nursing staff H returned to the facility with the resident. The speed limited posted at the main intersection was 40 miles per hour. According to Wunderground.com, on 2/27/16 at 9:53 A.M. the temperature was 52 degrees Fahrenheit, clear skies, and no wind. Observation, on 3/15/16 at 10:41 A.M., revealed the resident walked slowly, with his/her head tilted to the right, in the hallway of the facility and called out whoohoo. At 11:02 A.M. the resident continued walking in the hallway in the facility and called out whoohoo. On 3/15/15 at 11:07 A.M., administrative staff A reported on 2/27/16, the resident wanted to go a medical center (VA) and found the opportunity to leave without staff knowledge. When staff returned the resident to the facility, placed the resident on 15-minute checks and immediately repositioned the (front door) camera. During an interview, on 3/15/16 at 1:15 P.M., the resident reported he/she had two jobs here sanctioned by the emperor. The resident stated that past presidents of the country had been put into power by the emperor. The resident continued John Fitzgerald Kennedy sanctioned a trip for the country to put a plane on the moon, but the moon is actually a reflection of the sun from the earth and NOT a physical place. Review of a statement by direct care staff O, dated 2/27/16, documented staff observed the resident in the dining room at 9:10 A.M. and licensed nursing staff H called to report the resident had left the facility. On 3/15/16 at 1:18 P.M., licensed nursing staff H reported on 2/27/16 at 9:15 A.M., the resident was in the dining room clearing tables when he/she went out the facility front door and left on break in his/her car. Licensed nursing staff H revealed while driving to return to the facility at approximately 9:30 A.M., he/she observed the resident standing unsupervised, on the corner of an intersection. Licensed nursing staff H reported he/she called the facility at approximately. 9:43 A.M. to advise he/she was with the resident. On 3/15/16 at 1:12 P.M., licensed nursing staff I revealed he/she heard the door alarm on 2/27/16 at approximately 9:15 A.M., looked at the monitor to observed licensed nursing staff H leave the building, and silenced the alarm. Licensed nursing staff I revealed he/she did not observe the resident leave the building. On 3/15/16 at 4:40 P.M., direct care staff P revealed the resident was an elopement risk. Direct care staff P stated staff kept an eye out to make sure the resident was in the building, and when someone went out the door, staff needed to know who went out. During an interview on 3/15/16 at 4:38 P.M., housekeeping staff X reported he/she saw the resident in the lobby area of the building between 9:00 A.M. and 9:15 A.M. Housekeeping staff X reported the resident had tried to leave the building in the past, and was not supposed to leave the building without staff supervision. The facility provided policy for Resident Elopement, dated 6/2007, directed when an employee heard a door alarm, he/she would a) immediately go to the site of the alarm; b) if a resident was attempting to elope, follow the steps outlined for an attempted elopement; and c) if no resident was found to be exiting the facility, the employee would exit the facility, walk around the building, and ensure that a resident had not already exited the facility. The undated facility provided Door Monitor Policy, directed all outside doors with resident access were equipped with door monitors to alert staff to people entering/leaving the facility. The monitors were equipped to sound a loud signal at the Nurses' station and had to be reactivated at the control switch at the Nurses' station. When a door monitor sounded, all staff was to be alert as to who entered or left the building. The facility failed to provide supervision to prevent the resident, identified as at risk for elopement, from leaving the facility unattended without staff knowledge. This deficient practice placed this cognitively impaired resident at risk for elopement, in immediate jeopardy. The facility abated the immediate jeopardy on 3/17/16 at 3:00 P.M., when the facility: 1) Immediately placed the resident identified as elopement risk on 15-minute visual checks. 2) Staff adjusted the front door entrance camera immediately to lessen the blind spot of the view in the area in which the resident eloped. 3) Installed Ring doorbell mobile monitoring system with video and audio surveillance activated by motion as well as push button on 3/15/16 at 6:00 P.M. 4) Additional camera installed on 3/16/16 at 2:00 P.M., which provided complete views to both sides of the front door for the stationary monitor. 5) Revised a Door Monitor Policy on 3/17/16, which included direction to staff for the Ring Monitoring system. 6) Completed all staff inservices for Resident Elopement policy and Door Monitor policy on 3/17/16 at 3:00 P.M. The deficient practice remained at the scope and severity of a D.