Every finding on record at Coleman Healthcare Center

Based on observations, interviews, and record review the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. 1. The facility failed to ensure DA wore a hair net when he entered the kitchen.2. The facility failed to ensure the cook wore gloves while touching bread when serving food. These failures could place residents at risk for contamination and foodborne illnesses. Findings included: During an observation on 03/03/2026 at 9:59 AM the DA was wearing a baseball cap with hair pulled through the back (ponytail), without the use of a hair net . The [NAME] was observed touching the bread with her bare hand. During an interview on 03/05/2026 at 3:00 PM, the CCS stated all staff in the kitchen should have been wearing a hair net, he stated even if wearing a ball cap, no hair should be uncontained. The CCS stated if any staff were working in the kitchen, if they were going to touch food, the staff had to be gloved. He stated the DM should have monitored the staff in the kitchen better and that was where the failure was. The CCS stated there could have been the possibility of contamination with staff having not worn a glove while serving bread. During an interview on 03/06/2026 at 11:30 AM, the DM stated all staff entering the kitchen or working in the kitchen should always have a hairnet on prior to walking into where food was prepared and/or served. She stated when preparing food and plating residents' food, they should not at any time have touched food without a glove being worn. The DM stated there could be cross-contamination from both hairnets not being worn as well as touching the food without being gloved. The DM stated she should have been monitoring her staff closer and was her duty to do so. She stated her expectations in the kitchen were for staff to follow the protocols and guidelines that the facility gives out. During an interview on 03/06/2026 at 11:15 AM the dietician stated that all staff that enter the kitchen where the food was served, they should have a hairnet. She stated it would not be her recommendation for only a ballcap if the hair was out. The Dietician stated staff should not have touched ready to eat food without a glove. She stated the potential harm to residents was cross contamination. The Dietician stated the DM monitored the kitchen staff. She stated the failure occurred when the previous with the DM not enforcing or monitoring was not done as well as failed to comply with facility policies. The Dieticians expectations was for the DM in charge of kitchen follow policies. Record review of facility policy Food Preparation and Service dated 06/23/2025 revealed: Policy Statement: Food and nutrition services employees prepare and serve food in a manner that complies with safe food handling practices. Policy Interpretation and Implementation- food Preparation area. 5. Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness.Food Service/Distribution-5. 6. Bare hand contact with food is prohibited. Goves are worn when handling food directly and changed between tasks. Disposable gloves are single-use items and are discarded after each use. 7. Food and nutrition services staff wear hair restraint (hair net, hat, beard restraint, etc.) so that hair does not contact food. Review of the FDA Food Code 2022 Review of the FDA Food Code 2022 FDA Food Code 2022: Full Document accessed 02/27/2025 revealed: 2-402.11 Effectiveness. (Hair Restraints) 1. Code of Federal Regulations, Title 21, Sections 110.10 Personnel. (b) (1) Wearing outer garments suitable to the operation (4) Removing all unsecured jewelry (6) Wearing, where appropriate, in an effective manner, hair nets, head bands, caps, beard covers, or other effective hair restraints. (8) Confining .eating food, chewing gum, drinking beverages or using tobacco and (9) Taking other necessary precautions code accessed 03/23/2023 revealed: Review of the FDA Food Code 2022 Annex 4. Management of Food Safety Practices - Achieving Active Managerial Control of Foodborne Illness Risk Factors Annex 4 - 7: Full Document accessed 03/20/2025 revealed: .practicing no bare hand contact with ready-to-eat food as well as proper handwashing, and implementing an employee health policy to restrict or exclude ill employees are important control measures for viruses.

Based on interview and record review, the facility failed to ensure that the facility had an Administrator licensed by the state that was responsible for management for 1 of 1 facility's reviewed for governing body. The facility failed to ensure the Assistant Administrator, who was acting as the facility Administrator, had an active Texas Administrator license. The facility had not had a licensed administrator since 06/20/2025. This deficient practice could result in decreased quality of life and quality of care due to a lack of staff oversight and monitoring of care.The findings include:During Interview on 3/06/2026 at 3:30 p.m. The Assistant administrator stated she had failed her test to be a licensed Administrator. She stated she had applied to retest and was waiting for a date to test again. She stated RDO (Regional Director of Operations) was the licensed Administrator covering the building. She stated she could call her if she needed her. She stated there was no negative outcome for residents due to her lack of a valid Administrator license. During interview on 03/06/2026 at 3:45pm the RDO stated the facility has been without a licensed Administrator for several months. She stated she was a licensed Administrator in Texas. The Assistant Administrator was hired to move into the position of licensed administrator over the facility when she passed her licensure exam. She stated the Assistant Administrator failed the examination but had applied to test again. She stated she had not been actively seeking a licensed administrator because the job had been promised to the assistant administrator. She stated that she did not know of any negative outcome for residents as a result of the facility not having a licensed administrator She stated she had visited the facility about 4 times since the last licensed administrator's employment ended, and she was always available by phone for the assistant administrator if she was needed. She stated she thought the Assistant Administrator was doing an excellent job of managing the facility.During interview on 03/07/2026 at 4:15pm the DON stated he was the designated Abuse Coordinator if there was not an Administrator.Record review of the facility's Active Employee Report provided by the facility revealed the Assistant Administrator was hired on 07/23/2024.During the exit conference on 03.06.2026 at 5:00 PM the facility was unable to provide a policy regarding facility administration.

Based on interview and record review the facility failed to ensure Nurses' Aides were not working in the facility longer than four months without being enrolled in or having completed an approved training course for 2 (NA C and NA D) of 5 nurse aides reviewed. The facility failed to ensure NA C and NA D were certified within the required time frame. This failure could place residents at risk of receiving care from an individual whose skill level was unknown. Findings include: Record review of employee facilities files revealed: -NA C had a hire date of 4/08/2024, worked full time, and no evidence of nurse aide certification. -NA D had a hire date of 03/21/2025 and worked full time and no evidence of nurse aide certification. During an attempt at phone interviews on 03/06/2026 at 4:25 p.m. NA C and NA D were not available. During an interview on 03/06/2026 at 4:15 p.m. with the DON and ADON both stated that the expectation would be for the facility to have certified nurse assistants. The ADON stated that both she and the DON were aware that NA C and NA D had not been tested. She stated there had been no certified applicants and they had only been able to hire NAs. She stated that NA C had been terminated before for not having her CNA certification. She stated she had taken the CNA Class twice and not passed the test. She stated NA C required special accommodation for testing and will take the test again on 03/25/2026. She stated NA D Completed NA training on 06/25/2025 and was currently waiting on a test date. She stated there had been no negative outcome for residents, but receiving care from an uncertified aide could place a resident at risk of not receiving appropriate care. Review of facility policy titled The Role of the Hospitality Aide dated March 2020 revealed in part: The Hospitality Aide performs non-nursing, non-direct care duties under the supervision of licensed nursing personnel and assists in maintaining a positive physical social and psychosocial environment for the residents. Position qualification: Must possess a minimum of a high school diploma or equivalent, must complete a minimum of 10th grade education level, must be able to lift fifty pounds, any combination of experience and training which provides the required skill, knowledge and abilities, Answer call lights. Make unoccupied beds, assist with feeding non-aspiration on non -choking risk residents.

Based on observation, interview and record review, the facility failed to ensure the menu was followed, for 1 (lunch meal) of 1 meal observed for nutritional adequacy. The facility failed to ensure Resident #11 received condiments and roll during the lunch. These failures could place residents at risk of poor intake, chemical imbalance and/or weight loss.The findings include: Resident #11 Review of Resident #11's Face Sheet revealed an [AGE] year-old male initially admitted on [DATE]. Resident #11's medical diagnoses included disturbance, psychotic disturbance, mood disturbance, anxiety and lack of coordination. Review of Resident #11's Annual MDS dated [DATE] revealed in Section C - C0500. BIMS Summary Score a BIMS score had not been completed. Review of Resident #11's Comprehensive Care Plan initiated 12/01/2023 and reviewed/revised 01/13/2026 revealed the following focused areas: Nutrition: Focus - Resident has the potential nutritional problem r/t DX Protein-calorie malnutrition and remains at risk for Malnutrition. Goal- The resident will maintain adequate nutritional status as evidenced by no s/sx of malnutrition, and consuming at least 50% of at least 2 meals daily through review date of 03/22/2026. An intervention for the focus on nutrition included: Provide, serve diet as ordered, monitor intake and record every meal. Review of Resident #11's physician orders reviewed on 03/04/2026 revealed: Regular diet, Mechanical soft texture, thin consistency.Record Review on 03/03/2026 of week 1 facility menu revealed: Lunch: Shrimp Fettuccini Alfedt, [NAME] Beans, Dinner Roll, Gelatin w/Whip Topping, Tableside Condiments, Choice of Beverage, Water. Alternative-baked potato (w/condiments), soup and hamburger. Observation of noon meal on 03/03/2026 at 12:00 PM revealed Resident #11 was served soup, baked potato and no roll. During an interview on 03/03/2026 at 12:25 PM, Resident #11 stated he had requested the roll, and extra sour cream with his baked potato. He stated since he had not received the requested sour cream and cheese, he was not going to eat it. During an interview on 03/03/2026 at 2:00 PM, the DM stated the condiments should have been on his plate when the tray went out to the residents. She stated when there was something missing on the menu, the cook would go to residents and asked if they wanted something different. The DM stated the kitchen had no sour cream or cheese for the baked potato that was the alternative for the lunch meal but had not known they were out prior to service. She stated it was her responsibility to order enough food/condiments. During an interview on 03/05/2026 at 3:00 PM, CCS stated all residents should have received all products listed on the menu such as condiments. He stated the DM monitored the food and how much should have been ordered. The CCS stated he was unaware there were no condiments for the residents that ordered the alternate of a baked potato during lunch service. He stated as a nurse, the possible resident harm was not getting proper nutrition if the resident had not liked what he was served. During an interview on 03/06/2026 at 11:30 AM, the DM stated the residents should have been offered another alternative if there were no condiments. She stated she monitored along with the nurses on what the residents preferred. The DM stated her expectations were for all residents to get all items on the menu, and all condiments, as they were listed on the menu also. During an interview on 03/06/2026 at 11:55 AM, the Dietician stated she trained the staff on resident needs and nutrition. She stated the in-services to other kitchen staff members were completed by the DM. The Dietician stated that all residents should always receive all food listed on the menu, even condiments unless were an allergy to the product. She stated harm for residents would be not receiving the protein calories they may need. She stated her expectations were for the DM in charge of the kitchen should always follow the facility policies. During the exit conference held on 03/06/2026 at 5:00 PM the facility failed to provide a policy on food distribution.

During an observation, interview, and record review, the facility failed to provide food prepared by methods that conserve nutritive value, flavor, and appearance as well as failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature for 1 of 1 meal The facility failed to provide a lunch meal that was flavorful and palatable due to puree texture and thickness. This failure could place residents at risk for decreased meal satisfaction and weight loss.Findings Include: During an observation on 03/03/2026 at 12:00 PM, the [NAME] placed the puree meal and pureed bread in microwave for reheating. During an observation on 03/03/2026 at 12:35 PM, the CNA E was assisting residents with a puree meal. Observation of the pureed bread looked dry and too thick, the CNA was not assisting with feeding the pureed bread to the resident. During an interview on 03/03/2026 at 12:25 the [NAME] stated there was only on resident who received a pureed meal. The cook stated she always prepared the one residents puree meal and placed covered in the microwave until time to serve and then would reheat in the microwave. During an interview on 03/03/2026 at 12:36 PM, CNA E stated she decided not to assist feed Resident #9 the pureed bread due to being too thick. She stated it was also too hot to serve the resident. CNA E stated if she had made the decision to give the pureed bread to the resident, there was a possibility of Resident #9 getting burned and/or possibly choke. During an interview on 03/05/2026 at 3:00 PM, the CCS stated that food should have been placed on the steam holding table prior to serving. He stated he was not sure why the cook was using the microwave to warm the food prior to serving it to residents and not placing it on the holding steam table. During an interview on 03/06/2026 at 11:30 AM, the DM stated all food should be temped. She stated there was a failure with food being too hot and not temping it properly could harm the resident with the possibility of being burned. The DM stated residents could also choke or have improper nutrition. She stated her expectations was for all food to be temped correctly prior to being transported to the resident. She stated in not doing so and not holding the temperature at the proper temperature for a long amount of time, could cause illness. During an interview on 03/06/2026 at 11:55 AM, the Dietician stated in-services were provided by the DM. She stated that all food temperatures should be held on the steam table not the microwave. The Dietician stated in doing so, would be safer for the resident as it heats up too much, as well as lowers the nutrients in food. She stated she did not know what the facility policy stated but knew there should be temperature logs for all food that was delivered to residents. Record review of kitchen temperatures dated 03/03/2026 revealed no evidence of temperature log for pureed food. Record review of facility policy Food Preparation and Service dated 06/23/2025 revealed: 8.Raw food cooked in a microwave reaches 165 degrees F in all parts of the food. 9. Previously cooked food is reheated to an internal temperature of 165 degrees Fahrenheit for at least 15 seconds. 11. Mechanically altered hot foods prepared for a modified consistency diet remain above 135 degrees Fahrenheit during preparation, or they are reheated to 165 degrees for at least 15 seconds. Food service distribution-1. Proper hot and cold temperatures are maintained during food service. Foods that are held in the temperature danger zone are discarded after 4 hours. 2. The temperatures of foods held in steam tables are monitored throughout the meal by food and nutrition services staff.

Based on observations, interviews, and record reviews, the facility failed to ensure each resident had the right to a dignified existence for 1 of 1[TT1] resident (Resident #1) whose care was reviewed in that: Resident #1's indwelling urinary catheter bag was not covered. These deficient practices could affect residents who had indwelling urinary catheters by contributing to poor self-esteem, lack of information, and unmet needs.The findings were: Record[TT1] review of Resident #1's electronic face dated 09/9/25 sheet revealed he was a [AGE] year-old male that was admitted to the facility on [DATE] with a diagnosis that included kidney disease (unable to remove waste), heart failure, ureteral obstruction (kidney damage), cerebral infarction (Stroke). Record review of Resident #1's physician's electronic consolidated orders for August 2025 revealed the following: *Catheter care every shift with soap and water ordered.*Access Foley catheter for proper function and ensure proper placement of catheter bag every shift for Foley catheter care every shift related to urinary tract infection ordered.*Check for proper function in proper placement of tubing and bag ordered. *Catheter privacy bag over urine collection for dignity ordered.[TT2] Record review of Resident #1's Comprehensive Care plan dated 7/10/25, revealed a focus area to Monitor/document for UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. In an observation and interview on 09/9/25 at 10:25 AM, Resident #1 revealed a catheter bag hanging from the Resident #1's bed without a privacy bag. The resident's door was open, and the bag was viewable from the hall. Resident #1 stated never seeing a privacy bag cover for catheter. Resident #1 stated it would look better covered than letting everyone see a bag full of pee. Resident #1 stated that a privacy bag would be nice to have. In an interview on 09/9/24 at 11:30AM, LVN E revealed that she was not sure why the Resident #1's catheter bag was not covered. She said she knew it should be covered, and she would place a privacy cover on bag right now. LVN E stated that it was a dignity issue for catheter bags to be covered. In an interview on 09/11/25 at 1:45 PM the DON said the catheter bag should always be covered with a privacy bag if it was care planned, and Resident #1 had order to have a privacy bag covering the catheter bag. The DON stated the failure could place residents at risk for dignity issues if it was not covered. In an interview on 09/11/25 at 1:50 PM, the Admin stated the catheter bags should always be covered with a privacy bag, Admin stated that the failure could place residents at risk for dignity issues if it is not covered.

Based on observation and interview the facility failed to ensure residents had the right to a safe, clean, comfortable and homelike environment for Residents #6, #7, and #8 (Resident room # 302 and #306) reviewed for environment. The facility failed to ensure resident rooms #302 and #306 were thoroughly cleaned and sanitized. This deficient practice could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. Findings include: An observation on 7/1/25 at 9:45am of room [ROOM NUMBER], revealed the floor was sticky and stained, trash/candy wrappers, and food particles under beds A and B. There was also dirt, candy wrappers, and food particles behind dressers and nightstand., The room had a foul odor. Interview on 7/1/25 at 9:46am, in Resident room [ROOM NUMBER] bed A, Resident #6 stated she was well, staff were respectful., Resident #6 stated that housekeeping cleans the room., When asked when the last time it was swept and mopped, Resident #6 stated maybe last week, she did not recall. Resident stated that she would like her room to be cleaned, it makes her feel better. Resident #6 stated she did not complain to any staff about her room being upswept and needed mopping. Interview on 7/1/25 at 9:50am, Resident's room [ROOM NUMBER] bed B, Resident #8 stated that rooms are kept cleaned by housekeeping, they generally clean several times a week, resident stated he does not recall when the last time it was swept and mopped. Resident stated the floors do need to be swept and mopped and the floors are sticky. Resident stated he spilled tea a day ago and floor are sticky. Resident stated he did not say anything to anyone, stated they will get around to it. Resident stated he does like a clean environment, make him feel good. An observation on 7/1/25 at 9:59am, Resident's room [ROOM NUMBER] bed B, trash and food particles found on floor and under bed, behind dresser, nightstand and floors are sticky. Interview on 7/1/25 at 9:59am, Resident's room [ROOM NUMBER], Resident #7 stated he did not say anything to anyone about room needing to be cleaned, resident stated they (housekeeping) does a good job, but not under bed. Resident stated he likes his room clean. Interview on 7/1/25 at 2:07pm, CNA C stated housekeeping cleans rooms daily or as needed. CNA C stated that if she sees a room that needs to be cleaned, she will notify housekeeping or clean room herself. CNA C stated that residents deserve to live in a clean environment, it is their right. CNA C did not know why rooms #302 and #306 have not been cleaned. Interview on 7/1/25 at 2:37pm, LVN D stated that rooms should be swept and mopped if needed daily. Housekeeping cleans rooms several times per week, sweeping and mopping, daily if needed. LVN D stated she did not notice rooms #302 and #306 being unclean, LVN D stated she reports to housekeeping when rooms need attention. Interview on 7/2/25 at 9:00am, HK Director stated that housekeeping staff were responsible to sweep under beds and behind furniture each time rooms are cleaned. HK Director stated she has in-serviced HK staff on cleaning under beds and furniture and will do so again. HK Director stated that residents having clean rooms was a dignity and rights issues, clean rooms are a big part of Infection Control. HK Director's expectation was for the residents to have a clean and sanitary environment to live in. Interview on 7/2/25 at 9:45am, Administrator stated it was his expectation that the facility was clean 24/7, this falls on all staff not just HK to be observant and help keep the facility clean. The residents have a right to a clean, sanitary, and comfortable environment to live in.

Based on observation, interview, and record review the facility failed to ensure its medication error rates were not 5% or greater. The facility had a medication error rate of 8%, based on 2 errors out of 25 opportunities which involved 2 of 14 residents (Resident #134 and Resident #22) reviewed for medication administration and medication errors. 1. LVN A on 11/24/2024 administered 1 tablet of buspirone (medication used to treat anxiety) 5mg to Resident #134 when the physicians order date 04/19/2024 called for 2 tablets. 2. LVN B on 11/24/2024 administered 1 tablet of dicyclomine (medication used to relax abdominal muscles to reduce cramping) 20mg to Resident #22 when the physicians order dated 11/14/2024 called for 2 tablets. These failures could place residents at risk for not having the intended therapeutic benefit. The findings included: 1. Review of Resident #134's electronic face sheet revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included: brain bleed, cognitive decline, and diabetes. Review of Resident #134's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 which indicated no cognitive impairment. Further review of MDS Section N revealed antianxiety medications taken within the last seven days. Review of Resident #134's care plan initiated 03/28/2024 revealed, Focus: The resident uses anti-anxiety medications r/t anxiety (Buspirone). Goal: The resident will be free from discomfort or adverse reactions related to anti-anxiety therapy. Interventions: Administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness. Review of Resident #134's electronic physicians orders revealed: Buspirone tablet 5mg Give 2 tablets by mouth three times a day for anxiety, order date 04/19/2024. Review of Resident #134's pharmacy card containing buspirone 5mg tablets revealed: Buspirone tablet 5mg Give 2 tablets by mouth three times a day for anxiety. During an observation on 11/24/24 at 11:00 AM, LVN A prepared and administered Metamucil Smooth Texture Oral Powder 28.3 % 1 scoop, hydralazine Oral Tablet 50mg 1 tablet, and buspirone tablet 5mg 1 tablet to Resident #134. During an interview on 11/24/24 at 12:30 PM, LVN A stated she had only performed the medication pass a few times and she just wasn't paying attention and missed it. She stated she should have checked the five rights of medication (right resident, right medication, right dosage, right time, and right method route of administration) prior to passing the medications. LVN A stated this could cause Resident # 134 to not get the desired anxiety relief. 2.Review of Resident #22's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: adnominal hernia with obstruction, lung disease, and heart failure. Review of Resident #22's quarterly MDS assessment dated [DATE] revealed a BIMS score of 11 which indicated moderate cognitive impairment. Review of Resident #22's care plan initiated 08/29/2024 revealed, Focus: Resident is at risk related to alteration in bowel elimination. Goal: Resident will have decreased episodes of constipation. Interventions: Dicyclomine per MD orders. Review of Resident #22's electronic physicians orders revealed: Dicyclomine Tablet 20mg Give 2 tablet by mouth four times a day for treatment of irritable bowel syndrome, order date 11/14/2024. Review of Resident #22's pharmacy card containing Dicyclomine 20mg tablets revealed: Dicyclomine Tablet 20mg Give 2 tablet by mouth four times a day. During an observation on 11/24/24 at 11:30 AM, LVN B prepared and administered Dicyclomine Tablet 20mg 1 tablet to Resident #22. During an interview on 11/24/24 at 12:45 PM, LVN B stated she was nervous and didn't check the dose for Resident #22. She stated she did not know the negative effect because she did not know what that medication was used to treat. During an interview on 11/25/24 at 04:15 PM, the DON stated that the failure was due to nurses not paying attention. He stated the orders where entered clearly and this should not have happened. The DON stated the negative effect on residents was residents not getting desired dose of medication to properly treat and maintain their disease process. Review of the facility policy titled, Medication Administration, revised 7/8/24, revealed in part: Medications are administered in a safe and timely manner and as prescribed. Policy interpretation and implementation. 2. The director of nursing services supervises and directs all personnel who administer medications and/or have related functions . 4. Medications are administered in accordance with prescriber orders, including any required time frame . 6. Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or need for additional staff training . 10. The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method route of administration before giving the medication .

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and included the appropriate accessory and cautionary instructions for 1 of 2 medication carts (Hall 300/400 medication cart) and 3 of 35 residents (Resident #2, #18 and #29)) reviewed for medication labeling and storage. The Hall 300/400 medication cart contained a Humulin R flex pen insulin for Resident #2 with an open date of 10/20/2024, making it past 28 days meaning the medication had expired. The Hall 300/400 medication cart contained an Insulin Glargine flex pen insulin for Resident #18 with an open date of 10/18/2024, making it past 28 days meaning the medication had expired. The Hall 300/400 medication cart on 11/24/2024 contained a Lantus flex pen insulin for Resident #29 with an open date of 10/12/2024, making it past 28 days meaning the medication had expired and no pharmacy label with the resident's name written in marker and an Insulin Lispro flex pen insulin for Resident #29 with no open date and no label with the resident's name written in marker. These failures could place residents at risk of receiving expired medications. Findings included: Review of the electronic face sheet for Resident #2 revealed an admitted [DATE]. Resident was a [AGE] year-old male with a diagnosis of diabetes, heart failure, and multiple sclerosis. Review of the electronic physician's orders for Resident #2 revealed orders for Humulin R Injection Solution 100 UNIT/ML Inject as per sliding scale: if 0 - 60 Notify MD and start hypoglycemic protocol; 61 - 150 = 0; 150 - 200 = 3 units; 201 - 250 = 6 units; 251 - 300 = 8 units; 301 - 350 = 10 units; 351 - 400 = 14 units; 401 - 999 = 0 Notify MD, subcutaneously before meals and at bedtime. Review of the electronic face sheet for Resident #18 revealed an admitted [DATE]. Resident was a [AGE] year-old female with a diagnosis of diabetes, depression, and kidney failure. Review of the electronic physician's orders for Resident #18 revealed orders for Insulin Glargine Subcutaneous Solution 100 Unit/Ml inject 20 unit subcutaneously one time a day. Review of the electronic face sheet for Resident #29 revealed an admitted [DATE]. Resident was a [AGE] year-old female with a diagnosis of diabetes, breast cancer, and amputation. Review of the electronic physician's orders for Resident #29 revealed orders for Insulin Lispro Subcutaneous Solution Pen-Injector 100 UNIT/ML Inject as per sliding scale: if 0 - 150 = 0 Notify MD if Blood Sugar less than 60 or greater than 400; 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; subcutaneously before meals and at bedtime and Lantus Subcutaneous Solution Pen-Injector 100 Unit/Ml inject 6 unit subcutaneously at bedtime. During on observation on 11/24/2024 at 09:30 AM of the Hall 300/400 medication cart contained a Humulin R flex pen insulin for Resident #2 with an open date of 10/20/2024, an Insulin Glargine flex pen insulin for Resident #18 with an open date of 10/18/2024, a Lantus flex pen insulin for Resident #29 with an open date of 10/12/2024 and no pharmacy label with the residents name written in marker, and an Insulin Lispro flex pen insulin for Resident #29 with no open date and no label with the resident's name written in marker. During an interview on 11/24/24 at 01:27 PM, LVN A stated insulin vials and pens should have been dated when opened and discarded after 28 days. She stated all vials and pens should have the original pharmacy label. She stated it was each nurse's responsibility to ensure medications were labeled and not expired. During an interview on 11/25/24 at 12:12 PM, the DON stated insulin vials and pens should have been dated when opened and labeled with expiration date. He stated insulin expired within 28 days of opened date. He stated it was the nurse's responsibility to ensure that medications were not expired prior to giving them. DON stated he did not know why the medications where still on the cart and that this failure could lead to residents receiving expired medications. Review of the policy titled, Storage of Medications, last revised July 2024 read in part: Policy Statement: The facility store all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation: 2, Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received .3. The nursing staff is responsible for maintain medication storage .4. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. 5. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Review of the facility policy titled, Medication Administration, revised 7/8/24, read in part: Medications are administered in a safe and timely manner and as prescribed. Policy interpretation and implementation. 12. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container . 17. Insulin pens are clearly labeled with the resident's name or other identifying information. Prior to administering insulin with an insulin pen, the nurse verifies that the correct pen is used for that resident.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen. The facility failed to: A. dispose of food items after the use by or expiration date. B. Store, seal and date food items. These failures could place residents receiving oral nutritional intake at risk for foodborne illness and a decline in health status. The findings included: During observation on [DATE] from 9:47am to 10:30am of the kitchen Dry Storage: o One unsealed open 10 pounds plastic bag containing graham cracker crust with open date [DATE], o Four 32-ounce bottles of lemon juice with manufactures expire date of [DATE], and o Box with approximately eight individual cheese crackers with arrive date of [DATE] no open date. Refrigerator o One 10 ponds box containing individual 1.5 sausage patties in unsealed plastic bag open date [DATE] and o One unsealed plastic bag containing 5 pounds of raw hamburger meat from an original 10 pound package dated open [DATE] and use date [DATE]. Freezer o One half full unsealed open bag containing frozen biscuits arrive date of [DATE] and open date of [DATE] in 29.7-pound box. During an interview on [DATE] at 07:58 AM, the Dietary Manager stated that she was responsible to ensure foods were stored, labeled and dated properly. The Dietary Manger stated that if foods were not stored, labeled and dated properly that it could cause cross contamination, food Boerne illness' and make residents sick. The Dietary Manager stated that she had several new employees when she was asked what led to the failure of not properly storing, labeling and dating of foods. She went on to say that she will need to retrain her staff. The Dietary Manage stated that her expectation of her kitchen staff was that all employees would seal, label, date all foods properly. after opening. She stated that she was the primary person to trained staff to seal, label and the dating of foods. She stated she had physically showed them where, how to label and date with expirations, stated that I liked her staff to put their initials on the labels to know who had labeled foods. During an interview on [DATE] at 8:18 AM, the Cook stated that her supervisor the Dietary Manager had trained her how to properly store, label and date foods. She stated the negative effects of not storing, labeling and dating foods properly would make residents sick or kill them. She also stated that it could've even give them salmonella or E. coli which are all connected with improperly storage and cooking of foods or expired food. The Cook stated you must be very careful/mindful of storage and dates. She went on to say that need to make sure that you wash your hands and used gloves. During interview on [DATE] at 8:29 AM, the Dietary aide/Dishwasher stated that the Dietary Manager did the training to properly store, date and label foods. She stated that the negative effects of foods not being stored labeled and dated properly was that it could cause someone to get sick. She stated that is was everyone's job in the kitchen to make sure foods are stored properly. She stated that someone didn't do their job the right way that caused the failure of foods not being labeled, dated and stored properly. Review of facility policy titled Food Receiving and Storage of Food in dry food storage and Refrigerated/freezers, revised [DATE], revealed: All foods must be labeled with the contents and date food item was placed in storage.

45216 Based on interview, and record review, the facility failed to assure residents who have authorized the facility in writing to manage any personal funds have ready and reasonable access to those funds for 3 of 5 (Resident #10, Resident #16, and Resident #21) residents reviewed for trust funds. The facility failed to ensure Resident #'s 10, 16, and 21 personal use funds were disbursed monthly. This failure could place residents whose funds are managed by the facility at risk of not having money needed to purchase personal items. Findings Included: Record review of Resident #10's face sheet revealed an [AGE] year-old female admitted on [DATE] with medical diagnoses of high blood pressure, depression, chronic pain, heart disease, and dementia. Record review of Resident #10's quarterly MDS dated [DATE] revealed at BIMS score of 13 out of 15 indicating intact cognition. Record review of Resident #16's face sheet revealed a [AGE] year-old male admitted on [DATE] with medical diagnoses of cerebral palsy (abnormal brain development or damage to the developing brain that affects a person's ability to control his or her muscles) and epilepsy. Record review of Resident #16's quarterly MDS dated [DATE] revealed a BIMS score of 15 out of 15 indicating intact cognition. Record review of Resident #21's face sheet revealed a [AGE] year-old female admitted on [DATE] with medical diagnosis of liver failure, heart failure, kidney failure, curvature of the spine and seizures. Record review of Resident #21's quarterly MDS dated [DATE] revealed a BIMS score of 15 out of 15 indicating intact cognition. During an interview on 09/25/2023 at 12:22 PM, Resident #21 stated she had no complaints about the facility except the fact that she had not received her monthly allowance of $60 in at least 3 months. Resident #21 explained she had asked the BOM on several occasions when the funds would be available and was told the BOM was working with the social security office to resolve the problem, but the resident believed this to be untrue because she didn't do anything. Resident #21 also stated she had not received a statement from the facility in a long time. During an interview on 09/25/2023 at 02:25 PM, the Regional BOM stated residents had not received their monthly allowance since July 7, 2023, due to a change in ownership. She stated she emailed the former owner on 09/25/23 for a status update on the disbursements and was waiting for a reply. During an interview on 09/26/2023 at 11:34 AM, the Regional BOM stated she had received a reply from the corporate BOM of the former owners on 09/25/23. The Regional BOM stated she was told by the corporate BOM the resident trust fund account should have been closed months ago when the new administration took over. The corporate BOM explained she called the bank and found out the account had not been closed. The corporate BOM provided names to the Regional BOM of residents with funds available for transfer. The Regional BOM was waiting on a routing number and account numbers to make transfers into the resident trust account. She stated the transfers should be complete by 2 PM tomorrow. The Regional BOM explained that trust fund statements were generated quarterly. Residents responsible for their own finances received hand delivered statements and a copy was placed in their file. For residents with representatives, the representative received the statements, and a copy was placed in the resident's file. She stated the next statement cycle was at the end of September 2023. During an interview on 09/27/2023 at 10:15 AM, Resident #16 stated he was not aware disbursements had not been made into his account since July 2023. He stated he was glad someone was working on fixing the problem so that he had money for his snacks and drinks. During an interview on 09/27/2023 at 11:08 AM, Resident #10 stated she did not know the last time she received a monthly allowance. She stated she did not need much and hardly ever asked for money. During an interview on 09/27/2023 at 12:52 PM, the Regional BOM stated the new trust fund account for residents who authorized the facility to manage their funds was opened 06/23/2023. The Social Security Administration was still processing the paperwork to change the payee account. The Regional BOM stated the failure occurred because the former BOM left without notice last week. The Regional BOM was working on paperwork that either was not done or done properly. She stated the facility did not have a policy on disbursing resident funds. She stated the effect on the residents not receiving their money may be depression if they do not have the money to purchase wanted or needed items or go out to eat. During an interview on 09/27/2023 at 02:54 PM, the Administrator stated the BOM was responsible for reconciling the resident trust fund account and transferring funds to resident trusts. She stated the reason the failure occurred was the issues with the Social Security Administration during the leadership change. She stated the representative payee paperwork had to be refiled with the Social Security Administration. The Administrator stated the potential effects on residents was a lack of money could keep them from getting things they want. She stated the residents should not have any needs not met by the facility, so this issue pertains to personal wants. The Administrator stated her expectation was for residents to receive their money timely. When asked for a policy pertaining to resident funds the administrator stated there was not a policy. Record review of Resident Fund Management Service Authorization and Agreement to Handle Resident Funds, Resident #10 signed agreement, no date on the agreement. Record review of Resident Fund Management Service Authorization and Agreement to Handle Resident Funds, Resident #16 signed agreement, no date on the agreement. Record review of Resident Fund Management Service Authorization and Agreement to Handle Resident Funds, Resident #21 signed agreement on 05/15/2023.

Based on interviews and record reviews, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation of residents and misappropriation of resident property by failing to conduct a criminal history/EMR/NAR verification on employees prior to employment and/or annually for 3 of 18 (RN-A, RN-B, and SW-C) employees reviewed for abuse and neglect. Facility staff did not have criminal history verification and/or an EMR/NAR verification prior to offering employment to the facility and/or annually for employees. These findings could place residents at risk of receiving care by someone that was unemployable. The findings included: Record review on 09/27/2023 of the CMS-807 Employee files review revealed: RN-A was hired on 05/10/2023, the facility verified his CH on 09/26/2023. RN-A's EMR was dated 05/02/2023 and was verified on 09/26/2023. RN-B was hired on 08/05/2023, her EMR verification was dated 09/27/2023 and SW-C was hired on 04/12/2023, her CH verification was dated 09/26/2023. SW-C's EMR verification was dated 09/26/2023. During an interview on 09/27/2023 at 2:14: PM, the ADM stated the RSADM and RSHR from a sister facility had filled out the personnel file review form provided and did not know where they received the dates from. The ADM stated the RSHR had told her they might have gotten the dates wrong on the form. The ADM stated the RSHR had told her the CH and EMR's were most likely ran at different times. During a follow-up interview on 09/27/2023 at 2:44 PM, the ADM stated the facility no longer had an HR staff member to conduct CH and EMR verifications. The ADM stated she spoke to (corporate) CHR, and stated If they are not there, we don't have them. The ADM stated she did not believe the previous HR staff member did not do the CH and EMR's as she was trained. She stated there was no reason for these not to have been completed. The ADM stated the CH and EMR checks were to be completed prior to being hired due to maybe having a history of having an offense. She stated the negative impact to residents could be possible abuse or exploitation. She stated HR was responsible for running the background checks with the ADM monitoring. The ADM stated she did not realize HR was having the issues of not running those reports. The ADM stated the failure was with HR as she was not doing her job, with her expectations being for all of the pre-hire paperwork to be completed before their first day of working with residents. Record Review of facility policy Abuse Prohibition Policy with the revised dated of 09/14/2023 revealed: INTENT: This protocol was intended to assist in the prevention of abuse, neglect and misappropriation of property. Each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion and financial abuse . .Abuse Prohibition Program: The facilities abuse prevention program includes the following comment: o Screening o Training o Prevention o Identification o Investigation o Protection o Reporting/Response Screening: 1. Free employment screening will be completed on all employees, to include: o Criminal History Check o Reference Check o Professional licensure, certification, or registry check as applicable .3. Leave the facility cannot employ individuals who have had a disciplinary action taken against their professional license start a state licensure body as a result of a finding of abuse, neglect, mistreatment of residents or misappropriation of their property. Prevention: . .6. The Screening and training policies will be adhered to as outlined above . Record Review of facility policy Criminal History Record, undated revealed: Purpose: In order to conduct normal nursing facility business, the facility is required by the Texas Department of Aging and Disability Services to perform criminal history verifications on all potential employees and. In order to perform these criminal history verifications, the facility will access the Texas Department of Public Safety Secure Website to access the individual's criminal history data as authorized in Texas 411; Sub- chapter F. Purpose of Search: The purpose of the search is to comply with chapter 242 and 250, Health and Safety Codes. These codes require a licensed nursing facility to ensure that background checks are conducted on potential employees, volunteers etc, in order to assure that no one be allowed to work in the facility with a conviction that prohibits employment under the Chapter 250, Health and Safety Code .

Based on observation, interview and record review, the facility failed to maintain complete and accurate clinical records for 1 of 4 (Resident #2) residents reviewed for weights. The facility failed to weigh Resident #2 since 07/10/2023. These findings place residents at risk for quick interventions for weight loss. Findings included: Record review of Resident #2's Facesheet dated 09/25/23 revealed: An [AGE] year-old male admitted to the facility on [DATE]. He had a diagnosis list that included: COPD(Primary), Cognitive communication deficit, Amnesia, Dysphagia, Dementia with psychotic disturbance, Chronic pain, GERD, Vitamin B12 deficiency anemia, Vitamin D deficiency, Constipation. Record review of Resident #2's Significant Change MDS dated [DATE] revealed a BIMS of 2 meaning severe cognitive impairment. No chewing or swallowing difficulties. A weight of 137 lbs. No or unknown weight loss of 5 percent in last 6 months. Resident had a mechanically altered diet . Record review of Resident #2's Quarterly MDS dated [DATE] revealed a BIMS of 2 meaning severe cognitive impairment. He had no chewing or swallowing difficulties. The recorded weight was 137 lbs with no or unknown weight loss of 5 percent in the last 6 months. Resident #2 had a mechanically altered diet. Record review of Resident #2's Weight Records dated 09/26/23 revealed a weight of 136.5 pounds on 07/10/23, no other weights documented. Record review of Resident #2's Care Plan dated 09/27/23 revealed that Resident refuses monthly weights. As a part of the Focus problem of The resident is resistive to care (ADLs) at times. His goal for the problem included, The resident will cooperate with care through next review date. Interventions for the problem included, Allow the resident to make decisions about treatment regime, to provide sense of control . If resident resists with ADLs, reassure resident, leave and return 5-10 minutes later and try again. During an observation on 09/25/23 at 10:48 AM, Resident #2, he was a thin male laying in a low bed with a fall mat at his bedside. He did not respond to verbal or physical stimuli. During an interview on 09/27/23 at 08:36 AM with DON, she said Resident #2 had a refusal for weights on careplan in the dietary area. She said she knew he needed a weight obtained. DON said Resident #2 frequently refused to allow staff to weigh him. She said he was not losing weight but that it was hard to tell because he was just a small man. The DON said the facility did monthly weights by the 7th of each month and weekly weights on Thursdays for new residents or residents that had significant weight loss or gain. She said if the numbers were different from the last weight, then the facility would recalibrate the scale, and reweigh those residents. She said she would do a progress note to explain the weight loss or gain. The DON said the Dietician would look at the weights, but the previous dietician did not discuss anything about the weights. She said the facility had talked with Resident #2's doctor and he said, do the best you can. The DON said that not obtaining weights in 2 months and only 1 progress note at the end of august was simply a lack of documentation by the nurses. She said the point to obtain weights monthly was to catch issues early. Record review of Facility Policy labeled Weight Management last reviewed 01/17/23 revealed: The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents . Residents will routinely be weighed by facility staff monthly.

Based on interview and record review the facility failed to ensure a discharge was appropriately communicated and documented in the medical record of one (Resident #1) out of three residents reviewed for discharge requirements. The facility failed to ensure that Resident #1's medical record had physician documentation to address why the resident was being discharged , what needs of the resident the facility could not meet, and how the resident posed a danger to the existing resident population. This failure could place residents at risk for inappropriate discharge from the facility and cause psychological harm. The findings included: Review of Resident #1's face sheet revealed he was admitted on [DATE] and was discharged on [DATE]. Resident was a [AGE] year-old female with diagnoses that included: Alzheimer's disease, aftercare following surgery, anxiety disorder, schizoaffective disorder, and bipolar disorder. Review of Resident #1's comprehensive care plan last revised 10/19/2022 revealed: Category: Behavioral Symptoms: Resident #1 has physically abusive behavior symptoms (specify- others were hit, shoved, scratched, sexually abused). Goal: resident will not harm self or others secondary to physical abusive behavior. Approach: room change to prevent aggression with roommate. Assist resident to find room when wondering about facility to prevent agitation and acting out on other residents. Administer medications. Avoid overstimulation. Avoid power struggles with resident. Convey an attitude of acceptance towards the resident. Maintain a calm slow understandable approach with resident. Category: discharge plan. Go: resident will discharge to home. Approach oh has been made decide to leave resident in the facility long term. IDT team will coordinate plan discharge in coordination with the resident and resident responsible party. Review of Resident #1's Discharge MDS, dated [DATE], revealed a BIMS score of 1 which indicated severe cognitive impairment. Review of Resident #1's Physicians Progress note dated 10/12/2022 revealed no evidence of documentation to address reason the resident was being discharged , the needs of the resident the facility could not meet, and how the resident posed a danger to the existing resident population. Review of Resident #1's Psychiatric Progress Note dated 10/24/2022 revealed no evidence of documentation to address reason the resident was being discharged , the needs of the resident the facility could not meet, and how the resident posed a danger to the existing resident population. Review Resident #1 progress note dated 10/04/2022 1:22 PM documented by MDS nurse revealed: care plan conference held this AM with resident's husband address nursing residence plan of care including her most recent behaviors of defecating in public areas and her physical aggression towards other residents. Resident husband stated that he believes that president number one's behavior may have something to do with her room beating move all the way the end of all and wishes her to be moved back to her old home due to her state of Alzheimer's since she knows where that room is. Residents husband also wishes for the physician to review residents' medication list to see if there are any medications that can be decreased or eliminated stating that he does not give her all her medicine when she stays at the farm with him. Will try to redirect resident to her room when she appears to be wandering and possibly trying a moving program. Resident husband is in accordance with this. Review of Resident #1's progress note dated 10/28/2022 12:14 PM documented by RN A revealed: call placed to residents' husband regarding incident yesterday when resident was physically aggressive towards another resident. Discussed safety concerns with resident as well as safety of other residents. Informed residents' husband of intent to send 30-day discharge notice. Offered to assist residents' husband with finding alternative placement. Resident's husband declined assistance. Review of Resident #1's closed record revealed no evidence that showed that the facility followed their procedure for an appeal process after their verbal call to resident's husband in their intent to send 30-day discharge. Review of Resident #1's progress note dated 10/28/2022 2:04 PM documented by RN B revealed: IDT meeting held today related to resident aggression towards other residents. Discussed the aggression resident is displaying and the threat it places on other residents. Resident has been seen by psychiatric services and had medication changes. Numerous interventions attempted with poor outcomes. Resident's husband refuses facility to find appropriate placement for resident. Husband had been called with no answer for immediate discharge of resident today. Will continue to attempt to reach husband. Review of Resident #1's progress note dated 10/28/2022 2:46 PM documented by RN B revealed: spoke with husband related to resident's discharge today. Husband became very upset hollering at this nurse stating we needed to communicate. Explained to residents' husband that we had a meeting related to resident and this is what we have decided. Resident husband hung the phone up on this. Awaiting arrival of husband to pick up resident. Review of Resident #1's closed records reflected no evidence the resident or resident's representative were informed in writing that the resident was being discharged , no evidence of a discharge summary or discharge instructions, and no evidence of a discharge care plan. Further review of Resident #1's closed records reflected no referral to a higher level of medical or psychiatric care due to resident's dangerous and acute behaviors and subsequent immediate discharge. During an interview on 11/18/2022 at 10:00 AM, Resident #1's Representative stated he was notified the morning of 10/28/2022 by the facility that Resident #1 was going to be issued a 30-day discharge notice in writing. He stated he was called 2 hours later and informed that Resident #1 was being discharged immediately and to come pick her up. He stated no one from the facility could explain to him the urgency of the discharge. He stated when resident #1 was discharged he received no discharge instructions or paperwork. During an interview on 11/18/2022 at 12:00 PM, Administrator stated Resident #1 was discharged because she was a danger to other residents. She stated no other residents had been severely injured or required hospitalization due to Resident #1's behaviors. She stated no incidents or behaviors happened between informing Resident #1's representative of the 30-day notice of discharge and the decision for the immediate discharge. She stated she felt that it was an emergent discharge because she was afraid for the other residents. Administrator stated no new interventions were put into place to prevent Resident #1 from having any further behaviors to prevent the resident from harming other residents. She stated she was unaware that a discharge summary was not completed and that Resident #1's representative had not received any discharge instructions. She stated the facility had not had a stable Director of Nursing for the last few months and this could have been what lead to the failure in the discharge process. The Administrator stated that RN A, RN B, and DON at time of Resident #1's discharge was no longer employed with the facility and unable to be interviewed. A record review of the Facility's Policy titled Transfer or Discharge, Emergency date 2001, revealed in part, 2. If a resident exercises his or her right to appeal a transfer or discharge notice he or she will not be transferred or discharged while the appeal is pending unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. 3. If the resident is transferred or discharged despite his or her pending appeal, the danger that failure to transfer or discharge would pose will be documented. A record review of the Facility's policy titled Transfer or Discharge Notice dated 2001, revealed in part, 1. A resident, and/or his or her representative (sponsor), will be given a thirty (30) day advance notice of an impending transfer or discharge from our facility. 2. Under the following circumstances, the notice will be given as soon as it is practicable but before the transfer or discharge: a. The transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility. b. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility. c. The safety of the individuals in the facility is endangered. d. The health of individuals in the facility would otherwise be endangered. e. The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. f. An immediate transfer or discharge is required by the resident's urgent medical needs. g. The resident has not resided in the facility for thirty (30) days. h. The facility ceases to operate. 3. The resident and/or representative (sponsor) will be notified in writing of the following information: a. The reason for the transfer or discharge. b. The effective date of the transfer or discharge. c. The location to which the resident is being transferred or discharged . d. A statement of the resident's rights to appeal the transfer or discharge, including: (1) the name, address, email, and telephone number of the entity which receives such requests. (2) information about how to obtain, complete and submit an appeal form. (3) how to get assistance completing the appeal process. e. the facility bed-hold policy. f. The name, address, and telephone number of the Office of the State Long-term Care Ombudsman. g. The name, address, email, and telephone number of the agency responsible for the protection and advocacy of resident's wit intellectual and developmental (or related) disabilities (as applies). h. the name, address, email, and telephone number of the agency responsible for the protection and advocacy of residents with mental disorder or related disabilities (as applies); and i. The name, address, and telephone number of the state health department agency that has been designated to handle appeals of transfers and discharge notices. 4. A copy of the notice will be sent to the Office of the state Long-Term Care Ombudsman. 5. The reasons for the transfer or discharge will be documented in the resident's medical record.

Based on interview and record review, the facility failed to notify the resident, resident representative and send a copy to the Office of the State Long-Term Care Ombudsman, of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood for one (Resident #1) of three residents reviewed for discharge rights. The facility failed to send a copy of the written notice of discharge to Resident #1 and the Ombudsman when Resident #1 representative was informed that Resident #1 was being discharged immediately. The failure could affect residents by placing them at risk of not having access to available advocacy services, discharge/transfer options, and appeal processes. The findings included: Review of Resident #1's face sheet revealed he was admitted on [DATE] and was discharged on [DATE]. Resident was a [AGE] year-old female with diagnoses that included: Alzheimer's disease, aftercare following surgery, anxiety disorder, schizoaffective disorder, and bipolar disorder. Review of Resident #1's comprehensive care plan last revised 10/19/2022 revealed: Category: Behavioral Symptoms: Resident #1 has physically abusive behavior symptoms (specify- others were hit, shoved, scratched, sexually abused). Goal: resident will not harm self or others secondary to physical abusive behavior. Approach: room change to prevent aggression with roommate. Assist resident to find room when wondering about facility to prevent agitation and acting out on other residents. Administer medications. Avoid overstimulation. Avoid power struggles with resident. Convey an attitude of acceptance towards the resident. Maintain a calm slow understandable approach with resident. Category: discharge plan. Go: resident will discharge to home. Approach oh has been made decide to leave resident in the facility long term. IDT team will coordinate plan discharge in coordination with the resident and resident responsible party. Review of Resident #1's Discharge MDS, dated [DATE], revealed a BIMS score of 1 which indicated severe cognitive impairment. Review of Resident #1's Physicians Progress note dated 10/12/2022 revealed no evidence of documentation to address reason the resident was being discharged , the needs of the resident the facility could not meet, and how the resident posed a danger to the existing resident population. Review of Resident #1's Psychiatric Progress Note dated 10/24/2022 revealed no evidence of documentation to address reason the resident was being discharged , the needs of the resident the facility could not meet, and how the resident posed a danger to the existing resident population. Review Resident #1 progress note dated 10/04/2022 1:22 PM documented by MDS nurse revealed: care plan conference held this AM with resident's husband address nursing residence plan of care including her most recent behaviors of defecating in public areas and her physical aggression towards other residents. Resident husband stated that he believes that president number one's behavior may have something to do with her room beating move all the way the end of all and wishes her to be moved back to her old home due to her state of Alzheimer's since she knows where that room is. Residents husband also wishes for the physician to review residents' medication list to see if there are any medications that can be decreased or eliminated stating that he does not give her all her medicine when she stays at the farm with him. Will try to redirect resident to her room when she appears to be wandering and possibly trying a moving program. Resident husband is in accordance with this. Review of Resident #1's progress note dated 10/28/2022 12:14 PM documented by RN A revealed: call placed to residents' husband regarding incident yesterday when resident was physically aggressive towards another resident. Discussed safety concerns with resident as well as safety of other residents. Informed residents' husband of intent to send 30-day discharge notice. Offered to assist residents' husband with finding alternative placement. Resident's husband declined assistance. Review of Resident #1's progress note dated 10/28/2022 2:04 PM documented by RN B revealed: IDT meeting held today related to resident aggression towards other residents. Discussed the aggression resident is displaying and the threat it places on other residents. Resident has been seen by psychiatric services and had medication changes. Numerous interventions attempted with poor outcomes. Resident's husband refuses facility to find appropriate placement for resident. Husband had been called with no answer for immediate discharge of resident today. Will continue to attempt to reach husband. Review of Resident #1's progress note dated 10/28/2022 2:46 PM documented by RN B revealed: spoke with husband related to resident's discharge today. Husband became very upset hollering at this nurse stating we needed to communicate. Explained to residents' husband that we had a meeting related to resident and this is what we have decided. Resident husband hung the phone up on this. Awaiting arrival of husband to pick up resident. Review of Resident #1's closed medical records reflected no evidence the resident or resident's representative were informed in writing that the resident was being discharged , no evidence of a discharge summary or discharge instructions, no evidence of a discharge care plan and no evidence the State Ombudsman was notified by phone or in writing of resident's discharge. Further review of Resident #1's closed records reflected no referral to a higher level of medical or psychiatric care due to resident's dangerous and acute behaviors and subsequent immediate discharge. During an interview on 11/18/2022 at 10:00 AM, Resident #1's Representative stated he was notified the morning of 10/28/2022 by the facility that Resident #1 was going to be issued a 30-day discharge notice in writing. He stated he was called 2 hours later and informed that Resident #1 was being discharged immediately and to come pick her up. He stated no one from the facility could explain to him the urgency of the discharge. He stated when resident #1 was discharged he received no discharge instructions or paperwork. During an interview on 11/18/2022 at 12:00 PM, Administrator stated Resident #1 was discharged because she was a danger to other residents. She stated no other residents had been severely injured or required hospitalization due to Resident #1's behaviors. She stated no incidents or behaviors happened between informing Resident #1's representative of the 30-day notice of discharge and the decision for the immediate discharge. She stated she felt that it was an emergent discharge because she was afraid for the other residents. Administrator stated no new interventions were put into place to prevent Resident #1 from having any further behaviors to prevent the resident from harming other residents. She stated she was unaware that a discharge summary was not completed and that Resident #1's representative had not received any discharge instructions. She stated the facility had not had a stable Director of Nursing for the last few months and this could have been what lead to the failure in the discharge process. The Administrator stated that RN A, RN B, and DON at time of Resident #1's discharge was no longer employed with the facility and unable to be interviewed. A record review of the Facility's Policy titled Transfer or Discharge, Emergency date 2001, revealed in part, 2. If a resident exercises his or her right to appeal a transfer or discharge notice he or she will not be transferred or discharged while the appeal is pending unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. 3. If the resident is transferred or discharged despite his or her pending appeal, the danger that failure to transfer or discharge would pose will be documented. A record review of the Facility's policy titled Transfer or Discharge Notice dated 2001, revealed in part, 1. A resident, and/or his or her representative (sponsor), will be given a thirty (30) day advance notice of an impending transfer or discharge from our facility. 2. Under the following circumstances, the notice will be given as soon as it is practicable but before the transfer or discharge: a. The transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility. b. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility. c. The safety of the individuals in the facility is endangered. d. The health of individuals in the facility would otherwise be endangered. e. The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. f. An immediate transfer or discharge is required by the resident's urgent medical needs. g. The resident has not resided in the facility for thirty (30) days. h. The facility ceases to operate. 3. The resident and/or representative (sponsor) will be notified in writing of the following information: a. The reason for the transfer or discharge. b. The effective date of the transfer or discharge. c. The location to which the resident is being transferred or discharged . d. A statement of the resident's rights to appeal the transfer or discharge, including: (1) the name, address, email, and telephone number of the entity which receives such requests. (2) information about how to obtain, complete and submit an appeal form. (3) how to get assistance completing the appeal process. e. the facility bed-hold policy. f. The name, address, and telephone number of the Office of the State Long-term Care Ombudsman. g. The name, address, email, and telephone number of the agency responsible for the protection and advocacy of resident's wit intellectual and developmental (or related) disabilities (as applies). h. the name, address, email, and telephone number of the agency responsible for the protection and advocacy of residents with mental disorder or related disabilities (as applies); and i. The name, address, and telephone number of the state health department agency that has been designated to handle appeals of transfers and discharge notices. 4. A copy of the notice will be sent to the Office of the state Long-Term Care Ombudsman. 5. The reasons for the transfer or discharge will be documented in the resident's medical record.

Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure food was not kept in the refrigerator longer than 7 days or past the expiration date. The facility failed to adequately sanitize the food temperature testing device prior to, in between, and after taking temperatures of foods. The facility failed to ensure proper sanitation and food handling by not performing hand hygiene and changing gloves when contaminated. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. Findings include: During an observation of the kitchen on 07/26/22 at 10:30 AM, observed: 1.) 5 clear plastic zipped storage bags in a container in the refrigerator labeled chicken breast prepped 07/18/2022. 2.) Clear plastic zipped storage bags labeled honey smoked ham 06/02/2022 3.) Clear plastic zipped storage bags labeled honey smoked ham 07/12/2022. During an observation of meal service on 07/26/22 at 11:45 AM, Cook A donned gloves without washing her hands. Cook A wiped food temperature testing device with a wet blue food service towel that she picked up off the counter. Cook A placed food temperature testing device into a fried fish patty. Temperature read 178 degrees. Cook A then wiped food temperature testing device with the same wet towel she had in her hand. Cook A placed food temperature testing device inside a french fry. Temperature read 169 degrees. Cook A wiped food temperature testing device with same wet towel and placed food temperature testing device into the cabbage. Temperature read 35 degrees. Cook A dropped the towel on the floor, picked up the towel, and threw it in the trash can. Cook A did not change gloves, grabbed a dry food service towel, wiped food temperature testing device, and placed towel on the counter. Cook A placed food temperature testing device inside steam cabbage. Temperature read 186 degrees. Cook A picked up same dry towel from counter and wiped the food temperature testing device. Cook A placed the food temperature testing device into the pureed fish. Temperature read 192 degrees. Cook A wiped the food temperature testing device with same dry towel and placed food temperature testing device into mashed potatoes. Temperature read 197 degrees. Cook A removed gloves and washed her hands. During an observation of meal service on 07/26/22 11:45 AM performed by Cook A and Dietary Aide. Dietary Aide opened kitchen door, went to ice machine, and got ice out without gloves. Dietary Aide opened kitchen door to reenter and donned gloves without washing her hands. Cook A applied gloves without handwashing or sanitizing. Cook A then placed 3 serving trays on the steam table touching the top of the pans with pureed food in them on the steam table, she then placed 3 plates on the trays and touched each plate on top with her hands. Dietary aide applied gloves without handwashing or sanitizing. Dietary Aide went to the refrigerator, opened the door with gloves hands, and then went back to the serving table. Dietary Aide touched a piece of bread and placed in onto a resident's plate. Dietary Aide then grabbed a brownie in a plastic bag and placed it on the residents serving tray. Dietary Aide repeated this multiple times. Dietary Aide opened the kitchen door and pushed a cart full of trays into the dining room, reentered the kitchen, and grabbed a piece of bread and placed onto a resident's plate with no change of gloves. Cook A went to the refrigerator with same gloves on from serving and removed a plastic bag with cheese in it. Cook A touched the cheese and placed in onto a piece of bread, placed another piece of bread on top, and laid in on a plate. She placed butter in a frying pan and placed bread and cheese in the pan. Cook finished cooking sandwich and placed on a plate and handed to another staff for a resident. During an interview on 07/26/2022 at 1:00 PM, Dietary Cook A stated she had been working in the facility for 2 months. She stated she had her food handler's certification. She stated she should wash her hands after removing gloves and before applying new gloves. She stated touching things contaminates gloves and the gloves should be changed. She stated she should never touch an appliance and then handle food with the same gloves. She stated she did not have any alcohol wipes to sanitize the food temperature testing device, so she used a sanitized towel. She stated she should have placed the dry towel in the sanitation bucket before using it to wipe the temperature testing device. During an interview on 07/27/2022 at 09:45 AM, the Dietary Manager stated foods should be discarded after 7 days of opened date. She stated the dates on all the food were the open dates. She stated frozen food should only be thawed for a maximum of three days. She stated the temperature testing device should always be cleaned with alcohol and wiping it with a try towel in between temping foods was unacceptable. She stated she had been a dietary manger for 5 months and she has her dietary manager certification. During an interview on 07/27/2022 at 1:30 PM, Administrator stated she was a new administrator and did not know much about the kitchen. Administrator stated proper hand hygiene and sanitation was very important in the kitchen. Review of the facility's dietary contract company policy, Food Preparation, original dated October 2019 revealed: Policy Statement: It is the center policy that all foods are prepared in accordance with the guidelines of the FDA Food Code. Action Steps: 1.) The Dinning Services Director ensure that all staff practice proper hand washing technique and practice proper glove use. 2.) The Dinning Services Director or Cooks are responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination. 3.) The Dinning Services Director or Cooks are responsible to ensure that all utensils, food contact equipment, and food contact surfaces are cleaned and sanitized after every use .15.) All Time/temperature Control for Safety foods that are to be held for more than 24 hours at the temperature of 41 degrees or less, will be labeled and dated with a prepared date (Day 1) and a use by date (Day 7).

Based on interviews and record review, the facility failed to re-evaluate the use of an as needed (PRN) psychoactive drug, for one resident (Resident #25) of seven residents reviewed for unnecessary medications, in that: The facility administered a psychoactive medication ([MEDICATION(S)]) PRN (as needed) to Resident #25, for more than 14 days, without an evaluation by Resident #25's physician for the appropriateness of the medication. This failure could place all residents on psychoactive medications at risk for receiving unnecessary drugs. The findings included: Record review of Resident #25's May 2022 face sheet revealed Resident #25 was [AGE] year-old female admitted to the facility on [DATE]. Resident #25's diagnoses included respiratory failure, liver disease, anxiety, and [CONDITION(S)] disorder (a combination of [CONDITION(S)] symptoms such as hallucinations or delusions and mood disorder symptoms such as depression or [CONDITION(S)]). Record review of Resident #25's Minimum Data Set revealed the resident had a BIMS score of 10 of 15 indicating moderate cognitive decline. Record review of Resident #25's Care Plan dated 07/07/2022 indicated Problem: [CONDITION(S)] drug use; Resident receives antianxiety medications related to diagnosis of anxiety disorder. Intervention for this problem was Monitor for drug use effectiveness and adverse consequences. Record review of Resident #25's physician orders dated 05/21/2022 included [MEDICATION(S)] ([MEDICATION(S)]) 0.5 mg by mouth three times a day as needed for anxiety. Record review of Resident #25's Medication Administration Record for June 2022 revealed Resident #25 received: - one dose of [MEDICATION(S)] ([MEDICATION(S)]) 0.5 mg on 15 of 30 days and - two doses of [MEDICATION(S)] ([MEDICATION(S)]) 0.5 mg on 19 of 30 days. Record review of Resident #25's Medication Administration Record for July 2022 revealed Resident #25 received: - one dose of [MEDICATION(S)] 0.5 mg on 5 of 28 days and - two doses of [MEDICATION(S)] 0.5 mg on 1 of 28 days in July 2022. Record review of Resident #25's progress notes dated 6/2/22, 6/9/22, 6/16/22, 6/24/22, 7/1/22, 7/7/22, 7/15/22, 7/21/22, and 7/28/22 revealed a psychiatric nurse practitioner assessed the resident following the order for [MEDICATION(S)] ([MEDICATION(S)]) 0.5 mg. The psychiatric nurse practitioner notes indicated visits were due to psychiatric follow up and no medication change was needed. Record review of Resident #25's primary care provider notes of routine visits dated 6/10/22 and 7/14/22, indicated no new orders. Record review of Resident #25's consent forms revealed the Use of Psychoactive Medication Therapy form was not in the electronic medical record. During an interview on 07/28/22 at 1:30 p.m. LVN A reviewed Resident #25's MAR for May, June, and July 2022 and stated [MEDICATION(S)] was ordered for Resident #25 as needed beyond a 14-day limit. LVN A stated she was not aware a physician's review was required after 14 days for psychoactive medications ordered as needed. LVN A stated Resident #25 started refusing medications on 7/13/22. During an interview on 07/29/22 at 11:40 a.m., the DON stated the failure occurred because she should have reminded the physician to review the medication 14-days after it was prescribed. She was not able to explain how the facility monitors as needed psychoactive medication orders to ensure a review was done after 14 days. The DON stated the resident did not suffer any adverse effects due to receiving the medication beyond the 14-day guideline. Record review of the facility's policy, Administering Medications dated April 2019 stated, If a resident uses PRN medications frequently, the Attending Physician and Interdisciplinary Care Team, with support from the Consultant Pharmacist as needed, shall reevaluate the situation, examine the individual as needed, determine if there is a clinical reason for the frequent PRN use, and consider whether a standing dose of medication is clinically indicated. Record review of the facility's policy, Medication Monitoring Medication Management dated 2007 stated PRN orders for [CONDITION(S)] medications, excluding antipsychotics, Time Limitation 14 days; Exception Order may be extended beyond 14 days if the attending physician or prescribing practitioner believes it is appropriate to extend the order. Required Actions Attending physician or prescribing practitioner should document the rationale for the extended time period in the medical record and indicate a specific duration.

Based on observation, interview, and record review, the facility failed to follow menus for 2 of 2 pureed recipes observed for meal accuracy. The facility failed to ensure pureed recipes were prepared as directed while preparing pureed fish when the Dietary Cook A added thickener to the already prepared fish on the steam table. The facility failed to ensure pureed recipes were prepared as directed while preparing pureed meatballs when the Dietary Cook A did not measure any ingredients when preparing pureed meatballs. These failures could place residents at risk for dissatisfaction, poor intake, altered nutritional status, choking, and/or weight loss. The findings included: During observation of steamtable on 07/26/22 11:45 AM, Cook A picked up a plastic container labeled thickener and added 2 tablespoons of powdered thickener to the pureed fish in a small pan already on the steam table and stirred it. During on observation of pureed preparation on 07/27/2022 at 11:45 PM, Cook A placed 6 meat balls in the blender. She had 2 cups of what she stated to be beef broth already prepared in a cup and placed 4 scoops of power from a plastic container labeled as thickener into the cup. She poured ½ cup of the thickened broth into the blender and blender for approximately 1 minute. The Dietary Manager was in the kitchen and observed Cook A perform the task. Cook A did not have the recipe out while performing task. During an interview on 07/27/2022 at 12:00 PM, Cook A stated she did not use the recipe because she just judged it by looking at the thickness. She stated she should use the recipe when preparing pureed meals to ensure residents receive the proper proportions and nutritional value. She stated the pureed fish had gotten too thin while sitting on the steam table on 7/26/22, which was why she added more thickener. She stated she should have thrown out the thin pureed fish and prepared new pureed fish instead of adding the thickener. During an interview on 07/27/2022 at 12:10 PM, the Dietary Manager stated staff should always use a menu. She stated there were 2 residents with pureed diets. The Dietary Manager was unable to locate the recipe. She stated failing to follow the recipe could result in too small or too large portion sizes. During an interview on 07/27/2022 at 12:15 PM, the Dietician stated dietary staff should have followed the recipes for all foods and especially pureed foods. She stated this could affect the residents by not getting the proper nutrition leading to weight loss and other issues. During an interview on 07/27/2022 at 1:30 PM, the Administrator stated she was a new administrator and did not know much about the kitchen. She stated following recipes was very important to ensure residents receive the proper proportions and nutritional value. The administrator was unable to provide the pureed recipes. Review of the facility's dietary contract company policy, Food: Quality and Palatability, original date October 2019 revealed: Policy Statement: It is the center policy that, food is prepared by methods that conserve nutritive value, flavor, and appearance. Food is palatable, attractive, and served at a safe and appetizing temperature. Action Steps: 1.) The Dinning Services Director and Cooks are responsible for food preparation. Menu items are prepared according to the menu, production guidelines and standardized recipes.

Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen's reviewed. 1. Foods not sealed and/or labeled properly in freezers, dry food storage, refrigerators. 2. Cook J did not use proper hand hygiene while preparing pureed meal items and/or recording temperatures for meal items. These failures could place all 29 residents that eat out of the 1 kitchen at risk for food borne illnesses. Findings included: In an observation and interview on 05/11/21 at 10:20 AM of the 1 kitchen with the Dietary Manager (DM) revealed: Freezer 1. 2 packages of Sliced Fully cooked Turkey Breast with no received/best by date. DM said that when items were put in the freezer the received date should be on the item. 2. 1 bag with several small breaded balls, tied, but still open with no label to identify what item was or a received/opened/use by date. DM told surveyor it was hush puppies and that it was not completely sealed. 3. 1 bag of corn tortillas with a best by date of 3/10/21. 4. 1 bag of white strips with a date of 5/8/21, the label did not clearly identify the item. DM said it was chicken fajita strips. Asked DM about items being labeled. She said that items were labeled when they were received and then again when they were opened. She said the box was dated first and then when the box was opened and the bags were removed, the original date received was placed on the bags. Stove 2 pans of what DM said were [MEDICATION(S)] rolls rising from the heat of the oven were on an uncovered cookie sheet on top of the stove below the vent-a-hood. DM said that they usually have them covered while rising. Dry Food storage area 1. 1 clear tub labeled rice had a white Styrofoam cup inside the container. DM said that cups should never be stored in the containers. Further inspection of the stored rice revealed approximately 1 1/2 inches of bottom of tub with a different type of rice. DM said it might have been a new bag of rice was poured over the older rice when it came in. 2. 1 bag of bisquick biscuit mix. The bag edge was rolled over and taped. DM said that items like that should be in a plastic press and seal storage bag when opened and that a rolled over and taped package was not considered sealed. 3. 1 bag of brownie mix with the edge rolled over and taped. 4. 1 bag of white cake mix with no opened date, rolled over and taped. Refrigerator 1. 1 container of thick white liquid with black flakes, with no label to identify what item was or a cooked/use by date. DM said it was white pepper gravy and any item that has been cooked needs to be placed in the refrigerator with the label that identified the item and the date it was cooked. She said that any cooked item needed to be used within 3 days and then discarded. She said the gravy was cooked the day before, 5/10/21. 2. 1 container of turnip greens with lid over top not sealed. 3. 1 bag with several round thin brown patties, twisted closed with no label to identify the item or cooked/use by date. DM said that it was fully cooked sausage patties and they were placed in the refrigerator yesterday, 5/10/21, and would be used tomorrow, 5/12/21. 4. 1 bag of peeled hard-boiled eggs twisted and taped closed with no opened/use by date. 5. 1 tray of 1-pound butter blocks with a sticker of 4/16/18 on tray. DM said they received the butter last Monday, 5/3/21. She said the sticker they had on the tray must have come off that was over the top of former date of 4/16/18. DM said that she monitored the kitchen herself at least weekly to ensure that labels were on items and correct. She said they had a new cook working on the evening shift that had been working for 3 weeks. DM said that she trained the new cook on proper labeling and storing items. DM said that all residents of the facility ate from the kitchen. In an observation and interview with Cook J on 05/11/21 at 11:25AM revealed: Cook J placed the food processor in the dish machine and discarded gloves in the trash can. Cook J did not perform any hand hygiene with soap and water or an alcohol based hand sanitizer, and then donned new gloves. She touched her clothing several times with gloved hands, then picked up the food thermometer, holding the probe that touches the food, and began taking the temperature of the mashed potatoes and chicken and dumplings. Cook J touched the side of the dishwasher to remove the food processor, it had not completely cleared of previous food. Cook J placed the food processor back in the dish washer. She removed gloves, touched the trashcan lid to throw away discarded gloves with bare hands then donned new gloves without performing any hand hygiene. Cook J picked up the food thermometer and checked the temperature of carrots, removed gloves, placed them in the trash bin, touching the lid with bare hands. Cook J donned new pair of gloves without performing any hand hygiene. She then picked up the food thermometer and checked the temperature of the pureed carrots and the pulled pork. Cook J removed gloves, placed gloves in the trash bin, touching the lid with bare hands. Cook J donned new gloves, without performing any hand hygiene, grabbed 4 slices of bread to prepare for the pureed meal and prepared the pureed bread. Surveyor asked Cook J about hand hygiene and glove use, she said that a person should always wash hands before putting on gloves and after taking gloves off. She said that a person should not touch their clothing with a pair of gloves on. When asked if cook J ever washed her hands between glove changes, she said that she usually did, however during the observation, she did not wash her hands. She also confirmed that she did touch her clothing several times, trying to feel for the other food thermometer, while wearing gloves and then continued with the same gloves to take the temperature of meal items while failing to perform hand hygiene. In an interview with the corporate RN on 5/11/21 at 2:45PM, as she handed surveyor hand hygiene and food storage policies, she said that any staff that is wearing gloves, no matter what role they play, should perform hand hygiene before putting gloves on and after removing gloves. She said it did not matter how many times they changed gloves, they needed to perform some type of hand hygiene. Record review of facility policy labeled Food Storage - Dry Goods dated October 2019 stated, The Dining Services Director or designee ensures that all packaged and canned food items shall be kept clean, dry and properly sealed. The policy does not address a scoop or cup in the container with food items. Record review of facility policy labeled Food Storage: Cold dated October 2019 stated, The Dining Services Director/Cook ensures that all food items are stored properly in covered containers, labeled and dated and arranged in a manner to prevent cross contamination. Record review of facility policy labeled Handwashing/Hand Hygiene revised August 2019 stated, Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial ) and water for the following situations: .After removing gloves; .Before and after eating or handling food; .The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare- associated infections .Perform hand hygiene before applying non-sterile gloves Record review of facility policy labeled Food Receiving and Storage revised October 2017 stated, All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date) .Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date) . Record review of the Texas Food Establishment Rules accessed at https://www.dshs.texas.gov/foodestablishments/pdf/Laws/TFERFieldInspectionManual 6.pdf on 05/14/21 revealed: Food storage containers, identified with common name of food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food . is in a container or package that does not bear an expiration date or day .food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 degrees Celsius (41 degrees Fahrenheit) or less for a maximum of 7 days. The day of preparation shall be counted as day 1 . When to Wash. Food employees shall clean their hands and exposed portions of their arms . immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single-use articles .after touching bare human body parts other than clean hands and clean, exposed portions of arms; .after handling soiled equipment or utensils; .during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks .before donning gloves to initiate a task that involves working with food .after engaging in other activities that contaminate the hands.

Based on observation, interview and record review and in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that are complete and accurately documented for 3 residents. Resident #1 reviewed for medical records. Facility failed to: Document [MEDICAL TREATMENT] treatment records for Resident #1. This deficient practice placed all residents who receive treatments and medications from the facility at risk for less than therapeutic benefits, and/or not receiving ordered medications due to inaccurate documentation and a lack of infermation for physicians. The findings include: Record review of Resident #1's facesheet dated 10/29/19 revealed he was a [AGE] year-old man originally admitted on [DATE]. His [DIAGNOSES REDACTED]. Removal of surgical dressing, muscle spasm, muscle wasting, disorder of phosphorous metabolism, [MEDICAL CONDITION], cororany artery stent placement, [MEDICAL CONDITION], low vitamin D, nasal congestion, optic nerve, [MEDICAL CONDITION], disorders of the brain and therapeutic drug level monitoring right [MEDICAL CONDITION], wound right foot webbing, shingles. Record review of the minimum data set(MDS) completed on 7/8/19 revealed he had a Brief Interview for Mental Status(BIMS) score of 15 indicating he was cognitively intact. Record review of Resident #1 Care Plans printed on 10/30/19 addresses [MEDICAL TREATMENT], right foot wound care, activities(TVs and music),left [MEDICAL CONDITION], impaired vision, gastric reflux, inappropriate behavior(yelling, cursing)shortness of breath, irregular pulse,skin fragility, Code status--full,self care deficit,renal diet, hypercholestrol, phantom pain to amputated left leg,glucose fluctuations. Attempted interviews with Resident #1 on 10/29, 10/30, 10/31 with Resident #1, the answer was the same, No, get out/go away. Record review of Resident #1's treatment sheet, dated (MONTH) 2019, revealed Resident #1 had refused blood glucose monitoring, blood pressure checks and [MEDICAL TREATMENT] access evaluation many times during the month of October. Some of these were marked with an R for refusal, other dates were not marked at all. The nurse who failed to chart on the treatment sheet no longer works at this facility. Nurses had initialed some the items they had completed on the treatment record. There was no key to link the name associated with the initials. Interview with the new Assistant Director of Nursing (ADON) concerning the lack of documentation on the treatment sheets, she said it was one of the things she was going to work on as the ADON, however currently her ADON hours equal 12 per week. In an interview on 10/29/19 at 9:30am the Administrator said the facility had not been sending the [MEDICAL TREATMENT] communication forms to the [MEDICAL TREATMENT] center with Resident #1 for a long time. In an interview on 10/30/19 at 8:30am with local [MEDICAL TREATMENT] Center Registered Nurse reported [MEDICAL TREATMENT] communication forms have not been sent by the facility for a long time', she estimated '2 years of not receiving the [MEDICAL TREATMENT] communication form. The top half of the document was to be filled out by the facility to inform [MEDICAL TREATMENT] nurses of current vital signs, blood glucose, changes in appetite, compliant with fluid restriction, evaluation of the [MEDICAL TREATMENT] port, sign of infection, unusual bleeding, medication changes. The bottom half of the form was to be filled out by the [MEDICAL TREATMENT] nurses and sent back to the facility with the resident post [MEDICAL TREATMENT] to inform facility staff of pre-[MEDICAL TREATMENT] weight, post [MEDICAL TREATMENT] weight, pre-[MEDICAL TREATMENT] vital signs, post [MEDICAL TREATMENT] vital signs. Labs had been performed monthly by [MEDICAL TREATMENT] Center and results sent to the nursing home monthly. The most current labs were sent from local [MEDICAL TREATMENT] Center to the facility on [DATE]. Labs were reviewed by Resident #1's primary care physician. Record review of a written statement dated 10/30/19 (concerning [MEDICAL TREATMENT] patients at the facility) revealed the Administrator wrote, Nurses have been instructed this form ([MEDICAL TREATMENT] communication form) is to be sent with the resident, a copy will be made and placed in a binder prior to resident leaving the facility'. He also contacted local [MEDICAL TREATMENT] Center to notify them there would be a communication form sent with residents on [MEDICAL TREATMENT] to the [MEDICAL TREATMENT] center with facility information filled out. He requested the [MEDICAL TREATMENT] Center to fill out the bottom portion and send it back to the facility with the resident.

Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit neglect for two residents (Resident #1 and #12) of twelve residents reviewed for neglect. The facility failed to: 1) ensure Resident #1 who had been identified with active exit seeking and wandering behaviors was supervised to prevent his elopement from the facility. 2) ensure Resident #12's Wanderguard alarm transponder was functioning and alarm was sounding when the resident wandered into the perimeter of the alarmed exit door. These failures resulted in Resident #1's elopement from the facility on 2/14/15 sometime between 5:30 p.m. and 5:45 p.m. The facility is located on a busy highway with a speed limit of 45 miles per hour and the resident was found 3 hours later (8:30 p.m.) in a field behind an abandoned discount store (approximately 0.3 miles) filled with overgrown grass, barbed wire fencing and debris which placed him at risk for harm. An Immediate Jeopardy was identified on 3/09/15 at 4:05 p.m. The Immediate Jeopardy was lowered to the potential for more than minimal harm at a pattern on 3/10/15. The facility remained out of compliance due to the lack monitoring of the facility's plan for effectiveness. These failures could place the 5 residents the facility identified as wanderers at risk for leaving the facility unsupervised and place them in situations that could result in harm or death. The findings included: Resident #1 Review of Resident #1's Admission Record dated 02/13/15 indicated the [AGE] year-old male resident was admitted to the facility on [DATE], at 11:00 a.m., from a psychiatric hospital with the following Diagnoses: [REDACTED]. Review of Resident #1's physician's orders [REDACTED]. Review of Resident #1's Admission assessment dated [DATE] indicated the resident was alert and oriented only to person, had long and short-term memory problems, had severely impaired cognitive decision making skills, had behaviors of wandering. The resident was identified as independent with mobility. The resident had a Wanderguard placed to his right wrist for safety due to increased elopement risk. Review of the admission care plan dated 02/13/15 indicated Resident #1 was oriented to person only and was at risk for falls, safety risk and elopement and required a Wanderguard due to Alzheimer's dementia. Review of Resident #1's Consent for use of Wanderguard dated 02/13/15 indicated Resident #1's responsible party had consented to the use of a Wanderguard bracelet. Review of an Incident/Accident report dated 02/14/15, at 1:10 p.m.; indicated Resident #1 had opened and gone through hall #4's fire door. The alarm was sounding and the resident was found outside the door. The resident was escorted back into the building and was noted to be easily redirected. Review of Resident #1's Nursing Notes dated 02/14/15 with no documented time indicated the following: Door alarm sounding and staff noted resident had gone out, walked around to the front door with resident. DON notified and DON had maintenance director come check door. (The resident was placed on 15 minute checks for safety) Review of Incident/Accident report dated 02/14/15 with no documented time indicated the resident had eloped from the facility between 5:30 p.m. and 5:45 p.m. The resident was found at approximately 8:30 p.m. and taken to a local hospital by ambulance and admitted for evaluation and [DIAGNOSES REDACTED]. Review of a Nursing Note dated 02/14/15 at 9:05 p.m. indicated Resident #1 had required " very " frequent monitoring and redirection due to frequent attempts to get out of both front and side doors. The resident was last seen at 5:29 p.m., when he was sitting calmly in the lobby. At 5:45 p.m., it was discovered he was missing. At 5:50 p.m., a CNA did a complete building sweep, which did not result in resident being found. The Administrator was immediately notified and then 9-1-1 was called and reported missing resident to the Coleman police department. Then the resident's responsible party was contacted and a message was left. Review of the Coleman Police Department Incident and Crime Report dated 02/14/15 indicated, about 6:02 p.m., an officer was dispatched to the nursing facility in reference to a missing resident. Resident #1, a white male about 5 feet 6 and weighing 145 pounds, with gray hair, last seen wearing a blue long john-type shirt and blue jeans, which has [DIAGNOSES REDACTED]. The officer made an announcement to locate all county first responders who could assist looking for Resident #1. About 8:29 p.m., officers were notified that Resident #1 was last seen by a storage building in town and the officer and other units responded to the area. The officer was told that Resident #1 started running and was seen in a field behind an abandoned store lying on the ground. Fire personnel had made contact with Resident #1 and requested an ambulance due to Resident #1 getting caught up in some barbed wire. EMS arrived and transported Resident #1 to the local hospital to be checked out. Resident #1's family was on the scene and followed the ambulance to the hospital. Review of an assessment by a facility staff member (facility staff member arrived where resident was found at same time as EMS), upon finding Resident #1, dated 02/14/15 indicated on this evening, around 8:30 p.m., Resident #1 was evaluated by the EMS staff. He was in good spirits, alert, confused, and oriented only to person. He was in a pleasant mood, cooperative, and initially complaining of right knee pain. There were no other visual injuries noted. EMS staff assessed the resident's legs, ankles, hips, knees, his back, and the resident had no complaints of any pain after the EMS had assessed him. EMS staff asked if any medical [DIAGNOSES REDACTED]. The resident was transferred to the emergency room via ambulance to be assessed for his knee pain and overall assessment. Review of an Coleman Emergency Medical Services run sheet dated 02/14/15 indicated the following: Medical 1 EMS was dispatched emergency 9-1-1 to the vacant log behind an abandoned store for a male that went missing from a local nursing home earlier today. As EMS headed to the truck, they were notified that the patient was conscious and breathing. EMS alerted of finding an elderly man that had been missing from the nursing home for approximately three hours. EMS arrived on scene to find [AGE] year-old white male patient laying supine with his knees bent, beside the fence, on the ground in overgrown grass in a vacant lot. The patient is slightly confused. Healthcare provider nurse states the patient was reported missing from the nursing home at approximately 5:30 p.m. and a spouse of a facility employee and police officer had just found him. Healthcare provider nurse states the only complaint we could get out of him was right hip pain. Asked if patient fell . Healthcare provider states we do not know. Healthcare provider states patient allergic to [MEDICATION NAME] and had diagnose of Hypertension and Dementia. Did quick assessment as well as we could with just a flashlight in the dark. The patient denies all pain, except right knee at this time. No obvious deformities noted. The patient is wearing pants and a long sleeve shirt with socks and shoes noted. The patient ' s skin is cool to touch, but his hands are cold. C-spine cleared and warm blanket placed on patient. None of the patient ' s clothes are moist or wet. Patient placed on scoop stretcher and carried through vacant lot with overgrown grass up lot to EMS stretcher. Patient placed into warm unit. EMS delayed on scene due to extrication of patient. The area had waist high grass and weeds with unknown debris everywhere. It being dark made it very difficult to see with just a flashlight from where he was to the unit. Vital signs obtained and found blood pressure to be 120/72, pulse 100 strong and regular, respirations 18 and non-labored, O2 sat at 94% on room air. Tympanic temperature is 93.7. The patient complains of right knee pain, but is unable to rate it on a pain scale of 1 to 10 at this time. Review of a Hospital emergency room Department record dated 02/14/15, at 9:05 p.m., indicated the resident had arrived at the emergency room following being missing from the nursing home for four hours. Patient alert, confused, which is normal for patient. The patient complains of tenderness to right hip with palpation. The patient has grass all over him and EMS reports the patient was found lying in the field in very tall grass. The patient was lying on his back. The patient states he was trying to dig a hole to hide. The patient has tiny scratched to his hands. Review of a Provider Investigation Report dated 02/14/15 indicated at 5:45 p.m. Resident #1, who was identified as having a history of wandering and wearing a Wanderguard at the time of the incident, was found to be missing from the facility. Description of allegation: On 02/14/15, Resident #1 was discovered missing at 5:45 p.m. Staff RN activated " Code Green " , missing resident plan. A search was preformed of the interior facility and exterior facility without locating resident. Staff RN notified family, Administrator, and Director of Nurses. The search continued until the resident was located at 8:30 p.m., approximately 1-1/2 blocks away (0.3 miles), behind an abandoned store, in a field. Description of injuries included resident had superficial scratches to his hands and complained of right knee pain. Note: Resident had Wanderguard on wrist when found. Description of assessment indicated resident was evaluated by EMS and was found in good spirits, alert, confused, and oriented only to person. He was in a pleasant mood, cooperative, and initially complaining of right knee pain. Resident was transferred to a local hospital emergency room . At the emergency room , tiny scratches were discovered on the hands and the resident was found to have a UTI. Provider response indicated: 1) Staff performed code green, missing resident procedures, including searching room to room, searching facility and exterior of the building. Notified family, police, administrator, and director of nursing. Resident was last seen at 5:29 p.m. and could not be located at 5:45 p.m. 2) Additional staff was called in for search. 3) Photograph of resident was provided to police. 4) Additional photos were made for staff, volunteers, and authorities. 5) A search group was dispatched until the resident was located at 8:30 p.m. Investigation summary indicated staff performed head-to-head count for all other residents with all other residents located in the facility. RN staff members assigned search areas and notified families, police, administrator, and DON. Additional off-duty staff were called in to assist with the search. Police Department, Sheriff's Department, Fire department, Emergency Medical services, and community volunteers assisted in the search. Additional copies of resident's photographs were made and given to volunteers and authorities. Local businesses were searched and notified with a description of the missing resident. Interviews were conducted with staff, some residents, and known visitors. Abilene Police Department notified with a description of the resident and issued a bulletin to look out for the individual. Coleman Police were in progress of issuing a senior alert with DPS. Family assisted in the search. Resident was located by the spouse of an employee at 8:30 p.m., approximately 1-1/2 blocks from the facility, in a field behind the south side of an abandoned store. Volunteer was calling out resident's name and resident yelled back for help saying "I'm over here." Resident was fully clothed and found kneeling at the fence. He was advised to lie down until EMS could arrive. Resident spoke with Administrator at the scene. Resident was alert, but confused, which is normal for this individual. The provider action taken post investigation indicated family and facility agreed that the resident would need a secured, locked facility for safety. The facility assisted family in finding a facility with a locked unit. Upon discharge out of the hospital on [DATE], resident was transported to the facility of the family choice. All Wanderguard Roam Alert have been checked. The doors were found to be operational with no issues noted. It was found that staff followed the proper protocol and all preventative measures were in place. The probable cause was assumed to be going out the front door with a visitor, and a sign has been placed on the front door to prevent occurrences. During an interview on 3/09/15 at 1:37 p.m. RN I said she was the weekend RN and had been on duty the day of 2/14/15 when Resident #1 wandered from the facility. She said earlier in the day, around 1:30 p.m. Resident #1 had pushed open one of the fire doors on hall 4 and walked outside the door. She said staff immediately responded and walked the resident back around the facility. She said the resident had been exit seeking, however he had been easily redirected. She said he had activated the Wanderguard alarm on the front door multiple times; however seemed to become more cooperative and relaxed as the day went on. She said following the resident exiting out the fire doors; the resident had been placed on 15 minute checks. RN I said there had been numerous visitors to the facility due to being Valentine's Day. RN I said Resident #1 had been sitting quietly in the lobby/living room area and appeared very calm. She said the CNA's had informed her that Resident #1 did not want to go eat dinner in the dining room. She said she felt it was safe to leave the resident and go assist the CNA's in the dining room for dinner. She said she walked back through to check on the resident and he was no longer sitting there. She said she and a CNA immediately began searching the building; however the resident was not found. She said she initiated a "Code Green " (missing resident) per policy and began notifying everyone. RN I said when a resident with a Wanderguard gets within a specific distance (about 10 feet) from the exit door, the door automatically locked and the alarm sounded. She said she had not heard the resident's Wanderguard alarm sounding. She said she was unsure if the door alarmed if it was already opened. She said the door had a 15 second emergency release and the resident may have held the bar on the door to let someone in and walked out. She said following the incident, the door alarm system had been changed. During an interview on 3/09/15 at 2:00 p.m. The Administrator said she had received a call on 2/14/15 regarding Resident #1 wandering away from the facility. She said she was unaware of how the resident had exited through the door without the alarm sounding. She said they had assumed the resident had opened the door for visitors and had walked out the door. She said Resident #1 did not look like a "nursing home resident". She said prior to the incident, if a resident with a Wanderguard stepped towards the door, the door would lock and alarm; however she said if the resident walked out of the alarm perimeter the alarm would cease to sound. She said she felt when the resident had gone through the door and walked a few feet from the alarm system, it had silenced the alarm. She said following the incident the alarm company had been contacted and the door was now equipped with a key pad. She said the alarm would not quit sounding until the code was input into the keypad. During an interview on 3/09/15 at 2:00 p.m. the Maintenance Director said the original alarm system made a repetitive beeping sound and the doors locked when activated by the Wanderguard transponder. He said however, the doors have an emergency release and after 15 seconds of steadily holding the door bar, the doors open. He said the facility's front door was the only door linked to the Wanderguard system. He said the other exit doors were considered fire doors and all alarmed when opened. He said the new system used a keypad therefore the alarm continued until the code was put in properly. He said he was unaware how the resident could have gone through the door without the Wanderguard alarm sounding. He said the only conclusion he could come up with was when the resident walked close to the door the alarm sounded; however when he walked past a certain point outside the door the system would not detect the Wanderguard anymore and the alarm would have stopped sounding. During an interview on 3/10/15 at 2:35 p.m. CNA G said she had been on duty on 2/14/15 at the time Resident #1 had wandered from the facility. She said Resident #1 had stayed in the living room/lobby most of the afternoon and the Wanderguard alarm had gone off continuously due to Resident #1 getting to close to the door. She said the CNA's were responsible for completing the 15 minute checks on the resident. She said she and the other CNA had begun getting residents to the dining room and asked Resident #1 if he wanted to go have dinner in the dining room. She said the resident went to the dining room, then immediately walked out and sat back down in the lobby. She said the next thing she knew the resident was unaccounted for. She said she had not heard the Wanderguard alarm sounding. She said the staffing for that shift was 1 RN, 1 LVN and 2 CNA's, she felt that due to Resident #1's repeated attempts to exit the building an extra CNA was needed. She said she felt the resident should have been placed on a one on one status and had a staff member dedicated to monitoring him. During an interview on 3/10/15 at 2:40 p.m. CNA H said she had been on duty on 2/14/15 at the time Resident #1 had wandered from the facility. She said Resident #1's Wanderguard had activated the alarm system multiple times that afternoon. She said the resident had sat in the lobby most of the afternoon and would see visitors coming and try to open the door for them. She said when the resident's Wanderguard activated the alarm system, the door would lock. She said the staff would then have to press the door bar for 15 seconds to open the door. She said she felt the resident had watched the staff press on the door bar and figured out how to get the door open. She said she and the other CNA were helping get residents to the dining room when she was notified by RN I of the resident being missing. She said she had searched all of the facility rooms and outside the facility and the resident was not found. She said she felt there had been enough staff to take care of the resident's; however with Resident #1's multiple attempts to leave the facility another staff member was needed. During an observation on 3/10/15 at 4:30 p.m. the highway in front of the facility was observed to be a four lane highway with a near by speed limit sign of 45 miles per hour. The area around the abandoned discount store was observed as having thick straw colored grass that was approximately 3.5 to 4.5 feet tall through out the lot. Resident #12 Review of Resident #12's Admission Record indicated the [AGE] year old female resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #12's quarterly Minimum (MDS) data set [DATE] indicated the resident was identified with a BIMS (Brief Interview of Mental Status) score of 8 indicating the resident had moderate cognitive impairment. The resident was identified with no exhibited wandering behaviors during the assessment period. The resident was independent or required supervision with set up only for all activities of daily living. Review of Resident #12's Elopement Risk Evaluation dated 03/05/15 indicated the following; the resident was identified to be cognitively impaired with poor decision making skills, the resident had a [DIAGNOSES REDACTED]. Review of Resident #12's Consent for Wanderguard dated 03/05/15 indicated the following; a physician order [REDACTED].#12's daughter to place a Wanderguard on the resident. Review of Resident #12's most current consolidated Care plan dated 11/12/14 indicated no updates related to the resident's physician ordered Wanderguard. During an observation on 3/09/15 at 3:40 p.m. The Administrator was observed using a device to check the function of the resident's Wanderguards transponders with a code of "OK" if working properly. Upon entering Resident #12's room, the device read "noise" instead of "OK". The resident was escorted to the front lobby and the alarm did not sound nor did the door lock. The resident was asked if she could open the door and she placed her hands on the door bar and opened the door. The alarm continued not to sound. The Administrator said the alarm had been checked by the nurse with the device on the 10:00 p.m. to 6:00 a.m. shift and had been found to function properly. During an interview with the administrator on 3/09/15 at 4:05 p.m., the facility was advised an Immediate Jeopardy had been identified. The facility submitted the following action plan of removal on 3/10/15 at 4:00 p.m. 1) Resident #1 eloped on 2/14/15 and the facility determined that the door enunciator was not loud enough to alert staff of his departure. The alarm ceased to alert staff after the resident was approximately 15 ft. away from the door. a) Alternate placement was found for the resident on a secure unit on 2/16/15. b) Alarm Company was contracted to adjust the enunciator and Q/AAC determined to place a manual code aspect to the system on. c) Enhanced supervision of residents identified as requiring the Wanderguard (roam alert) system within visual sight, arm ' s length or placed on specific timed observations. d) Compliance audit of clinical services to ensure plan was in place and residents were safe. Including additional teaching/training of facility and contract staff. e) Exit doors checked weekly by Maintenance Director and found to be working properly. f) The front door alarm now requires a manual code to cease the enunciator. 2) Resident #12's Wanderguard Roam Alert sensor (transponder) failed to activate the door alarm and lock system on 3/09/15. A new senor was immediately applied and functioning. a) Charge Nurse will now check the sensor operation each shift rather than once daily and document in the Wander Risk Notebook. b) Administrator/ Designee will visualize and personally use the testing device to ensure no manufacture malfunction for existing roam alert sensors. c) Staff member's inserviced on electronic monitoring again on 3/09/15 on the purpose of Roam alert system and residents identified as high risk for elopement. d) The Wander Risk Assessment Notebook is continually updated each shift and located at the nurse's station. e) Each resident with a Roam Alert sensor has the sensor visualized every shift to ensure placement. f) Elopement Risk Assessments and Care plans updated after each elopement attempt. g) Continuation of daily door alarm check performed by nursing staff with the door alarm check tool and on weekly maintenance door checks. h) Out of cycle QAA review process to ensure resident safety. i) Medical Director notified of situation on 3/10/15. During interviews on 3/11/15 and 3/12/15, 10 staff members' were able to relate all aspects of the Wanderguard system and residents who were identified at risk for wandering. 3 LVN's were able to relate expectations of the Wander Risk Assessment Notebook and documentation of monitoring each shift. During observations on 3/11/15 and 3/12/15, the Wanderguard alarm system was fully audible throughout the facility and required manual code entry into keypad to cancel alarm. After verification of the facility's plan of removal dated 03/10/15 the Immediate Jeopardy was lowered to the potential for more than minimal harm at a pattern. The effective date was 3/10/15 and was completed prior to exit on 03/12/15. The facility remained out of compliance due to the lack monitoring needed of the facility's plan for effectiveness. During an interview on 3/12/15 at 11:00 a.m. the Administrator said there were currently 5 residents in the facility that required Wanderguard bracelets and were identified at risk for elopement from the facility. Review of the Policy and Procedure; Investigating Allegations of Neglect dated 01/15/15 indicated the following: Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, mental illness or the deterioration of a residents physical or mental condition. Neglect also means the failure to protect the resident from abuse, neglect, or exploitation. Neglect is repeated conduct or a single incident of carelessness which produces or could reasonably be expected to result in serious physical or psychological injury or substantial risk of death.

Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit neglect for two residents (Resident #1 and #12) of twelve residents reviewed for neglect. The facility failed to (A). Ensure Resident #1 who had been identified with active exit seeking and wandering behaviors was supervised to prevent his elopement from the facility and..... ensure Resident #12's Wanderguard alarm transponder was functioning and alarm was sounding when the resident wandered into the perimeter of the alarmed exit door. These failures resulted in Resident #1's elopement from the facility on 2/14/15 sometime between 5:30 p.m. and 5:45 p.m. The facility is located on a busy highway with a speed limit of 45 miles per hour and the resident was found 3 hours later (8:30 p.m.) in a field behind an abandoned discount store (approximately 0.3 miles) filled with overgrown grass, barbed wire fencing and debris which placed him at risk for harm. These failures could have affected (5) residents identified by the facility as Residents who wore Wanderguards for safety and who were at risk for elopement. These (5) residents were at risk of leaving the facility unsupervised and which could place them in situations that could result in harm and/or death. (B). The facility failed to do reference checks to determine employee background information and work history for 1 Licensed Vocational Nurse (LVN A) and 4 Certified Nurses' Aides (CNAs B, C, D, E) and one cook (Cook F) of 16 employee files reviewed. This failure could place the census of 35 residents at risk of abuse, neglect, mistreatment, and/or misappropriation of personal property. An Immediate Jeopardy was identified on 3/09/15 at 4:05 p.m. The Immediate Jeopardy was lowered to the potential for more than minimal harm at a pattern on 3/10/15. The facility remained out of compliance due to the lack monitoring of the facility's plan for effectiveness. The findings included: (A) Review of the Policy and Procedure; Investigating Allegations of Neglect dated 01/15/15 indicated the following: Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, mental illness or the deterioration of a residents physical or mental condition. Neglect also means the failure to protect the resident from abuse, neglect, or exploitation. Neglect is repeated conduct or a single incident of carelessness which produces or could reasonably be expected to result in serious physical or psychological injury or substantial risk of death. Resident #1 Review of Resident #1's Admission Record dated 02/13/15 indicated the [AGE] year-old male resident was admitted to the facility on [DATE], at 11:00 a.m., from a psychiatric hospital with the following Diagnoses: [REDACTED]. Review of Resident #1's physician's orders [REDACTED]. Review of Resident #1's Admission assessment dated [DATE] indicated the resident was alert and oriented only to person, had long and short-term memory problems, had severely impaired cognitive decision making skills, had behaviors of wandering. The resident was identified as independent with mobility. The resident had a Wanderguard placed to his right wrist for safety due to increased elopement risk. Review of the admission care plan dated 02/13/15 indicated Resident #1 was oriented to person only and was at risk for falls, safety risk and elopement and required a Wanderguard due to Alzheimers' dementia. Review of Resident #1's Consent for use of Wanderguard dated 02/13/15 indicated Resident #1's responsible party had consented to the use of a Wanderguard bracelet. Review of an Incident/Accident report dated 02/14/15, at 1:10 p.m.; indicated Resident #1 had opened and gone through hall #4's fire door. The alarm was sounding and the resident was found outside the door. The resident was escorted back into the building and was noted to be easily redirected. Review of Resident #1's Nursing Notes dated 02/14/15 with no documented time indicated the following: Door alarm sounding and staff noted resident had gone out, walked around to the front door with resident. DON notified and DON had maintenance director come check door. (The resident was placed on 15 minute checks for safety) Review of Incident/Accident report dated 02/14/15 with no documented time indicated the resident had eloped from the facility between 5:30 p.m. and 5:45 p.m. The resident was found at approximately 8:30 p.m. and taken to a local hospital by ambulance and admitted for evaluation and [DIAGNOSES REDACTED]. Review of a Nursing Note dated 02/14/15 at 9:05 p.m. indicated Resident #1 had required " very " frequent monitoring and redirection due to frequent attempts to get out of both front and side doors. The resident was last seen at 5:29 p.m., when he was sitting calmly in the lobby. At 5:45 p.m., it was discovered he was missing. At 5:50 p.m., a CNA did a complete building sweep, which did not result in resident being found. The Administrator was immediately notified and then 9-1-1 was called and reported missing resident to the Coleman police department. Then the resident's responsible party was contacted and a message was left. Review of the Coleman Police Department Incident and Crime Report dated 02/14/15 indicated, about 6:02 p.m., an officer was dispatched to the nursing facility in reference to a missing resident. Resident #1, a white male about 5 feet 6 and weighing 145 pounds, with gray hair, last seen wearing a blue long john-type shirt and blue jeans, which has [DIAGNOSES REDACTED]. The officer made an announcement to locate all county first responders who could assist looking for Resident #1. About 8:29 p.m., officers were notified that Resident #1 was last seen by a storage building in town and the officer and other units responded to the area. The officer was told that Resident #1 started running and was seen in a field behind an abandoned store lying on the ground. Fire personnel had made contact with Resident #1 and requested an ambulance due to Resident #1 getting caught up in some barbed wire. EMS arrived and transported Resident #1 to the local hospital to be checked out. Resident #1's family was on the scene and followed the ambulance to the hospital. Review of an assessment by a facility staff member (facility staff member arrived where resident was found at same time as EMS), upon finding Resident #1, dated 02/14/15 indicated on this evening, around 8:30 p.m., Resident #1 was evaluated by the EMS staff. He was in good spirits, alert, confused, and oriented only to person. He was in a pleasant mood, cooperative, and initially complaining of right knee pain. There were no other visual injuries noted. EMS staff assessed the resident's legs, ankles, hips, knees, his back, and the resident had no complaints of any pain after the EMS had assessed him. EMS staff asked if any medical [DIAGNOSES REDACTED]. The resident was transferred to the emergency room via ambulance to be assessed for his knee pain and overall assessment. Review of an Coleman Emergency Medical Services run sheet dated 02/14/15 indicated the following: Medical 1 EMS was dispatched emergency 9-1-1 to the vacant log behind an abandoned store for a male that went missing from a local nursing home earlier today. As EMS headed to the truck, they were notified that the patient was conscious and breathing. EMS alerted of finding an elderly man that had been missing from the nursing home for approximately three hours. EMS arrived on scene to find [AGE] year-old white male patient laying supine with his knees bent, beside the fence, on the ground in overgrown grass in a vacant lot. The patient is slightly confused. Healthcare provider nurse states the patient was reported missing from the nursing home at approximately 5:30 p.m. and a spouse of a facility employee and police officer had just found him. Healthcare provider nurse states the only complaint we could get out of him was right hip pain. Asked if patient fell . Healthcare provider states we do not know. Healthcare provider states patient allergic to [MEDICATION NAME] and had diagnose of Hypertension and Dementia. Did quick assessment as well as we could with just a flashlight in the dark. The patient denies all pain, except right knee at this time. No obvious deformities noted. The patient is wearing pants and a long sleeve shirt with socks and shoes noted. The patient ' s skin is cool to touch, but his hands are cold. C-spine cleared and warm blanket placed on patient. None of the patient ' s clothes are moist or wet. Patient placed on scoop stretcher and carried through vacant lot with overgrown grass up lot to EMS stretcher. Patient placed into warm unit. EMS delayed on scene due to extrication of patient. The area had waist high grass and weeds with unknown debris everywhere. It being dark made it very difficult to see with just a flashlight from where he was to the unit. Vital signs obtained and found blood pressure to be 120/72, pulse 100 strong and regular, respirations 18 and non-labored, O2 sat at 94% on room air. Tympanic temperature is 93.7. The patient complains of right knee pain, but is unable to rate it on a pain scale of 1 to 10 at this time. Review of a Hospital emergency room Department record dated 02/14/15, at 9:05 p.m., indicated the resident had arrived at the emergency room following being missing from the nursing home for four hours. Patient alert, confused, which is normal for patient. The patient complains of tenderness to right hip with palpation. The patient has grass all over him and EMS reports the patient was found lying in the field in very tall grass. The patient was lying on his back. The patient states he was trying to dig a hole to hide. The patient has tiny scratched to his hands. Review of a Provider Investigation Report dated 02/14/15 indicated at 5:45 p.m. Resident #1, who was identified as having a history of wandering and wearing a Wanderguard at the time of the incident, was found to be missing from the facility. Description of allegation: On 02/14/15, Resident #1 was discovered missing at 5:45 p.m. Staff RN activated " Code Green " , missing resident plan. A search was preformed of the interior facility and exterior facility without locating resident. Staff RN notified family, Administrator, and Director of Nurses. The search continued until the resident was located at 8:30 p.m., approximately 1-1/2 blocks away (0.3 miles), behind an abandoned store, in a field. Description of injuries included resident had superficial scratches to his hands and complained of right knee pain. Note: Resident had Wanderguard on wrist when found. Description of assessment indicated resident was evaluated by EMS and was found in good spirits, alert, confused, and oriented only to person. He was in a pleasant mood, cooperative, and initially complaining of right knee pain. Resident was transferred to a local hospital emergency room . At the emergency room , tiny scratches were discovered on the hands and the resident was found to have a UTI. Provider response indicated: 1) Staff performed code green, missing resident procedures, including searching room to room, searching facility and exterior of the building. Notified family, police, administrator, and director of nursing. Resident was last seen at 5:29 p.m. and could not be located at 5:45 p.m. 2) Additional staff was called in for search. 3) Photograph of resident was provided to police. 4) Additional photos were made for staff, volunteers, and authorities. 5) A search group was dispatched until the resident was located at 8:30 p.m. Investigation summary indicated staff performed head-to-head count for all other residents with all other residents located in the facility. RN staff members assigned search areas and notified families, police, administrator, and DON. Additional off-duty staff were called in to assist with the search. Police Department, Sheriff's Department, Fire department, Emergency Medical services, and community volunteers assisted in the search. Additional copies of resident's photographs were made and given to volunteers and authorities. Local businesses were searched and notified with a description of the missing resident. Interviews were conducted with staff, some residents, and known visitors. Abilene Police Department notified with a description of the resident and issued a bulletin to look out for the individual. Coleman Police were in progress of issuing a senior alert with DPS. Family assisted in the search. Resident was located by the spouse of an employee at 8:30 p.m., approximately 1-1/2 blocks from the facility, in a field behind the south side of an abandoned store. Volunteer was calling out resident's name and resident yelled back for help saying "I'm over here." Resident was fully clothed and found kneeling at the fence. He was advised to lie down until EMS could arrive. Resident spoke with Administrator at the scene. Resident was alert, but confused, which is normal for this individual. The provider action taken post investigation indicated family and facility agreed that the resident would need a secured, locked facility for safety. The facility assisted family in finding a facility with a locked unit. Upon discharge out of the hospital on [DATE], resident was transported to the facility of the family choice. All Wanderguard Roam Alert have been checked. The doors were found to be operational with no issues noted. It was found that staff followed the proper protocol and all preventative measures were in place. The probable cause was assumed to be going out the front door with a visitor, and a sign has been placed on the front door to prevent occurrences. During an interview on 3/09/15 at 1:37 p.m. RN I said she was the weekend RN and had been on duty the day of 2/14/15 when Resident #1 wandered from the facility. She said earlier in the day, around 1:30 p.m. Resident #1 had pushed open one of the fire doors on hall 4 and walked outside the door. She said staff immediately responded and walked the resident back around the facility. She said the resident had been exit seeking, however he had been easily redirected. She said he had activated the Wanderguard alarm on the front door multiple times; however seemed to become more cooperative and relaxed as the day went on. She said following the resident exiting out the fire doors; the resident had been placed on 15 minute checks. RN I said there had been numerous visitors to the facility due to being Valentine's Day. RN I said Resident #1 had been sitting quietly in the lobby/living room area and appeared very calm. She said the CNA's had informed her that Resident #1 did not want to go eat dinner in the dining room. She said she felt it was safe to leave the resident and go assist the CNA's in the dining room for dinner. She said she walked back through to check on the resident and he was no longer sitting there. She said she and a CNA immediately began searching the building; however the resident was not found. She said she initiated a "Code Green " (missing resident) per policy and began notifying everyone. RN I said when a resident with a Wanderguard gets within a specific distance (about 10 feet) from the exit door, the door automatically locked and the alarm sounded. She said she had not heard the resident's Wanderguard alarm sounding. She said she was unsure if the door alarmed if it was already opened. She said the door had a 15 second emergency release and the resident may have held the bar on the door to let someone in and walked out. She said following the incident, the door alarm system had been changed. During an interview on 3/09/15 at 2:00 p.m. The Administrator said she had received a call on 2/14/15 regarding Resident #1 wandering away from the facility. She said she was unaware of how the resident had exited through the door without the alarm sounding. She said they had assumed the resident had opened the door for visitors and had walked out the door. She said Resident #1 did not look like a "nursing home resident". She said prior to the incident, if a resident with a Wanderguard stepped towards the door, the door would lock and alarm; however she said if the resident walked out of the alarm perimeter the alarm would cease to sound. She said she felt when the resident had gone through the door and walked a few feet from the alarm system, it had silenced the alarm. She said following the incident the alarm company had been contacted and the door was now equipped with a key pad. She said the alarm would not quit sounding until the code was input into the keypad. During an interview on 3/09/15 at 2:00 p.m. the Maintenance Director said the original alarm system made a repetitive beeping sound and the doors locked when activated by the Wanderguard transponder. He said however, the doors have an emergency release and after 15 seconds of steadily holding the door bar, the doors open. He said the facility's front door was the only door linked to the Wanderguard system. He said the other exit doors were considered fire doors and all alarmed when opened. He said the new system used a keypad therefore the alarm continued until the code was put in properly. He said he was unaware how the resident could have gone through the door without the Wanderguard alarm sounding. He said the only conclusion he could come up with was when the resident walked close to the door the alarm sounded; however when he walked past a certain point outside the door the system would not detect the Wanderguard anymore and the alarm would have stopped sounding. During an interview on 3/10/15 at 2:35 p.m. CNA G said she had been on duty on 2/14/15 at the time Resident #1 had wandered from the facility. She said Resident #1 had stayed in the living room/lobby most of the afternoon and the Wanderguard alarm had gone off continuously due to Resident #1 getting to close to the door. She said the CNA's were responsible for completing the 15 minute checks on the resident. She said she and the other CNA had begun getting residents to the dining room and asked Resident #1 if he wanted to go have dinner in the dining room. She said the resident went to the dining room, then immediately walked out and sat back down in the lobby. She said the next thing she knew the resident was unaccounted for. She said she had not heard the Wanderguard alarm sounding. She said the staffing for that shift was 1 RN, 1 LVN and 2 CNA's, she felt that due to Resident #1's repeated attempts to exit the building an extra CNA was needed. She said she felt the resident should have been placed on a one on one status and had a staff member dedicated to monitoring him. During an interview on 3/10/15 at 2:40 p.m. CNA H said she had been on duty on 2/14/15 at the time Resident #1 had wandered from the facility. She said Resident #1's Wanderguard had activated the alarm system multiple times that afternoon. She said the resident had sat in the lobby most of the afternoon and would see visitors coming and try to open the door for them. She said when the resident's Wanderguard activated the alarm system, the door would lock. She said the staff would then have to press the door bar for 15 seconds to open the door. She said she felt the resident had watched the staff press on the door bar and figured out how to get the door open. She said she and the other CNA were helping get residents to the dining room when she was notified by RN I of the resident being missing. She said she had searched all of the facility rooms and outside the facility and the resident was not found. She said she felt there had been enough staff to take care of the resident's; however with Resident #1's multiple attempts to leave the facility another staff member was needed. During an observation on 3/10/15 at 4:30 p.m. the highway in front of the facility was observed to be a four lane highway with a near by speed limit sign of 45 miles per hour. The area around the abandoned discount store was observed as having thick straw colored grass that was approximately 3.5 to 4.5 feet tall through out the lot. Resident #12 Review of Resident #12's Admission Record indicated the [AGE] year old female resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #12's quarterly Minimum (MDS) data set [DATE] indicated the resident was identified with a BIMS (Brief Interview of Mental Status) score of 8 indicating the resident had moderate cognitive impairment. The resident was identified with no exhibited wandering behaviors during the assessment period. The resident was independent or required supervision with set up only for all activities of daily living. Review of Resident #12's Elopement Risk Evaluation dated 03/05/15 indicated the following; the resident was identified to be cognitively impaired with poor decision making skills, the resident had a [DIAGNOSES REDACTED]. Review of Resident #12's Consent for Wanderguard dated 03/05/15 indicated the following; a physician order [REDACTED].#12's daughter to place a Wanderguard on the resident. Review of Resident #12's most current consolidated Care plan dated 11/12/14 indicated no updates related to the resident's physician ordered Wanderguard. During an observation on 3/09/15 at 3:40 p.m. The Administrator was observed using a device to check the function of the resident's Wanderguards transponders with a code of "OK" if working properly. Upon entering Resident #12's room, the device read "noise" instead of "OK". The resident was escorted to the front lobby and the alarm did not sound nor did the door lock. The resident was asked if she could open the door and she placed her hands on the door bar and opened the door. The alarm continued not to sound. The Administrator said the alarm had been checked by the nurse with the device on the 10:00 p.m. to 6:00 a.m. shift and had been found to function properly. During an interview with the administrator on 3/09/15 at 4:05 p.m., the facility was advised an Immediate Jeopardy had been identified. The facility submitted the following action plan of removal on 3/10/15 at 4:00 p.m. 1) Resident #1 eloped on 2/14/15 and the facility determined that the door enunciator was not loud enough to alert staff of his departure. The alarm ceased to alert staff after the resident was approximately 15 ft. away from the door. a) Alternate placement was found for the resident on a secure unit on 2/16/15. b) Alarm Company was contracted to adjust the enunciator and Q/AAC determined to place a manual code aspect to the system on. c) Enhanced supervision of residents identified as requiring the Wanderguard (roam alert) system within visual sight, arm ' s length or placed on specific timed observations. d) Compliance audit of clinical services to ensure plan was in place and residents were safe. Including additional teaching/training of facility and contract staff. e) Exit doors checked weekly by Maintenance Director and found to be working properly. f) The front door alarm now requires a manual code to cease the enunciator. 2) Resident #12's Wanderguard Roam Alert sensor (transponder) failed to activate the door alarm and lock system on 3/09/15. A new senor was immediately applied and functioning. a) Charge Nurse will now check the sensor operation each shift rather than once daily and document in the Wander Risk Notebook. b) Administrator/ Designee will visualize and personally use the testing device to ensure no manufacture malfunction for existing roam alert sensors. c) Staff member's inserviced on electronic monitoring again on 3/09/15 on the purpose of Roam alert system and residents identified as high risk for elopement. d) The Wander Risk Assessment Notebook is continually updated each shift and located at the nurse's station. e) Each resident with a Roam Alert sensor has the sensor visualized every shift to ensure placement. f) Elopement Risk Assessments and Care plans updated after each elopement attempt. g) Continuation of daily door alarm check performed by nursing staff with the door alarm check tool and on weekly maintenance door checks. h) Out of cycle QAA review process to ensure resident safety. i) Medical Director notified of situation on 3/10/15. During interviews on 3/11/15 and 3/12/15, 10 staff members' were able to relate all aspects of the Wanderguard system and residents who were identified at risk for wandering. 3 LVN's were able to relate expectations of the Wander Risk Assessment Notebook and documentation of monitoring each shift. During observations on 3/11/15 and 3/12/15, the Wanderguard alarm system was fully audible throughout the facility and required manual code entry into keypad to cancel alarm. After verification of the facility's plan of removal dated 03/10/15 the Immediate Jeopardy was lowered to the potential for more than minimal harm at a pattern. The effective date was 3/10/15 and was completed prior to exit on 03/12/15. The facility remained out of compliance due to the lack monitoring needed of the facility's plan for effectiveness During an interview on 3/12/15 at 11:00 a.m. the Administrator said there were currently 5 residents in the facility that required Wanderguard bracelets and were identified at risk for elopement from the facility. (B) Review of the facility's Abuse and Neglect Policy and Procedure, dated 1/15/15, documented in part: Facility will conduct background investigations, including employment background checks, to prevent abuse, neglect, or mistreatment of [REDACTED]. Review of LVN A's employee file indicated she was hired on 8/27/13. There was no indication reference checks were done. Review of CNA B's employee file indicated she was hired on 10/1/14. There was no indication reference checks were done. Review of CNA C's employee file indicated she was hired on 12/30/14. There was no indication reference checks were done. Review of CNA D's employee file indicated she was hired on 7/5/13. There was no indication reference checks were done. Review of CNA E's employee file indicated she was hired on 1/16/15. There was no indication reference checks were done. Review of Cook F's employee file indicated she was hired on 12/14/13. There was no indication reference checks were done. In an interview on 3/12/15 at 10:50 a.m. the business office manager (BOM) said she has been working at the facility since October 2014. The BOM said she has not been checking references for new hires because she didn't know she was supposed to. The BOM said she thought the Director of Nurses (DON) was supposed to do that and that no one had ever told her she was supposed to do it. In an interview on 3/12/15 at 11:00 a.m., the DON said she has not been checking references on new hires. The DON said that was the BOM's responsibility.

Based on observation, interview, and record review, the facility failed to provide supervision and utilize assistance devices to prevent elopement for two residents (Resident #1 and #12) of five residents reviewed for wandering behaviors. The facility failed to: 1) ensure Resident #1 who had been identified with active exit seeking and wandering behaviors was supervised to prevent his elopement from the facility on 2/14/15. 2) ensure Resident #12's Wanderguard alarm transponder was functioning when the resident walked into the perimeter of the alarmed exit door; the alarm failed to sound, the door failed to lock and the resident was able to open the door. 3) ensure Resident #12 who had been identified with wandering behaviors had supervision and was not left unsupervised long enough to obtain the keys to the shower room and shower unsupervised without her whereabouts being detected by staff. These failures resulted in Resident #1's elopement from the facility on 2/14/15 sometime between 5:30 p.m. and 5:45 p.m. The facility is located on a busy highway with a speed limit of 45 miles per hour and the resident was found 3 hours later (8:30 p.m.) in a field behind an abandoned discount store (approximately 0.3 miles) filled with overgrown grass, barbed wire fencing and debris which placed him at risk for harm. The failure to ensure Resident #12's Wanderguard was functioning properly and the resident had increased supervision could have lead to the resident's elopement from the facility going undetected by staff. An Immediate Jeopardy was identified on 3/09/15 at 4:05 p.m. The Immediate Jeopardy was lowered to the potential for more than minimal harm at a pattern on 3/10/15. The facility remained out of compliance due to the lack monitoring of the facility's plan for effectiveness. These failures could place the 5 residents the facility identified as having wandering behaviors at risk for leaving the facility unsupervised and place them in situations that could result in harm or death. The findings included: Resident #1 Review of Resident #1's Admission Record indicated the [AGE] year-old male resident was admitted to the facility from a psychiatric hospital on [DATE], at 11:00 a.m., with the following Diagnoses: [REDACTED]. Review of Resident #1's physician's orders [REDACTED]. Review of Resident #1's Admission assessment dated [DATE] indicated the resident was alert and oriented only to person, had long and short-term memory problems, had severely impaired cognitive decision making skills, had behaviors of wandering. The resident was identified as independent with mobility. The resident had a Wanderguard placed to his right wrist for safety due to increased elopement risk. Review of Resident #1's Consent for use of Wanderguard dated 02/13/15 indicated Resident #1's responsible party had consented to the use of a Wanderguard bracelet. Review of an Incident/Accident report dated 02/14/15, at 1:10 p.m.; indicated Resident #1 had opened and gone through hall #4's fire door. The alarm was sounding and the resident was found outside the door. The resident was escorted back into the building and was noted to be easily redirected. Review of Resident #1's Nursing Notes dated 02/14/15 with no documented time indicated the following: Door alarm sounding and staff noted resident had gone out, walked around to the front door with resident. DON notified and DON had maintenance director come check door. (The resident was placed on 15 minute checks for safety) Review of Incident/Accident report dated 02/14/15 with no documented time indicated the resident had eloped from the facility between 5:30 p.m. and 5:45 p.m. The resident was found at approximately 8:30 p.m. and taken to a local hospital by ambulance and admitted for evaluation and [DIAGNOSES REDACTED]. Review of a Nursing Note dated 02/14/15 at 9:05 p.m. indicated Resident #1 required frequent monitoring and redirection due to frequent attempts to get out of both front and side exit doors. According to the note the resident was last seen at 5:29 p.m. sitting calmly in the lobby and was discovered missing 5:45 p.m. At 5:50 p.m. a CNA did a complete building sweep, which did not result in resident being found. The Administrator was immediately notified and then 9-1-1 was called and reported missing resident to the police department. Then the resident's responsible party was contacted and a message was left. Review of a Coleman Police Department Incident and Crime Report dated 02/14/15 indicated, about 6:02 p.m., an officer was dispatched to the nursing facility in reference to a missing resident. Resident #1, a white male about 5 feet 6 and weighing 145 pounds, with gray hair, last seen wearing a blue long john-type shirt and blue jeans, which has [DIAGNOSES REDACTED]. The officer made an announcement to locate all county first responders who could assist looking for Resident #1. About 8:29 p.m., officers were notified that Resident #1 was last seen by a storage building in town and the officer and other units responded to the area. The officer was told that Resident #1 started running and was seen in a field behind an abandoned store lying on the ground. Fire personnel had made contact with Resident #1 and requested an ambulance due to Resident #1 getting caught up in some barbed wire. EMS arrived and transported Resident #1 to the local hospital to be checked out. Resident #1's family was on the scene and followed the ambulance to the hospital. Review of an assessment by a facility staff member (facility staff member arrived where resident was found at same time as EMS), upon finding Resident #1, dated 02/14/15 indicated on this evening, around 8:30 p.m., Resident #1 was evaluated by the Coleman EMS staff. He was in good spirits, alert, confused, and oriented only to person. He was in a pleasant mood, cooperative, and initially complaining of right knee pain. There were no other visual injuries noted. EMS staff assessed the resident's legs, ankles, hips, knees, his back, and the resident had no complaints of any pain after the EMS had assessed him. EMS staff asked if any medical [DIAGNOSES REDACTED]. The resident was transferred to the emergency room via ambulance to be assessed for his knee pain and overall assessment. Review of an Coleman Emergency Medical Services run sheet dated 02/14/15 indicated the following: Medical 1 EMS was dispatched emergency 9-1-1 to the vacant lot behind an abandoned store for a male that went missing from a local nursing home earlier today. As EMS headed to the truck, they were notified that the patient was conscious and breathing. EMS alerted of finding an elderly man that had been missing from the nursing home for approximately three hours. EMS arrived on scene to find [AGE] year-old white male patient laying supine with his knees bent, beside the fence, on the ground in overgrown grass in a vacant lot. The patient is slightly confused. Healthcare provider nurse states the patient was reported missing from the nursing home at approximately 5:30 p.m. and a spouse of a facility employee and police officer had just found him. Healthcare provider nurse states the only complaint we could get out of him was right hip pain. Asked if patient fell . Healthcare provider states we do not know. Healthcare provider states patient allergic to penicillin and had diagnose of Hypertension and Dementia. Did quick assessment as well as we could with just a flashlight in the dark. The patient denies all pain, except right knee at this time. No obvious deformities noted. The patient is wearing pants and a long sleeve shirt with socks and shoes noted. The patient ' s skin is cool to touch, but his hands are cold. C-spine cleared and warm blanket placed on patient. None of the patient ' s clothes are moist or wet. Patient placed on scoop stretcher and carried through vacant lot with overgrown grass up lot to EMS stretcher. Patient placed into warm unit. EMS delayed on scene due to extrication of patient. The area had waist high grass and weeds with unknown debris everywhere. It being dark made it very difficult to see with just a flashlight from where he was to the unit. Vital signs obtained and found blood pressure to be 120/72, pulse 100 strong and regular, respirations 18 and non-labored, O2 sat at 94% on room air. Tympanic temperature is 93.7. The patient complains of right knee pain, but is unable to rate it on a pain scale of 1 to 10 at this time. Review of a Coleman Hospital emergency room Department record dated 02/14/15, at 9:05 p.m., indicated the resident had arrived at the emergency room following being missing from the nursing home for four hours. Patient alert, confused, which is normal for patient. The patient complains of tenderness to right hip with palpation. The patient has grass all over him and EMS reports the patient was found lying in the field in very tall grass. The patient was lying on his back. The patient states he was trying to dig a hole to hide. The patient has tiny scratched to his hands. Review of a Provider Investigation Report dated 02/14/15 indicated at 5:45 p.m. Resident #1, who was identified as having a history of wandering and wearing a Wanderguard at the time of the incident, was found to be missing from the facility. Description of allegation: On 02/14/15, Resident #1 was discovered missing at 5:45 p.m. Staff RN activated " Code Green " , missing resident plan. A search was preformed of the interior facility and exterior facility without locating resident. Staff RN notified family, Administrator, and Director of Nurses. The search continued until the resident was located at 8:30 p.m., approximately 1-1/2 blocks away (0.3 miles), behind an abandoned store, in a field. Description of injuries included resident had superficial scratches to his hands and complained of right knee pain. Note: Resident had Wanderguard on wrist when found. Description of assessment indicated resident was evaluated by EMS and was found in good spirits, alert, confused, and oriented only to person. He was in a pleasant mood, cooperative, and initially complaining of right knee pain. Resident was transferred to a local hospital emergency room . At the emergency room , tiny scratches were discovered on the hands and the resident was found to have a UTI. Provider response indicated: 1) Staff performed code green, missing resident procedures, including searching room to room, searching facility and exterior of the building. Notified family, police, administrator, and director of nursing. Resident was last seen at 5:29 p.m. and could not be located at 5:45 p.m. 2) Additional staff was called in for search. 3) Photograph of resident was provided to police. 4) Additional photos were made for staff, volunteers, and authorities. 5) A search group was dispatched until the resident was located at 8:30 p.m. Investigation summary indicated staff performed head-to-head count for all other residents with all other residents located in the facility. RN staff members assigned search areas and notified families, police, administrator, and DON. Additional off-duty staff were called in to assist with the search. Police Department, Sheriff's Department, Fire department, Emergency Medical services, and community volunteers assisted in the search. Additional copies of resident's photographs were made and given to volunteers and authorities. Local businesses were searched and notified with a description of the missing resident. Interviews were conducted with staff, some residents, and known visitors. Abilene Police Department notified with a description of the resident and issued a bulletin to look out for the individual. Coleman Police were in progress of issuing a senior alert with DPS. Family assisted in the search. Resident was located by the spouse of an employee at 8:30 p.m., approximately 1-1/2 blocks from the facility, in a field behind the south side of an abandoned store. Volunteer was calling out resident's name and resident yelled back for help saying "I'm over here." Resident was fully clothed and found kneeling at the fence. He was advised to lie down until EMS could arrive. Resident spoke with Administrator at the scene. Resident was alert, but confused, which is normal for this individual. The provider action taken post investigation indicated family and facility agreed that the resident would need a secured, locked facility for safety. The facility assisted family in finding a facility with a locked unit. Upon discharge out of the hospital on [DATE], resident was transported to the facility of the family choice. All Wanderguard Roam Alert have been checked. The doors were found to be operational with no issues noted. It was found that staff followed the proper protocol and all preventative measures were in place. The probable cause was assumed to be going out the front door with a visitor, and a sign has been placed on the front door to prevent occurrences. During an interview on 3/09/15 at 1:37 p.m. RN I said she was the weekend RN and had been on duty the day of 2/14/15 when Resident #1 wandered from the facility. She said earlier in the day, around 1:30 p.m. Resident #1 had pushed open one of the fire doors on hall 4 and walked outside the door. She said staff immediately responded and walked the resident back around the facility. She said the resident had been exit seeking, however he had been easily redirected. She said he had activated the Wanderguard alarm on the front door multiple times; however seemed to become more cooperative and relaxed as the day went on. She said following the resident exiting out the fire doors; the resident had been placed on 15 minute checks. RN I said there had been numerous visitors to the facility due to being Valentine's Day. RN I said Resident #1 had been sitting quietly in the lobby/living room area and appeared very calm. She said the CNA's had informed her that Resident #1 did not want to go eat dinner in the dining room. She said she felt it was safe to leave the resident and go assist the CNA's in the dining room for dinner. She said she walked back through to check on the resident and he was no longer sitting there. She said she and a CNA immediately began searching the building; however the resident was not found. She said she initiated a "Code Green " (missing resident) per policy and began notifying everyone. RN I said when a resident with a Wanderguard gets within a specific distance (about 10 feet) from the exit door, the door automatically locked and the alarm sounded. She said she had not heard the resident's Wanderguard alarm sounding. She said she was unsure if the door alarmed if it was already opened. She said the door had a 15 second emergency release and the resident may have held the bar on the door to let someone in and walked out. She said following the incident, the door alarm system had been changed. During an interview on 3/09/15 at 2:00 p.m. The Administrator said she had received a call on 2/14/15 regarding Resident #1 wandering away from the facility. She said she was unaware of how the resident had exited through the door without the alarm sounding. She said they had assumed the resident had opened the door for visitors and had walked out the door. She said Resident #1 did not look like a "nursing home resident". She said prior to the incident, if a resident with a Wanderguard stepped towards the door, the door would lock and alarm; however she said if the resident walked out of the alarm perimeter the alarm would cease to sound. She said she felt when the resident had gone through the door and walked a few feet from the alarm system, it had silenced the alarm. She said following the incident the alarm company had been contacted and the door was now equipped with a key pad. She said the alarm would not quit sounding until the code was input into the keypad. During an interview on 3/09/15 at 2:00 p.m. the Maintenance Director said the original alarm system made a repetitive beeping sound and the doors locked when activated by the Wanderguard transponder. He said however, the doors have an emergency release and after 15 seconds of steadily holding the door bar, the doors open. He said the facility's front door was the only door linked to the Wanderguard system. He said the other exit doors were considered fire doors and all alarmed when opened. He said the new system used a keypad therefore the alarm continued until the code was put in properly. He said he was unaware how the resident could have gone through the door without the Wanderguard alarm sounding. He said the only conclusion he could come up with was when the resident walked close to the door the alarm sounded; however when he walked past a certain point outside the door the system would not detect the Wanderguard anymore and the alarm would have stopped sounding. During an interview on 3/10/15 at 2:35 p.m. CNA G said she had been on duty on 2/14/15 at the time Resident #1 had wandered from the facility. She said Resident #1 had stayed in the living room/lobby most of the afternoon and the Wanderguard alarm had gone off continuously due to Resident #1 getting to close to the door. She said the CNA's were responsible for completing the 15 minute checks on the resident. She said she and the other CNA had begun getting residents to the dining room and asked Resident #1 if he wanted to go have dinner in the dining room. She said the resident went to the dining room, then immediately walked out and sat back down in the lobby. She said the next thing she knew the resident was unaccounted for. She said she had not heard the Wanderguard alarm sounding. She said the staffing for that shift was 1 RN, 1 LVN and 2 CNA's, she felt that due to Resident #1's repeated attempts to exit the building an extra CNA was needed. She said she felt the resident should have been placed on a one on one status and had a staff member dedicated to monitoring him. During an interview on 3/10/15 at 2:40 p.m. CNA H said she had been on duty on 2/14/15 at the time Resident #1 had wandered from the facility. She said Resident #1's Wanderguard had activated the alarm system multiple times that afternoon. She said the resident had sat in the lobby most of the afternoon and would see visitors coming and try to open the door for them. She said when the resident's Wanderguard activated the alarm system, the door would lock. She said the staff would then have to press the door bar for 15 seconds to open the door. She said she felt the resident had watched the staff press on the door bar and figured out how to get the door open. She said she and the other CNA were helping get residents to the dining room when she was notified by RN I of the resident being missing. She said she had searched all of the facility rooms and outside the facility and the resident was not found. She said she felt there had been enough staff to take care of the resident's; however with Resident #1's multiple attempts to leave the facility another staff member was needed. During an observation on 3/10/15 at 4:30 p.m. the highway in front of the facility was observed to be a four lane highway with a near by speed limit sign of 45 miles per hour. The area around the abandoned discount store was observed as having thick straw colored grass that was approximately 3.5 to 4.5 feet tall through out the lot. Resident #12 Review of Resident #12 ' s Admission Record indicated the [AGE] year old female resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #12 ' s quarterly Minimum (MDS) data set [DATE] indicated the resident was identified with a BIMS (Brief Interview of Mental Status) score of 8 indicating the resident had moderate cognitive impairment. The resident was identified with no exhibited wandering behaviors during the assessment period. The resident was independent or required supervision with set up only for all activities of daily living. Review of Resident #12 ' s Elopement Risk Evaluation with no documented date indicated the following; the resident was identified to be cognitively impaired with poor decision making skills, the resident had a [DIAGNOSES REDACTED]. Review of Resident #12 ' s Consent for Wanderguard dated 3/05/15 indicated the following; a physician order [REDACTED].#12 ' s daughter to place a Wanderguard on the resident. Review of Resident #12 ' s most current consolidated Care plan dated 11/12/14 indicated no updates, goals or approaches that addressed the resident ' s physician ordered Wanderguard. Review of Resident #12 ' s Nursing Notes dated 3/07/15 indicated; Resident came behind nurse ' s station and got into a drawer and took the bathroom keys. The resident let herself into the shower room, took a shower (unsupervised) and then placed the keys back at the nurse ' s station. During an observation on 3/09/15 at 3:40 p.m. The Administrator was observed using a device to check the function of the resident ' s Wanderguard's transponders with a code of " OK " if working properly. Upon entering Resident #12 ' s room, the device read " noise " instead of " OK " . The resident was escorted to the front lobby and the alarm did not sound nor did the door lock. The resident was asked if she could open the door and she placed her hands on the door bar and opened the door. The alarm continued not to sound. The Administrator said the alarm had been checked by the nurse on the 10:00 p.m. to 6:00 a.m. shift and had been found to function properly. During an interview on 3/09/15 at 4:05 p.m., the facility was advised an Immediate Jeopardy had been identified During an interview on 3/10/15 at 2:35 p.m. CNA G said she had been on duty on 3/07/15 when Resident #12 had taken the keys out of the nurse ' s station and taken a shower unsupervised. She said she was unsure when the resident had taken the keys. She said Resident #12 frequently went behind the nurse ' s station and took keys. She said there had been multiple occasions when the staff would be looking for the keys to the bathroom/shower room and have to go ask Resident #12 if she has the keys or knows where they are. During an interview on 3/10/15 at 2:45 p.m. the DON said she was not aware of Resident #12 having access to the keys, letting herself into the shower room and taking a shower unsupervised. She said she was unsure of any reason why the staff would have been unaware of the resident ' s whereabouts for her to retrieve the keys and take a shower. She said due to the residents wandering behaviors; it was her expectation for the staff to have an increased sense of supervision of the resident. The facility submitted the following action plan of removal on 3/10/15 at 4:00 p.m. 1) Resident #1 eloped on 2/14/15 and the facility determined that the door enunciator was not loud enough to alert staff of his departure. The alarm ceased to alert staff after the resident was approximately 15 ft. away from the door. a) Alternate placement was found for the resident on a secure unit. b) Alarm Company was contracted to adjust the enunciator and QAAC determined to place a manual code aspect to the system on 2/16/15. c) Enhanced supervision of residents identified as requiring the Wanderguard (roam alert) system within visual sight, arm ' s length or placed on specific timed observations. d) Compliance audit of clinical services to ensure plan was in place and residents were safe. Including additional teaching/training of facility and contract staff. e) Exit doors checked by Maintenance Director and found to be working properly. f) The front door alarm now requires a manual code to cease the enunciator. 2) Resident #12 ' s Wanderguard Roam Alert sensor (transponder) failed to activate the door alarm and lock system on 3/09/15. A new senor was immediately applied and functioning. a) Charge Nurse will now check the sensor operation each shift rather than once daily and document in the Wander Risk Notebook. b) Administrator/ Designee will visualize and personally use the testing device to ensure no manufacture malfunction for existing roam alert sensors. c) Staff member ' s inserviced on electronic monitoring again on 3/09/15 on the purpose of Roam alert system and residents identified as high risk for elopement. d) The Wander Risk Assessment Notebook is continually updated and located at the nurse ' s station. e) Each resident with a Roam Alert sensor has the sensor visualized every shift to ensure placement. f) Elopement Risk Assessments and Care plans updated after each elopement attempt. g) Continuation of daily door alarm check performed by nursing staff with the door alarm check tool and on weekly maintenance door checks. h) Out of cycle QAA review process to ensure resident safety. i) Medical Director notified of situation on 3/10/15. During interviews on 3/11/15 and 3/12/15, 10 staff members ' were able to relate all aspects of the Wanderguard system and residents who were identified at risk for wandering. 3 LVN ' s were able to relate expectations of the Wander Risk Assessment Notebook and documentation of monitoring each shift. During observations on 3/11/15 and 3/12/15, the Wanderguard alarm system was fully audible throughout the facility and required manual code entry into keypad to cancel alarm. Review of the Policy and Procedure; Electronic Monitoring Device System dated 6/09/14 indicated; every effort will be made to prevent wandering episodes while maintaining the least restrictive environment for resident who are at risk for elopement. After verification of the facility's plan of removal dated 03/10/15 the Immediate Jeopardy was lowered to the potential for more than minimal harm at a pattern. The effective date was 3/10/15 and was completed prior to exit on 03/12/15. The facility remained out of compliance due to the lack monitoring needed of the facility's plan for effectiveness During an interview on 3/12/15 at 11:00 a.m. the Administrator said there were currently 5 residents in the facility that required Wanderguard bracelets and were identified at risk for elopement from the facility.

Based on interview, observation and record review, the Administrator and DON failed to ensure the facility was administered in a manner, which enabled it to use its resources effectively and efficiently to maintain the highest practicable physical well-being for 2 of 6 residents (Resident #1 and #12) reviewed for wandering behaviors received adequate supervision and assistive devices to prevent elopement. 1) The Administrator failed to implement the facility's abuse and neglect policy by not adequately providing goods and services necessary to avoid elopement of wandering residents when on 2/14/15 Resident #1 was missing from the facility and found 3 hours later in a field behind an abandoned store. 2) The Administrator and DON failed to supervise the nursing staff to ensure Resident #1 received increased supervision following the resident exiting through the fire door on 2/14/15 at 1:30 p.m. prior to his elopement on 2/14/15 at 5:30 p.m. 3) The Administer and DON failed to supervise the nursing staff to ensure Resident #12 ' s Wanderguard alarm transponder was functioning properly and alarm was sounding when the resident wandered into the perimeter of the alarmed exit door. These failures resulted in Resident #1's elopement from the facility on 2/14/15 sometime between 5:30 p.m. and 5:45 p.m. The facility is located on a busy highway with a speed limit of 45 miles per hour and the resident was found 3 hours later (8:30 p.m.) in a field behind an abandoned discount store (approximately 0.3 miles) filled with overgrown grass, barbed wire fencing and debris which placed him at risk for harm. The failure to ensure Resident #12's Wanderguard was functioning properly and the resident had increased supervision could have led to the resident's elopement from the facility going undetected by staff. An Immediate Jeopardy was identified on 3/09/15 at 4:05 p.m. The Immediate Jeopardy was lowered to the potential for more than minimal harm at a pattern on 3/10/15. The facility remained out of compliance due to the lack monitoring of the facility's plan for effectiveness. These failures could place the 5 residents the facility identified as wanderers at risk for leaving the facility unsupervised and place them in situations that could result in harm or death. The findings included: ***Resident #1 Review of Resident #1's Admission Record dated 02/13/15 indicated the [AGE] year-old male resident was admitted to the facility on [DATE], at 11:00 a.m., from a psychiatric hospital with the following Diagnoses: [REDACTED]. Review of Resident #1's physician's orders [REDACTED]. Review of Resident #1's Admission assessment dated [DATE] indicated the resident was alert and oriented only to person, had long and short-term memory problems, had severely impaired cognitive decision making skills, had behaviors of wandering. The resident was identified as independent with mobility. The resident had a Wanderguard placed to his right wrist for safety due to increased elopement risk. Review of the admission care plan dated 02/13/15 indicated Resident #1 was oriented to person only and was at risk for falls, safety risk and elopement and required a Wanderguard due to Alzheimers' dementia. Review of Resident #1's Consent for use of Wanderguard dated 02/13/15 indicated Resident #1's responsible party had consented to the use of a Wanderguard bracelet. Review of an Incident/Accident report dated 02/14/15, at 1:10 p.m.; indicated Resident #1 had opened and gone through hall #4's fire door. The alarm was sounding and the resident was found outside the door. The resident was escorted back into the building and was noted to be easily redirected. Review of Resident #1's Nursing Notes dated 02/14/15 with no documented time indicated the following: Door alarm sounding and staff noted resident had gone out, walked around to the front door with resident. DON notified and DON had maintenance director come check door. (The resident was placed on 15 minute checks for safety) Review of Incident/Accident report dated 02/14/15 with no documented time indicated the resident had eloped from the facility between 5:30 p.m. and 5:45 p.m. The resident was found at approximately 8:30 p.m. and taken to a local hospital by ambulance and admitted for evaluation and [DIAGNOSES REDACTED]. Review of a Nursing Note dated 02/14/15 at 9:05 p.m. indicated Resident #1 had required " very " frequent monitoring and redirection due to frequent attempts to get out of both front and side doors. The resident was last seen at 5:29 p.m., when he was sitting calmly in the lobby. At 5:45 p.m., it was discovered he was missing. At 5:50 p.m., a CNA did a complete building sweep, which did not result in resident being found. The Administrator was immediately notified and then 9-1-1 was called and reported missing resident to the Coleman police department. Then the resident's responsible party was contacted and a message was left. Review of the Coleman Police Department Incident and Crime Report dated 02/14/15 indicated, about 6:02 p.m., an officer was dispatched to the nursing facility in reference to a missing resident. Resident #1, a white male about 5 feet 6 and weighing 145 pounds, with gray hair, last seen wearing a blue long john-type shirt and blue jeans, which has [DIAGNOSES REDACTED]. The officer made an announcement to locate all county first responders who could assist looking for Resident #1. About 8:29 p.m., officers were notified that Resident #1 was last seen by a storage building in town and the officer and other units responded to the area. The officer was told that Resident #1 started running and was seen in a field behind an abandoned store lying on the ground. Fire personnel had made contact with Resident #1 and requested an ambulance due to Resident #1 getting caught up in some barbed wire. EMS arrived and transported Resident #1 to the local hospital to be checked out. Resident #1's family was on the scene and followed the ambulance to the hospital. Review of an assessment by a facility staff member (facility staff member arrived where resident was found at same time as EMS), upon finding Resident #1, dated 02/14/15 indicated on this evening, around 8:30 p.m., Resident #1 was evaluated by the EMS staff. He was in good spirits, alert, confused, and oriented only to person. He was in a pleasant mood, cooperative, and initially complaining of right knee pain. There were no other visual injuries noted. EMS staff assessed the resident's legs, ankles, hips, knees, his back, and the resident had no complaints of any pain after the EMS had assessed him. EMS staff asked if any medical [DIAGNOSES REDACTED]. The resident was transferred to the emergency room via ambulance to be assessed for his knee pain and overall assessment. Review of an Coleman Emergency Medical Services run sheet dated 02/14/15 indicated the following: Medical 1 EMS was dispatched emergency 9-1-1 to the vacant log behind an abandoned store for a male that went missing from a local nursing home earlier today. As EMS headed to the truck, they were notified that the patient was conscious and breathing. EMS alerted of finding an elderly man that had been missing from the nursing home for approximately three hours. EMS arrived on scene to find [AGE] year-old white male patient laying supine with his knees bent, beside the fence, on the ground in overgrown grass in a vacant lot. The patient is slightly confused. Healthcare provider nurse states the patient was reported missing from the nursing home at approximately 5:30 p.m. and a spouse of a facility employee and police officer had just found him. Healthcare provider nurse states the only complaint we could get out of him was right hip pain. Asked if patient fell . Healthcare provider states we do not know. Healthcare provider states patient allergic to [MEDICATION NAME] and had diagnose of Hypertension and Dementia. Did quick assessment as well as we could with just a flashlight in the dark. The patient denies all pain, except right knee at this time. No obvious deformities noted. The patient is wearing pants and a long sleeve shirt with socks and shoes noted. The patient ' s skin is cool to touch, but his hands are cold. C-spine cleared and warm blanket placed on patient. None of the patient ' s clothes are moist or wet. Patient placed on scoop stretcher and carried through vacant lot with overgrown grass up lot to EMS stretcher. Patient placed into warm unit. EMS delayed on scene due to extrication of patient. The area had waist high grass and weeds with unknown debris everywhere. It being dark made it very difficult to see with just a flashlight from where he was to the unit. Vital signs obtained and found blood pressure to be 120/72, pulse 100 strong and regular, respirations 18 and non-labored, O2 sat at 94% on room air. Tympanic temperature is 93.7. The patient complains of right knee pain, but is unable to rate it on a pain scale of 1 to 10 at this time. Review of a Hospital emergency room Department record dated 02/14/15, at 9:05 p.m., indicated the resident had arrived at the emergency room following being missing from the nursing home for four hours. Patient alert, confused, which is normal for patient. The patient complains of tenderness to right hip with palpation. The patient has grass all over him and EMS reports the patient was found lying in the field in very tall grass. The patient was lying on his back. The patient states he was trying to dig a hole to hide. The patient has tiny scratched to his hands. Review of a Provider Investigation Report dated 02/14/15 indicated at 5:45 p.m. Resident #1, who was identified as having a history of wandering and wearing a Wanderguard at the time of the incident, was found to be missing from the facility. Description of allegation: On 02/14/15, Resident #1 was discovered missing at 5:45 p.m. Staff RN activated " Code Green " , missing resident plan. A search was preformed of the interior facility and exterior facility without locating resident. Staff RN notified family, Administrator, and Director of Nurses. The search continued until the resident was located at 8:30 p.m., approximately 1-1/2 blocks away (0.3 miles), behind an abandoned store, in a field. Description of injuries included resident had superficial scratches to his hands and complained of right knee pain. Note: Resident had Wanderguard on wrist when found. Description of assessment indicated resident was evaluated by EMS and was found in good spirits, alert, confused, and oriented only to person. He was in a pleasant mood, cooperative, and initially complaining of right knee pain. Resident was transferred to a local hospital emergency room . At the emergency room , tiny scratches were discovered on the hands and the resident was found to have a UTI. Provider response indicated: 1) Staff performed code green, missing resident procedures, including searching room to room, searching facility and exterior of the building. Notified family, police, administrator, and director of nursing. Resident was last seen at 5:29 p.m. and could not be located at 5:45 p.m. 2) Additional staff was called in for search. 3) Photograph of resident was provided to police. 4) Additional photos were made for staff, volunteers, and authorities. 5) A search group was dispatched until the resident was located at 8:30 p.m. Investigation summary indicated staff performed head-to-head count for all other residents with all other residents located in the facility. RN staff members assigned search areas and notified families, police, administrator, and DON. Additional off-duty staff were called in to assist with the search. Police Department, Sheriff's Department, Fire department, Emergency Medical services, and community volunteers assisted in the search. Additional copies of resident's photographs were made and given to volunteers and authorities. Local businesses were searched and notified with a description of the missing resident. Interviews were conducted with staff, some residents, and known visitors. Abilene Police Department notified with a description of the resident and issued a bulletin to look out for the individual. Coleman Police were in progress of issuing a senior alert with DPS. Family assisted in the search. Resident was located by the spouse of an employee at 8:30 p.m., approximately 1-1/2 blocks from the facility, in a field behind the south side of an abandoned store. Volunteer was calling out resident's name and resident yelled back for help saying "I'm over here." Resident was fully clothed and found kneeling at the fence. He was advised to lie down until EMS could arrive. Resident spoke with Administrator at the scene. Resident was alert, but confused, which is normal for this individual. The provider action taken post investigation indicated family and facility agreed that the resident would need a secured, locked facility for safety. The facility assisted family in finding a facility with a locked unit. Upon discharge out of the hospital on [DATE], resident was transported to the facility of the family choice. All Wanderguard Roam Alert have been checked. The doors were found to be operational with no issues noted. It was found that staff followed the proper protocol and all preventative measures were in place. The probable cause was assumed to be going out the front door with a visitor, and a sign has been placed on the front door to prevent occurrences. During an interview on 3/09/15 at 1:37 p.m. RN I said she was the weekend RN and had been on duty the day of 2/14/15 when Resident #1 wandered from the facility. She said earlier in the day, around 1:30 p.m. Resident #1 had pushed open one of the fire doors on hall 4 and walked outside the door. She said staff immediately responded and walked the resident back around the facility. She said the resident had been exit seeking, however he had been easily redirected. She said he had activated the Wanderguard alarm on the front door multiple times; however seemed to become more cooperative and relaxed as the day went on. She said following the resident exiting out the fire doors; the resident had been placed on 15 minute checks. RN I said there had been numerous visitors to the facility due to being Valentine's Day. RN I said Resident #1 had been sitting quietly in the lobby/living room area and appeared very calm. She said the CNA's had informed her that Resident #1 did not want to go eat dinner in the dining room. She said she felt it was safe to leave the resident and go assist the CNA's in the dining room for dinner. She said she walked back through to check on the resident and he was no longer sitting there. She said she and a CNA immediately began searching the building; however the resident was not found. She said she initiated a "Code Green " (missing resident) per policy and began notifying everyone. RN I said when a resident with a Wanderguard gets within a specific distance (about 10 feet) from the exit door, the door automatically locked and the alarm sounded. She said she had not heard the resident's Wanderguard alarm sounding. She said she was unsure if the door alarmed if it was already opened. She said the door had a 15 second emergency release and the resident may have held the bar on the door to let someone in and walked out. She said following the incident, the door alarm system had been changed. During an interview on 3/09/15 at 2:00 p.m. The Administrator said she had received a call on 2/14/15 regarding Resident #1 wandering away from the facility. She said she was unaware of how the resident had exited through the door without the alarm sounding. She said they had assumed the resident had opened the door for visitors and had walked out the door. She said Resident #1 did not look like a "nursing home resident". She said prior to the incident, if a resident with a Wanderguard stepped towards the door, the door would lock and alarm; however she said if the resident walked out of the alarm perimeter the alarm would cease to sound. She said she felt when the resident had gone through the door and walked a few feet from the alarm system, it had silenced the alarm. She said following the incident the alarm company had been contacted and the door was now equipped with a key pad. She said the alarm would not quit sounding until the code was input into the keypad. During an interview on 3/09/15 at 2:00 p.m. the Maintenance Director said the original alarm system made a repetitive beeping sound and the doors locked when activated by the Wanderguard transponder. He said however, the doors have an emergency release and after 15 seconds of steadily holding the door bar, the doors open. He said the facility's front door was the only door linked to the Wanderguard system. He said the other exit doors were considered fire doors and all alarmed when opened. He said the new system used a keypad therefore the alarm continued until the code was put in properly. He said he was unaware how the resident could have gone through the door without the Wanderguard alarm sounding. He said the only conclusion he could come up with was when the resident walked close to the door the alarm sounded; however when he walked past a certain point outside the door the system would not detect the Wanderguard anymore and the alarm would have stopped sounding. During an interview on 3/10/15 at 2:35 p.m. CNA G said she had been on duty on 2/14/15 at the time Resident #1 had wandered from the facility. She said Resident #1 had stayed in the living room/lobby most of the afternoon and the Wanderguard alarm had gone off continuously due to Resident #1 getting to close to the door. She said the CNA's were responsible for completing the 15 minute checks on the resident. She said she and the other CNA had begun getting residents to the dining room and asked Resident #1 if he wanted to go have dinner in the dining room. She said the resident went to the dining room, then immediately walked out and sat back down in the lobby. She said the next thing she knew the resident was unaccounted for. She said she had not heard the Wanderguard alarm sounding. She said the staffing for that shift was 1 RN, 1 LVN and 2 CNA's, she felt that due to Resident #1's repeated attempts to exit the building an extra CNA was needed. She said she felt the resident should have been placed on a one on one status and had a staff member dedicated to monitoring him. During an interview on 3/10/15 at 2:40 p.m. CNA H said she had been on duty on 2/14/15 at the time Resident #1 had wandered from the facility. She said Resident #1's Wanderguard had activated the alarm system multiple times that afternoon. She said the resident had sat in the lobby most of the afternoon and would see visitors coming and try to open the door for them. She said when the resident's Wanderguard activated the alarm system, the door would lock. She said the staff would then have to press the door bar for 15 seconds to open the door. She said she felt the resident had watched the staff press on the door bar and figured out how to get the door open. She said she and the other CNA were helping get residents to the dining room when she was notified by RN I of the resident being missing. She said she had searched all of the facility rooms and outside the facility and the resident was not found. She said she felt there had been enough staff to take care of the resident's; however with Resident #1's multiple attempts to leave the facility another staff member was needed. During an observation on 3/10/15 at 4:30 p.m. the highway in front of the facility was observed to be a four lane highway with a near by speed limit sign of 45 miles per hour. The area around the abandoned discount store was observed as having thick straw colored grass that was approximately 3.5 to 4.5 feet tall through out the lot. Resident #12 Review of Resident #12 ' s Admission Record indicated the [AGE] year old female resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #12 ' s quarterly Minimum (MDS) data set [DATE] indicated the resident was identified with a BIMS (Brief Interview of Mental Status) score of 8 indicating the resident had moderate cognitive impairment. The resident was identified with no exhibited wandering behaviors during the assessment period. The resident was independent or required supervision with set up only for all activities of daily living. Review of Resident #12 ' s Elopement Risk Evaluation with no documented date indicated the following; the resident was identified to be cognitively impaired with poor decision making skills, the resident had a [DIAGNOSES REDACTED]. Review of Resident #12 ' s Consent for Wanderguard dated 3/05/15 indicated the following; a physician order [REDACTED].#12 ' s daughter to place a Wanderguard on the resident. Review of Resident #12 ' s most current consolidated Care plan dated 11/12/14 indicated no updates, goals or approaches related to the resident ' s physician ordered Wanderguard. Review of Resident #12 ' s Nursing Notes dated 3/07/15 indicated; Resident came behind nurse ' s station and got into a drawer and took the bathroom keys. The resident let herself into the shower room, took a shower (unsupervised) and then placed the keys back at the nurse ' s station. During an observation on 3/09/15 at 3:40 p.m. The Administrator was observed using a device to check the function of the resident ' s Wanderguard's transponders with a code of " OK " if working properly. Upon entering Resident #12 ' s room, the device read " noise " instead of " OK " . The resident was escorted to the front lobby and the alarm did not sound nor did the door lock. The resident was asked if she could open the door and she placed her hands on the door bar and opened the door. The alarm continued not to sound. The Administrator said the alarm had been checked by the nurse on the 10:00 p.m. to 6:00 a.m. shift and had been found to function properly. During an interview on 3/09/15 at 4:05 p.m., the facility was advised an Immediate Jeopardy had been identified During an interview on 3/10/15 at 2:35 p.m. CNA G said she had been on duty on 3/07/15 when Resident #12 had taken the keys out of the nurse ' s station and taken a shower unsupervised. She said she was unsure when the resident had taken the keys. She said Resident #12 frequently went behind the nurse ' s station and took keys. She said the staff will be looking for the keys and have to go ask Resident #12 if she has the keys or knows where they are. During an interview on 3/10/15 at 2:45 p.m. the DON said she was not aware of Resident #12 having access to the keys, letting herself into the shower room and taking a shower unsupervised. She said she was unsure of any reason why the staff would have been unaware of the resident ' s whereabouts for her to retrieve the keys and take a shower. She said due to the residents wandering behaviors; it was her expectation for the staff to have an increased sense of supervision of the resident. The facility submitted the following action plan of removal on 3/10/15 at 4:00 p.m. 1) Resident #1 eloped on 2/14/15 and the facility determined that the door enunciator was not loud enough to alert staff of his departure. The alarm ceased to alert staff after the resident was approximately 15 ft. away from the door. a) Alternate placement was found for the resident on a secure unit. b) Alarm Company was contracted to adjust the enunciator and QAAC determined to place a manual code aspect to the system on 2/16/15. c) Enhanced supervision of residents identified as requiring the Wanderguard (roam alert) system within visual sight, arm ' s length or placed on specific timed observations. d) Compliance audit of clinical services to ensure plan was in place and residents were safe. Including additional teaching/training of facility and contract staff. e) Exit doors checked by Maintenance Director and found to be working properly. f) The front door alarm now requires a manual code to cease the enunciator. 2) Resident #12 ' s Wanderguard Roam Alert sensor (transponder) failed to activate the door alarm and lock system on 3/09/15. A new senor was immediately applied and functioning. a) Charge Nurse will now check the sensor operation each shift rather than once daily and document in the Wander Risk Notebook. b) Administrator/ Designee will visualize and personally use the testing device to ensure no manufacture malfunction for existing roam alert sensors. c) Staff member ' s inserviced on electronic monitoring again on 3/09/15 on the purpose of Roam alert system and residents identified as high risk for elopement. d) The Wander Risk Assessment Notebook is continually updated and located at the nurse ' s station. e) Each resident with a Roam Alert sensor has the sensor visualized every shift to ensure placement. f) Elopement Risk Assessments and Care plans updated after each elopement attempt. g) Continuation of daily door alarm check performed by nursing staff with the door alarm check tool and on weekly maintenance door checks. h) Out of cycle QAA review process to ensure resident safety. i) Medical Director notified of situation on 3/10/15. During interviews on 3/11/15 and 3/12/15, 10 staff members ' were able to relate all aspects of the Wanderguard system and residents who were identified at risk for wandering. 3 LVN ' s were able to relate expectations of the Wander Risk Assessment Notebook and documentation of monitoring each shift. During observations on 3/11/15 and 3/12/15, the Wanderguard alarm system was fully audible throughout the facility and required manual code entry into keypad to cancel alarm. After verification of the facility's plan of removal dated 03/10/15 the Immediate Jeopardy was lowered to the potential for more than minimal harm at a pattern. The effective date was 3/10/15 and was completed prior to exit on 03/12/15. The facility remained out of compliance due to the lack monitoring needed of the facility's plan for effectiveness . During an interview on 3/12/15 at 11:00 a.m. the Administrator said there were currently 5 residents in the facility that required Wanderguard bracelets and were identified at risk for elopement from the facility. Review of the Policy and Procedure; Investigating Allegations of Neglect dated 01/15/15 indicated the following: Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, mental illness or the deterioration of a residents physical or mental condition. Neglect also means the failure to protect the resident from abuse, neglect, or exploitation. Neglect is repeated conduct or a single incident of carelessness which produces or could reasonably be expected to result in serious physical or psychological injury or substantial risk of death.