Every finding on record at Darcy Hall of Life Care

Based on record review and interview, the facility failed to ensure an effective infection prevention and control program to help prevent the development and transmission of the communicable disease scabies, as evidenced by the failure to ensure documented evidence of the provision of ivermectin, a medication to treat scabies, and ensure dermatological appointment for Resident #1; failure to initiate timely contact precautions for 3 of 11 sampled residents (Residents #8, #5, and #2); failure to ensure an effective Infection Control Surveillance plan as evidenced by the failure to log 7 of 10 sampled residents who presented with a rash and were reported to the State Agency in October 2025 (Residents #1, #7, #9, #10, #11, #12, and #13), and 2 of 2 sampled residents in November 2025 (Residents #2 and # 8); failure to ensure appropriate housekeeping and laundry services for residents affected with and or treated for scabies for 1 of 6 units affected (West Unit); and failure to ensure staff education in November 2025 during a potential scabies outbreak.The findings included:1) Review of the record revealed Resident #1 was admitted to the facility on [DATE]. Review of the weekly skin assessments from 12/01/25 through 02/02/26 all documented the resident had a rash.a) Review of physician orders revealed an order dated 12/30/25 to administer ivermectin on 12/31/25 and 01/14/26 for scabies. A progress note dated 01/01/26 documented a nurse contacted the pharmacy regarding the ivermectin and the pharmacy stated it would be sent again on the 5 PM run that same day. The record lacked any evidence of the provision of the medication.b) A progress note dated 01/05/26 documented the resident was to be added to the dermatology consultants list to be seen at the next visit. A subsequent physician order dated 01/28/26 documented a dermatological consultation for a rash on the resident's back and upper arms. The record lacked any evidence of the provision of this consultation.During a side-by-side record review and interview on 03/18/26 at 10:54 AM the Infection Control Preventionist (ICP) agreed with the findings. 2) Review of the policy titled Care of the Resident with Scabies revised 05/13/23, documented in part, that residents with scabies should be placed on contact precautions prior to and during the treatment period.a) Review of the record revealed Resident #8 was treated for scabies as per physician order for permethrin cream on 11/12/25, 11/19/25, 12/13/25, 12/20/25, 12/31/25, and 01/07/26. Resident #8 was also administered ivermectin as per physician order on 12/13/25, 12/20/25, 12/31/25, and 01/14/26.Further review of the record revealed appropriate contact precautions from 11/12/25 through 11/20/25, but lacked further contact precautions until 12/31/25, eight-teen days after continued treatment.b) Review of the record revealed Resident #5 was treated with permethrin cream as per physician order on 07/18/25, 07/25/25, and 01/26/26. Resident #5 received ivermectin as per physician order on 02/07/26 and 02/21/26. The record lacked any evidence of contact precautions during the treatment.c) Review of the record revealed Resident #2 was admitted to the facility on [DATE].Review of the record revealed Resident #2 was treated with permethrin as per physician order on 01/11/26, 01/15/26, 01/22/26, 03/15/26 and 03/16/26. Resident #2 was also administered ivermectin as per physician order on 12/13/25 01/11/26, 01/15/26, 01/22/26, and 03/14/26.Further review of the record documented contact precautions were ordered from 12/06/25 - 12/22/25, 01/15/26 through 01/24/26, four days after initiation of treatment, and then not initiated until the evening shift on 03/16/26, two days after initiation of treatment.During an interview on 03/17/26 at 12:50 PM, when asked about the care and services at the facility, Resident #2 stated everything was okay except for the rash that he got at the facility. The resident stated he has been treated on an off for a few months.During an interview on 03/18/26 at 11:17 AM, when asked about the initiation of contact precautions for scabies, the ICP confirmed they would start the precautions with suspicion and or treatment for scabies. The ICP stated their onsite dermatologist would sometimes order treatment directly from the pharmacy and they would all of the sudden receive tubes of the permethrin cream, without having previous knowledge of the pending treatment. 3) During an interview on 03/18/26 at approximately 11:30 AM, the ICP was asked to locate and provide evidence of notification to the State Agency of their rash/scabies outbreak. Review of the provided log documented ten residents who presented with an itchy rash as of 10/16/25 and two additional residents who presented with an itchy rash on 11/17/25.Review of the corresponding Infection Surveillance Line Listing Report revealed seven of the ten residents in October 2025, including Residents #1, #7, #9, #10, #11, #12, and #13, were not included in the facility's surveillance log. The two residents in November 2025, Residents #2 and # 8, were also not included in the facility's surveillance log.During an interview on 03/18/26 in the afternoon, upon discussion of the facility's Infection Surveillance Line Listing Report and the report sent to the State Agency, the ICP explained the State Agency only wanted a line listing of those residents with a rash and or symptoms like itching. When told not all of the residents on the State Agency report were included in the facility's surveillance log, the ICP had no explanation but agreed the log was used to track and trend infections. 4) Review of the policy Care of the Resident with Scabies revised 05/13/23, documented in part, the facility should place any bed linens, towels, washcloths, or lift slings present in the room, along with any clothing that had been worn in the preceding 3 days, in a plastic bag that could be sealed through tying or taping. The policy then described specifically how the items should be laundered or maintained to eliminate the scabies. This policy further documented mattresses should be thoroughly vacuumed.During three interviews on 03/18/26 in the afternoon, when asked the environmental process when a resident was being treated for scabies, the Director of Environmental Services explained he and his staff would remove all the linens, curtains, and personal belongings and put them in a red bag. He further described the subsequent washing process. The director finally stated the room would need to be cleaned from top to bottom. When asked if there was documentation of their process for the recent November 2025 outbreak the director stated he would provide it.The director returned with documented evidence of Routine Cleaning Schedule for November 2025. These documents lacked any evidence of a thorough or deep cleaning, or any documented evidence linens or personal belongings were treated. The director then stated he would bring another form they utilize.Review of the second forms provided titled, Terminal Cleaning Checklist included six pages, dated 11/13/25 through 11/18/25, with the first page only documenting the [NAME] Unit, which was the unit affected by the scabies, and the other forms not documenting any unit. The forms also lacked any room numbers in the area to document same. These forms were initialed by the director and contained checkmarks down the list of to do items. This list documented staff where to remove facility provided linens for laundering. This list lacked any documentation related to the bagging of linens and personal items, or the thorough vacuuming of the mattress, as indicated in their policy. The Director of Environmental Services agreed with the findings. 5) During an interview on 03/18/26 at 11:30 AM, when asked to provide evidence of education related to scabies, the ICP stated it was ongoing. When asked specifically if education was provided in November 2025 with that outbreak, the ICP stated it was. The ICP was asked to locate and provide documented staff education.The ICP provided evidence of education for scabies outbreak to 21 staff on 12/08/25, 33 staff on 01/21/26, and 37 staff on 01/13/26. The ICP was unable to locate any training from October of November of 2025.

Based on record review and interview, the facility failed to promote healing of a facility acquired pressure ulcer for 1 of 3 sampled residents (Resident #1).The findings included: Record review revealed Resident #1 was initially admitted to the facility on [DATE], with multiple readmissions, with a diagnosis that included Dementia. A review of a comprehensive assessment dated [DATE] documented that the resident had severe cognitive impairment and required total assistance with all activities of daily living. The assessment further documented Resident #1 had weight loss, two stage 3 pressure ulcers and was always incontinent of bladder and bowel.Record review revealed Resident #1 was care planned for at risk for break in skin integrity, dated 10/22/19. Interventions included clean and dry skin after each incontinent episode, turn and reposition frequently, and a low air loss mattress.Record review revealed Resident #1 was care planned for a left buttock and sacral pressure ulcer, dated 01/11/26. Interventions included to administer treatments as ordered, and frequent incontinent care, and strive to keep skin clean and dry.Record review revealed a progress note dated 01/11/26 that documented Resident #1 had wounds to the left buttock and sacrum identified by a certified nurse assistant (CNA).Record review revealed wound care notes documented Resident #1 was seen by wound care on 01/13/26 and the wounds were a stage 3.A review of Resident #1's physician orders revealed an order dated 01/15/26 for wound care to be done daily and as needed (if dressings are soiled, wet, or fall off). A review of Resident #1's Medication Administration Record (MAR) revealed wound care was not done on 01/16/26 and there was no documentation of why the wound care was not completedRecord review revealed Resident #1 was seen for wound care on 01/21/26. The left buttock wound had resolved. The sacral wound had deteriorated. The wound care/dressing changes were changed to twice daily. A review of Resident #1's MAR revealed wound care was not done on 01/22/26 evening, and there was no reason given. Record review revealed orders for a sacral wound culture were received and done on 01/27/26. Resident #1 was seen by wound care on 01/28/26. The resident's sacral wound had deteriorated to a stage 4 pressure ulcer. Wound care orders were changed but continued at twice a day. Further record review revealed on 01/31/26, Resident #1's sacral wound culture came back positive for 3 different bacteria, and the resident was started on intravenous (IV) antibiotics. A sacral x-ray was ordered and completed on 02/02/26 which indicated Resident #1 had osteomyelitis (bone infection). Resident #1 started on IV Vancomycin on 02/03/26. Record review revealed Resident #1 was seen by wound care on 02/04/26 and the sacral wound was unchanged. Since the resident had just started on IV antibiotics, the plan was to send the resident to the hospital in a week if the sacral wound did not improve. Record review revealed Resident #1 was sent out to the hospital on [DATE] for a feeding tube placement. The resident returned to the facility on [DATE].An interview was conducted with the wound care nurse (WCN) on 02/24/26 at 1:00 PM. The WCN confirmed Resident #1's left buttock and sacral wounds were first identified as stage 3 pressure ulcers. The left buttock wound resolved, but the sacral wound deteriorated.

Based on interviews, observation, record and policy review, the facility failed to provide necessary supervision to prevent the likelihood of serious injury, harm, impairment, or death by allowing an elopement for 1 of 3 sampled residents (Resident #1) reviewed for an elopement. The facility failed to ensure effective measures were in place to prevent the elopement in both the secured unit and the exit from the building.The deficient practice allowed Resident #1 to exit the facility undetected on 08/30/25 at 4:23 PM. There were 182 residents in the facility at the time of the survey. The facility's Administrator was notified of Immediate Jeopardy and given the IJ Template on 09/04/25 at 3:05 PM. The immediate jeopardy was removed on 09/04/25 at 4:45 PM and the deficiency was lowered to a scope and severity of D, isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Cross reference to F600.The findings included:A review of the facility's policy titled, Missing Residents/Actual Elopement, review date 03/27/25, documented: Definition of elopement, this occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. Situation in which a resident with decision, making capacity leaves the facility intentionally but generally not be considered an elopement unless the facility is unaware of the resident's departure and/or whereabouts. The Executive Director or designee will report the event to all appropriate agencies as well as the regional divisional team. The event will be reviewed in an ad-hoc QAPI meeting, to determine how to ensure that a plan and system is in place to mitigate another occurrence.Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, General Muscle Weakness, Dysphagia, Cognitive Communication Deficit, Major Depressive Disorders, Altered Mental Status, Epilepsy, Alcohol Abuse, and Blindness of the Right Eye.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #1 had a Brief Interview for Mental Status (BIMS) score of 11, on a 0 to 15 scale, indicating the resident had moderate cognitive impairment. This same MDS indicated that Resident #1 was able to ambulate without any assistive devices with supervision and touching assistance. A BIMS score conducted on 09/01/2025 revealed a score of 5 indicating the resident had severe cognitive impairment. An Elopement risk evaluation conducted on 08/06/2025 indicated the resident was at risk for Elopement. Review of the clinical census revealed Resident #1 had been in the facility's secured unit (west wing) since her admission date. (A secured unit is a designated area within a facility that offers enhanced security and supervision for residents who may be prone to wandering or require specialized care. These units are specifically designed to meet the unique needs of individuals with memory-related disorders, ensuring their safety and well-being.)Review of Resident #1's care plan initiated on 08/03/25 documented, At risk for elopement . Goal: The resident will not leave facility unattended through the review date with an intervention that documented, Provide for safe wandering - resident is an elopement risk.Review of the active orders dated 08/09/25 documented, Exit seeking. Provide safe wandering, resident is at risk for elopement. every shift.The video of the elopement incident, involving Resident #1 was viewed by the surveyor on 09/03/25 at 1:36 PM. The following was noted: On 08/30/25 at 4:23 PM the receptionist was attending to two visitors in the main lobby by the entrance of the facility. These two visitors blocked the view of the receptionist who was sitting down at that moment and Resident #1 walked behind the two visitors and walked out towards the door. During this same time at 4:23 PM, another visitor is buzzed in by the receptionist Resident #1 walked out quickly as the visitor walked in. (This door remains locked and must manually be unlocked by an individual after engaging a buzzer to enter the facility). The receptionist did not notice Resident #1 had exited the facility unaccompanied, via the main entrance camera in front of her, which she was responsible for monitoring. The resident was observed to be wearing a red T-shirt, red leggings with a pattern and black tennis shoes. She was seen walking in a fast and steady manner with no assistive devices at the time of exit. In the surveillance footage, there were no additional staff present at the main entrance at time of the resident's exit.Resident #1's room was located on the west side of the facility in a locked unit. Two hallways lead to the west unit (C and D unit) both unsecured. A middle hallway ( center core) joins the C and D unit on the west side; this same hallway's east side leads to two additional units (A and B units) which lead to the East Unit on the opposite side of the building. The middle hallway leads to the main lobby and facility's main entrance.An interview with the administration team was conducted on 09/03/25 at 10:35 AM. The Executive Director (Administrator), Director of Nursing (DON), Regional Director of Clinical Services, Regional [NAME] President, and Divisional Director of Clinical Services were present. When asked what happened regarding the incident that occurred on 08/30/25, involving Resident #1, the Administrator stated, I was contacted on 08/30/25 at approximately 5:19 PM by the facility that there was a missing resident. The Administrator voiced at that time there was a birthday party for another resident, who was turning 100, going on in back of the main dining room. This dining room was not located in the locked unit. They stated their investigation led them to believe that a visitor from the birthday party let Resident #1 out of the locked unit. They assumed Resident #1 could have passed as a visitor and was let off the unit by visitors. When asked what was done when they found out Resident #1 was missing, the Regional Director of Clinical Services and the Administrator stated they did an immediate in-house and facility wide search. When they confirmed she was not in the building, they called law enforcement. They stated the nurses and team which involved all department heads of the facility split into a grid and individual staff were assigned to a search zone. They added that this occurred over the weekend, but regional and divisional staff were still involved. When asked where Resident #1 was found, they stated law enforcement found her approximately 2 miles from the facility on [NAME] Street. Law enforcement contacted the facility, and the administration team brought her back to the facility. When asked how Resident #1's condition was when found, the Regional Director of Clinical Services stated she had dirt on her feet and sides of her pants and a skin tear but, denied falling. When asked what interventions were in place prior to Resident #1's elopement, they stated she had a care place in place, assessments, placed in a locked unit, and that staff watched for behaviors. They added the day of the incident, she did not display any behaviors indicating a risk for elopement. When asked if Resident #1 had family, they stated she was estranged from her family and does not get any visitors; they have found a couple numbers in the chart but have not been able to contact anyone. Resident #1 occasionally spoke of a sister, brother, and a friend but they have been unsuccessful in determining who. The Regional Director of Clinical Services added Resident #1 had not been deemed incapacitated. When asked if there were cameras in the area she eloped from, they stated they were unable to determine which exit (C or D unit exit) she eloped from; neither unit had cameras.During an interview on 09/03/25 at 11:17 AM, Resident #1 was observed with a one-to-one sitter, Staff A, Certified Nursing Assistant (CNA). The resident was observed sitting in bed fiddling with her personal belongings and attempting to get out of bed unassisted; a wheelchair was seen by her bedside. Resident #1 did not have the appearance to pass as a visitor. When the surveyor asked what her name was and the date and her location, she responded, My name is [Resident #1], I am located in a facility somewhere and the date is late May 2025. When asked, Did you leave the facility on Saturday 08/30/25?, she stated that was what she was being told but stated she didn't remember what happened. When asked where she was trying to go and who let her out, Resident #1 stated, no particular place, Saturday is my favorite day of the week and I decided to go out; I don't remember who let me out, I just walked out; I was bored so I left. When asked if she left because she felt unsafe at the facility, Resident #1 stated she felt safe, but she just wanted to leave.During an interview on 09/03/25 at 11:30 AM, when asked if she knew what happened on Saturday 08/30/25 with Resident #1, Staff A stated she heard what happened, but she was not working that day. She stated that Resident #1 went missing and didn't know how she was able to leave the facility. When asked if Resident #1 ever tried to elope or wander, Staff A stated, No, she can walk but her balance is not that good, so she uses a wheelchair instead.An observation and interview was conducted on 09/03/25 at 11:51 AM, when asked where the back of the main dining room was located, the DON offered to show the surveyor a tour to see the location. It was observed that the dining room was not located in the secured unit and upon entrance to the main dining room this same room led to the back dining room (another smaller dining room where the Birthday Party was held on Saturday for another Resident)When asked where the birthday party member resided, the DON stated she also resided in the locked unit (west wing). The DON voiced that the visitors were coming in and out (of the locked unit) that day. When asked if there were other visitors that day also visiting the unit, she stated not to her knowledge and that there was a kiosk in the front they used for check in; she would have to check there. When asked if the family members were called to confirm if they let a resident out by mistake, the DON stated not that she was aware of. When asked how did family get access to the locked unit, the DON stated prior to the incident, you could push the door to get into the unit without a passcode, but needed a code to leave; now you need a code to enter and exit the facility, due to the incident. When asked where Resident #1 was admitted from, she stated from a hospital from another county. When asked how long the resident was missing, on the day of the incident, she stated from 08/30/25 at 4:23 PM, law enforcement found her on 08/31/25 at 12:10 AM and then called the facility; she was brought back to facility around 1:00 AM on 08/31/25. When asked if she went to the hospital, the DON stated that the doctor saw her the following day and ordered an X-ray and labs but did not order her to go to the hospital. When asked what psych evaluated upon Resident #1's arrival and if they made any changes to her treatment, the DON stated they changed her Trazadone (medication) dose to help her sleep, did an assessment and a BIMS re-evaluation upon her arrival on 08/31/25.An interview was conducted on 09/03/25 at 11:57 AM, when asked what was evaluated for Resident #1 after the incident from 08/30/25, the Advanced Registered Nurse Practitioner (ARNP) for Psychiatry stated she saw Resident #1 via Telehealth on 08/31/2025. She stated I got a report that the resident was not sleeping all night and eloped. When I saw the resident, she was calm with on and off confusion; there were no more signs. She stated she changed her Trazadone dose to help her sleep and when asked if her BIMS evaluation changed, she stated her BIMS was 11 prior to the incident and had a BIMS of 10 on 08/31/2025 after the incident. She stated she checked it yesterday on 09/2/25 and her BIMS score was a 10 in the morning and her BIMS was 12 at about 2:30 PM that same day. She stated there are no other treatment changes and the plan was to reassess the resident every day since she has an ongoing one-to-one sitter.During an interview on 09/03/25 at 12:25 PM, when asked if she knew anything regarding the incident from 08/30/25 related to Resident #1, the Assistant Director of Nursing (ADON) stated she was not working the day of the incident but had seen the resident the following day. The ADON voiced that the resident had stated I was riding my bike looking for my kitty. The ADON stated she completed a head-to-toe assessment and spoke to her doctor who came to see the resident and also performed an assessment on her. When asked which residents are considered elopement risks, the ADON stated everyone in the secured unit (west wing) was identified as an elopement risk. When asked if there were residents in unsecured units with elopement risks, she replied no and stated they arrange beds in the locked unit as necessary. The ADON provided a census of residents with risk of elopement, who reside on the secured unit, at the time of the survey which was a total of 52. The secured unit has a capacity of 56 beds.During an interview on 09/03/25 at 12:39 PM, when asked about Resident #1's incident, the Social Services Director stated she was not at the facility on the day of the incident but recalled a resident in the locked unit was turning 100 and his family requested to have his birthday party in the back of the main dining room. When asked how the family would have access to the secured unit, the Social Service Director stated before the incident you could push a button and then push the doors to the unit to get in without a code; to exit you would need a code or a staff member to exit. When asked if staff are allowed to give codes to family, the Social Service Director stated typically staff lets them out and they don't give out codes. The Social Service Director stated she believed upon entering the unit, someone could have let her (Resident #1) out.A telephone interview was attempted on 09/03/25 at 12:58 PM with Staff C, a Licensed Practical Nurse (LPN) who was the primary nurse assigned to Resident #1 on the 3-11 shift on 08/30/25. Staff C stated she wasn't feeling well and couldn't talk.Review of a progress note written by Staff C on 08/30/25 at 8:41 PM with an effective time at 4:20 PM documented, Writer noticed resident was not present during meds pass and dinner, writer alerted all staff to search for resident in all the room, and went to central to notified all staff and supervisor made aware, PCP was called no answered and left voice mail, Emergency contact was called the woman in the phone stated she does not know the resident.A telephone interview was attempted on 09/03/25 at 1:12 PM with the local Police Department involved in the elopement incident regarding Resident #1, a voicemail was left, and a call back was not received during the time of the survey.A telephone interview was conducted on 09/03/25 at 1:16 PM with Staff D, a Certified Nursing Assistant (CNA) who was the primary CNA assigned to Resident #1 on the 3-11 shift on 08/30/25. When asked what happened on her shift on 08/30/25, Staff D stated. I was floating that day; I was assigned to west, but to both sides of the hallways. My shift started at 3 PM but at around 2:50 PM, I started doing my rounds. Resident #1 was in the dining room in the unit. Resident #1 usually walks around but doesn't try to leave the floor. At 4:00 PM I saw her by the medication cart. At around 4:10 PM another CNA I was working with saw her food arrive. I told her she was by the dining room, and I told her to check there. She could not find Resident #1 in the dining room, so she checked her room, and she was not there. At about 4:20 PM, we told the primary nurse, and the nurse called the supervisor. When asked if Resident #1 was showing any behaviors of trying to escape the unit that day, Staff D stated, no she has never done this before, this was the first time this happened on my shift. Staff D voiced Resident #1 can walk by herself and move without a wheelchair. When asked if Resident #1 was alert and oriented, she stated she was not too confused, when you ask her to do something she does it. When asked how family members came in on 08/30/25, Staff D stated, I think they had a party that day, but everyday family members come in. When asked, do you give a code to family members, Staff D stated, No we are not supposed to do that. Staff D voiced, Before this happened you didn't need a code to get in, but to get out you did. I think they might have changed it now.On 09/03/25 at 1:36 PM, the surveyor reviewed the surveillance footage of Resident #1's incident side-by-side with the Administrator. The video revealed the following: On 08/31/25 at 12:37 AM upon re-entering the facility, Resident #1 was observed to enter the facility accompanied by the Administrator, Regional Director of Clinical Services, Divisional Director of Clinical Services, Maintenance Director, Social Services Director, Marketer, and the DON. Resident #1 was observed to be wearing the same outfit she left with but was walking in with only socks on and her tennis shoes were missing. When asked what happened to Resident #1's shoes, the Administrator stated, We don't know what happened to her shoes. The resident was observed to walk in with a steady gait.An interview was conducted on 09/03/25 at 2:17 PM with Staff E, Registered Nurse (RN), who worked the 7 AM- 3PM shift on 08/30/25. When asked what happened in Resident #1's incident, Staff E recalled the events, It was a quiet day, I had no issues that day; I gave report to the next nurse, Staff C. I gave report on 08/30/25 at about 3:45 PM; Resident #1 was next to me standing while I was giving report. Staff C doesn't work there often. I don't know if she is per diem or part time and normally works in another unit. Staff C was not really familiar with Resident #1; she was not a regular nurse who worked there. After I gave report, I left a little after 4 PM. I was called around 5:00 pm and they told me the resident was missing. I told them she was standing next to him during report. Staff E voiced Resident #1 was always walking around by the hallway rails but never saw her try to leave; she was not showing any behaviors that day. She never pushed any doors or tried to leave. I never thought in my mind she would exit the facility, she normally doesn't walk fast, she normally walks very slow. Staff E stated he drove around to see if he saw her, he lived close by and knew the neighborhood well but could not locate her. He stated, They called me in the middle of the night to tell me she came back; I was happy she was back, we try to keep everybody safe, unfortunately this happened. When asked how he believed Resident #1 got out, Staff E stated, I remember there was a party for another resident, but I don't really know. When asked if he saw family visitors that day on his shift, Staff E stated, a resident was turning [AGE] years old in the west unit and their family was in their room. When asked if the staff gives codes to family, Staff E stated, No that doesn't happen, if there is a suspicion they might know a code it gets changed right away. When asked how you could get to the locked unit, Staff E stated, Before you push the green knob and could open the door, but to get out you would need a code, now it is changed you need a code in and out.On 09/04/25 at approximately 10:15 AM, the surveyor travelled the route by car from [NAME] Hall of Life Care to [NAME] Drive in [NAME] Palm Beach Florida which led to a residential trailer park. Review of the route revealed the resident walked approximately 2 miles by foot. The resident would have likely passed 2 canals, with uneven sidewalks/pavement, through commercial and residential areas, onto a busy 4 lane and 8 lane roadways with speed limits in between 30 and 45 MPH (miles per hour). The resident was at extreme risk of getting hit by a automobile, tripping and falling, drowning, getting injured or death. The weather in [NAME] Palm Beach, Florida on 08/30/25 at 4PM- 08/31/25 at12AM was approximately in between 94 degrees Fahrenheit during the day and 84 degrees at night and wind speeds were in between 6-8 miles per hour (mph) with no precipitation.Review of the record revealed a Skin Assessment was conducted on Resident #1 on 08/31/25. The Assessment documented Abrasion: Right posterior forearm- c-shaped abrasion, no active bleeding, no acute signs of infection. left lateral face vertical abrasion- no active bleeding no drainage on signs of infection. Bruising(s): Right upper arm, right lateral thigh with scattered scab. Scars(s) Right elbow, long oval scar Scabs on left knee and chin, left hand. Doctor made aware of skin issues. Resident denies pain at this time. No active bleeding to sites, no acute signs of infection. Treatment to left forearm rendered, resident tolerated well.In a review of the Medication Administration Record (MAR) for August, 2025, it revealed that on 08/30/25 Resident #1 missed the 5 PM of Bethanechol Chloride Oral Tablet 25 MG for urinary retention, the 5 PM dose of Carbidopa-Levodopa Oral Tablet 25-100 MG for Parkinson's, the 5 PM dose of Clonazepam Oral Tablet 0.5 MG for anxiety, the 8 PM dose of Famotidine Oral Tablet 20 MG for acid reflux, the 8 PM dose of Gabapentin Capsule 300 MG for nerve pain, the 8 PM dose of Metoprolol Tartrate Tablet 12.5 MG for hypertension, the 9 PM dose of Rosuvastatin Calcium Oral Tablet 10 MG for high cholesterol, the 9 PM dose of Tamsulosin HCl Oral Capsule 0.4 MG for urinary issues, and the 9 PM dose of Topiramate Oral Tablet 200 MG for seizures.The facility submitted an acceptable Immediate Jeopardy removal plan on 09/04/25, which was verified by observations, interviews and record review, as follows: 1. 08/30/25- 100% headcount of residents was completed to ensure no other residents were missing. All other residents were accounted for. 2. 08/30/25 a whole house search of the facility was completed. 3. 08/30/25 the Executive Director was notified by the weekend supervisor who in turn, notified facility managers to report to work to assist in the search. Regional and divisional staff were also notified and reported to the facility to assist in the search. The Medical Director and primary physician were notified. 4. 08/30/25 an external search of the community was initiated. 5. 08/30/25 Executive Director notified the local Police Department who assisted in the search. 6. 08/31/25 upon return, the resident was placed on one-to-one supervision on the secured unit. 1:1 monitoring ordered 09/02/25.Observed on lock unit in room with 1:1 sitter on 09/04/25 2:00 PM, ambulating in hallway 09/04/25 at 3:00 PM. Resident cannot recall elopement. 7. 08/30/25 all facility exit door alarms and screamer devices were inspected by the Maintenance Director. Interviewed Maintenance Director with no concerns 09/05/25 at 1:00 PM. 8. 08/30/25 keypad code to secure unit was changed by the maintenance director. Interviewed maintenance director with no concerns. Push pad changed to key pad 09/02/25. 9. 08/30/25 immediate education on abuse neglect and exploitation and risk of elopement initiated. 8/30/25 13-11 shift sign-in sheet reviewed. 08/31/25 11-7 signage sheet reviewed. 10. 08/30/25 - 09/02/25 the elopement risk assessments of all residents were reviewed for accuracy.Verified 3 sampled residents. 11. 08/30/25 an elopement drill was performed for the 11-7 shift.Verified sign-in sheet.12. 08/31/25 the resident was assessed by the nurse upon return and by the physician on the same day. Skin assessment done 08/31/25. 13. 08/31/25 an elopement drill was performed for the 7-3 shift. Verified by sign-in sheet. 14. 09/02/25 the care plans and kardexes of residents at risk for elopement were reviewed for accuracy.3 sampled residents reviewed. 15. 08/31/25 visitor lanyards were ordered for identification of visitors/vendors to differentiate visitors from residents. The lanyards arrived on 09/02/25 and were put into use immediately.Visitors observed wearing visitor lanyards on 09/04/25 and 09/05/25. 16. 09/01/25 keypad order to replace push button for entry to units. Keypad was installed 09/02/25.Observed on 09/04/25. (photographic evidence obtained). 17. 09/02/25 elopement books were reviewed for accuracy.Observed at nursing stations and receptionist desk on 09/04/25 and 09/25/24. 18. 09/02/25 an ad hoc QAPI was performed by the facility IDT and reviewed by the Medical Director. Sign-in sheet dated 09/02/25 verified.19. On 08/30/25, the Assistant Executive Director notified the Department of Children and Families of the elopement of Resident #1. 20. A Federal Immediate Report was also submitted on 08/30/25. 21. From 08/30/25 until 09/04/25 current facility staff were provided education by the director of nursing and assistant director of nursing pertaining to unsafe wandering and elopement prevention. 202 out of 285 current facility staff education was completed by 09/04/25. New employees hired after 09/04/25 will receive education we're in the facility orientation process. Education pertaining to unsafe wandering and elopement prevention is provided annually and as needed. Sign-in sheets reviewed. 22. Director of Nursing designee to complete daily new admission chart reviews to ensure risks for elopement is identified and care planned times 4 weeks, weekly times 2 months, then quarterly and as needed thereafter to ensure no concerns related to risk for elopement. Audits reviewed. 23. Root cause analysis was performed on 09/02/25 by the Regional Director of Clinical services related to the circumstances of the resident elopement which occurred on 08/30/25. 24. On 09/02/25 an IDT review an investigation of the residents episode of elopement was completed through the ad hoc coffee process. Included in the investigation was a view of the residence condition preadmission and post admission resident evaluations including the accuracy of the allotment evaluation, resident care plan, staffing, facility environment and equipment. 25. The resident elopement risk evaluation was completed accurately at the time of admission and a care plan for elopement risk was initiated. Initial 08/04/25 not at risk. 08/06/25 at risk. 26. The resident was correctly placed on the locked [NAME] unit at the time of admission. The staffing PPD on 08/30/25 for 1.28 for licensed nurse assist and 2.43 for CNA's. On The [NAME] Wing units on the 3:00 PM to 11:00 PM if there were two nurses and five CNA's for the 52 residents. Verified admitted to [NAME] unit (locked unit 08/04/25). 27. Staff who predominantly work on the [NAME] Wing were interviewed via a questionnaire and asked if the resident displayed any exit seeking behaviors prior to the incident, verbalizations of wanting to leave, packing belongings, or pushing on exit doors. The staff report no indications of such desire to exit or knowledge of any exit seeking behavior. Reviewed statements. Staff on west unit interviewed by surveyor with no concerns. 28. The investigation and root cause analysis revealed potential root cause scenarios (birthday party and push button entrance).Via ad-hoc 09/02/25. 29. Elopement risk evaluation facility systems processes in place related to patient identification of potential for elopement/slash wandering and safety in place and followed.Policy reviewed. 30. The elopement risk evaluation is completed on admission, quarterly, and after a significant change period the evaluation consists of ambulatory mobility status, wandering behaviors, cognitive status, and exit seeking indicators.Policy reviewed. New admission audits reviewed. 31. If a patient is identified as a potential risk, based upon the evaluation, a patient identification form, which will include a current photo, a current description, and personalized care plans, and interventions, and redirection strategies. He locks the patient elopement book contains copy of the patient identification form, a colored photo of the patient and a face sheet. The elopement books are maintained at each nursing station and at the entrance to the reception facility area.Verified at nursing stations and reception desk. 32. Elopement drills are completed quarterly, including nights and weekends. These drills are monitored for quality by using the elopement drill performance summary and discuss at QAPI. 33. Facility door prevention maintenance, monitoring and checked for function weekly conducted as scheduled. No deficits noted.Weekly audits reviewed. 34. All exit doors are inspected weekly.Weekly audits reviewed. 35. All designated entrance/exit areas have scheduled staff assigned to the receptionist area from 8:00 AM to 8:00 PM seven days a week. 36. Staffing schedules are monitored daily by staffing coordinator and reviewed with executive director of nursing and/or nursing supervisor on duty to ensure adequate staffing is maintained. Adequate staffing means all minimum PPD, and ratios are met and in addition, staffing is adjusted based on acuity of patient needs. 2 weeks staffing calculations (State only requirement) reviewed with no concerns. 37. All staff are screened prior to hire and a job specific orientation is performed. Receptionist not only receive training but have a completed competency on file.Training/education verified by sign-in sheet for receptionist. 38. On 09/02/25 a review of five of five receptionist staff employees file revealed all had completed training and had a competency on file. The receptionist on duty on 08/30/25 at the time of the residence elopement was suspended immediately and has subsequently been terminated. Training/education verified by sign-in sheet. 39. Immediately on 08/30/25 the maintenance staff performed an inspection of the facility exit doors and screamer devices and all were found to be fully functional.Audit reviewed and interviewed. 40. Weekly door checks by the maintenance director will be performed to ensure proper function. On 09/02/25, the push button entry system onto the memory care unit was replaced with the keypad the truth device.In-voice dated 09/04/25 was reviewed. 41. From 08/31/25 through 09/01/25 facility licensed nurses completed a review of the accuracy of 185 current residents elopement risk evaluations period of the 185 residents, 52 residents resided on the memory care unit and 51 of those who were already assessed to be at risk for elopement. The remaining 1 of 52 residents was originally placed on The [NAME] Wing unit for behavior management but has since become a risk for elopement. The residence assessment was updated to reflect the risk of elopement. Audits reviewed. No concerns. 42. On 09 02/25 the care plans and CNA kardexes of 52 of 52 residents at risk for elopement were reviewed. All were found to be in compliance with risk for elopement identified.Sample of 3 residents reviewed with no concerns. 43. Director of nursing/designee to complete monitoring of new admission evaluations to ensure risk for elopement inaccuracy identified and care plan and kardex are reflective of the risk, where appropriate. 3 admissions on 09/04/25 and audited (for west unit). 44. The Medical Director was informed of the citations and is in agreement with the removal plan. The following staff were interviewed for verification of staff education: Staff A, CNA was interviewed on 09/03/25 at 11:30 AM. Staff A stated she had recently completed elopement and abuse & neglect education after the incident with Resident #1; knowledge verified.Staff D, CNA was interviewed on 09/03/25 at 1:17 PM, Staff D stated she had recently completed elopement and abuse & neglect education after the incident with Resident #1; knowledge verified.Staff E, RN was interviewed 09/03/25 at 2:17 PM, Staff E stated a code silver which means a missing person in the facility was called and every department participated in search. The education was provided after the incident occurred.The ADON was interviewed on 09/04/25 at 3:30 PM, the ADON had an elopement drill this morning. A written Elopement quiz was completed and stated some were do[TRUNCATE

Based on interviews, observations, record and policy review, the facility failed to protect the resident's right to be free from neglect by failing to provide necessary supervision to prevent the likelihood of serious injury, harm, impairment, or death by allowing an elopement for 1 of 3 sampled residents (Resident #1) reviewed for an elopement. The facility failed to ensure effective measures were in place to prevent the elopement in both the secured unit and the exit from the building.The deficient practice allowed Resident #1 to exit the facility undetected on 08/30/25 at 4:23 PM. There were 182 residents in the facility at the time of the survey. The facility's Administrator was notified of Immediate Jeopardy and given the IJ Template on 09/04/25 at 3:05 PM. The immediate jeopardy was removed on 09/04/25 at 4:45 PM, and the deficiency was lowered to a scope and severity of D, isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Cross reference to F689.The findings included: A review of the facility's policy titled Abuse and Neglect, reviewed 11/19/24, documented: To minimize the threat of abuse and or neglect, nursing homes must incorporate clear cut policies and practices that demonstrate a hard line, 0 tolerance approach to resident abuse. Each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation of any type by anyone. How: The facility has procedures in place to provide protection for the health, welfare and rights of each resident residing in the facility. In order to provide these protections, the facility has implemented procedures to prohibit and prevent abuse, neglect, exploitation of residents, and misappropriation of resident property. These procedures include but are not limited to the following.2). Training, 3). Prevention, 4). Identification.6). Protection.Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, General Muscle Weakness, Dysphagia, Cognitive Communication Deficit, Major Depressive Disorders, Altered Mental Status, Epilepsy, Alcohol Abuse, and Blindness of the Right Eye.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #1 had a Brief Interview for Mental Status (BIMS) score of 11, on a 0 to 15 scale, indicating the resident had moderate cognitive impairment. This same MDS indicated that Resident #1 was able to ambulate without any assistive devices with supervision and touching assistance. A BIMS score conducted on 09/01/2025 revealed a score of 5 indicating the resident had severe cognitive impairment. An Elopement risk evaluation conducted on 08/06/2025 indicated the resident was at risk for Elopement. Review of the clinical census revealed Resident #1 had been in the facility's secured unit (west wing) since her admission date. (A secured unit is a designated area within a facility that offers enhanced security and supervision for residents who may be prone to wandering or require specialized care. These units are specifically designed to meet the unique needs of individuals with memory-related disorders, ensuring their safety and well-being.)Review of Resident #1's care plan initiated on 08/03/25 documented, At risk for elopement . Goal: The resident will not leave facility unattended through the review date with an intervention that documented, Provide for safe wandering - resident is an elopement risk.Review of the active orders dated 08/09/25 documented, Exit seeking. Provide safe wandering, resident is at risk for elopement. every shift.The video of the elopement incident, involving Resident #1 was viewed by the surveyor on 09/03/25 at 1:36 PM. The following was noted: On 08/30/25 at 4:23 PM the receptionist was attending to two visitors in the main lobby by the entrance of the facility. These two visitors blocked the view of the receptionist who was sitting down at that moment and Resident #1 walked behind the two visitors and walked out towards the door. During this same time at 4:23 PM, another visitor is buzzed in by the receptionist Resident #1 walked out quickly as the visitor walked in. (This door remains locked and must manually be unlocked by an individual after engaging a buzzer to enter the facility). The receptionist did not notice Resident #1 had exited the facility unaccompanied, via the main entrance camera in front of her, which she was responsible for monitoring. The resident was observed to be wearing a red T-shirt, red leggings with a pattern and black tennis shoes. She was seen walking in a fast and steady manner with no assistive devices at the time of exit. In the surveillance footage, there were no additional staff present at the main entrance at time of the resident's exit.Resident #1's room was located on the west side of the facility in a locked unit. Two hallways lead to the west unit (C and D unit) both unsecured. A middle hallway ( center core) joins the C and D unit on the west side; this same hallway's east side leads to two additional units (A and B units) which lead to the East Unit on the opposite side of the building. The middle hallway leads to the main lobby and facility's main entrance.An interview with the administration team was conducted on 09/03/25 at 10:35 AM. The Executive Director (Administrator), Director of Nursing (DON), Regional Director of Clinical Services, Regional [NAME] President, and Divisional Director of Clinical Services were present. When asked what happened regarding the incident that occurred on 08/30/25, involving Resident #1, the Administrator stated, I was contacted on 08/30/25 at approximately 5:19 PM by the facility that there was a missing resident. The Administrator voiced at that time there was a birthday party for another resident, who was turning 100, going on in back of the main dining room. This dining room was not located in the locked unit. They stated their investigation led them to believe that a visitor from the birthday party let Resident #1 out of the locked unit. They assumed Resident #1 could have passed as a visitor and was let off the unit by visitors. When asked what was done when they found out Resident #1 was missing, the Regional Director of Clinical Services and the Administrator stated they did an immediate in-house and facility wide search. When they confirmed she was not in the building, they called law enforcement. They stated the nurses and team which involved all department heads of the facility split into a grid and individual staff were assigned to a search zone. They added that this occurred over the weekend, but regional and divisional staff were still involved. When asked where Resident #1 was found, they stated law enforcement found her approximately 2 miles from the facility on [NAME] Street. Law enforcement contacted the facility, and the administration team brought her back to the facility. When asked how Resident #1's condition was when found, the Regional Director of Clinical Services stated she had dirt on her feet and sides of her pants and a skin tear but, denied falling. When asked what interventions were in place prior to Resident #1's elopement, they stated she had a care place in place, assessments, placed in a locked unit, and that staff watched for behaviors. They added the day of the incident, she did not display any behaviors indicating a risk for elopement. When asked if Resident #1 had family, they stated she was estranged from her family and does not get any visitors; they have found a couple numbers in the chart but have not been able to contact anyone. Resident #1 occasionally spoke of a sister, brother, and a friend but they have been unsuccessful in determining who. The Regional Director of Clinical Services added Resident #1 had not been deemed incapacitated. When asked if there were cameras in the area she eloped from, they stated they were unable to determine which exit (C or D unit exit) she eloped from; neither unit had cameras.During an interview on 09/03/25 at 11:17 AM, Resident #1 was observed with a one-to-one sitter, Staff A, Certified Nursing Assistant (CNA). The resident was observed sitting in bed fiddling with her personal belongings and attempting to get out of bed unassisted; a wheelchair was seen by her bedside. Resident #1 did not have the appearance to pass as a visitor. When the surveyor asked what her name was and the date and her location, she responded, My name is [Resident #1], I am located in a facility somewhere and the date is late May 2025. When asked, Did you leave the facility on Saturday 08/30/25?, she stated that was what she was being told but stated she didn't remember what happened. When asked where she was trying to go and who let her out, Resident #1 stated, no particular place, Saturday is my favorite day of the week and I decided to go out; I don't remember who let me out, I just walked out; I was bored so I left. When asked if she left because she felt unsafe at the facility, Resident #1 stated she felt safe, but she just wanted to leave.During an interview on 09/03/25 at 11:30 AM, when asked if she knew what happened on Saturday 08/30/25 with Resident #1, Staff A stated she heard what happened, but she was not working that day. She stated that Resident #1 went missing and didn't know how she was able to leave the facility. When asked if Resident #1 ever tried to elope or wander, Staff A stated, No, she can walk but her balance is not that good, so she uses a wheelchair instead.An observation and interview was conducted on 09/03/25 at 11:51 AM, when asked where the back of the main dining room was located, the DON offered to show the surveyor a tour to see the location. It was observed that the dining room was not located in the secured unit and upon entrance to the main dining room this same room led to the back dining room (another smaller dining room where the Birthday Party was held on Saturday for another Resident)When asked where the birthday party member resided, the DON stated she also resided in the locked unit (west wing). The DON voiced that the visitors were coming in and out (of the locked unit) that day. When asked if there were other visitors that day also visiting the unit, she stated not to her knowledge and that there was a kiosk in the front they used for check in; she would have to check there. When asked if the family members were called to confirm if they let a resident out by mistake, the DON stated not that she was aware of. When asked how did family get access to the locked unit, the DON stated prior to the incident, you could push the door to get into the unit without a passcode, but needed a code to leave; now you need a code to enter and exit the facility, due to the incident. When asked where Resident #1 was admitted from, she stated from a hospital from another county. When asked how long the resident was missing, on the day of the incident, she stated from 08/30/25 at 4:23 PM, law enforcement found her on 08/31/25 at 12:10 AM and then called the facility; she was brought back to facility around 1:00 AM on 08/31/25. When asked if she went to the hospital, the DON stated that the doctor saw her the following day and ordered an X-ray and labs but did not order her to go to the hospital. When asked what psych evaluated upon Resident #1's arrival and if they made any changes to her treatment, the DON stated they changed her Trazadone (medication) dose to help her sleep, did an assessment and a BIMS re-evaluation upon her arrival on 08/31/25.An interview was conducted on 09/03/25 at 11:57 AM, when asked what was evaluated for Resident #1 after the incident from 08/30/25, the Advanced Registered Nurse Practitioner (ARNP) for Psychiatry stated she saw Resident #1 via Telehealth on 08/31/2025. She stated I got a report that the resident was not sleeping all night and eloped. When I saw the resident, she was calm with on and off confusion; there were no more signs. She stated she changed her Trazadone dose to help her sleep and when asked if her BIMS evaluation changed, she stated her BIMS was 11 prior to the incident and had a BIMS of 10 on 08/31/2025 after the incident. She stated she checked it yesterday on 09/2/25 and her BIMS score was a 10 in the morning and her BIMS was 12 at about 2:30 PM that same day. She stated there are no other treatment changes and the plan was to reassess the resident every day since she has an ongoing one-to-one sitter.During an interview on 09/03/25 at 12:25 PM, when asked if she knew anything regarding the incident from 08/30/25 related to Resident #1, the Assistant Director of Nursing (ADON) stated she was not working the day of the incident but had seen the resident the following day. The ADON voiced that the resident had stated I was riding my bike looking for my kitty. The ADON stated she completed a head-to-toe assessment and spoke to her doctor who came to see the resident and also performed an assessment on her. When asked which residents are considered elopement risks, the ADON stated everyone in the secured unit (west wing) was identified as an elopement risk. When asked if there were residents in unsecured units with elopement risks, she replied no and stated they arrange beds in the locked unit as necessary. The ADON provided a census of residents with risk of elopement, who reside on the secured unit, at the time of the survey which was a total of 52. The secured unit has a capacity of 56 beds.During an interview on 09/03/25 at 12:39 PM, when asked about Resident #1's incident, the Social Services Director stated she was not at the facility on the day of the incident but recalled a resident in the locked unit was turning 100 and his family requested to have his birthday party in the back of the main dining room. When asked how the family would have access to the secured unit, the Social Service Director stated before the incident you could push a button and then push the doors to the unit to get in without a code; to exit you would need a code or a staff member to exit. When asked if staff are allowed to give codes to family, the Social Service Director stated typically staff lets them out and they don't give out codes. The Social Service Director stated she believed upon entering the unit, someone could have let her (Resident #1) out.A telephone interview was attempted on 09/03/25 at 12:58 PM with Staff C, a Licensed Practical Nurse (LPN) who was the primary nurse assigned to Resident #1 on the 3-11 shift on 08/30/25. Staff C stated she wasn't feeling well and couldn't talk.Review of a progress note written by Staff C on 08/30/25 at 8:41 PM with an effective time at 4:20 PM documented, Writer noticed resident was not present during meds pass and dinner, writer alerted all staff to search for resident in all the room, and went to central to notified all staff and supervisor made aware, PCP was called no answered and left voice mail, Emergency contact was called the woman in the phone stated she does not know the resident.A telephone interview was attempted on 09/03/25 at 1:12 PM with the local Police Department involved in the elopement incident regarding Resident #1, a voicemail was left, and a call back was not received during the time of the survey.A telephone interview was conducted on 09/03/25 at 1:16 PM with Staff D, a Certified Nursing Assistant (CNA) who was the primary CNA assigned to Resident #1 on the 3-11 shift on 08/30/25. When asked what happened on her shift on 08/30/25, Staff D stated. I was floating that day; I was assigned to west, but to both sides of the hallways. My shift started at 3 PM but at around 2:50 PM, I started doing my rounds. Resident #1 was in the dining room in the unit. Resident #1 usually walks around but doesn't try to leave the floor. At 4:00 PM I saw her by the medication cart. At around 4:10 PM another CNA I was working with saw her food arrive. I told her she was by the dining room, and I told her to check there. She could not find Resident #1 in the dining room, so she checked her room, and she was not there. At about 4:20 PM, we told the primary nurse, and the nurse called the supervisor. When asked if Resident #1 was showing any behaviors of trying to escape the unit that day, Staff D stated, no she has never done this before, this was the first time this happened on my shift. Staff D voiced Resident #1 can walk by herself and move without a wheelchair. When asked if Resident #1 was alert and oriented, she stated she was not too confused, when you ask her to do something she does it. When asked how family members came in on 08/30/25, Staff D stated, I think they had a party that day, but everyday family members come in. When asked, do you give a code to family members, Staff D stated, No we are not supposed to do that. Staff D voiced, Before this happened you didn't need a code to get in, but to get out you did. I think they might have changed it now.On 09/03/25 at 1:36 PM, the surveyor reviewed the surveillance footage of Resident #1's incident side-by-side with the Administrator. The video revealed the following: On 08/31/25 at 12:37 AM upon re-entering the facility, Resident #1 was observed to enter the facility accompanied by the Administrator, Regional Director of Clinical Services, Divisional Director of Clinical Services, Maintenance Director, Social Services Director, Marketer, and the DON. Resident #1 was observed to be wearing the same outfit she left with but was walking in with only socks on and her tennis shoes were missing. When asked what happened to Resident #1's shoes, the Administrator stated, We don't know what happened to her shoes. The resident was observed to walk in with a steady gait.An interview was conducted on 09/03/25 at 2:17 PM with Staff E, Registered Nurse (RN), who worked the 7 AM- 3PM shift on 08/30/25. When asked what happened in Resident #1's incident, Staff E recalled the events, It was a quiet day, I had no issues that day; I gave report to the next nurse, Staff C. I gave report on 08/30/25 at about 3:45 PM; Resident #1 was next to me standing while I was giving report. Staff C doesn't work there often. I don't know if she is per diem or part time and normally works in another unit. Staff C was not really familiar with Resident #1; she was not a regular nurse who worked there. After I gave report, I left a little after 4 PM. I was called around 5:00 pm and they told me the resident was missing. I told them she was standing next to him during report. Staff E voiced Resident #1 was always walking around by the hallway rails but never saw her try to leave; she was not showing any behaviors that day. She never pushed any doors or tried to leave. I never thought in my mind she would exit the facility, she normally doesn't walk fast, she normally walks very slow. Staff E stated he drove around to see if he saw her, he lived close by and knew the neighborhood well but could not locate her. He stated, They called me in the middle of the night to tell me she came back; I was happy she was back, we try to keep everybody safe, unfortunately this happened. When asked how he believed Resident #1 got out, Staff E stated, I remember there was a party for another resident, but I don't really know. When asked if he saw family visitors that day on his shift, Staff E stated, a resident was turning [AGE] years old in the west unit and their family was in their room. When asked if the staff gives codes to family, Staff E stated, No that doesn't happen, if there is a suspicion they might know a code it gets changed right away. When asked how you could get to the locked unit, Staff E stated, Before you push the green knob and could open the door, but to get out you would need a code, now it is changed you need a code in and out.Review of the record revealed a Skin Assessment was conducted on Resident #1 on 08/31/25. The Assessment documented Abrasion: Right posterior forearm- c-shaped abrasion, no active bleeding, no acute signs of infection. left lateral face vertical abrasion- no active bleeding no drainage on signs of infection. Bruising(s): Right upper arm, right lateral thigh with scattered scab. Scars(s) Right elbow, long oval scar Scabs on left knee and chin, left hand. Doctor made aware of skin issues. Resident denies pain at this time. No active bleeding to sites, no acute signs of infection. Treatment to left forearm rendered, resident tolerated well.In a review of the Medication Administration Record (MAR) for August, 2025, it revealed that on 08/30/25 Resident #1 missed the 5 PM of Bethanechol Chloride Oral Tablet 25 MG for urinary retention, the 5 PM dose of Carbidopa-Levodopa Oral Tablet 25-100 MG for Parkinson's, the 5 PM dose of Clonazepam Oral Tablet 0.5 MG for anxiety, the 8 PM dose of Famotidine Oral Tablet 20 MG for acid reflux, the 8 PM dose of Gabapentin Capsule 300 MG for nerve pain, the 8 PM dose of Metoprolol Tartrate Tablet 12.5 MG for hypertension, the 9 PM dose of Rosuvastatin Calcium Oral Tablet 10 MG for high cholesterol, the 9 PM dose of Tamsulosin HCl Oral Capsule 0.4 MG for urinary issues, and the 9 PM dose of Topiramate Oral Tablet 200 MG for seizures.The facility submitted an acceptable Immediate Jeopardy removal plan on 09/04/25, which was verified by observations, interviews and record review, as follows: 1. 08/30/25- 100% headcount of residents was completed to ensure no other residents were missing. All other residents were accounted for. 2. 08/30/25 a whole house search of the facility was completed. 3. 08/30/25 the executive director was notified by the weekend supervisor who in turn notified facility managers to report to work to assist in the search. Regional and divisional staff were also notified and reported to the facility to assist in the search. The medical director and primary physician were notified. 4. 08/30/25 an external search of the community was initiated. 5. 08/30/25 Executive Director notified the local Police Department who assisted in the search. 6. 08/31/25 upon return, the resident was placed on one-to-one supervision on the secured unit. (1:1 monitoring ordered 09/02/25).Observed on lock unit in room with 1:1 sitter on 09/04/25 2:00 PM, ambulating in hallway 09/04/25 at 3:00 PM. Resident cannot recall elopement. 7. 08/30/25 all facility exit door alarms and screamer devices were inspected by the Maintenance Director.Interviewed Maintenance Director with no concerns 09/05/25 at 1:00 PM. 8. 08/30/25 keypad code to secure unit was changed by the Maintenance Director. Interviewed Maintenance Director with no concerns. Push pad changed to keypad 09/02/25. 9. 08/30/25 immediate education on abuse neglect and exploitation and risk of elopement initiated. 08/30/25 3-11 shift sign-in sheet reviewed. 08/31/25 11-7 signage sheet reviewed. No concerns. 10. 08/30/25 - 09/02/25 the elopement risk assessments of all residents were reviewed for accuracy.Verified 3 sampled residents. 11. 08/30/25 an elopement drill was performed for the 11-7 shift.Verified the sign-in sheet.12. 08/31/25 the resident was assessed by the nurse upon return and by the physician on the same day. Skin assessment done 08/31/25. 13. 08/31/25 an elopement drill was performed for the 7-3 shift. Verified by sign-in sheet. 14. 09/02/25 the care plans and kardexes of residents at risk for elopement were reviewed for accuracy.3 sampled residents reviewed. 15. 08/31/25 visitor lanyards were ordered for identification of visitors/vendors to differentiate visitors from residents. The lanyards arrived on 09/02/25 and were put into use immediately.Visitors observed wearing visitor lanyards on 09/04/25 and 09/05/25. 16. 09/01/25 keypad order to replace push button for entry to units. Keypad was installed 09/02/25.Observed on 09/04/25. (photographic evidence obtained). 17. 09/02/25 elopement books were reviewed for accuracy.Observed at nursing stations and receptionist desk on 09/04/25 and 09/25/24. 18. 09/02/25 an ad hoc QAPI was performed by the facility IDT and reviewed by the Medical Director. Sign-in sheet dated 09/02/25 verified. 19. 08/30/25, the Executive Director initiated education related to abuse/neglect reporting. 20. On 08/30/25, the Assistant Executive Director notified the Department of Children and Families of the elopement of Resident #1. 21. A Federal Immediate Report was submitted on 08/30/25. 22. From 08/30/25 until 09/4/25, current facility staff were provided education by the Director of Nursing and Assistant Director of Nursing pertaining to what constitutes resident mistreatment, abuse, neglect, and misappropriation of resident property. 202 out of 285 current facility staff had education completed by 09/04/25. Any employees who have not received the training were notified they must receive the training prior to working their next scheduled shift. New employees hired after 09/04/25 will receive education during the facility orientation process. Education pertaining to abuse/neglect is provided annually and as needed. 23. Facility practices which assist in monitoring/identifying potential abuse and neglect include, but are not limited to: grievance process, complaints resolution process, facility theft and loss reporting, resident council, incident reporting, internal audits of resident trust accounts, daily staffing practices, and regular direct indirect supervision of nursing home employees and resident care by supervisory and administrative staff. 24. Root cause analysis was performed on 09/02/25 by the regional director of clinical services related to the circumstances of the resident elopement which occurred on 08/30/25. Also, on 09/02/25, an IDT review and investigation of the residence episode of elopement was completed through the ad hoc copy process. Included in the investigation was reviewed the residence condition preadmission and post admission, resident evaluations including the accuracy of elopement evaluation resident care plan, staffing, facility environments and equipment.Verified by sign-in sheets. 25. The residency elopement risk evaluation was completed accurately at the time of admission and a care plan for elopement risk was initiated. The resident was correctly placed on the locked [NAME] wing unit at the time of admission. 26. The staffing PPD on 08/30/25 for 1.28 for licensed nurse assist and 2.43 for CNA's. On the [NAME] Wing units on the 3:00 PM to 11:00 PM shift, if there were two nurses and five CNA's for the 52 residents. 2 weeks staffing calculations (State only Requirement) reviewed with no concerns. 27. Staff who predominantly work on the [NAME] Wing were interviewed via a questionnaire and asked if the resident displayed any exit seeking behaviors prior to the incident, verbalizations of wanting to leave, packing belongings, or pushing on exit doors. The staff report no indications of such desire to exit or knowledge of any exit seeking behavior.Interviews reviewed and staff interviewed by surveyor. Resident had no exit seeking behaviors. 28. The investigation and root cause analysis revealed potential root cause scenarios (birthday party and push button entrance).Per ad-hoc on 09/02/25 29. Elopement risk evaluation facility systems processes in place related to patient identification of potential for elopement/ wandering and safety in place and followed.Policy reviewed. 30. The elopement risk evaluation is completed on admission, quarterly, and after a significant change period the evaluation consists of ambulatory mobility status, wandering behaviors, cognitive status, and exit seeking indicators. Policy reviewed. 31. If a patient is identified as a potential risk, based upon the evaluation, a patient identification form, which will include a current photo, a current description, and personalized care plans, and interventions, and redirection strategies. He locks the patient elopement book contains copy of the patient identification form, a colored photo of the patient and a face sheet. The elopement books are maintained at each nursing station and at the entrance to the reception facility area.Elopement books verified at nursing desk and reception desk. 32. Facility door prevention maintenance, monitoring and checked for function weekly conducted as scheduled. No deficits noted.Weekly log reviewed. 33. All exit doors are inspected weekly.Weekly log reviewed. 34. All designated entrance/exit areas have scheduled staff assigned to the receptionist area from 8:00 AM to 8:00 PM seven days a week. 35. Staffing schedules are monitored daily by staffing coordinator and reviewed with executive director of nursing and or nursing supervisor on duty to ensure adequate staffing is maintained. Adequate staffing means all minimum PPD, and ratios are met and in addition, staffing is adjusted based on acuity of patient needs.2 weeks staffing reviewed (State requirements only). No concerns. 36. All staff are screened prior to hire and a job specific orientation is performed. Receptionist not only receive training but have a completed competency on file.Sign-in reviewed for training. 37. On 09/02/25 a review of five receptionist staff employees' file revealed all had completed training and had a competency on file. The receptionist on duty on 08/30/25 at the time of the residence elopement was suspended immediately and has subsequently been terminated.Signage reviewed for training. 38. Immediately on 08/30/25 the maintenance staff performed an inspection of the facility exit doors and screamer devices and all were found to be fully functional.Audit reviewed and interviewed. 39. Weekly door checks by the Maintenance Director will be performed to ensure proper function. On 09/02/25, the push button entry system onto the memory care unit was replaced with the keypad the truth device. Audit reviewed. 40. From 08/31/25 through 09/01/25 facility licensed nurses completed a review of the accuracy of 185 current residents elopement risk evaluations period of the 185 residents, 52 residents resided in the memory care unit and 51 of those who were already assessed to be at risk for elopement. The remaining 1 of 52 residents was originally placed on The [NAME] Wing unit for behavior management but has since become a risk for elopement. The residence assessment was updated to reflect the risk of elopement.Sample of 3 confirmed. 41. On 09 02/25 the care plans and CNA Kardexs' of 52 of 52 residents at risk for elopement were reviewed. All were found to be in compliance with risk for elopement identified.Audit verified. 42. Director of Nursing /designee to complete monitoring of new admission evaluations to ensure risk for a low moment inaccuracy identified and care plan and Kardex are reflective of the risk, where appropriate.3 new admissions, 09/04/25 audited reviewed. 43. The Medical Director was informed of the citations and is in agreement with the removal plan. The following staff were interviewed for verification of staff education: Staff A, CNA was interviewed on 09/03/25 at 11:30 AM. Staff A stated she had recently completed elopement and abuse & neglect education after the incident with Resident #1; knowledge verified.Staff D, CNA was interviewed on 09/03/25 at 1:17 PM, Staff D stated she had recently completed elopement and abuse & neglect education after the incident with Resident #1; knowledge verified.Staff E, RN was interviewed 09/03/25 at 2:17 PM, Staff E stated a code silver which means a missing person in the facility, was called and every department participated in search. The education was provided after the incident occurred.The ADON was interviewed on 09/04/25 at 3:30 PM, the ADON had an elopement drill this morning. A written Elopement quiz was completed and stated some were done over the phone. She stated on the [NAME] unit they changed the entrance touch pad to have a code residents have a wrist band on, and visitors wear red lanyard for identification. An elopement book is on every unit as well as at the receptionist's desk.Staff F, CNA was interviewed on 09/04/25 at 3:45 PM. Staff F gave examples of wandering behavior and elopement such as pushing doors and staying next to the exit. She stated they call a code silver- missing person if they have an elopement and training included what to do if there is a missing resident. Staff F acknowledged the change of the lock system up[TRUN

Based on interviews and clinical and administrative record review, the facility failed to ensure the necessary care and services were provided for 1 of 2 sampled residents, (Resident # 2), reviewed for medical appointments and/or medical procedures, as evidenced by the facility's failure to provide the necessary nursing supervision during transport to medical procedure for an incapacitated resident; and failed to ensure the health care surrogate was fully informed and adhered to preferences voiced or informed when changes are made prior to implementation. The findings included: Review of the clinical record for Resident #2, revealed the resident was admitted to the facility on [DATE] with diagnoses that included Cerebrovascular Accident (CVA), Hypertension (HTN), Diabetes Mellitus (DM), Dysphagia following cerebral infarction, Epilepsy and expressive aphasia. Review of the Significant Change MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview of Mental Status) score of 1, indicating severe cognitive impairment. The resident is dependent on staff for total care of all activities of daily living (ADLs). An interview was conducted on 07/08/25 in the morning with a family member of Resident #2 who stated that her non-verbal, total care family member was sent to a facility more than 80 miles away unaccompanied by nursing staff to receive a procedure under anesthesia.The family member and health care proxy gave approval for her family member to have a feeding tube inserted and was asked her hospital preferences. She provided the facility with multiple local hospitals within 15 miles of the facility. The resident was sent to Miami (80 miles away) without her prior knowledge or approval. She stated the facility contacted her when the resident had already left the facility and was traveling to Miami. She was informed that her family member was staying overnight, thus they did not send an aide to accompany her. She stated she had informed the caller that she did not approve of the transport to Miami, especially for her incapacitated family member to travel alone with just the transport driver. She further stated the facility was aware that she could not attend the appointment and requested that they cancel the transport. This was not done. The family member stated she was later informed that the resident would not be staying overnight but would be returning to the facility later that day. She further stated that the original information for this appointment she was provided for [another hospital - Name provided in Palm Beach County] on 06/09/25 and she would be accompanied by a Certified Nursing Assistant (CNA) since she (the family member) was out of the country. Since they rescheduled the appointment to 06/10/25, all information changed and it was not approved by her, who was the health care proxy. Review of the Nursing Progress Note on 06/03/25 at 10:10 AM, documented, Verbal orders received to send resident to ER [Emergency Room] for PEG [Percutaneous Endoscopic Gastrostomy] tube placement. Call placed to resident's family member regarding PEG tube placement and that NP [Nurse Practitioner] would like to send to ER for placement. Resident's family member would like for resident to go to [Name provided - hospital in Palm Beach County] for PEG tube placement. This writer will contact resident's family member on transportation time and when resident will be leaving building, resident's family member verbalized understanding. Another note at 11:57 from the nurse documented, This writer was made aware that resident is now under another medical service with new orders received to schedule an appointment with a physician with these services. On 06/07/25 at 5:00 PM, the Advance Registered Nurse Practitioner (ARNP) documented the resident is a candidate for a G-tube placement and has an appointment early Monday morning to go to the hospital on [DATE]. There are no further notes until 06/10/25 at 8:36 AM, which documented Resident left via stretcher with as needed [PRN] portable oxygen tank with resident accompanied by two transportation personnel from Nursing Services (transport company). Call then placed to resident's family member that resident has left the building on her way to the hospital in Miami [area]. It was at that time that resident's family member stated that she did not authorize resident to go to Miami. Call then placed to the (medical services) NP regarding resident's family member does not want resident to go to Miami [area] and that the resident is currently enroute. The Medical Service NP states that she would call this writer back with any updates. Awaiting return call. An interview was conducted on 07/08/25 at 3:26 PM with the ARNP, who confirmed that the resident was prescribed to have G-tube placement. He stated there was some mix-up with transportation on Monday, so the appointment had to be rescheduled. He stated he rescheduled the appointment and transportation, and when he called the transportation company, [Name provided], they did not have an order to transport Resident #2 on 06/09 but had placed it for pick-up on 06/10/25.The ARNP stated he spoke with the family member the previous week and she was on a cruise, so we discussed having the appointment on Monday, 06/09/25. He doesn't recall whether he mentioned to the family member that the appointment was in Miami [area], but she did agree with the PEG tube placement. An interview was conducted on 07/09/25 at 3:44 PM with the Clinical Advisor Nurse Practitioner, who stated the facility called her the morning the resident was transferred out. She stated she provided clarification to the family, but she didn't write a progress note. She stated the family was given some misinformation about the procedure. She informed the family the procedure was a same day intervention, and the resident would be coming back to the facility. She stated she only provided the clarification to the family. An interview was conducted on 07/09/25 at 4:00 PM with the nurse, Staff A, who had called the family member on 06/10/25. She confirmed she was also the nurse who received the original order for the PEG tube placement and she spoke with the family member. She agreed to the placement of the tube at a local hospital. She was originally under the impression that the resident would be sent to the emergency room for placement and [a second family member] provided her with her hospital preferences. She later learned that the resident was under another medical service, and she thought the Nurse Practitioner (NP) would discuss with the family member all the details for the procedure. She confirmed she had contacted the resident's family member on the morning the resident left the facility for the procedure. The family member was apparently unaware that the resident was traveling to Miami area, and the resident was not accompanied by staff. Staff A stated the facility does not provide supervision for medical / surgical appointments.

Based on observation, interview and record review, the facility failed to accommodate a resident's food preferences and offer an alternative food option after the resident refused a meal, for 1 of 8 sampled residents reviewed for nutrition (Resident #18). The findings include: Record review revealed Resident #18 was admitted to the facility on [DATE]. Her diagnoses included Protein Calorie Malnutrition, Malignant Neoplasm of Breast and Anxiety Disorder. Review of Resident #18's Minimum Data Set quarterly assessment dated [DATE], documented the resident's Brief Interview of Mental Status score was 99, which indicated the resident was unable to complete the interview. She was noted to rarely/never understand, and rarely/never be understood. A nutrition intervention listed on Resident #18's care plan last revised on 01/23/25, was to provide and serve the diet as ordered. Record review of the Resident's Nutrition Care Plan dated 1/23/25, documented Resident #18 had increased needs for nutrition due to her diagnosis of Malignant Neoplasm of Breast. Her most recent weight on 01/22/25 was 119.2 lbs. Her weight decreased 11.6 lbs., 8.8%, since 12/24/24. A review of Resident #18's diet and food preferences listed on her meal ticket documented that she was on a mechanically altered diet, and her dislikes included mayonnaise, rice, and red meat. A review of the facility's recipe for turkey salad included mayonnaise. The Food Service Director provided the recipe to the surveyor upon request. An observation in Resident #18's room on 01/27/25 at 2:35 PM, revealed that her lunch plate contained a scoop of ground pepper steak, cut up stir fried vegetables, pureed rice, and mashed potatoes. The dislikes listed on her meal ticket showed no red meat and she disliked rice. During an observation on 01/27/25 at 5:39 PM, Resident #18 was observed sitting in her wheelchair near the tray table in her room. Her dinner plate had a scoop of turkey salad, sliced beets, and a scoop of bread puree. The resident consumed approximately 5% of her meal tray. A review of the facility's recipe for turkey salad, provided by the Food Service Director, revealed the recipe included mayonnaise, which was listed as a dislike on her meal ticket. During an observation on 01/28/25 at 5:20 PM, Resident #18's dinner was served. The meal plate contained ground Kielbasa (pork) with gravy, roasted potatoes, broccoli and carrots. A bowl of sliced peaches, coffee, milk, and diet soda were on her tray. The surveyor observed the resident pick up her bowl of sliced peaches and she slammed it down on the table. A Certified Nursing Assistant (CNA) observed the surveyor speaking to Resident #18 about food preferences. The CNA called for Staff I, a Registered Nurse, to attend to the issue. Staff I then entered Resident #18's room at 5:24 PM. During an interview with Staff I on 01/28/25 at 5:24 PM, when asked why she thought Resident #18 wasn't eating the dinner meal, Staff I answered, sometimes they say they don't want to eat and then they change their minds. Staff I stated that she will give the resident a Glucerna (nutrition supplement) to replace the meal. Staff I retrieved a carton of Glucerna and offered Resident #18 a sip of the supplement. During an interview with the resident's family member on 01/29/25 at 10:29 AM, the family member stated that [Resident #18] didn't like beef too much and that she was raised eating pasta, not rice. The family member stated she had previously communicated [Resident #18's] food preferences to the Registered Dietitian in the past. Photographic evidence obtained.

Based on interview and record review, the facility failed to honor a resident's choices related to showers for 1 of 3 sampled residents reviewed for choices (Resident #16). The findings included: A review of Resident #16's medical records revealed she was admitted to the facility on [DATE], with diagnoses to include Hemiplegia (paralysis of one side of the body) and Hemiparesis (one-sided muscle weakness) following a Cerebral Infarction (stroke), affecting the right dominant side, Muscle Weakness and Diabetes. A review of Resident #16's Quarterly MDS (Minimum Data Set) assessment documented her BIMS (Brief Interview for Mental Status) score as a 9, indicating moderate impaired cognition. The assessment (Section GG) documented Resident #16 is dependent on showers/bathing and she has upper and lower impairment on one side of her body. A review of care plans documented Resident #16 requires assistance by staff with showering and bathing. During an interview on 01/28/25 at 12:31 PM, Resident #16 was asked if she receives showers or bed baths. She stated that she wants a shower but only receives bed baths. She was asked when her last shower was, however, she could not recall. She stated that she had been telling everyone she would like a shower but has not received one. A review of Resident #16's task sheet for showering/bathing for the last 30 days (12/31/24-01/29/25), documented she received one shower in the last 30 days, which was on 12/31/24. The other 29 days documented she received a sponge bath. During an interview on 01/29/2025 at 1:00 PM with Staff E, CNA (Certified Nursing Assistant), she was asked if she works with Resident #16, and she stated yes. She was asked how she knew when to give this resident a shower. She stated, when she asks for one. Staff E, CNA was asked what Resident #16's shower days are, but she didn't know. The Surveyor and Staff E, CNA, went to Resident #16's room. The Surveyor asked the resident, Do you want someone to give you a shower?, she stated yes, I want it when you can do it today. The RN for Resident #16 was in the hallway and overheard the conversation, and responded by saying, we will get her one Upon request on 01/29/25 at 2:05 PM, the unit nurse presented the Surveyor with the shower assignment book, which included documentation that Resident #16 is assigned to receive a shower on Tuesdays and Fridays, on the 7:00 AM-3:00 PM shift.

Based on record review and interview, the facility failed to document an accurate Advance Directive care plan for 1 of 39 sampled records reviewed (Resident #121). The findings concluded: Record review revealed Resident #121 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had severe cognitive impairment and was dependent for activities of daily living (ADL). The assessment further documented the resident was receiving hospice services. A review of Resident #121's care plan revealed a care plan dated [DATE] that documented the resident had an Advance Directive for CPR (Cardiopulmonary Resuscitation) and was a full code (a medical term that indicates a resident's preference for resuscitation and all life saving measures during a medical emergency). A review of Resident #121's orders revealed an order dated [DATE] for DNR (Do Not Resuscitate). Further review of Resident #121's records revealed a State of Florida DNR order form dated [DATE]. An interview was conducted with the Central Unit Manager (UM) on [DATE] at 12:00 PM. The UM stated the care plan for Resident #121 reflecting the resident being a full code, was entered in error.

Based on observations, interviews, and record reviews, the facility failed to provide proper care and treatment, as evidenced by not providing a communication board, to maintain the resident's communication abilities for 1 of 1 sampled resident, Resident #75, reviewed for Activities of Daily Living (ADLs). The findings included: Record review revealed Resident #75 was admitted to the facility on [DATE]. The resident was admitted to Hospice Services on 08/02/24 with diagnoses that included Anxiety Disorder, Major Depressive Disorder, Persistent Mood Disorder, Panic Disorder, and Dementia. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] documented the resident needed or wanted an interpreter to communicate with a doctor or health care staff. Resident #75 was dependent on assistance with activities of daily living which included care for incontinence. Review of Resident #75's care plans noted that she had a communication problem. The intervention for the communication problem since 05/21/23 was to have a communication board at the bedside as needed. An observation was conducted on 01/27/25 at 4:26 PM revealed Resident #75 was laying down in bed when she motioned for the surveyor to move closer to her. She requested assistance and pointed towards her incontinence brief. She said the words: water, water, and she lifted her right hand with extended fingers over the brief. She swept her fingers downward. The resident indicated she wanted her brief to be changed. Resident #75 then pulled her blanket off to expose her stomach and brief. The resident moved her open fingers in sweeping down motion over her brief and again said water, water. The surveyor suggested she press the call bell for assistance from nursing. Staff G, Certified Nursing Assistant (CNA), answered the call bell. After Staff G entered the room, during an interview with the CNA, the surveyor asked how she communicated with this resident. The CNA answered that Resident #75 spoke a different language, but she speaks to the resident in English. The resident lifted the plastic along the top edge of the brief. She moved her fingers above the brief and motioned from the top to the lower part of the brief. She said water, water. The CNA told the resident she was on her way to get her a drink of water when she heard the call bell. The CNA said that she would be back with water. The surveyor asked the CNA how she knew the resident wanted to receive water. Again, the resident motioned her fingers in the same way as before. With non-verbal communication, Resident #75 requested to be cleaned because she was wet. The CNA answered she would be right back with a drink of water. After the CNA exited the room, the resident threw her arms up in the air. There was no communication board observed in the resident's room. On 01/29/25 at 5:40 PM, Resident #75 was observed sitting in a wheelchair in the hallway just outside her bedroom door. Staff H, CNA, approached the surveyor and Resident #75. In an interview on 01/29/25 at 5:48 PM, Staff H was asked how she communicated with this resident, and responded the resident spoke some English. Staff H stated when she didn't understand the resident, she would ask the resident to try and clarify what she meant. The CNA said that she listened until she understood what the resident wanted. Resident #75 looked at the CNA and touched her fingertips to her mouth. She said the word food. The CNA excused herself and went to get her the dinner tray.

Based on observation, interview, and record review, the facility failed to address a skin condition in a timely manner for 1 of 1 sampled resident (Resident #27); failed to provide blood pressure medications as ordered, as evidenced by nurses randomly holding medications for a low heart rate, without parameters and failure to notify the physician of held medications for 1 of 1 sampled residents (Resident #45); failed to follow parameters for physician orders for blood pressure medications for 1 of 1 sampled resident (Resident #57); and failed to provide a pillow between the legs of a resident as ordered by the physician for 1 of 1 sampled resident (Resident #77), to prevent knee abduction and lower body contractures. The findings included: 1) Record review revealed Resident #27 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented that the resident was cognitively intact and was dependent for activities of daily living. Further record review revealed Resident #27 was care planned for potential for skin impairment related to fragile skin. A review of Resident #27's physician orders revealed an order dated 12/26/24, to apply Zinc to upper/lower back at bedtime for Heat Rash; an order dated 01/07/25 for Hydrocortisone Cream to upper/lower back every day and evening shift for Rash; and an order dated 01/07/25 for a dermatology consult (consultation) for rash to upper and lower back. An interview was conducted with Resident #27 on 01/28/25 at 11:00 AM in the resident's room. The resident stated his back had been itchy for about 3 weeks now. The resident stated they (staff) put cream on his back twice a day, but the cream only helps for a little while. Resident #27 further stated he was supposed to see a dermatologist for the itching, but did not know when. The resident stated he was in agony over the itching. An interview was conducted with Resident #27 on 01/30/25 at 10:00 AM. The resident stated his back was itching so bad that he could not take it. The resident stated they continue to put a cream on his back twice daily, but it is not working. An interview was conducted with Staff Z, a Licensed Practical Nurse, on 01/30/25 at 11:00 AM. Staff Z stated Resident #27 was being treated for a heat rash to his back with Hydrocortisone Cream (steroid) twice daily. Staff Z further stated the resident had a dermatology consult ordered, but did not know when he would be seen. Staff Z stated the Social Worker arranges the consultations. An observation of Resident #27's back was conducted with Staff Z on 01/30/25 at 11:30 AM. The resident had dried scaly patches to his back. Resident #27 stated he felt like he was being tortured as the itching was so bad. Again, the resident stated it had been going on for about 3 weeks now. An interview was conducted with the Social Service Director (SSD) on 01/30/25 at 12:00 PM. The SSD stated the dermatologist comes to the facility on ce a month, at different times. There was no set date. The SSD stated the dermatologist already came to the facility on [DATE] to see residents. The SSD stated Resident #27 was not on the list to be seen. The SSD acknowledged Resident #27's order for a dermatologist consult on 01/07/25. The SSD stated she did not put the request in for the dermatologist to see Resident #27 until 01/14/25. The SSD stated she believes that was when it was brought to her attention that Resident #27 had a consult ordered for a dermatologist. The SSD stated Resident #27 would not be seen by the dermatologist until next visit in 02/25, but did not have a set date. 25404 2) Review of the record revealed Resident #45 was admitted to the facility on [DATE]. Review of the current physician orders revealed the resident was prescribed two medications for high blood pressure, to include Amlodipine 2.5 mg (milligrams) once daily, and Lisinopril 10 mg once daily. Resident #45 was also prescribed Carvedilol 6.25 mg twice daily for Coronary Artery Disease. Further review of the orders lacked any type of blood pressure or heart rate parameters for holding any of the three medications. Review of the current January 2025 Medication Administration Record (MAR) revealed all three medications were held on 01/06/25 for the 9 AM dose because of the resident's heart rate of 55 beats per minute. The Carvedilol was held on 01/17/25 for the 5 PM dose, with a corresponding progress note that documented, hold per BP (blood pressure) value. The documented blood pressure for that administration was 124/59. Review of the December 2024 MAR revealed all three of the above mentioned medications were held on 12/06/24 at 9 AM, 12/07/24 at 9 AM, and 12/09/24 at 9 AM. The corresponding progress notes documented a heart rate of 57 on 12/06/24 but lacked any documented vital signs or rationale for the 12/07/24 and 12/09/24 held medications. Final review of the record lacked any notification to the physician for any of the held medication. During a side-by-side review of the record on 01/30/25 at 12:05 PM, the [NAME] Unit Manager was shown the held medications for Resident #45 and had no response. During an interview on 01/30/25 at 1:17 PM, the Director of Nursing (DON) agreed with the findings and that there were no parameters to hold the medications. 33103 3) Review of Resident #57's medical records revealed he was admitted to the facility on [DATE]. His diagnosis included Essential Hypertension, Encephalopathy, End Stage Renal Disease, Coronary Artery Disease and Type II Diabetes. A review of the resident's physician orders, and the current MAR (Medication Administration Record) revealed that Resident #57 had parameters for two of his medications that were not being followed. Further review of the physician orders dated 07/07/24 documented, Northera Oral Capsule 100 MG (Droxidopa) give 1 capsule by mouth three times a day for hypotension. Hold for SBP (Systolic blood pressure) greater than 120. The following times and dates documented the medication was given when it should have been held: 9:00 AM Dose: 01/09/25 with a B/P (blood pressure) of 132/85 01/13/25 with a B/P of 154/69 01/23/25 with a B/P of 130/70 01/25/25 with a B/P of 139/78 01/27/25 with a B/P of 168/92 01/28/25 with a B/P of 128/67 01/29/25 with a B/P of 121/71 1:00 PM Dose: 01/09/25 with a B/P of 141/52 01/13/25 with a B/P of 124/65 01/25/25 with a B/P of 139/78 01/27/25 with a B/P of 168/92 01/29/25 with a B/P of 124/73 5:00 PM Dose: 01/07/25 with a B/P of 149/88 01/10/25 with a B/P of 139/72 01/17/25 with a B/P of 130/65 01/18/25 with a B/P of 126/69 01/21/25 with a B/P of 144/74 A review of the physician's orders dated 03/29/24 and the MAR (Medication Administration Record) revealed documented medication with parameters including, Clonidine HCl Tablet 0.1 MG, give 1 tablet by mouth every 6 hours as needed for Hypertension for SBP (Systolic blood pressure) over 140, do not give on dialysis days. The following dates the medication was not given when the blood pressure was above 140. 01/07/25 B/P 149/88 taken at 1700 01/21/25 B/P 144/74 taken at 1700 01/09/25 B/P 141/52 taken at 1300 During an interview on 01/30/25 at 7:16 AM, Staff F, LPN (Licensed Practical Nurse) stated she has worked at the facility for 3 months. Staff F reviewed the MAR with the Surveyor and was asked about the medication order and the parameters for Northera Oral for Hypotension. She stated that some patients have a fragile side, and their B/P can change rapidly. She was asked about the Clonidine PRN order that documented to give if B/P is over 140. She stated she would not give it if it was above 140. If it was 145, she said she would have the resident watch his salt intake. She stated that Clonidine is not a batch medication, and is usually given PRN (as needed), if the resident asks for it. Clonidine is not a batch medication. The surveyor asked her to elaborate what she meant by that remark; she said Tylenol is always on the MAR as a PRN med. She then said, I don't look for PRN''s unless I think the patient is in Jeopardy. She then said she was not aware he (Resident #57) had PRN medication. During an interview on 01/30/25 at 7:30 AM with the DON and the Regional Nurse Consultant they reviewed the MAR with the Surveyor, and both acknowledged the concerns with the two medications and the parameters. 50895 4) Record review revealed Resident #77 was admitted to the facility on [DATE]. Her diagnoses included Frontal Lobe and Executive Function Deficit following Nontraumatic Intracerebral Hemorrhage, Vascular Dementia, and Major Depressive Disorder. Review of the Minimum Data Set quarterly assessment dated [DATE], documented Resident #77 had one or more unhealed pressure injuries, and she had significant weight loss. Review of the Occupational Therapy Evaluation and Plan of Treatment dated 12/26/24, documented to use a pillow between the resident's knees to prevent knee adduction and lower body contractures. Documentation in Resident #77's medical record, dated 12/30/2024, revealed a doctor's order, that documented: Patient to use pillow between her leg to ensure wheelchair positioning. Calf pads and extenders for lower body position. Record review revealed that there was no care plan in place that corresponded to the doctor's order, and the goal stated in the Occupational Therapist's evaluation, to place a pillow between the legs to prevent knee adduction and lower body contractures. During an observation on 01/27/25 at 4:03 PM, Resident #77 was observed sitting in a high back wheelchair, in her bedroom. Observation revealed heel protection boots covered the resident's heels, and there were cushions on the resident's arm rests. Resident #77's knees were noted to be pressing against each other. There was no pillow in between her legs. During an observation on 01/29/25 at 5:05 PM, Resident #77 was observed sitting in a high back wheelchair, in her bedroom. Her knees were observed pressed together. There was no pillow in between her legs. During an interview on 01/29/25 at 6:03 PM with Staff G, when asked how she knew when to place a pillow in between Resident #77's knees, she answered that sometimes CNAs (Certified Nursing Assistant) place pillows behind the resident's head and under the resident's arms. Staff G did not mention placing a pillow between the resident's legs or knees. In an interview with the Director of Rehabilitation (DOR) on 01/30/25 at 8:33 AM, she was asked what the process was when she sees someone in a wheelchair with their knees pressed together. The DOR stated that a therapist would evaluate a resident if it was reported to the therapy department. After the surveyor informed the DOR regarding the concerns for Resident #77, the DOR stated that Resident #77 was evaluated for a possible leg contracture. She revealed that the therapist determined the positioning of this resident's legs was mostly behavioral. Her recommendation was to train the staff regarding wheelchair positioning and to use a pillow in between the residents' knees. The DOR explained that the therapists encouraged the CNAs to use the recommended positioning for Resident #77 to keep her knees without touching each other.

Based on record review and interview, the facility failed to discard narcotics/controlled medications in a timely manner for 2 of 8 sampled residents (Resident #64 and #124); and failed to reconcile narcotics, as evidenced by not documenting the medication administration on the Medication Administration Record (MAR) for 2 of 8 sampled residents (Resident #124 and #263). The findings included: A review of the facility's policy titled, Administration of Medication, last reviewed on 09/16/24, documented: Medication administration should be documented timely following the administration to the resident. 1. Record review revealed Resident #64 was admitted to the facility on [DATE]. A medication storage observation was conducted with Staff A, a Licensed Practical Nurse, of the Northwest medication cart on 01/29/25 at 4:00 PM. The observation revealed 6 medication packs of Lorazepam (anti-anxiety medication) for Resident #64 as follows: a. A medication pack of 3 pills of Lorazepam 0.5 mg. The pack was received on 02/02/24. b. A medication pack of 1 pill of Lorazepam 0.5 mg. The pack was received on 04/17/24. c. A medication pack of 3 pills of Lorazepam 0.5 mg. The pack was received on 05/08/24. d. A medication pack of 1 pill of Lorazepam 0.5 mg. The pack was received on 07/10/24. e. A medication pack of 3 pills of Lorazepam 0.5 mg. The pack was received on 08/03/24. f. A medication pack of 1 pill of Lorazepam 0.5 mg. The pack was received on 11/13/24. During the medication storage observation, Staff A could not explain why the 6 packets of Lorazepam for Resident #64 were in the medication cart. A review of Resident #64's Physician orders revealed an order dated 03/19/23 for Lorazepam 0.5 mg, give 1 tablet one time a day for dental cleaning for one day. Further review of Resident #64's Physician orders revealed an order dated 08/04/24 for Lorazepam 0.5 mg, give 3 tablets one time only for 1 hour prior dental procedure for one day. No other orders for Lorazepam were found. An interview was conducted with the Director of Nursing (DON) on 01/30/25 at 12:00 PM. The DON stated it appeared that the pharmacy kept sending packets of Lorazepam for Resident #64. The DON further stated the unused medication should have been returned to pharmacy. 2. Record review Resident #124 was admitted to the facility on [DATE]. A medication storage observation was conducted with Staff A, a Licensed Practical Nurse, on northwest medication cart on 01/29/25 at 4:10 PM. The observation revealed a medication pack for Resident #124 of Lorazepam (anti-anxiety medication) 0.5 mg ,containing 16 pills. A side by side review with Staff A of Resident #124's Controlled Medication Utilization Record revealed Lorazepam 0.5 mg was removed for administration on 12/11/24 at 9:00 PM and 12/22/24 at 4:05 PM. A side by side review of Resident #124's Medication Administration Record (MAR) revealed no evidence of Lorazepam administered to the resident on 12/11/24 at 9:00 PM and 12/22/24 at 4:05 PM. Staff C acknowledged the above. A review of Resident #124's Physician orders revealed an order dated 07/22/24 to discontinue the Ativan (Lorazepam) 0.5 mg order. An interview was conducted with the Director of Nursing (DON) on 01/30/25 at 12:00 PM. The DON stated the unused medication should have been returned to pharmacy. 3. Record review revealed Resident #263 was admitted to the facility on [DATE]. Record review revealed an order dated 01/13/25 for Lorazepam 0.5 mg every 6 hours as needed for anxiety for 14 days. A medication storage observation was conducted with Staff D, a Licensed Practical Nurse, of Southwest med cart on 01/29/25 at 4:30 PM. A side by side review with Staff D of Resident #263's Controlled Medication Utilization Record revealed Lorazepam 0.5 mg was removed for administration on 01/19/25 at 5:20 PM and 11:00 PM, 01/20/25 at 9:00 AM, 01/21/25 at 9:00 AM and 9:00 PM, 01/22/25 at 9:00 AM and 5:10 PM, 01/23/25 at 9:00 AM and 4:46 PM, 01/24/25 at 9:10 AM and 5:15 PM, 01/25/25 at 9:00 AM and 4:17 PM, 01/26/25 at 9:00 AM and 4:41 PM, 01/27/25 at 9:42 AM and 4:37 PM. A side by side review with Staff D of Resident #263's Medication Administration Record (MAR), revealed no evidence of Lorazepam administered to the resident from 01/13/25 -01/27/25. Staff D acknowledged the findings.

Based on observation and interview, the facility failed to ensure safe medication storage for 1 of 8 medications carts (D Unit) and 1 of 3 treatment carts (West Unit), as evidenced by these carts being left unlocked and unattended, with independently ambulatory residents noted. The findings included: 1) On 01/27/25 at 9:54 AM, the medication cart on the D Unit was observed unattended and the push in lock was not engaged. The lock was easily pulled out and the medication cart drawers were easily opened. The medication cart was filled with medications for the 22 residents residing on the D Unit along with the generic stock medications. While awaiting the arrival of a staff member, Resident #100 was observed independently ambulating in the hallway in front of the medication cart. There were no staff observed in the hallway of the D Unit. A few minutes later the Assistant Director of Nursing (ADON) came to the medication cart and agreed with the concern of the unlocked medication cart. On 01/27/25 at 9:58 AM, Staff A, Licensed Practical Nurse (LPN), returned to the medication cart and immediately tried to pull open the lock without using her key. When asked if there was a reason she did not lock the cart, the nurse stated, I swear I pushed the lock in. The LPN was questioned about the partially engaged lock previously observed and again stated she thought she had pushed in the lock all the way. At the time of the survey there were 14 independently ambulatory residents residing on the A, B, C, and D Units, all of which had access to the D unit medication cart. 2) On 01/27/24 at 1:34 PM, an unattended and unlocked treatment cart was observed in the hallway of the [NAME] Unit, which was the locked memory care unit (Photographic Evidence Obtained). Upon opening the treatment cart, numerous wound care supplies and medicated wound ointments were noted to include Santyl (an ointment used to debride wounds), Clobetasol (an ointment to treat itching and or psoriasis), Aspercreme (a lotion with Lidocaine for pain), Hibiclense (an antiseptic skin cleanser), Triamcinolone cream (a corticosteroid cream), and collagen powder. The cart also contained a box of curettes (sharp instruments used to mechanically debride a wound). There was no staff noted in the area of the treatment cart. Throughout the survey multiple cognitively impaired residents were observed ambulating or wheeling themselves up and down the hallway of the [NAME] Unit. The surveyor went to the [NAME] Unit nurses' station and reported the open treatment cart to Staff B, Registered Nurse (RN). The RN went to the treatment cart and acknowledged the findings. There were 19 cognitively impaired independently ambulatory residents on the [NAME] Unit, where the unlocked and unattended treatment cart was located.

Based on observations and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, sanitary conditions, and the prevention of foodborne illnesses. This had the potential to affect approximately 158 of 165 residents. The findings included: During the initial tour of the Main Kitchen on 01/27/25 at 10:13 AM, accompanied by the Food Service Director (FSD), the following was observed: 1. A personal backpack was observed on a shelf below the food preparation area. The backpack was resting on dishware. 2. In the dry storage room, a gray plastic bin was observed with dark colored sediment on the handle of the container, on the inside of the bottom of the container, and on the handles of at least four of the scoop serving utensils. 3. The Cleveland steamer had brown/red wet residue around the perimeter of the upper steamer and the upper exterior of the lower steamer. During a subsequent interview during the tour, the FSD acknowledged the findings. A tour of the nourishment room in the [NAME] Wing was conducted on 01/28/25 at 5:06 PM. The surveyor was accompanied by the DON. The following was observed and noted: 4. An opened plastic container of Med Plus 2.0 Nutritional Drink was on a shelf inside the refrigerator. There was no date written on the container to indicate the date that it was opened. The recommended storage and handling of this item, per the manufacturer's instructions, are to refrigerate the product after it is opened and to consume the drink within 4 days, if properly refrigerated. 5. An unlabeled styrofoam cup with liquid was on a shelf in the refrigerator. This had no product name, no resident's name, and no date. During a subsequent interview during the tour, the DON acknowledged the findings.

The facility failed to provide food in a puree form to meet the individual needs of residents for 3 of 17sampled residents (Resident #48, Resident #46, Resident #65) on a medically ordered pureed diet. The findings include: Review of the facility's Life Care Centers of America Policy, reviewed on 5/01/2024, documented the Pureed diet consists of foods that are easy to swallow because they are blended, whipped, or mashed until they are pudding-like texture. All foods on this diet should be smooth and free of lumps. (National Dysphagia Definition). The purpose of the pureed diet is designed to minimize the amount of chewing required and to facilitate the ease of swallowing food. This diet is designed for residents who have moderate to severe dysphagia, with poor oral phase abilities and reduced ability to protect their airway. 1). Record review revealed Resident #46's active diagnoses included Alzheimer's disease, and Dementia. A review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE], documented the resident's Brief Interview for Mental Status score was 99. This indicated that the resident was unable to complete the assessment. In addition, the MDS assessment noted that Resident #46 was rarely/never able to make herself understood. The diet was coded therapeutic and mechanically altered. A pureed diet is a mechanically altered diet. According to the Diet Type Report dated 01/27/25, Resident #46's Diet Order was a Regular diet, with Puree texture, and Nectar/ Mildly consistency fluids. During an observation in the small dining room on 01/27/25 at 11:48 AM, Resident #46 was provided with assistance with feeding. Review of the menu ticket documented the resident was to receive a pureed diet. The lunch listed on the menu for the pureed diet was pureed pepper steak, pureed rice, pureed cabbage, and pureed stir fry vegetables. Further observation of the meal revealed the pureed cabbage and rice was lumpy. 2). Record review revealed that Resident #48 was admitted to the facility on [DATE]. Resident #48's diagnoses included Alzheimer's disease and Oropharyngeal Dysphagia. The Minimum Data Set Annual assessment documented Resident #48 was on a mechanically altered diet. The Brief Interview for Mental Status was 99. This indicated that the resident was unable to complete the assessment. The diet order dated 12/04/2023 documented the resident was on a Regular diet, Puree texture, and Nectar/ Mildly consistency. The care plan dated 01/14/2019 documented Resident #48's nutritional risk was related to Alzheimer's disease, and dysphagia. An observation on 1/27/25 at 12:16 PM revealed Resident #48 in the [NAME] Unit Dining Room eating lunch. Review of the menu ticket documented the resident was to receive a pureed diet with nectar thick liquids. Resident #48 took a bite of the mashed potatoes served on her plate. The mashed potatoes were not smooth, and a large lump was noted in the serving. Further observation revealed the resident bit the lump of mashed potatoes in half, and spit half of the lump back onto her spoon. The resident then took a second attempt at eating the spoonful of mashed potatoes. 3). Record review of Resident #65's Minimum Data Set (MDS) Annual assessment dated [DATE], revealed the resident's active diagnoses included Cerebrovascular Accident, Transient Ischemic Attack, or Stroke, Dementia, Hemiplegia or Hemiparesis, and Aphasia. The score of the Brief Interview for Mental Status was 04. This indicated that the resident had severe cognitive impairment. In addition, the MDS assessment noted that Resident #65 was sometimes able to make herself understood. The diet was coded therapeutic and mechanically altered. A pureed diet is a mechanically altered diet. According to the MDS annual assessment, Resident #65 was dependent on assistance with feeding. According to the Diet Type Report dated 01/27/25, Resident #65's Diet Order was a Regular diet, with Puree texture, and Nectar/ Mildly consistency fluids. An observation on 01/27/25 at 1:03 PM revealed that Resident #65 was served lunch at the tray table in her room. Review of the menu ticket documented the resident was to receive a pureed diet. Observation revealed the meal plate contained pureed pepper steak, pureed rice, pureed cabbage, and pureed stir fry vegetables. Further observation of the meal revealed the pureed cabbage and rice was lumpy. During an interview with the Food Service Director (FSD) on 01/27/25 at 1:15 PM, the surveyor expressed concern that the pureed foods were not smooth. The surveyor requested a sample of the pureed lunch plate, which included pureed beef, pureed rice, pureed stir fry vegetables, and mashed potatoes were on the plate. When the surveyor informed the FSD that the pureed rice was not smooth, the FSD said, yes I see the bumps, they look like little pearls. When the surveyor tasted the pureed rice, it was not smooth and contained solid particles. The surveyor then tasted the pureed stir fry vegetables. Visible strands in the vegetables were observed. When asked why there were strands in the stir fry vegetables, the FSD answered, because they are vegetables. Photographic evidence obtained.

Based on record review and interview, the facility failed to protect a resident from repeated physical abuse for 1 of 1 sampled resident reviewed for abuse (Resident #1). The findings included: A review of the Facility's policy Abuse Prevention, issued on 10/04/22 and reviewed on 07/18/23, Documented: It is the policy of this facility to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation. Procedure #4 documented: To identify, assess, care plan for appropriate interventions, and monitor residents with needs and behaviors, which might lead to conflict or neglect, such as verbally aggressive behavior and physically aggressive behavior. A review of the facility's abuse log revealed a resident (Resident #2) to resident (Resident #1) substantiated allegation specifically, of abuse on 10/14/23 and 10/26/23. Resident #1 was assaulted by Resident #2 on 10/14/23. Resident #2 was transferred to the hospital for unrelated concerns on 10/14/23. Resident #2 returned to the facility on [DATE]. Without any interventions in place, Resident #1 was again assaulted by Resident #2 on 10/26/23. Both residents resided in a locked memory care unit in adjacent rooms. Record review revealed Resident #1 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had cognitive deficit and was independent with activities of daily living. The resident was care planned for wandering with decreased attention span. Record review revealed Resident #2 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had severe cognitive deficit, and required supervision with set-up help only for activities of daily living. The resident was care planned for behavior problems, tends to be aggressive with other residents if they actually go into his room/bed. On 10/14/23 altercation with another resident in which he struck the resident in the face. The resident has exhibited physically aggressive behavior towards others related to impulse control. An intervention dated 10/14/23 included a psych consultation for aggressive/assaultive episodes. A review of Resident #1's progress note dated 10/14/23 at 9:50 AM revealed the resident was involved in an altercation with another resident (Resident #2), in which the other resident (Resident #2) walked up to Resident #1 and slapped him on his head and forehead, unprovoked, causing injury to his nose and forehead. First aid was provided, and appropriate entities were notified. A review of Resident #2's progress note dated 10/14/23 at 11:26 AM revealed the resident was placed on 1:1 supervision. Resident #2 was later transferred to the hospital the same day for unrelated reasons. Resident #2 was readmitted to the facility on [DATE], in the same room adjacent to Resident #1. There was no evidence Resident #2 was evaluated by psych. An interview was conducted with the facility's Risk Manager (RM) on 11/08/23 at 12:00 PM. The RM acknowledged the assault/abuse of Resident #1 by Resident #2 on 10/14/23. The RM reviewed abuse allegations and investigation of Resident #1 by Resident #2 on 10/26/23. The RM stated Resident #2 shoved Resident #1 after striking a nurse. The RM stated Resident #2 was transferred to the hospital for increased agitation and restlessness. When Resident #2 returned to the facility on [DATE], his room was changed. Resident #1 was observed sitting in a chair in his doorway looking out into the hallway on 11/08/23 at 12:45 AM. An interview was conducted with the unit manager (UM) on 11/08/23 at 12:45 PM. The UM stated Resident #1 usually sat in his doorway, or in hallway next to nurse cart (parked outside room W5). The UM further stated after 2nd incident with Resident #2, the resident was moved from his room (adjacent to Resident #1) to another room (opposite end of the hallway). A review of Resident #2's orders revealed an order dated 10/29/23 for an antipsychotic medication (mood stabilizer).

Based on observation, interview, and record review, the facility's approved menu was not followed for 16 residents (includes sampled Resident #16, #20, #54, and #72) with physician ordered Pureed Diet for, 17 residents (includes sampled Resident #70) with physician ordered Easy To Chew Diet, and 14 residents (includes sampled Resident #28, #59, and #125). The findings included: 1) During the review of the approved facility menu to be served for the lunch meal on 10/02/23, the following were noted: Regular Diet: Kielbasa (4 ounce edible portion) Regular Diet: Potatoes O'Brien, Fruit Crisp Easy To Chew Diet: Ground Pork Roast, Soft Potatoes O'Brien, Soft Fruit Crisp Mechanically Altered Diet: Ground Pork Roast, Soft Potatoes O'Brien, Pureed fruit Crisp Pureed Diet: Pureed Pork Roast, Pureed , Soft Potatoes O'Brien, Pureed fruit Crisp Regular Diet: Potatoes O'Brien Alternate Regular Diet: Chop Steak (4 ounce Edible Portion) Alternate Regular Diet Starch: Buttered Corn Alternate Easy To Chew Diet & Mechanical Altered Diet: Buttered Corn Alternate Pureed Diet: Pureed Buttered Corn During the observation of the lunch meal in the main kitchen on 01/03/23 at 11:45 AM, the following were noted: < Easy To Chew Diet, Mechanical Altered Diet, Pureed Diet: Ground Pork Roast and Pureed Pork Roast were not prepared or served. Kielbasa was served < Easy To Chew Diet , Mechanical Altered Diet, and Pureed Diet: Soft Potatoes O'Brien and Pureed Potatoes O'Brien were not prepared or served. Roasted Potatoes were served. < Easy To Chew Diet , Mechanical Altered Diet, and Pureed Diet: Soft Fruit Crisp and Pureed Fruit Crisp were not prepared or served. Watermelon was served. < Easy To Chew Diet, Mechanical Altered Diet, and Pureed Diet: Buttered Cord was not prepared or served. Instant Mashed Potatoes were served. < Entree portions were weighed utilizing the facility's calibrated portion scale were conducted. The weighing noted that an average portion of Kielbasa was only 3 ounces, and average portion of Chop Steak Was only 2.75 ounces. 2) During the review of the approved facility menu for the breakfast meal of 10/03/23, the following were noted: Pureed Diet:#8 Scoop of Pureed Hot Cereal Easy to Chew : #16 Scoop Bacon Mechanically Altered : #16 Scoop Bacon Pureed Diet: #16 Scoop Pureed Bacon Observation of the meal tray assembly line in the main kitchen on 10/03/23 at 7:30 AM noted the following: 1) Pureed Hot Cereal not prepared or served. 2) Easy to Chew and Mechanical Altered Bacon was not prepared or served 3) Pureed Bacon not prepared or served. * Review of the facility's approved diet manual on 10/03/23 noted that pureed bacon must be commercially prepared and purchased. Interview with the Food Service Director on 10/03/23 noted that commercially prepared bacon is not purchased. 3) During the review of the approved menu for the lunch meal of 10/04/23, the following were noted: Mechanically Altered: 2 Ounces Ground Meatball (2 ounces), Cut Up Noodles (4 ounces), Pureed Diet : Pureed Meatball (2 ounces) Easy To Chew: Cut Up Noodles (4 ounces) Alternate Entree (Regular) : Grilled Shrimp (3 ounces) Alternate Entree (Easy To Chew): Cut Up Shrimp (3 ounces) 4) During the review of the facility's Diet Census for 10/03/23, the following were noted: (a) Current Physician Orders for Pureed Diet = 16 Residents : Includes Resident #16, #20, #54 and #72. (b) Current Physician Orders for Easy To Chew Diet = 17 Residents: Includes Resident #28. (c) Current Physician Orders for Mechanical Altered Diet = 14 Residents: Includes Resident #28, #59, and #125.

Based on observation and interview, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for potentially 175 of the facility resident's. The findings included: 1) During the initial kitchen/food service observation tour conducted on 10/02/23 at 9:15 AM and accompanied with the with the Food Service Director and Regional Administrator, the following were noted: (a) Ceiling mounted air-conditioning vent and drip pan located above food preparation surfaces and the 3-compartment sink was noted to be soiled and full of condensation. Further observation noted that the contaminated condensation was dripping down on food preparation counters, 3-compartment sink area, and the floor area under the vent. It was discussed with the Food Service Manager (FSD) that there was a potential of contamination from the dripping condensation. The surveyor requested that staff not have access to the areas surrounding the vent and drip pan until the issues was resolved. (b) The commercial plate warmer located on the tray line serving area was noted to be soiled and to have a heavy build-up of dried food matter. The surveyor discussed with the FSD that the soiled warmer was contaminating clean plates. (c) A personal staff purse was noted to be stored directly on top clean disposable dishware. The surveyor discussed with the FSD that the purse was potentially contaminating the disposable dishes. (d) Observation of the Victory Reach-in refrigerator #1 noted to have 9 of 9 food storage shelves the were heavily rust laden and in need of replacement. It was discussed with the FSD that the reach-in unit not be used until the food storage shelves were replaced. (e) Observation of the dish machine noted that 1 of the 3 internal separation curtains located within the machine was missing. The machine was in use without the curtain and the surveyor informed the FSD that the internal curtain separate dirty, clean and sanitizing sections of the machine and that there was a potential to contaminate clean dishes exiting the machine. (f) The lens covers of 3 commercial ceiling lights were noted to be broken and had large cracked areas. The surveyor discussed with the FSD that there was the potential of broken plastic light lens to fall into prepared foods. 2) During the second follow-up visit to the kitchen/food service department on 10/03/23 at 7:30 AM noted the following: (g) The second ceiling air conditioner vent located over the tray line area was noted to have a heavy build-up of black mold type matter around the unit and ceiling area. There was a potential of food contamination and food borne illness from the molded area. (h) Numerous observations of residents eating plates (10) were noted to have a heavy yellow stain of the entire eating exterior. The surveyor requested that all stained plates be removed and discarded. (i) During the observation of the tray line food, temperatures were taken by the use of the facility's calibrated digital food thermometer. The results of the temperature testing noted that cold foods were not being held by the regulatory requirement as evidenced by: * Non-fat Yogurt (10 servings) = 54 degrees F * Honey Thick Milk (8 portions) = 49 degrees F * Individual Orange Juice (40 servings) = 46 degrees F Photographic evidence obtained for all examples.

Based on observations, interviews and record reviews, the facility failed to provide adaptive eating equipment as per Occupational Therapy (OT) assessment and orders for 3 of 8 sampled residents reviewed for nutrition (Resident #70, #41 and #164). The findings included: 1) Resident #41 was admitted to the facility on [DATE] with diagnoses which included Dysphasia, Alzheimer's, Dementia, Depression, Anxiety, Gastroesophageal Reflux Disease, Hypothyroidism, and Protein Calorie Malnutrition. During record review for Resident #41, an order for Adaptive Equipment, dated 04/11/23, required dycem under plate, foam handled built-up utensils, 2 handled cup with lid and straw, and divided plate for all meals. Resident #41's OT Assessment Discharge Summary, dated 06/08/23, recommended for Feeding: 3 compartment divided plate, dycem under the plate, foam built up utensils and 2 handled cup with lid and straw. A weight change note dated 07/07/23 and a dietary note, dated 07/15/23, both documented that Resident #41 was to be provided with dycem under plate, foam handled built-up utensils, 2-handled cup with lid and straw, and divided plate with all meals. Resident #41's latest Care Plan related to resident's nutritional problem or potential for nutritional problem, dated, 09/18/23, included the following interventions: OT to screen and provide adaptive equipment for feeding as needed - Divided plate, 2 handled cup with lid and straw, foam handled built-up utensils on all trays. During a lunch observation on 10/02/23 at 11:31 PM, Resident #41 was observed eating her lunch, independently, in the dining room. During this meal, Resident #41 was not provided a Dysem (non-stick pad) under her plate, nor was she given a built-up knife to cut up her food. Both of these missing items were listed on her meal ticket as being required during meals. On 10/04/23 at 1:00 PM during a second lunch observation, it was noted that Resident #41 had received a dysem under her plate; however, at this time, she was not provided with a weighted fork, only a weighted spoon and knife (photographic evidence obtained). 2) Resident #70 was admitted to the facility on [DATE] with diagnoses which included End-Stage Renal Disease, Hemiplegia and Hemiparesis following cerebral infraction, Dysphasia, Protein-calorie Malnutrition, Diabetes Mellitus 2, Dementia, Depression, and Gastroesophageal Reflux Disease. During record review for Resident #70, an order for adaptive devices, dated 07/18/23, specified: Patient to have built up foam utensils, divided plate, 2 handle cups with straw lids for all meals. Resident #70's OT Assessment Discharge Summary, dated 08/01/23, recommended for Self-Feeding: Divided plate, 2 handled cup with lid and straw, and foam built-up utensils. A dietary note, dated 07/15/23, documented that Resident #70 was to be provided with adaptive equipment: built up foam utensils, divided plate, 2-handeled cup with straw and lid. Resident #70's latest Care Plan related to resident's altered nutritional needs, dated, 08/07/23, included the following interventions: Adaptive equipment as ordered (built up foam utensils, divided plate, 2 handled up w/lid). During lunch observation on 10/04/23 at 1:10 PM, it was noted that Resident #70 did not receive foam built-up utensils or a 2 handled cup with straw and lid (photographic evidence obtained). Interview with Director of Rehabilitation on 10/05/23 at approximately 1:00 PM confirmed OT assessments and adaptive equipment orders for Resident #41 and #70. 25404 3) An observation on 10/02/23 at 1:35 PM, Resident #164 was observed eating in the [NAME] Unit Dining Room. Review of the menu ticket documented to use a Dycem (non-stick pad). A second meal observation on 10/03/23 at 9:23 AM revealed a lack of Dycem on the tray of Resident #164. Review of the record revealed Resident #164 was admitted to the facility on [DATE]. A physician order dated 06/25/23 documented the use of the Dycem under the resident's meal plate as adaptive equipment needed. Nutritional assessments dated 07/20/23 and 09/19/23 also documented the use of the Dycem. Review of the current care plans revealed the use of the Dycem non-skid pad beneath the plate during meals, as adaptive equipment. Review of the OT (occupational therapy) Discharge Summary for Resident #164, for the service period of 07/19/23 through 08/09/23 documented the discharge recommendation of Dycem under the resident's plate in order to facilitate self feeding, and that the order was placed.

Based on observations, interviews, record review, and review of the shower binder, the facility failed to honor resident's choice for receiving and scheduling of showers for 1 of 2 sampled residents (Resident #117). The findings included: Record review revealed Resident #117 was admitted to the facility on [DATE] with pertinent diagnoses of Dementia with behavioral disturbance, and Malignant Neoplasm of Colon. Review of Resident #117's Annual Minimal Data Set (MDS) assessment dated [DATE], section F, revealed that it is very important for the resident to choose between a tub bath and a shower. The MDS also documented Resident #117 requires a one-person physical assist for bathing and for Activities of Daily Living (ADLs). During the initial tour of the facility conducted on Monday, 10/02/23 at 10:12 AM, Resident #117 was observed in his wheelchair waiting in the hallway. When the surveyor greeted Resident #117, he stated I want a shower. The surveyor returned to the unit at 12:35 PM, Resident #117 was still waiting in the hallway for a shower. Review of the facility's daily shower list revealed that Resident #117 is scheduled to have a shower on Tuesdays and Fridays (Photographic evidence obtained). An interview was conducted on 10/04/23 at 11:00 AM with Staff B, Certified Nursing Assistant (CNA), who provides care for Resident #117, regarding the facility's shower protocol. Staff B stated that he obtained the list of residents scheduled for showers for the day at the Nurses' station. He then stated that residents are offered showers once a week. If the resident refuses the shower, he lets the nurse know, then he tries again in 15 minutes to see if the resident changed their mind. If they refuse again, he lets the nurse know so the nurse can document. He fills out a Bathing & Skin report for the resident and documents on the computer in the Point of Care (POC) section. On 10/04/23 at 3:10 PM, an interview was conducted with Staff C, Registered Nurse (RN) regarding the facility's shower protocol. Staff C stated that the CNA would let her know if residents agreed or refused to shower. The CNA will fill out the Bathing & Skin report for each resident. Then she will sign the report and the CNA will put the report in the shower binder located at the Nurses' station. On 10/04/23 at 3:18 PM, an interview was conducted with the [NAME] unit manager and was asked to explain the shower protocol. She stated that if the resident is scheduled for a shower in the 7 AM - 3 PM shift and refuses, then the staff will try again in the 3 PM -11 PM shift on the same day. If the resident still refuses, the staff will try again the next day. The surveyor asked if the CNA fills-out a report each time there is an attempt to have the resident showered. The unit manager stated that all CNAs will fill-out the report each time the resident receives a shower or refuses. Plus, the CNA will document it on the POC. The Shower binder (where the Bathing & Skin reports are kept) revealed that Resident #117 had showers only on 09/02/23 and 10/02/23. The record lacked any evidence of a shower preference for Resident #117. Furthermore, the facility's shower schedule was not followed for Resident #117 and refusal of any showers on the scheduled days was not documented. (Photographic evidence obtained). During a follow up interview with Resident #117 on Thursday, 10/05/23 at 11:45 AM, he was asked how often he would like a shower. Resident #117 stated he would like to get showers every other day at least. The surveyor asked the resident if the staff has asked him if he wanted a shower since Monday 10/02/23 (Resident's last documented shower date), Resident #117 stated no. During an interview on 10/04/23 at 3:20 PM, the unit manager was asked to provide documentation for showers (whether in the shower binder or on the computer) for Resident #117. The unit manager was unable to show documentation of any times Resident #117 refused a shower within a 30-day period.

Based on observations, interviews, record reviews, and policy review, the facility failed to dispose of expired medications in 1 of 5 medications carts (Southwest unit), affecting Resident #30, and in 1 of 2 medication storage rooms (Southwest unit); and failed to ensure the proper route of administration in the labeling of medications for 1 of 7 sampled residents observed during medication administration observations (Resident #32). The findings included: Review of the facility's policy title Storage and Expiration Dating of Medication, Biologicals, dated 12/01/07, revealed the following: Facility should destroy or return all discontinued, outdated/expired, or deteriorated medications or biologicals in accordance with Pharmacy return/destruction guidelines and other Applicable Law, and in accordance with Policy 8.2 (Disposal/Destruction of Expired or Discontinued Medication). Policy 8.2: Facility should place all discontinued or outdated medications in a designated, secure location which is solely for discontinued medications or marked to identify the medications are discontinued and subject to destruction. Facility should request that Pharmacy perform a routine nursing unit inspection for each nursing station in Facility to assist Facility in complying with its obligations pursuant to Applicable Law relating to the proper storage, labeling, security and accountability of medications and biologicals. 1) A medication storage cart observation was conducted on 10/05/23 at 11:46 AM on the Southwest unit with Staff A, Registered Nurse (RN). Upon inspection of the cart, a small plastic clear zip-lock bag labeled with Resident #30's name, the name of the medication (Ondansetron, a medication for nausea), and dated 08/22/22. This surveyor showed the medication to Staff A, in which he stated that the resident still resides at the facility, and the medication is an as needed (PRN) medication. However, he had not noticed the expiration date (Photographic evidence obtained). Record Review of Resident #30 physician's orders revealed the medication was discontinued on 01/17/23. 2) A medication storage room observation in the facility's [NAME] unit was conducted on 10/05/23 at 11:55 AM with Staff A, RN and the unit manager. While inspecting the over-the-counter (OTC) medications, an observation was made of a Geri-Lanta Regular strength bottle which had an expiration date of 09/23, and a box of Acetaminophen Suppositories 650mg with an expiration date 03/23 (Photographic evidence obtained). The unit manager was made aware and agreed that the medications were expired and needed to be removed. 25404 3) A medication pass observation for Resident #32 was made on 10/04/23 at 9:01 AM, with Staff A, Registered Nurse (RN). The RN obtained six medications that included Losartan (a blood pressure medication) 50 mg (milligrams). The RN crushed the medications and administered them to Resident #32 via her PEG (percutaneous endoscopic gastrostomy, a surgical procedure for placing a feeding tube). Review of the label of the Losartan packaging documented the losartan was to be given by mouth (Photographic Evidence Obtained). Review of the physician order dated 09/10/23 documented the Losartan was to be given via the PEG tube. During an interview after the medication administration, when asked about the route of medications for Resident #32, Staff A, RN, explained the resident used to take all of her medications by mouth, but a few weeks prior, Resident #32 stopped eating, was sent to the hospital, and now has a PEG tube. Staff A agreed the medications were to be given to Resident #32 through her PEG. The RN obtained a Direction Change sticker from the medication cart, placed it on the Losartan packaging, and explained the proper process.

Based on observation, interview, and record review, the facility failed to act to ensure the nursing services being provided for residents with tracheostomies meet professional standards of quality of care placing residents at risk by a lack of oversight and training. The facility failed to provide necessary respiratory care and services, [CONDITION(S)] care and suctioning, to meet the identified needs for 2 of 2 sampled residents with tracheostomies (Resident #1 and #260). On 05/18/21 at 7:37 PM, it was determined that the findings of the survey posed an immediate jeopardy to the health and safety of the residents residing in the facility requiring [CONDITION(S)] care. The facility's Administrator was informed of the immediate jeopardy on 05/19/21 at 5:50 PM. The immediate jeopardy was identified on 05/19/21, as beginning on 05/18/21 and removed on 05/21/21. The scope and severity level was decreased to a D, no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The scope and severity was lowered as a result of the facility's corrective actions implemented as of 05/21/21 at 9:09 PM. The findings included: Review of the Executive Director (ED) Job Description provided by the facility documented the ED is responsible to provide quality patient care in accordance with all laws, regulations and Life Care Standards and key oversight for human resources and clinical operations. The ED implements policies pertaining to patient care, caregiving and support staff and must be knowledgeable of administration practices and procedures as well as the laws, regulations and guidelines governing administrative functions in the post-acute care facility. Essential functions of the ED include ensuring patients receive high quality care, facility is compliant with all Federal, State, and local requirements. He or she must ensure the facility is clean and safe for the comfort, convenience and safety of patients, families and staff and effectively supervise the team. Competency requirements include responsibility for every department and program within the facility and he/she hires, trains, evaluates, supports and supervises the facility team including department heads. The ED consults with department heads regarding issue resolution and improving services. He or she serves as the Compliance and Ethics Liaison for his or her respective facility and maintains working knowledge of the current laws, regulations and policies that affect his/her position and level of responsibility. Review of the Director of Nursing (DON) job description provided by the facility documented the DON plans, organizes, develops, and directs the overall operation of the nursing department to assure patient safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each patient in accordance with all applicable laws, regulations, and Life Care standards in the post-acute facility. The DON is the liaison with patients, families, support departments, to adequately plan for patient needs a knowledge expert in his/her field of practice. He or she must be able to recruit, select, hire, train, evaluate, counsel and supervise nursing staff and direct the care provided by the nursing staff and provide direct nursing care as necessary, performing functions of a staff nurse as required. The DON must maintain current, up-to-date knowledge in the administration of health care and nursing practice regulatory compliance and requirements and ensure nursing systems are in place to promote the competency of nursing staff. Management responsibilities of the DON include planning, development, organization, implementation, evaluation, and direction of the Nursing Services department. He or she is involved in recruitment, selection and evaluation of nursing staff and can effectively teach them. The DON has systems, processes, procedures, and protocols to support the delivery of care and practice of nursing in the facility and participates in the selection of residents for admission to the facility. He/she provides information to the Executive Director relative to nursing needs of residents and Nursing Services' ability to meet those needs. The DON is also responsible to schedule daily rounds to observe residents and ensure nursing needs are being met and ensures adequate supply of medications, supplies, and equipment. He/she coordinates 24-hour resident care management with RN assistance to ensure quality and effective nursing practice/services and is responsible to ensure appropriate nursing oversight to promote the highest level of delivery of resident care. During an interview on 05/19/21 at 11:45 AM, the Respiratory Therapist (RT) stated, she was called in by administration to start in-servicing the nurses on [CONDITION(S)] care and suctioning. She said her responsibility is to change out the entire [CONDITION(S)] monthly for any residents who have them. She will also come in as needed when called. The staff are responsible for daily [CONDITION(S)] care. The RT said, the facility is supposed to call her when residents are admitted and/or readmitted to the facility after hospitalization , but this facility has not done so recently. The RT stated, she has observed a lack of equipment at the bedside, lack of competent staff, and the re-use of single use suction equipment. The RT stated, I came here two weeks ago. All different staff, they didn't know what was needed for a [CONDITION(S)] patient or how to properly take care of a [CONDITION(S)] patient, some of them didn't know you are supposed to change the suction catheter every day. The RT stated that she voiced her concerns to the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), related to staff competency in providing care. The RT stated, that she provided the Central supply person, the ADON, and the DON with a list of missing and needed supplies, stating this was on 05/05/21. The RT stated, an Inservice was scheduled for 05/21/21. The RT also said when she removes the packaging from any equipment, she gives it to the Central Supply Coordinator, so he knows exactly what to order. On 05/19/21 at 2:30 PM the Administrator, the DON and the ADON were asked about the RT's identified concerns regarding nursing staff providing [CONDITION(S)] care and the lack of supplies. The DON stated that they had scheduled an in-service for 05/21/21 for [CONDITION(S)] care. The DON was asked if the RT identified these issues on 05/05/21, she stated, 'yes'. The DON was asked what action was taken regarding the lack of supplies for residents requiring [CONDITION(S)] care. The DON stated that we (the facility) should have the supplies the residents need. The Administrator stated that he was aware that an in-service was scheduled for 05/21/21. The facility's Immediate Jeopardy Removal Plan was received on 05/20/21 at 1:36 PM. The Facility's actions to remove the Immediate Jeopardy and corrective actions included: 1. Resident #1 was discharged on [DATE]. 2. Resident #260 was discharged on [DATE]. 3. Required supplies have been obtained. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 260 is receiving care from licensed nurses that have been trained and deemed competent in [CONDITION(S)] care and suctioning. No licensed staff will be able to work with the resident until training and competency is completed. 4. Residents with tracheostomies were reviewed on 05/19/21 to ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan and care directives were updated on 05/17/21 to include information regarding the size of cannula, other equipment needs and care of the [CONDITION(S)]. 5. Current residents with tracheostomies were assessed by the respiratory therapist on 5/19/2021. 6. When 100% of licensed nurses have been trained and deemed competent and the facility begins readmitting residents with tracheostomies, each newly admitted resident will be reviewed by the IDT (interdisciplinary) team to ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan and care directives will also be reviewed by the IDT team to ensure appropriate interventions to clearly communicate care needs are present, including size of the cannula and other equipment needs. 7. An inventory of central supply was completed on 05/19/2021 to ensure the facility has a 7-day supply of equipment including cannulas, emergency supplies and suction equipment to care for residents with a [CONDITION(S)]. The Central Supply Director placed an additional order of supplies on 5/20/21. The DON/designee will assess on a weekly basis the supply needs for residents with tracheostomies and order additional supplies on a weekly basis. 8. The respiratory therapist or DON / designee has initiated [CONDITION(S)] care and [CONDITION(S)] suctioning training including competency with return demonstration on 05/19/21 for all licensed nurses. The training includes appropriate infection control techniques. Training and competency will continue until 100% of licensed nurses have been trained and deemed competent. 9. Only licensed nurses that are trained and competent on [CONDITION(S)] care and suctioning will provide care to residents with tracheostomies. 10. The DON / designee will not assign agency nurses to the care of [CONDITION(S)] patients without validation of training and competency. The DON/ designee will coordinate training and validation of competency with the agency nurse prior to entrance into the facility. 11. [CONDITION(S)] care and suctioning training including competency with return demonstration will be completed during the orientation process to all new licensed nurses by the SDC / designee. 12. The medical director was notified, involved in the review and oversight, and approved the plan of removal for ensuring residents with tracheostomies receive the required care, services and supplies necessary to ensure the highest practical well-being on 05/19/21. 13. The facility held an immediate QAPI (Quality Assurance and Performance Improvement) meeting on 05/20/21 to review the plan of removal. Facility QAPI meetings will be held weekly for 4 weeks, bi-weekly x 2 and monthly thereafter. 14. The SDC (Staff Development Coordinator) / designee will audit licensed nurses training and competency records for [CONDITION(S)] care and suctioning weekly to validate completion of training and competency. Training and competency record audits will be reviewed for compliance at the facility QAPI meeting weekly x4, bi-weekly x2 and monthly thereafter. 15. The DON / Designee will complete weekly audits of central supply and utility rooms to ensure adequate supplies are available to meet the needs of residents with tracheostomies. The DON/ designee will complete weekly room observations for residents with tracheostomies to assess for supply needs to ensure at least a 7 day inventory is available and order any additional supplies if needed. Results of the audits will be trended and reviewed at the QAPI meeting weekly x 4, bi-weekly x 2 and monthly thereafter. 16. The DON or designee will complete ongoing weekly [CONDITION(S)] care and suctioning observations of licensed nurses on all shifts including weekends. Results of the audits will be reviewed at the QAPI meeting weekly x 4, bi- weekly x 2 and monthly thereafter. 17. The DON / designee will review the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 18. The DON / designee will also review the care plan and care directive weekly to ensure the care needs and equipment needs for tracheostomies are accurate and clearly communicated according to the physician order. Results of the audits will be reviewed at the QAPI meeting weekly x 4, bi-weekly x 2 and monthly thereafter. 19. The DON / designee will complete monthly audits to assure all new licensed nurses have completed [CONDITION(S)] care and suctioning training and competency upon hire. Results of these audits will be trended and reviewed at the facility QAPI meeting weekly x 4, bi-weekly x 2 and monthly thereafter. On 05/21/21, verification of IJ Removal Plan included: The facility demonstrated as of 05/20/21 that 35 licensed nurses have been trained out of 48 total licensed nurses working at the facility. Of the 35 trained, 6 were agency staff. The remaining 13 nurses who need the in-servicing, training, and competency had been called by the Staffing Coordinator to come to the facility for the mandatory training by 05/21/21. When 100% of licensed nurses have been trained and deemed competent and the facility begins readmitting residents with tracheostomies, each newly admitted resident will be reviewed by the Interdisciplinary Team (IDT) team to ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan and care directives will also be reviewed by the IDT team to ensure appropriate interventions to clearly communicate care needs are present including size of the cannula and other equipment needs. An inventory of Central Supply was completed on 05/19/21 to ensure the facility has a 7-day supply of equipment including cannulas, emergency supplies and suction equipment to care for residents with a [CONDITION(S)]. The Central Supply Director placed an additional order of supplies on 05/20/21. The DON / designee will assess on a weekly basis the supply needs for residents with tracheostomies (traches) and order additional supplies on a weekly basis. Reviewed purchase orders, dated 05/20/21, for Shiley Inner Fenestrated traches 4 cases, suction catheter kit 4 cases, [CONDITION(S)] tube Shiley 6 cases (50 in case), tubbing connector 24 units, suction connector tubing cardinal 4 units, air life handheld nebulizer kit 12 units, aerosol drainage bags 12 units, mask collar 12 units, tee adapter air life 24 units, [CONDITION(S)] care tray, 28 units and mask [CONDITION(S)] tube 16 units. On 05/21/21 at 10:05 AM, observation of the Central Supply room revealed it had: 92 Yankauers (oral suctioning tool); 50 [CONDITION(S)] masks; 30 [CONDITION(S)] holders; 10, 6 inner cannula; 10, 4 inch inner cannulas; 2, 4 DCFS (Disposable Cannula Cuffless Tracheotomy tube size); 1, 6 DCFS; 1344 drain sponges; 4 suction cannisters; 35 suction tubing cannister; 35 suction tubing short and 7 long; 32 [CONDITION(S)] clean kits; 24 suction catheter trays; 24 tee adapters; 2 ambu bags; 10, 6 inch disposable tubing; 14, 240 ml sterile water; 13, 1000 ml sterile water; 10, 650 ml sterile water; 2, 1070 ml sterile water; 15 drainage sponges; and 9 [CONDITION(S)] mist units. Review of the training material included: Procedures - [CONDITION(S)] tube cannula and stoma care, [CONDITION(S)] suction and a [CONDITION(S)] care post-test. On 05/21/21 at 5:05 PM, an observation of [CONDITION(S)] care, suctioning, inner cannula changing, dressing change, with Staff J, a Registered Nurse, and the Assistant Director of Nursing (ADON), for Resident #260 was conducted. During the observation of suctioning, Staff failed to assess the resident's vital signs, breath sounds, or respiratory effort. Staff failed to position the resident in upright with head in neutral alignment. Staff failed to attach the resident to a pulse oximeter during suctioning. Staff failed to assess the resident's ability to cough and breathe deeply. Staff J failed to lubricate the outside of the suction catheter with sterile solution. Staff J failed to suction sterile solution prior to suctioning the resident. Staff failed to encourage the resident to take deep breathes prior to suctioning. Staff J failed to clear the suction catheter with sterile solution. Surveyor intervention was required prior to Staff changing the resident's inner cannula. Staff J were asked to assess Resident #260. The ADON produced a pulse oximeter from his pocket placed it on the resident's finger and stated it is not working. Staff J requested a Blood Pressure, Pulse and Heart Rate monitor from staff in the hallway outside of Resident #260's room. The ADON stated that the monitor was not working properly, after several attempts to obtain a set of vital signs, the ADON stated the connections are loose, you really have to wiggle the cord just right to get it to work. Staff J and the ADON confirmed they had participated in the [CONDITION(S)] staff education today (05/21/21). Staff J obtained a set of vitals. Staff J proceeded to change Resident #260's inner cannula. Staff J failed to assess the resident's breath sounds. Staff J failed to position the resident in an upright, head neutral position. On 05/21/21 at 5:40 PM, the Regional Nurse Consultant and DON were informed of the observation. On 05/21/21 at 5:55 PM, the Regional Operations Consultant was informed of the observations, stated that they are seeking placement for Resident #260, and the facility will voluntarily stop admitting residents with tracheostomies. The Immediate Jeopardy Removal Plan was accepted by the Agency on 05/21/21 at 7:26 PM, with the discharge of Resident #260. Resident #260 was discharged to the hospital 05/21/21 at 9:09 PM.

Based on observation, interview, and record review, the facility failed to ensure the nursing staff possessed the competencies and skill set to provide nursing services to meet the needs of residents requiring [CONDITION(S)] care. This impacted 2 of 2 sampled residents with tracheostomies (Resident #1 and #260). On 05/18/21 at 7:37 PM, it was determined that the findings of the survey posed an immediate jeopardy to the health and safety of the residents residing in the facility requiring [CONDITION(S)] care. The facility's Administrator was informed of the immediate jeopardy on 05/19/21at 5:50 PM. The immediate jeopardy was identified on 05/19/21, as beginning on 05/18/21 and removed on 05/21/21. The scope and severity level was decreased to a D, no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The scope and severity was lowered as a result of the facility's corrective actions implemented as of 05/21/21 at 9:09 PM. The findings included: Review of the Resident Census and Condition Form 672, that the facility provided on 05/17/21, revealed the facility currently (05/17/21) had one resident that required [CONDITION(S)] care. The survey team discovered during the screening process that the facility had two (2) residents (Resident #1 and #260) that required [CONDITION(S)] care. 1. On 05/17/21 during the initial resident screening process of the survey at approximately 3:45 PM, Resident #1 was observed in respiratory distress. Resident #1 was observed to have a [CONDITION(S)] (a surgical procedure to create an opening through the neck into the windpipe) and presented to have paralysis of all four limbs. Resident #1 was exerting a great deal of effort to breath having a respiratory rate of 20 breaths per minute and was using accessory chest muscles to the extent possible. When asked, Resident #1 was able to mouth the words, without sound, that he needed suctioning. Staff A, a Registered Nurse (RN), assigned to care for Resident #1 was standing at a medication cart. Staff A was informed Resident #1 was having trouble breathing and needed suctioning. Staff A identified herself as an agency nurse. Staff A said, 'Yeah, I know, someone is coming'. The surveyor returned to the room to check on the patient. The surveyor asked Resident #1 if he had already informed staff that he needed suctioning. Resident #1 said, he did ask for suctioning and the nurse told him he had already had it around 12:30 PM. Within a few minutes, the surveyor stepped back into the hallway and saw the Director of Nursing (DON). The DON was asked to look at Resident #1 and questioned if this is how Resident #1 normally presents. The DON looked at Resident #1 and said, 'no' and told Staff A he needed to be suctioned. Staff C, the Evening Supervisor RN, was coming from the direction of the medication cart. As Staff C was approaching the resident's room, he said to the DON, 'Yeah, I'm here .she (Staff A) was leery about doing it, so I am going to do it'. Staff C proceeded to the room and suctioned Resident #1 without using sterile technique and then left the room. Resident #1 then verbalized, they don't know how to take care of me. Resident #1 also said, I have been to the hospital 7 times so far. It should also be noted, the oxygen tubing and drainage bag were resting on the floor. On 05/17/21 at 4:12 PM, Resident #1 was observed struggling to breathe again, demonstrating the same signs as above. No staff members were visible in the hallway. Resident #1, a quadriplegic, was encouraged to use his call light (mouth activated) to summon assistance to the room. It took five minutes for a CNA to arrive. The CNA was informed by the resident that a nurse was needed because he was having difficulty breathing. Staff A arrived two minutes later. Staff A stated she would get a pulse oximeter. She returned with a pulse oximeter attached to a vital sign machine. Staff A attached the pulse oximeter to a finger on Resident #1's left hand, but after a few moments, no results appeared on the screen. Staff A said, this one isn't working, I'll go get another one. As Staff A turned to leave the room, she was asked her assessment of Resident #1's respiratory status. Staff A acknowledged Resident #1 was having respiratory difficulty. Staff A said she would go get help from someone who knew the resident and left the room. On 05/17/21 at 4:26 PM Staff D, an RN, arrived and began suctioning Resident #1. When he finished, Staff D stated, He needs deeper suctioning than most of them (nursing staff) feel comfortable providing. Staff D was asked how the facility would ensure Resident #1 would receive appropriate [CONDITION(S)] care and suctioning when he wasn't there. Staff D responded, that is a good question and left the room. Afterwards, Resident #1 stated, I feel like I'm going to die here with tears in his eyes. On 05/17/21 at 5:41 PM, observation in Resident #1's room revealed one opened and used suction catheter inside a small plastic bag. Resident #1 verbalized staff was washing and re-using the same suction catheters for three weeks. Resident #1 also indicated the box of inner cannulas in the room was the wrong size and that he thought he had pneumonia. Tan colored, frothy secretions were noted on the resident's chest at the margin of his [CONDITION(S)], under the oxygen attachment where a gauze dressing should have been. Approximately 20 minutes later, Staff E, an RN Unit Manager, notified the survey team that Nurse B, an RN, was familiar with Resident #1 and would be taking care of him. On 05/17/21 at 6:00 PM, Staff E, Unit Manager and Staff A, were again suctioning Resident #1, without any type of oxygen saturation monitoring. Staff E, identified as an agency nurse, arrived in Resident #1's room, and was asked about suctioning to ensure adequate care could be provided for Resident #1. Staff E said that she wasn't comfortable suctioning him and only agreed to help Staff A. Staff E said she had only cared for Resident #1 once before. (The Survey Team was informed by Staff E that Nurse B knew Resident #1 and was comfortable caring for him and would be taking over his care for the evening). At approximately 6:15 PM, the Central Supply Coordinator delivered one (1) single use suction catheter and said it was the only one left in the facility. The DON was then asked about the staff cleaning and reusing single use catheters for the past three weeks as Resident #1 said was occurring. The DON responded, Well, we clean them with normal saline. The DON was shown the label on the single use catheter that says, single use only. Central Supply was asked how many single use suction catheters were available and he stated there were no more. On 05/17/21 at 6:25 PM, the DON was asked to review Resident #1's orders and confirmed there were no orders related to the size of Resident #1's [CONDITION(S)] cannula. Further review with the DON revealed the record lacked the [CONDITION(S)] care on any care plan. At this point the DON stated, If we don't have equipment and supplies, we have to send him out. The DON was also asked how they know their agency nurses are qualified to provide the care needed to the residents at the facility. She said, we expect them to send us nurses that can function in all aspects as a nurse. The facility did not assess the skills of any of the agency nurses before considering resident assignments. During the interview, Staff D, a Unit Manager, entered the DON's office. Staff D was asked what size inner cannula Resident #1 needed. Staff D said he knew the size from speaking with the Respiratory Therapist (RT). Staff D was handed the printed care plan and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #1. Resident #1's orders and care plan did not reflect adequate information to provide [CONDITION(S)] care. The DON stated that the residents record, orders and care plan should provide the information needed to care for Resident #1. On 05/17/21 at approximately 6:45 PM, during an interview Staff A was asked about the size of Resident #1's [CONDITION(S)], and who would know since the order does not say, it just says to clean. Staff A stated, she would have to ask someone because she didn't have any experience with tracheostomies. Staff A reviewed the current suctioning orders that were to suction every four hours as needed and to lavage if needed. When asked if she was comfortable with that, Staff A stated, 'no' and that she did not know what lavage was. Staff A stated, she has long-term care experience, but that this was her first [CONDITION(S)] patient. When asked about supplies, Staff A was unaware of where to get them, but would go to the Unit Manager or another nurse. Staff A stated, she has worked at the facility one to two times a week for two months. When asked if her agency had ever assessed her skills about suctioning or [CONDITION(S)] care, Staff A stated, 'no'. When asked how she would determine if the resident needs to go to the hospital, Staff A stated, her nursing judgement indicated Resident #1 should go out for an evaluation because even though he was being suctioned, it wasn't working. Staff B, agreed, and they went to speak with Staff E, the Unit Manager, about sending Resident #1 to the hospital. At 7:15 PM, the resident was ready for transfer to the hospital. Record review revealed, Resident #1 was initially admitted to the facility on [DATE] with his most recent readmission on 05/11/21. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Admission Minimum Data Set (MDS) from 12/20/20 showed his Brief Interview of Mental Status (BIMS) score was 13 of 15, which indicated Resident #1 was cognitively intact. Record review revealed, Resident #1's active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed, the resident's current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's active care plan did not contain any information about the size of the inner canula for replacement. Further record review revealed six out of eight hospitalization s, including the 05/17/21 admission since 01/08/21 were related to respiratory distress / shortness of breath. Between 01/08/21 and 05/16/21, this resident had spent 52 overnight stays in the hospital between seven hospital admissions during that time. On 04/06/21, the staff found him unresponsive with an oxygen saturation level of 84% prior to his transfer. Resident #1 was transferred to the hospital on 05/17/21 between 7:00 PM and 8:00 PM for shortness of breath / difficulty breathing after surveyor interventions and continued to be hospitalized as of 05/21/21. On 05/18/21, the DON provided copies of all in-services or competency training for [CONDITION(S)] care / suctioning that had been requested by the team. A copy of the in-service attendance list from 12/10/20 and 12/16/20 was also provided. The subject of the in-service was titled, Care of the [CONDITION(S)] Resident, with subtopics of Suctioning, Set-up, and [CONDITION(S)]-care included. There were thirteen (13) nurses on the list with ten (10) of them still being employed at the facility per administration. There was no evidence of previous competencies for [CONDITION(S)] care or suctioning provided to the survey team. To attempt to meet the needs of the residents in the building, the facility relies heavily on staffing agency nurses. On 05/17/21 for the afternoon/evening shift, 44% of the direct care nurses were agency nurses. On 05/19/21 at 2:30 PM, the Nursing Home Administrator (NHA), Regional Vice President, Regional Clinical Director and the DON were in the conference room with the survey team. They were asked if they were aware Resident #1 had been sent to the hospital eight times, this one being the ninth time since 01/09/21. When asked what systems were in place or what they had done to prevent his frequent transfers to the hospital, they had no response. In addition, the Regional Clinical Director commented that they would not be able to say since they didn't know the reasons he had been sent out and if all the transfers were related to his [CONDITION(S)]/difficulty breathing. As per the NHA on 05/19/21 at 2:30 PM, they use SMS (Respiratory Therapy contract) to provide education. They also use Health Care Academy (online education) for orientation and some annual competencies. They are unsure if [CONDITION(S)] or respiratory care is one of the items in the Health Care Academy upon hire but will provide a list. The NHA stated there are different avenues to provide education, and with management changes it is sometimes hard to track. When asked specifically about Resident #1, the NHA stated that nursing reviews the discharges and they are discussed in morning meeting. The NHA and DON did not have any response, but stated they would investigate it. 2. During the initial screening process on 05/18/21 at 11:04 AM, Resident #260 was observed in bed with a [CONDITION(S)] mask attached to an oxygen concentrator. Resident #260's [CONDITION(S)] dressing had a visible yellow moist discharge. A suction canister on the bedside table, undated, with grey-yellow liquid in it (photographic evidence obtained). Resident #260 was asked when the staff changed the [CONDITION(S)] dressing last. The resident stated he was not sure. An audible rattle was noted when Resident #260 coughed. Resident #260 was asked if he needed suctioning and he stated, yes. Staff F, a Registered Nurse, was informed Resident #260 wanted to be suctioned. A review of Resident #260's physicians orders revealed there were none for [CONDITION(S)] care or suctioning. Staff F, who identified herself as an agency nurse, was asked to review Resident #260's orders for [CONDITION(S)] care, and upon review stated she could not find any. Staff F was asked how long Resident #260 had been in the facility, Staff F stated Resident #260 had been admitted on [DATE]. Staff F was asked if she had been assigned to Resident #260 prior to today (05/18/21). She stated, yes, I had him the other day. Staff F was asked if she had provided [CONDITION(S)] care for Resident #260, she stated, yes, I provided standard [CONDITION(S)] care. Staff F was asked what standard [CONDITION(S)] care was, she stated that she would need to look into that. Interview and record review on 05/18/21 at 11:35 AM, with Unit Manager-C confirmed a lack of orders related to the [CONDITION(S)] for Resident #260. Unit Manager-C was asked where are the staff documenting Resident #260's [CONDITION(S)] care. She stated that she would have to ask the nurses. Review of the care plan revealed no documentation related to [CONDITION(S)] care. At 12:00 PM, Unit Manager-C and this surveyor went to the Resident #260's bedside and found two single use suction catheters and one size 4 [CONDITION(S)] inner cannula (photographic evidence obtained). There were no disposable inner cannulas (the inner cannula fits inside the [CONDITION(S)] tube and acts as a liner). Unit Manager-C was asked what size [CONDITION(S)] Resident #260 required. She stated that she was not sure. Unit Manager-C was asked what supplies should be at the bedside for Resident #260. She stated that she was not sure. Unit Manager C stated the suction canister should be dated and confirmed a lack of date on the [CONDITION(S)] collar and could not explain the lack of documented [CONDITION(S)] care. The Unit Manager stated Respiratory Therapy has never seen the resident. Review of Resident 260's record on 05/18/21 revealed an initial admission of 04/20/21, with a readmission of 05/12/21. Resident #260's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #260's Admission / Readmission assessment of 05/12/21 revealed, a respiratory assessment, respiratory rate and characteristics documented as normal. Further review of the respiratory assessment revealed, Resident #260 had a [CONDITION(S)]. The month and year of [CONDITION(S)] was left blank. The last date the [CONDITION(S)] was changed was left blank. The size of Resident #260's [CONDITION(S)] was left blank. Further review of Resident #260's record revealed no active Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/18/21 at 2:40 PM, the DON was asked to review Resident #260's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated that there should be orders for [CONDITION(S)] care. The DON was asked what care the staff were providing for Resident #260. She stated that she is sure they are providing care. The DON was asked when the last time Resident #260's inner cannula was changed, when was the last time the [CONDITION(S)] dressing was changed, when was the last time Resident #260 had been suctioned, and what size was Resident #260's [CONDITION(S)]. The DON stated that she was not sure, and she asked that the Assistant Director of Nurses (ADON) help review the record. While waiting for the ADON, the DON stated that as part of their morning meeting she and all the Unit Managers review all admission and readmission charts and go over all the orders. The ADON joined the record review for Resident #260, and they (DON and ADON) stated they do not know why Resident #260 did not have any physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON and the ADON were asked how many nurses had been assigned to Resident #260 since his readmission on 05/12/21. The ADON stated probably 12-14. The DON and the ADON were asked why 12-14 licensed nurses had not identified that a resident with a [CONDITION(S)] did not have physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated that the Respiratory Therapist was coming on 05/21/21 to in-service the nursing staff on [CONDITION(S)] care. The facility's Immediate Jeopardy Removal Plan was received on 05/20/21 at 1:36 PM. The Facility's actions to remove the Immediate Jeopardy and corrective actions included: 1. Resident #1 was discharged on [DATE]. 2. Resident #260 was discharged on [DATE]. 3. Required supplies have been obtained. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 260 is receiving care from licensed nurses that have been trained and deemed competent in [CONDITION(S)] care and suctioning. No licensed staff will be able to work with the resident until training and competency is completed. 4. Residents with tracheostomies were reviewed on 05/19/21 to ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan and care directives were updated on 05/17/21 to include information regarding the size of cannula, other equipment needs and care of the [CONDITION(S)]. 5. Current residents with tracheostomies were assessed by the respiratory therapist on 5/19/2021. 6. When 100% of licensed nurses have been trained and deemed competent and the facility begins readmitting residents with tracheostomies, each newly admitted resident will be reviewed by the IDT (interdisciplinary) team to ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan and care directives will also be reviewed by the IDT team to ensure appropriate interventions to clearly communicate care needs are present, including size of the cannula and other equipment needs. 7. An inventory of central supply was completed on 05/19/2021 to ensure the facility has a 7-day supply of equipment including cannulas, emergency supplies and suction equipment to care for residents with a [CONDITION(S)]. The Central Supply Director placed an additional order of supplies on 5/20/21. The DON/designee will assess on a weekly basis the supply needs for residents with tracheostomies and order additional supplies on a weekly basis. 8. The respiratory therapist or DON / designee has initiated [CONDITION(S)] care and [CONDITION(S)] suctioning training including competency with return demonstration on 05/19/21 for all licensed nurses. The training includes appropriate infection control techniques. Training and competency will continue until 100% of licensed nurses have been trained and deemed competent. 9. Only licensed nurses that are trained and competent on [CONDITION(S)] care and suctioning will provide care to residents with tracheostomies. 10. The DON / designee will not assign agency nurses to the care of [CONDITION(S)] patients without validation of training and competency. The DON/ designee will coordinate training and validation of competency with the agency nurse prior to entrance into the facility. 11. [CONDITION(S)] care and suctioning training including competency with return demonstration will be completed during the orientation process to all new licensed nurses by the SDC / designee. 12. The medical director was notified, involved in the review and oversight, and approved the plan of removal for ensuring residents with tracheostomies receive the required care, services and supplies necessary to ensure the highest practical well-being on 05/19/21. 13. The facility held an immediate QAPI (Quality Assurance and Performance Improvement) meeting on 05/20/21 to review the plan of removal. Facility QAPI meetings will be held weekly for 4 weeks, bi-weekly x 2 and monthly thereafter. 14. The SDC (Staff Development Coordinator) / designee will audit licensed nurses training and competency records for [CONDITION(S)] care and suctioning weekly to validate completion of training and competency. Training and competency record audits will be reviewed for compliance at the facility QAPI meeting weekly x4, bi-weekly x2 and monthly thereafter. 15. The DON / Designee will complete weekly audits of central supply and utility rooms to ensure adequate supplies are available to meet the needs of residents with tracheostomies. The DON/ designee will complete weekly room observations for residents with tracheostomies to assess for supply needs to ensure at least a 7 day inventory is available and order any additional supplies if needed. Results of the audits will be trended and reviewed at the QAPI meeting weekly x 4, bi-weekly x 2 and monthly thereafter. 16. The DON or designee will complete ongoing weekly [CONDITION(S)] care and suctioning observations of licensed nurses on all shifts including weekends. Results of the audits will be reviewed at the QAPI meeting weekly x 4, bi- weekly x 2 and monthly thereafter. 17. The DON / designee will review the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 18. The DON / designee will also review the care plan and care directive weekly to ensure the care needs and equipment needs for tracheostomies are accurate and clearly communicated according to the physician order. Results of the audits will be reviewed at the QAPI meeting weekly x 4, bi-weekly x 2 and monthly thereafter. 19. The DON / designee will complete monthly audits to assure all new licensed nurses have completed [CONDITION(S)] care and suctioning training and competency upon hire. Results of these audits will be trended and reviewed at the facility QAPI meeting weekly x 4, bi-weekly x 2 and monthly thereafter. On 05/21/21, verification of IJ Removal Plan included: The facility demonstrated as of 05/20/21 that 35 licensed nurses have been trained out of 48 total licensed nurses working at the facility. Of the 35 trained, 6 were agency staff. The remaining 13 nurses who need the in-servicing, training, and competency had been called by the Staffing Coordinator to come to the facility for the mandatory training by 05/21/21. When 100% of licensed nurses have been trained and deemed competent and the facility begins readmitting residents with tracheostomies, each newly admitted resident will be reviewed by the Interdisciplinary Team (IDT) team to ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan and care directives will also be reviewed by the IDT team to ensure appropriate interventions to clearly communicate care needs are present including size of the cannula and other equipment needs. An inventory of Central Supply was completed on 05/19/21 to ensure the facility has a 7-day supply of equipment including cannulas, emergency supplies and suction equipment to care for residents with a [CONDITION(S)]. The Central Supply Director placed an additional order of supplies on 05/20/21. The DON / designee will assess on a weekly basis the supply needs for residents with tracheostomies (traches) and order additional supplies on a weekly basis. Reviewed purchase orders, dated 05/20/21, for Shiley Inner Fenestrated traches 4 cases, suction catheter kit 4 cases, [CONDITION(S)] tube Shiley 6 cases (50 in case), tubbing connector 24 units, suction connector tubing cardinal 4 units, air life handheld nebulizer kit 12 units, aerosol drainage bags 12 units, mask collar 12 units, tee adapter air life 24 units, [CONDITION(S)] care tray, 28 units and mask [CONDITION(S)] tube 16 units. On 05/21/21 at 10:05 AM, observation of the Central Supply room revealed it had: 92 Yankauers (oral suctioning tool); 50 [CONDITION(S)] masks; 30 [CONDITION(S)] holders; 10, 6 inner cannula; 10, 4 inch inner cannulas; 2, 4 DCFS (Disposable Cannula Cuffless Tracheotomy tube size); 1, 6 DCFS; 1344 drain sponges; 4 suction cannisters; 35 suction tubing cannister; 35 suction tubing short and 7 long; 32 [CONDITION(S)] clean kits; 24 suction catheter trays; 24 tee adapters; 2 ambu bags; 10, 6 inch disposable tubing; 14, 240 ml sterile water; 13, 1000 ml sterile water; 10, 650 ml sterile water; 2, 1070 ml sterile water; 15 drainage sponges; and 9 [CONDITION(S)] mist units. Review of the training material included: Procedures - [CONDITION(S)] tube cannula and stoma care, [CONDITION(S)] suction and a [CONDITION(S)] care post-test. On 05/21/21 at 5:05 PM, an observation of [CONDITION(S)] care, suctioning, inner cannula changing, dressing change, with Staff J, a Registered Nurse, and the Assistant Director of Nursing (ADON), for Resident #260 was conducted. During the observation of suctioning, Staff failed to assess the resident's vital signs, breath sounds, or respiratory effort. Staff failed to position the resident in upright with head in neutral alignment. Staff failed to attach the resident to a pulse oximeter during suctioning. Staff failed to assess the resident's ability to cough and breathe deeply. Staff J failed to lubricate the outside of the suction catheter with sterile solution. Staff J failed to suction sterile solution prior to suctioning the resident. Staff failed to encourage the resident to take deep breathes prior to suctioning. Staff J failed to clear the suction catheter with sterile solution. Surveyor intervention was required prior to Staff changing the resident's inner cannula. Staff J were asked to assess Resident #260. The ADON produced a pulse oximeter from his pocket placed it on the resident's finger and stated it is not working. Staff J requested a Blood Pressure, Pulse and Heart Rate monitor from staff in the hallway outside of Resident #260's room. The ADON stated that the monitor was not working properly, after several attempts to obtain a set of vital signs, the ADON stated the connections are loose, you really have to wiggle the cord just right to get it to work. Staff J and the ADON confirmed they had participated in the [CONDITION(S)] staff education today (05/21/21). Staff J obtained a set of vitals. Staff J proceeded to change Resident #260's inner cannula. Staff J failed to assess the resident's breath sounds. Staff J failed to position the resident in an upright, head neutral position. On 05/21/21 at 5:40 PM, the Regional Nurse Consultant and DON were informed of the observation. On 05/21/21 at 5:55 PM, the Regional Operations Consultant was informed of the observations, stated that they are seeking placement for Resident #260, and the facility will voluntarily stop admitting residents with tracheostomies. The Immediate Jeopardy Removal Plan was accepted by the Agency on 05/21/21 at 7:26 PM, with the discharge of Resident #260. Resident #260 was discharged to the hospital 05/21/21 at 9:09 PM.

Based on observation, interview, and record review, the facility failed to provide necessary respiratory care and services, [CONDITION(S)] care and suctioning, to meet the identified needs for 2 of 2 sampled residents with tracheostomies (Resident #1 and #260). On 05/18/21 at 7:37 PM, it was determined that the findings of the survey posed an immediate jeopardy to the health and safety of the residents residing in the facility requiring [CONDITION(S)] care. The facility's Administrator was informed of the immediate jeopardy on 05/19/21at 5:50 PM. The immediate jeopardy was identified on 05/19/21, as beginning on 05/18/21 and removed on 05/21/21. The scope and severity level was decreased to a D, no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The scope and severity was lowered as a result of the facility's corrective actions implemented as of 05/21/21 at 9:09 PM. The findings included: 1. On 05/17/21 during the initial resident screening process of the survey at approximately 3:45 PM, Resident #1 was observed in respiratory distress. Resident #1 was observed to have a [CONDITION(S)] (a surgical procedure to create an opening through the neck into the windpipe) and presented to have paralysis of all four limbs. Resident #1 was exerting a great deal of effort to breath having a respiratory rate of 20 breaths per minute and was using accessory chest muscles to the extent possible. When asked, Resident #1 was able to mouth the words, without sound, that he needed suctioning. Staff A, a Registered Nurse (RN), assigned to care for Resident #1 was standing at a medication cart. Staff A was informed Resident #1 was having trouble breathing and needed suctioning. Staff A identified herself as an agency nurse. Staff A said, 'Yeah, I know, someone is coming'. The surveyor returned to the room to check on the patient. The surveyor asked Resident #1 if he had already informed staff that he needed suctioning. Resident #1 said, he did ask for suctioning and the nurse told him he had already had it around 12:30 PM. Within a few minutes, the surveyor stepped back into the hallway and saw the Director of Nursing (DON). The DON was asked to look at Resident #1 and questioned if this is how Resident #1 normally presents. The DON looked at Resident #1 and said, 'no' and told Staff A he needed to be suctioned. Staff C, the Evening Supervisor RN, was coming from the direction of the medication cart. As Staff C was approaching the resident's room, he said to the DON, 'Yeah, I'm here .she (Staff A) was leery about doing it, so I am going to do it'. Staff C proceeded to the room and suctioned Resident #1 without using sterile technique and then left the room. Resident #1 then verbalized, they don't know how to take care of me. Resident #1 also said, I have been to the hospital 7 times so far. It should also be noted, the oxygen tubing and drainage bag were resting on the floor. On 05/17/21 at 4:12 PM, Resident #1 was observed struggling to breathe again, demonstrating the same signs as above. No staff members were visible in the hallway. Resident #1, a quadriplegic, was encouraged to use his call light (mouth activated) to summon assistance to the room. It took five minutes for a CNA to arrive. The CNA was informed by the resident that a nurse was needed because he was having difficulty breathing. Staff A arrived two minutes later. Staff A stated she would get a pulse oximeter. She returned with a pulse oximeter attached to a vital sign machine. Staff A attached the pulse oximeter to a finger on Resident #1's left hand, but after a few moments, no results appeared on the screen. Staff A said, this one isn't working, I'll go get another one. As Staff A turned to leave the room, she was asked her assessment of Resident #1's respiratory status. Staff A acknowledged Resident #1 was having respiratory difficulty. Staff A said she would go get help from someone who knew the resident and left the room. On 05/17/21 at 4:26 PM Staff D, an RN, arrived and began suctioning Resident #1. When he finished, Staff D stated, He needs deeper suctioning than most of them (nursing staff) feel comfortable providing. Staff D was asked how the facility would ensure Resident #1 would receive appropriate [CONDITION(S)] care and suctioning when he wasn't there. Staff D responded, that is a good question and left the room. Afterwards, Resident #1 stated, I feel like I'm going to die here with tears in his eyes. On 05/17/21 at 5:41 PM, observation in Resident #1's room revealed one opened and used suction catheter inside a small plastic bag. Resident #1 verbalized staff was washing and re-using the same suction catheters for three weeks. Resident #1 also indicated the box of inner cannulas in the room was the wrong size and that he thought he had pneumonia. Tan colored, frothy secretions were noted on the resident's chest at the margin of his [CONDITION(S)], under the oxygen attachment where a gauze dressing should have been. Approximately 20 minutes later, Staff E, an RN Unit Manager, notified the survey team that Nurse B, an RN, was familiar with Resident #1 and would be taking care of him. On 05/17/21 at 6:00 PM, Staff E, Unit Manager and Staff A, were again suctioning Resident #1, without any type of oxygen saturation monitoring. Staff E, identified as an agency nurse, arrived in Resident #1's room, and was asked about suctioning to ensure adequate care could be provided for Resident #1. Staff E said that she wasn't comfortable suctioning him and only agreed to help Staff A. Staff E said she had only cared for Resident #1 once before. (The Survey Team was informed by Staff E that Nurse B knew Resident #1 and was comfortable caring for him and would be taking over his care for the evening). At approximately 6:15 PM, the Central Supply Coordinator delivered one (1) single use suction catheter and said it was the only one left in the facility. The DON was then asked about the staff cleaning and reusing single use catheters for the past three weeks as Resident #1 said was occurring. The DON responded, Well, we clean them with normal saline. The DON was shown the label on the single use catheter that says, single use only. Central Supply was asked how many single use suction catheters were available and he stated there were no more. On 05/17/21 at 6:25 PM, the DON was asked to review Resident #1's orders and confirmed there were no orders related to the size of Resident #1's [CONDITION(S)] cannula. Further review with the DON revealed the record lacked the [CONDITION(S)] care on any care plan. At this point the DON stated, If we don't have equipment and supplies, we have to send him out. The DON was also asked how they know their agency nurses are qualified to provide the care needed to the residents at the facility. She said, we expect them to send us nurses that can function in all aspects as a nurse. The facility did not assess the skills of any of the agency nurses before considering resident assignments. During the interview, Staff D, a Unit Manager, entered the DON's office. Staff D was asked what size inner cannula Resident #1 needed. Staff D said he knew the size from speaking with the Respiratory Therapist (RT). Staff D was handed the printed care plan and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #1. Resident #1's orders and care plan did not reflect adequate information to provide [CONDITION(S)] care. The DON stated that the residents record, orders and care plan should provide the information needed to care for Resident #1. On 05/17/21 at approximately 6:45 PM, during an interview Staff A was asked about the size of Resident #1's [CONDITION(S)], and who would know since the order does not say, it just says to clean. Staff A stated, she would have to ask someone because she didn't have any experience with tracheostomies. Staff A reviewed the current suctioning orders that were to suction every four hours as needed and to lavage if needed. When asked if she was comfortable with that, Staff A stated, 'no' and that she did not know what lavage was. Staff A stated, she has long-term care experience, but that this was her first [CONDITION(S)] patient. When asked about supplies, Staff A was unaware of where to get them, but would go to the Unit Manager or another nurse. Staff A stated, she has worked at the facility one to two times a week for two months. When asked if her agency had ever assessed her skills about suctioning or [CONDITION(S)] care, Staff A stated, 'no'. When asked how she would determine if the resident needs to go to the hospital, Staff A stated, her nursing judgement indicated Resident #1 should go out for an evaluation because even though he was being suctioned, it wasn't working. Staff B, agreed, and they went to speak with Staff E, the Unit Manager, about sending Resident #1 to the hospital. At 7:15 PM, the resident was ready for transfer to the hospital. Resident #1 was transferred to the hospital 05/17/21 between 7:00 PM and 8:00 PM for shortness of breath / difficulty breathing after surveyor interventions. The resident remained hospitalized , at least until 05/21/21 at 6:15 PM, which was confirmed during a conversation with the resident's relative at this time on 05/21/21. Record review revealed, Resident #1 was initially admitted to the facility on [DATE] with his most recent readmission on 05/11/21. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Admission Minimum Data Set (MDS) from 12/20/20 showed his Brief Interview of Mental Status (BIMS) score was 13 of 15, which indicated Resident #1 was cognitively intact. Record review revealed, Resident #1's active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed, the resident's current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's active care plan did not contain any information about the size of the inner canula for replacement. Further record review revealed six out of eight hospitalization s, including the 05/17/21 admission since 01/08/21 were related to respiratory distress / shortness of breath. Between 01/08/21 and 05/16/21, this resident had spent 52 overnight stays in the hospital between seven hospital admissions during that time. On 04/06/21, the staff found him unresponsive with an oxygen saturation level of 84% prior to his transfer. Resident #1 was transferred to the hospital on 05/17/21 between 7:00 PM and 8:00 PM for shortness of breath / difficulty breathing after surveyor interventions and continued to be hospitalized as of 05/21/21. On 05/18/21, the DON provided copies of all in-services or competency training for [CONDITION(S)] care / suctioning that had been requested by the team. A copy of the in-service attendance list from 12/10/20 and 12/16/20 was also provided. The subject of the in-service was titled, Care of the [CONDITION(S)] Resident, with subtopics of Suctioning, Set-up, and [CONDITION(S)]-care included. There were thirteen (13) nurses on the list with ten (10) of them still being employed at the facility per administration. There was no evidence of previous competencies for [CONDITION(S)] care or suctioning provided to the survey team. To attempt to meet the needs of the residents in the building, the facility relies heavily on staffing agency nurses. On 05/17/21 for the afternoon/evening shift, 44% of the direct care nurses were agency nurses. On 05/19/21 at 2:30 PM, the Nursing Home Administrator (NHA), Regional Vice President, Regional Clinical Director and the DON were in the conference room with the survey team. They were asked if they were aware Resident #1 had been sent to the hospital eight times, this one being the ninth time since 01/09/21. When asked what systems were in place or what they had done to prevent his frequent transfers to the hospital, they had no response. In addition, the Regional Clinical Director commented that they would not be able to say since they didn't know the reasons he had been sent out and if all the transfers were related to his [CONDITION(S)]/difficulty breathing. As per the NHA on 05/19/21 at 2:30 PM, they use SMS (Respiratory Therapy contract) to provide education. They also use Health Care Academy (online education) for orientation and some annual competencies. They are unsure if [CONDITION(S)] or respiratory care is one of the items in the Health Care Academy upon hire but will provide a list. The NHA stated there are different avenues to provide education, and with management changes it is sometimes hard to track. When asked specifically about Resident #1, the NHA stated that nursing reviews the discharges and they are discussed in morning meeting. The NHA and DON did not have any response, but stated they would investigate it. During the investigation, a grievance filed on 05/12/21 by Resident #1's sister was identified. The narrative identified the sister's concerns as follows: 1) Resident #1 was not being suctioned properly/enough; 2) Sister wants a care plan; and 3) Whenever family calls, nobody answers the phone, it rings for a long time with no response. The person identified to investigate was the Social Service Director. On Friday, 05/21/21, just after 5:00 PM, interview by phone with Resident #1's sister who lives out of state revealed, the sister said complaints have been coming from the resident about suctioning. When she spoke with someone at the facility, she was told they haven't had a patient like him in a long time. When the sister asked about staff training, she was told they know how to suction and they were doing it properly and, If your brother thinks we are going to suction him every 20-30 minutes that's not going to happen, we just don't do it that way and you can only be suctioned once an hour. Resident #1's sister said she received a care plan and called the corporate office to find out why it hadn't been updated every time he returned from the hospital as most of the dates on it were from his initial admission (December 2020). She also said they had been refused appointments for visitation on multiple occasions. They were told they would not make an exception beyond the visiting hours which excluded evenings, weekends, and holidays. The SSD told her it takes too long to get him up and they do not have a proper chair to put him in. 2. During the initial screening process on 05/18/21 at 11:04 AM, Resident #260 was observed in bed with a [CONDITION(S)] mask attached to an oxygen concentrator. Resident #260's [CONDITION(S)] dressing had a visible yellow moist discharge. A suction canister on the bedside table, undated, with grey-yellow liquid in it (photographic evidence obtained). Resident #260 was asked when the staff changed the [CONDITION(S)] dressing last. The resident stated he was not sure. An audible rattle was noted when Resident #260 coughed. Resident #260 was asked if he needed suctioning and he stated, yes. Staff F, a Registered Nurse, was informed Resident #260 wanted to be suctioned. A review of Resident #260's physicians orders revealed there were none for [CONDITION(S)] care or suctioning. Staff F, who identified herself as an agency nurse, was asked to review Resident #260's orders for [CONDITION(S)] care, and upon review stated she could not find any. Staff F was asked how long Resident #260 had been in the facility, Staff F stated Resident #260 had been admitted on [DATE]. Staff F was asked if she had been assigned to Resident #260 prior to today (05/18/21). She stated, yes, I had him the other day. Staff F was asked if she had provided [CONDITION(S)] care for Resident #260, she stated, yes, I provided standard [CONDITION(S)] care. Staff F was asked what standard [CONDITION(S)] care was, she stated that she would need to look into that. Interview and record review on 05/18/21 at 11:35 AM, with Unit Manager-C confirmed a lack of orders related to the [CONDITION(S)] for Resident #260. Unit Manager-C was asked where are the staff documenting Resident #260's [CONDITION(S)] care. She stated that she would have to ask the nurses. Review of the care plan revealed no documentation related to [CONDITION(S)] care. At 12:00 PM, Unit Manager-C and this surveyor went to the Resident #260's bedside and found two single use suction catheters and one size 4 [CONDITION(S)] inner cannula (photographic evidence obtained). There were no disposable inner cannulas (the inner cannula fits inside the [CONDITION(S)] tube and acts as a liner). Unit Manager-C was asked what size [CONDITION(S)] Resident #260 required. She stated that she was not sure. Unit Manager-C was asked what supplies should be at the bedside for Resident #260. She stated that she was not sure. Unit Manager C stated the suction canister should be dated and confirmed a lack of date on the [CONDITION(S)] collar and could not explain the lack of documented [CONDITION(S)] care. The Unit Manager stated Respiratory Therapy has never seen the resident. Review of the Resident Census and Condition Form 672, that the facility provided on 05/17/21, revealed the facility currently, on 05/17/21 had one resident that required [CONDITION(S)] care. The survey team discovered during the screening process that the facility had two (2) residents that required [CONDITION(S)] care. The Director of Nursing (DON) had signed the Resident Census and Condition Form 672. Review of Resident 260's record on 05/18/21 revealed an initial admission of 04/20/21, with a readmission of 05/12/21. Resident #260's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #260's Admission / Readmission assessment of 05/12/21 revealed, a respiratory assessment, respiratory rate and characteristics documented as normal. Further review of the respiratory assessment revealed, Resident #260 had a [CONDITION(S)]. The month and year of [CONDITION(S)] was left blank. The last date the [CONDITION(S)] was changed was left blank. The size of Resident #260's [CONDITION(S)] was left blank. Further review of Resident #260's record revealed no active Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/18/21 at 2:40 PM, the DON was asked to review Resident #260's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated that there should be orders for [CONDITION(S)] care. The DON was asked what care the staff were providing for Resident #260. She stated that she is sure they are providing care. The DON was asked when the last time Resident #260's inner cannula was changed, when was the last time the [CONDITION(S)] dressing was changed, when was the last time Resident #260 had been suctioned, and what size was Resident #260's [CONDITION(S)]. The DON stated that she was not sure, and she asked that the Assistant Director of Nurses (ADON) help review the record. While waiting for the ADON, the DON stated that as part of their morning meeting she and all the Unit Managers review all admission and readmission charts and go over all the orders. The ADON joined the record review for Resident #260, and they (DON and ADON) stated they do not know why Resident #260 did not have any physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON and the ADON were asked how many nurses had been assigned to Resident #260 since his readmission on 05/12/21. The ADON stated probably 12-14. The DON and the ADON were asked why 12-14 licensed nurses had not identified that a resident with a [CONDITION(S)] did not have physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's Immediate Jeopardy Removal Plan was received on 05/20/21 at 1:36 PM. The Facility's actions to remove the Immediate Jeopardy and corrective actions included: 1. Resident #1 was discharged on [DATE]. 2. Resident #260 was discharged on [DATE]. 3. Required supplies have been obtained. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 260 is receiving care from licensed nurses that have been trained and deemed competent in [CONDITION(S)] care and suctioning. No licensed staff will be able to work with the resident until training and competency is completed. 4. Residents with tracheostomies were reviewed on 05/19/21 to ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan and care directives were updated on 05/17/21 to include information regarding the size of cannula, other equipment needs and care of the [CONDITION(S)]. 5. Current residents with tracheostomies were assessed by the respiratory therapist on 5/19/2021. 6. When 100% of licensed nurses have been trained and deemed competent and the facility begins readmitting residents with tracheostomies, each newly admitted resident will be reviewed by the IDT (interdisciplinary) team to ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan and care directives will also be reviewed by the IDT team to ensure appropriate interventions to clearly communicate care needs are present, including size of the cannula and other equipment needs. 7. An inventory of central supply was completed on 05/19/2021 to ensure the facility has a 7-day supply of equipment including cannulas, emergency supplies and suction equipment to care for residents with a [CONDITION(S)]. The Central Supply Director placed an additional order of supplies on 5/20/21. The DON/designee will assess on a weekly basis the supply needs for residents with tracheostomies and order additional supplies on a weekly basis. 8. The respiratory therapist or DON / designee has initiated [CONDITION(S)] care and [CONDITION(S)] suctioning training including competency with return demonstration on 05/19/21 for all licensed nurses. The training includes appropriate infection control techniques. Training and competency will continue until 100% of licensed nurses have been trained and deemed competent. 9. Only licensed nurses that are trained and competent on [CONDITION(S)] care and suctioning will provide care to residents with tracheostomies. 10. The DON / designee will not assign agency nurses to the care of [CONDITION(S)] patients without validation of training and competency. The DON/ designee will coordinate training and validation of competency with the agency nurse prior to entrance into the facility. 11. [CONDITION(S)] care and suctioning training including competency with return demonstration will be completed during the orientation process to all new licensed nurses by the SDC / designee. 12. The medical director was notified, involved in the review and oversight, and approved the plan of removal for ensuring residents with tracheostomies receive the required care, services and supplies necessary to ensure the highest practical well-being on 05/19/21. 13. The facility held an immediate QAPI (Quality Assurance and Performance Improvement) meeting on 05/20/21 to review the plan of removal. Facility QAPI meetings will be held weekly for 4 weeks, bi-weekly x 2 and monthly thereafter. 14. The SDC (Staff Development Coordinator) / designee will audit licensed nurses training and competency records for [CONDITION(S)] care and suctioning weekly to validate completion of training and competency. Training and competency record audits will be reviewed for compliance at the facility QAPI meeting weekly x4, bi-weekly x2 and monthly thereafter. 15. The DON / Designee will complete weekly audits of central supply and utility rooms to ensure adequate supplies are available to meet the needs of residents with tracheostomies. The DON/ designee will complete weekly room observations for residents with tracheostomies to assess for supply needs to ensure at least a 7 day inventory is available and order any additional supplies if needed. Results of the audits will be trended and reviewed at the QAPI meeting weekly x 4, bi-weekly x 2 and monthly thereafter. 16. The DON or designee will complete ongoing weekly [CONDITION(S)] care and suctioning observations of licensed nurses on all shifts including weekends. Results of the audits will be reviewed at the QAPI meeting weekly x 4, bi- weekly x 2 and monthly thereafter. 17. The DON / designee will review the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 18. The DON / designee will also review the care plan and care directive weekly to ensure the care needs and equipment needs for tracheostomies are accurate and clearly communicated according to the physician order. Results of the audits will be reviewed at the QAPI meeting weekly x 4, bi-weekly x 2 and monthly thereafter. 19. The DON / designee will complete monthly audits to assure all new licensed nurses have completed [CONDITION(S)] care and suctioning training and competency upon hire. Results of these audits will be trended and reviewed at the facility QAPI meeting weekly x 4, bi-weekly x 2 and monthly thereafter. On 05/21/21, verification of IJ Removal Plan included: The facility demonstrated as of 05/20/21 that 35 licensed nurses have been trained out of 48 total licensed nurses working at the facility. Of the 35 trained, 6 were agency staff. The remaining 13 nurses who need the in-servicing, training, and competency had been called by the Staffing Coordinator to come to the facility for the mandatory training by 05/21/21. When 100% of licensed nurses have been trained and deemed competent and the facility begins readmitting residents with tracheostomies, each newly admitted resident will be reviewed by the Interdisciplinary Team (IDT) team to ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan and care directives will also be reviewed by the IDT team to ensure appropriate interventions to clearly communicate care needs are present including size of the cannula and other equipment needs. An inventory of Central Supply was completed on 05/19/21 to ensure the facility has a 7-day supply of equipment including cannulas, emergency supplies and suction equipment to care for residents with a [CONDITION(S)]. The Central Supply Director placed an additional order of supplies on 05/20/21. The DON / designee will assess on a weekly basis the supply needs for residents with tracheostomies (traches) and order additional supplies on a weekly basis. Reviewed purchase orders, dated 05/20/21, for Shiley Inner Fenestrated traches 4 cases, suction catheter kit 4 cases, [CONDITION(S)] tube Shiley 6 cases (50 in case), tubbing connector 24 units, suction connector tubing cardinal 4 units, air life handheld nebulizer kit 12 units, aerosol drainage bags 12 units, mask collar 12 units, tee adapter air life 24 units, [CONDITION(S)] care tray, 28 units and mask [CONDITION(S)] tube 16 units. On 05/21/21 at 10:05 AM, observation of the Central Supply room revealed it had: 92 Yankauers (oral suctioning tool); 50 [CONDITION(S)] masks; 30 [CONDITION(S)] holders; 10, 6 inner cannula; 10, 4 inch inner cannulas; 2, 4 DCFS (Disposable Cannula Cuffless Tracheotomy tube size); 1, 6 DCFS; 1344 drain sponges; 4 suction cannisters; 35 suction tubing cannister; 35 suction tubing short and 7 long; 32 [CONDITION(S)] clean kits; 24 suction catheter trays; 24 tee adapters; 2 ambu bags; 10, 6 inch disposable tubing; 14, 240 ml sterile water; 13, 1000 ml sterile water; 10, 650 ml sterile water; 2, 1070 ml sterile water; 15 drainage sponges; and 9 [CONDITION(S)] mist units. Review of the training material included: Procedures - [CONDITION(S)] tube cannula and stoma care, [CONDITION(S)] suction and a [CONDITION(S)] care post-test. On 05/21/21 at 5:05 PM, an observation of [CONDITION(S)] care, suctioning, inner cannula changing, dressing change, with Staff J, a Registered Nurse, and the Assistant Director of Nursing (ADON), for Resident #260 was conducted. During the observation of suctioning, Staff failed to assess the resident's vital signs, breath sounds, or respiratory effort. Staff failed to position the resident in upright with head in neutral alignment. Staff failed to attach the resident to a pulse oximeter during suctioning. Staff failed to assess the resident's ability to cough and breathe deeply. Staff J failed to lubricate the outside of the suction catheter with sterile solution. Staff J failed to suction sterile solution prior to suctioning the resident. Staff failed to encourage the resident to take deep breathes prior to suctioning. Staff J failed to clear the suction catheter with sterile solution. Surveyor intervention was required prior to Staff changing the resident's inner cannula. Staff J were asked to assess Resident #260. The ADON produced a pulse oximeter from his pocket placed it on the resident's finger and stated it is not working. Staff J requested a Blood Pressure, Pulse and Heart Rate monitor from staff in the hallway outside of Resident #260's room. The ADON stated that the monitor was not working properly, after several attempts to obtain a set of vital signs, the ADON stated the connections are loose, you really have to wiggle the cord just right to get it to work. Staff J and the ADON confirmed they had participated in the [CONDITION(S)] staff education today (05/21/21). Staff J obtained a set of vitals. Staff J proceeded to change Resident #260's inner cannula. Staff J failed to assess the resident's breath sounds. Staff J failed to position the resident in an upright, head neutral position. On 05/21/21 at 5:40 PM, the Regional Nurse Consultant and DON were informed of the observation. On 05/21/21 at 5:55 PM, the Regional Operations Consultant was informed of the observations, stated that they are seeking placement for Resident #260, and the facility will voluntarily stop admitting residents with tracheostomies. The Immediate Jeopardy Removal Plan was accepted by the Agency on 05/21/21 at 7:26 PM, with the discharge of Resident #260. Resident #260 was discharged to the hospital 05/21/21 at 9:09 PM.

Based on interview, observation and record review, the facility failed to provide adequate supervision within a secured unit for 1 of 22 sampled residents, Resident #1, who was identified as an Elopement Risk and residing in the facility's secured (locked) unit. The deficient practice allowed Resident #1 to exit the facility's secured unit, undetected on 11/28/20 at 3:37 AM. At the time of the elopement the facility had 20 residents in the secured unit. The facility's failure to provide adequate supervision and a mechanical failure of the exit door lock and alarm, allowed the resident to elope undetected by staff. Based upon hospital records, Resident #1 was seen wandering near a night club approximately one mile southeast of the facility. The resident was aided, and then transported by ambulance to a local hospital for evaluation and treatment, by public first responders. Resident #1 arrived at the hospital at 4:58 AM. Resident #1 was returned to the facility on [DATE] where the resident was re-evaluated at approximately 10:05 AM. The findings included: Review of the facility's policy titled, Unsafe Wandering and Elopement, effective Date: 12/13/18; Reviewed: 4/15/19, defines Elopement: Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for [REDACTED]. A resident who leaves a safe area may be at risk of (or has potential to experience) heat or cold exposure, dehydration, and /or other medical complications, drowning or being struck by a motor vehicle. Record review revealed Resident #1, was admitted to the facility 12/20/19. The resident's Annual Minimum Data Set (MDS) assessment dated [DATE], documented Resident #1 had a Brief Interview of Mental Status (BIMS) of 00, which indicates Resident #1 is severely cognitively impaired with a poor memory. Resident #1 was identified under section D as not having any mood issues. Under section E- Behavior, Resident #1 was identified as a wander risk. For the question, Does the wandering place the resident at significant risk of getting to a potentially dangerous place (e.g., stairs, outside of the facility)? The answer was, Yes. This was documented as being unchanged from the previous assessment, her quarterly done on 09/27/20. Under Activities of Daily Living (ADL) Resident #1 was identified as a total assist with one person assist for bathing, limited assistance with one person assist for personal hygiene and dressing, and supervision with set-up for all other ADLs. Under Section I - Active [DIAGNOSES REDACTED]. Resident #1 was assessed to be insulin dependent. Resident #1 had a care plan initiated on 12/20/19 for Risk for Elopement. On 01/03/20 the care plan for Risk for Elopement was revised. The focus of the care plan was documented as: Resident is at risk for elopement. She has tendency for exit seeking. The Goal for the plan stated: The resident will not leave facility unattended through the review date. Interventions included: Add resident to the Elopement Book; Complete Elopement Risk Assessment; Encourage to participate in activities to divert from exit seeking behavior; Frequent monitoring while ambulating on unit; Provide for safe wandering - resident is an elopement risk. Review of the Physicians orders and the Medication Administration Record (MAR) for November 2020 revealed, the resident was receiving the following medications, [MEDICATION NAME] HCl ([MEDICATION NAME]) Tablet 10 mg Give 1 tablet by mouth three times a day (8 AM, 2 PM and 8 PM) for Anxiety; [MEDICATION NAME] Tablet 10 mg Give 1 tablet by mouth one time a day (9AM) for DM (Diabetes Mellitus); [MEDICATION NAME] Solution 100 unit/ml(milliliter) (Insulin Detemir) Inject 10 unit subcutaneously at bedtime for DM rotate injection site; [MEDICATION NAME] HCl Tablet 1000 mg Give 1 tablet by mouth two times (9 AM and 5 PM) a day for DM; [MEDICATION NAME] Tablet 10 mg Give 1 tablet by mouth one time a day [MEDICAL CONDITION](Hypertension aka High Blood Pressure) hold for SBP (Systolic Blood Pressure) less than 110; [MEDICATION NAME] Tablet 10 mg Give 1 tablet by mouth one time a day (9 AM) [MEDICAL CONDITION] for SBP less than 110; Atorvastatin Calcium Tablet 10 mg Give 1 tablet by mouth at bedtime for [MEDICAL CONDITION] (High cholesterol); Donepezil HCl Tablet 10 mg Give 1 tablet by mouth at bedtime for Dementia; Memantine HCl Tablet 10 mg Give 1 tablet by mouth every morning (9 AM) and at bedtime for Dementia; Calcium + D3 Tablet 600-200 mg-unit Give 1 tablet by mouth in the evening for Vit D Deficiency; Vitamin D2 Tablet Give unit by mouth one time a day every Mon (Monday) for Vit D Deficiency. The following medications were documented on the MAR as not given on 11/28/20 with the reason code of 4, which means hospitalized , [MEDICATION NAME] and [MEDICATION NAME]. All identified medications had a 9 AM scheduled time. All medications prior to the elopement and for the time following the elopement after the resident returned to the facility, were administered as ordered. Through record review, including the incident report with witness statements, and interviews with the Executive Director, and Maintenance Director, who were both on the facility tour conducted at on 01/19/21 11:53 AM, a determination was made that Resident #1 eloped from the facility's secured unit, undetected on 11/28/20 at 3:37 AM. The exact time was determined by video surveillance, which was no longer available. According to the Maintenance Director and the Executive Director, some time prior to the elopement, the alarm on the West Wing door had been disarmed. Additionally, according to the Maintenance Director, the exit door, where the elopement had occurred, had not fully latched, and this was determined to be a failure of the magnetic door latch. These two mechanical failures, coupled with a lack of supervision, allowed Resident #1 to elope. On 01/19/21, at 11:53 AM, a facility tour, including an exterior perimeter tour, was conducted with the Maintenance Director. During the outside tour locations of security cameras were identified. The Maintenance Director explained that the cameras had a live feed that can be viewed in the Executive Director's office. It was later learned, on 01/21/21 at approximately 2:30 PM, from the Regional Vice President, that the camera system has the capability of recording a weeks' worth of data, but it will record over the material after the week has passed from the oldest date to newest date. The system can store specific data for a longer period if needed, however, as there was no police report or investigation the facility did not save the video from the date of the elopement, 11/28/20. On 01/19/21 at 1:26 PM, a tour of the West Wing, where Resident #1 resides, was conducted with the Maintenance Director to explain and demonstrate the changes made to the wing after the elopement. The Maintenance Director stated that after the elopement there were changes made to the alarm system on the doors to improve safety and to prevent further elopements. The changed alarm boxes have a continuous alarm that cannot be shut off without the key, it does not stop on its own as the other alarms did. The shut off key accessibility was limited to the Maintenance Director, his two assistants, and the Executive Director. The key is placed in a lockbox at the central nurse's station. The lockbox code is changed frequently by the Maintenance Director and the code is shared with the two assistants and the Executive Director. If the alarm is set-off and the responsible parties are not on site, the staff is instructed to call for the lockbox code to get the key to turn off the alarm. Additionally, according to the Maintenance Director, the key only turns off the alarm sound and lights, the alarm always remains armed. The Maintenance Director demonstrated the alarm, which, when set off, makes an ear-piercing sound and has bright strobe lights flashing. The Maintenance Director stated he checks the exit doors twice weekly. The Maintenance Director stated that at the time of the elopement the alarm for the West Wing door, where the elopement occurred, had been turned off. The Maintenance Director stated that the facility was unable to pinpoint when the alarm had been turned off and by whom. The system for centralizing and limiting keys was developed for this reason. The Maintenance Director stated that on the memory unit (West Wing) the doors cannot be opened without a code, no matter how much the residents press on the exit bar. The door was checked during this tour and noted to operate as reported by the Maintenance Director. On 01/19/21, at 2:08 PM, a second, independent, walking tour of the facility's perimeter was conducted to collect photographic evidence of the environmental hazards that Resident #1 encountered at the time of the elopement. On 01/19/21, at 3:18 PM, an interview was conducted with Staff A, a Registered Nurse (RN) on Memory Care (West Wing) unit. Staff A works the 7:00 AM to 3:30PM (1st) shift. Staff A stated that if the alarm sounds the first thing to do is to check outside and determine if the resident is outside. A perimeter check is done by all available staff. After that a head count is done to make sure all residents are present. If head count is good (accurate) then the alarm is turned off. Otherwise the whole facility is searched for the resident. If the resident is still not found, then the police are called. An overhead page is made with Code Silver to inform the rest of the staff that a resident is missing. Staff A stated that the facility has been having elopement drills every 2 weeks and that in-services for elopement were started on the day of the elopement and have continued weekly. On 01/20/21, at approximately 9:00 AM a driving tour of the area, where Resident #1 was reported to have been found and from which was transported to the hospital, was conducted. The following observations were made during these two tours: the facility is in an area where there are hazards to an unsupervised cognitively impaired resident. The resident walked in an area where there was a high traffic volume 6-lane roadway with traffic lights that intersects a 4-lane side street. The 4-lane side street heads southeast toward an 8-laned high traffic roadway, with traffic lights, approximately 1 mile away. The resident was reported to have been found on the opposite side (south side) of the 8-lane roadway, which means she had to cross the roadway. The area where the resident was found is an industrial area with uneven pavement and fall hazards. Along the 4-lane roadway, directly behind the nursing facility, there is a canal with rocks along the embankment. The slope of the embankment is steep, the ground is uneven, the grass is unmown and littered with debris of various sizes and materials. On the same roadway, on the same side of the road as the nursing facility, just beyond the canal there is a residential neighborhood. On 01/20/21 at 12:05 PM, an interview was conducted with Staff B, an RN, who works from 11:00 PM to 7:30 AM (3rd shift). Staff B stated, she was assigned to the Central Nursing station, located just beyond the main lobby at the beginning of the A and D wings and adjacent to all the main wings (A-D). Staff B stated, she did not hear an alarm on 11/28/20, but she did hear an overhead page of Code Silver (missing person) between 4:30 AM and 5:00 AM. Staff B explained, when there is an alarm or Code Silver (aka Code Grey) she checks her residents to make sure they are accounted for and then proceeds to the area where the Code Silver/Grey was called. Staff B explained that she searches the resident rooms, bathrooms and on the floors to see if a resident has wandered into the wrong room and had fallen or gotten confused and lost. Staff B stated she responded to the overhead page but did not remember details of what happened. Staff B stated that the facility has been having drills and provided in-services regarding elopements. On 01/20/21 at 12:07 PM an interview was conducted with Staff C, a Certified Nursing Assistant (CNA) who works the 3rd shift. When asked about entry and exiting the facility she explained that she uses the keypad outside the West Wing to enter the building. It was later established, by the Executive Director during an interview on 01/20/21 at approximately 1:00 PM, that Staff C enters the D Wing door which is adjacent to the locked West Wing (memory care unit). The Executive director explained that after being screened for COVID-19 the staff proceeds outside the building to the D Wing, where they use a keypad to enter the building. On 01/20/21 at 12:26 PM an interview was conducted with Staff D, a Licensed Practical Nurse (LPN), who works both 3:00PM - 11:30 PM (2nd shift) and 11:00PM - 7:30 AM (3rd shift). Staff D stated, around 2:45 AM on 11/28/20, Resident #1 was sitting in the hallway complaining she was hungry. Staff D obtained Resident #1 a snack and went back to working at the desk (nurse's station). Staff D stated that at 4:45 AM, Resident #1 was not found in her room by the Certified Nursing Assistant (CNA) and a search of the resident's whereabouts was conducted. When the resident could not be found on the unit, a Code Grey (aka Silver, missing person) was called. By 6:00 AM, the Director of Nursing was notified that the resident was missing, and the police was called. Staff D stated, after the elopement her alarm key was taken away. Staff D stated, she had been assigned to check the alarms, but now she couldn't because none of the nurses had keys. Staff D reported, the facility has been having elopement drills and in-services frequently. On 01/21/20 at 11:05 AM, an interview was conducted with Staff E, a Registered Nurse, who works the 1st shift on the West Wing (Memory Care Unit). Staff E explained, he and the CNA check on the residents every 15 to 30 minutes to make sure they are safe and to redirect them as needed. During the interview, an alarm sounded that indicted an exterior door had been opened. Staff E instructed the CNA to check on the residents and do a head count. Staff E then proceeded to determine that the Alarm was sounding from the D Wing exit adjacent to the West Wing. As Staff E approached the door to check outside, the Executive Director and Infection Preventionist responded to the alarm. The Executive Director and Infection Preventionist checked the perimeter of the building for any resident. Staff E was instructed to return to his unit and check on the residents. The head count conducted by the CNA established that all residents were present. It was later learned that all residents in the facility were present without incident. Staff E reported that the facility had been having regular drills for elopement and staff were being in-serviced weekly for elopements. On 01/21/20 at 11:41 AM, an interview was conducted with Staff F, a CNA on the B-wing. When asked if an alarm is ringing what is she supposed to do? Staff F responded, she helps check to see if all of the residents on her wing are present. Staff F stated that she checks the door if it is on her wing. She stated, she would go outside to look to see if she can see who went out of the door. After that she helps with a head count and if anyone is missing, she reports to the nurse. Staff F stated, if she hears an overhead page for Code Silver (missing person, aka Code Grey), she checks her residents to make sure they are safe, she then goes to the part of the building where the Code Silver was called and helps with looking for missing residents. Interview with Staff G, on 01/21/21 at 1:02 PM, Health Information Management (HIM). Staff G stated that when there is an overhead page (Code Grey or Code Silver) for a missing person and her responsibility is to check on the whereabouts of the residents who are closest to her office on the B-wing. She will then report to the area where the resident is missing and assist as directed. Staff G stated that the elopement books are kept at all nurse's stations and they contain the resident's pictures and information to help identify the resident. The facility's corrective actions included: From 11/28/20 to 12/10/20 the following staff were educated/re-educated on Elopement and Code Silver (Missing Person) for all shifts, 7:00 AM to 3:30 PM, 3:00 PM to 11:30 PM, and 11:00 PM to 7:30 AM: Nursing - Registered Nurses, Licensed Practical Nurses and Certified Nursing Assistants - 113 employees Housekeeping/ Laundry - 9 employees Therapy Staff - Physical Therapy, Occupational Therapy, and Speech Therapy - 12 employees Dietary/Cook/Food Services - including Dietician - 13 employees Maintenance - 3 employees Social Workers - 2 employees Receptionists - 3 employees Activities - 3 Miscellaneous other staff - 10 There were 168 out of 186 total staff members, including department heads, for the timeframe specified. This equals 90.3 % of staff educated. At the time of the survey from 01/20/21 to 01/21/21 an additional 17 members of the staff were educated/re-educated on the topics of Elopement and Code Silver. This brought the total staff educated/re-educated to 185 out of 186 or 99.5%. One Housekeeping Assistant was out of the country and has not been educated/re-educated. Elopement in-services are occurring weekly, Code Silver alerts and alarm drills are occurring every two weeks. The functionality of doors and alarms are being conducted by the Maintenance Director at least weekly. As of 12/11/20, the repairs to the magnetic door locks were completed. The order for the upgraded alarm boxes was initiated on 12/01/20 and the upgraded alarm boxes were installed prior to this investigation of 01/19/21 - 01/25/21. The exact date was not documented by the facility. The elopement books were updated with new photographs where needed. These were reviewed with the Director of Nursing on 01/25/21.

Based on observation, interviews and record review the facility failed to provide prescribed medication for a newly admitted resident resulting in the resident suffering a [MEDICAL CONDITION] and needing emergent hospitalization . This affected 1 of 3 sampled residents (Resident #1). The findings included: Review of the facility policy Medication Reconciliation across the Continuum of Care (Issued 06/08/20) revealed upon admission or as close to the actual time of admission as possible medication will be reconciled by a licensed nurse. Clinically significant medication issues identified will be communicated to the physician, acted upon, and documented in the medical record. On 08/05/20 at 12:10 PM during a telephone interview with the responsible party, a family member for Resident #1, stated that Resident #1 had been admitted to the facility on [DATE] after testing positive for COVID-19 at the long term care facility that she had resided in for more than [AGE] years. The responsible party stated that Resident #1 is intellectually disabled and epileptic. The responsible party stated that Resident #1 has a very specific schedule for the medications that prevent her from having [MEDICAL CONDITION] and she has not had a [MEDICAL CONDITION] in 4 years. The responsible party stated that she called the facility 20 times between Resident #1's admission on the evening on 07/24/20 and 2:00 PM on 07/25/20. On 07/25/20 at 2:00 PM the responsible party spoke with Staff C, a registered nurse. The responsible party stated that Staff C told her Resident #1 was fine and ended the call. The responsible party stated that she received a call from Staff D, a registered nurse, at 1:00 AM on 07/27/20. Staff D told the responsible party that Resident #1 was vomiting blood and was emergently transferred to the hospital. A record review on 08/04/20 revealed Resident #1 had been admitted to the facility on [DATE] at 9:40 PM. Resident #1 has [DIAGNOSES REDACTED]. Review of the record revealed no admission assessment or admission notes on 07/24/20. Resident #1's admission assessment was started on 07/25/20 at 11:32 AM. Resident #1's medications were entered electronically at 2:34 PM on 07/25/20. Review of the pharmacy delivery receipt revealed Resident #1's medications were signed for at the facility on 07/25/20 at 11:51 PM. Record review revealed Resident #1 had a physician order for [REDACTED]. The [MEDICATION NAME] was to be administered at 06:00 AM and 06:00 PM. Review of Resident #1's Medication Administration Record [REDACTED]. Resident # 1 did not receive the [MEDICATION NAME] on 07/26/20 at 06:00 PM. Resident #1 had a physician order for [REDACTED]. The [MEDICATION NAME] was to be administered at 09:00 AM daily. Review of Resident #1's MAR indicated [REDACTED]. Resident # 1 did not receive the [MEDICATION NAME] on 07/26/20 at 09:00 AM. Resident #1 had a physician order for [REDACTED]. Review of Resident #1's MAR indicated [REDACTED]. Resident # 1 did not receive the [MEDICATION NAME] on 07/26/20 at 09:00 AM. Resident #1 had a physician order for [REDACTED]. Review of Resident #1's MAR indicated [REDACTED]. Resident # 1 did not receive the [MEDICATION NAME] on 07/26/20 at 09:00 AM. Resident # 1 did not receive the [MEDICATION NAME] on 07/26/20 at 5:00 PM. Resident #1 had a physician order for [REDACTED]. Resident # 1 did not receive the [MEDICATION NAME] on 07/25/20 at 09:00 AM. Review of Resident #1's MAR indicated [REDACTED]. Resident # 1 did not receive the [MEDICATION NAME] on 07/26/20 at 5:00 PM. During an observation and interview on 08/04/20 at 4:40 PM Staff C stated that he had received Resident #1 as an admission on 07/24/20 at approximately 9:30 PM. Staff C stated that he worked until 11:00 PM on 07/24/20 and was relieved by Staff D. Staff C stated that he returned to the facility on [DATE] at 7:00 AM and realized that Resident #1's admission assessments had not been done. Staff C stated that Resident #1's medications did not get sent to the pharmacy until approximately 2:00 PM on 07/25/20. Review of Resident #1's Medication Administration Record [REDACTED]. Staff C stated that he did not document the missed dose or notify the physician. Staff C stated the Resident #1 did not receive the [MEDICATION NAME] on 07/25/20 at 09:00 AM. Staff C stated that he did not document the missed dose or notify the physician. Review of the record revealed Staff D documented a progress note on 07/27/20 at 1:23 AM Resident #1 was transferred to the hospital after being found at 8:40 PM verbally unresponsive vomiting a moderate amount of streaked blood with episodes of tremors. MD and family notified. Resident #1 was readmitted to the facility on [DATE]. Review of Resident #1's hospital discharge listed an 08/26/20 hospital admitting [DIAGNOSES REDACTED]. Further review of Resident #1's record on 08/05/20 at 1:40 PM with the Regional Nurse Consultant and the ADON revealed Staff E, a licensed practical nurse, document on 07/26/20 at 7:04 AM that Resident #1 did not receive physician order [MEDICATION NAME] Tablet 0.5 MG Give 1 tablet by mouth every 12 hours for [MEDICAL CONDITION]. Staff E documented that Resident #1 was a new admission and her medication had not arrived from the pharmacy. The Regional Nurse Consultant and the ADON were asked to confirm the arrival time of Resident #1's medications. Resident #1's medications were signed for at the facility on 07/25/20 at 11:51 PM. The Regional Nurse Consultant stated that Staff E is from an outside agency, and the facility is responsible for their residents. The ADON stated that they have struggled with agency nurses.

Based on observation, interviews and record review, the facility failed to provide interventions to help prevent further falls for 3 of 7 sampled residents for accidents (Resident #38, #51, #119) which resulted in harm to Resident # 38. The findings included: 1. An interview was conducted with the family member of Resident #38 on 09/09/19 at 2:00 PM which revealed that the resident used to be ambulatory, but now uses a wheelchair. It was further revealed that she has had many falls; she would fall out of bed or while getting out of bed; and she fell while in her wheelchair, which has anti-tippers on it. A review of the medical record for Resident #38 was conducted on 09/10/19 at 12:55 PM revealed that she was initially admitted to the facility on [DATE] and re-admitted on [DATE] following a fall with a [MEDICAL CONDITION] hip. The resident's [DIAGNOSES REDACTED]. A chart review also revealed the resident had multiple falls in 2019. Resident #38's care plan dated 01/31/19 and revised on 09/09/19 revealed a focus that the resident is at risk for falls. The resident's care plan documented: confusion, gait/balance problems, vision problems, decreased mobility related to (R/T) status [REDACTED]. The interventions for this focus are to anticipate and meet the resident's needs with date initiated 01/31/19; assist with activities of daily living (ADLs) as needed with date initiated 01/31/19; bed in lowest position as ordered with date initiated 06/14/19; bed in lowest position, floor mats as ordered date initiated 09/09/19; call light within reach date initiated 01/31/19; complete fall risk assessment date initiated 01/31/19; encourage resident to request assistance from staff to pick items up off the floor for her date initiated 02/06/19; and orient resident to room date initiated 01/31/19. The Minimum Data Set (MDS) documented the brief interview for mental status (BIMS) for Resident #38 was 7, indicating severe cognitive impairment (the annual assessment with a target date of 01/19/19). On the significant change assessment with a target date of 06/14/19 the BIMS score was 8, indicating moderate cognitive impairment. A review of the facility's documentation was conducted on 09/10/19 at 1:30 PM regarding 7 falls that occurred with Resident #38 in 2019, specifically: On 02/07/19, the resident was observed on the floor in the east wing patio in front of a chair. The documentation revealed that the resident has impaired mobility and utilizes a walker to ambulate. She is alert with a history of dementia and falls. These factors place the resident at risk for falls. The care plan review revealed no care plan update after this fall. On 03/10/19 the resident had an unwitnessed fall in her room. The nurse was notified by a certified nursing assistant (CNA) that the resident was on the floor. Upon entering the room, the resident was observed lying on the floor on her back with a stuffed pink and gray animal behind her back. The resident was noted with hematoma to the top of the scalp. There were no updates to the resident's care plan were noted. On 04/07/19 the resident was observed on the floor in front of the vending machine. Resident stated that she was trying to buy some chips when her leg gave out. There were no injuries observed, no witnesses found and there were no care plan updates. On 04/11/19 the resident was found sitting on the floor in her room with her legs straight by her bed. There were no injuries observed. She is ambulatory with assistance. Resident is non-compliant with using the call light and the hand held reacher. There were no care plan updates. On 06/02/19 the resident had an unwitnessed fall in the hallway. The nurse was alerted by a CNA at 6:00 PM that the resident had fallen out of her wheelchair in the hallway. The resident was assisted back to her wheelchair and put back to bed. There were no visible injuries noted. There was pain to right hip noted. The resident was given 650 milligrams (mg) of Tylenol by mouth (PO). A stat x-ray was negative for fracture. Next of kin was notified at 6:10 PM. Physician was notified at 6:13 PM and supervisor was on site. On 06/03/19 the resident was sent to the hospital in the morning. The facility documentation does not reveal that the resident did have a [MEDICAL CONDITION] hip which resulted in surgery. There were no care plan updates except for adding the date of the fall to the focus of at risk for falls. On 06/10/19 the resident was readmitted to the facility post right hip surgery. On 06/11/19 the resident was observed lying on the floor beside her bed on her right side with her arm under her head. The side rails were up. There were no witnesses to the fall. The resident was assessed .the doctor ordered bilateral hips x-ray. The results of the x-ray revealed the right hip with recent surgery and staples intact. The call light was not on and both side rails elevated. The resident was educated to call for help before getting out of bed. The care plan updated on 06/14/19 for bed in lowest position as ordered. On 09/08/19 the resident had a fall resulting in a fracture to clavicle in the dining room after dinner. A review of the witness statement of Staff B written on 09/08/19, revealed Staff B was in the back dining room assisting a resident- the resident (Resident #38) could not wait for us to take her to the east wing and got up and fell . A review of the witness statement for Staff A written on 09/08/19 reveals that Staff A was assisting a resident in the back dining room and she heard a kitchen staff calling out that the resident (Resident #38) was about to fall and before she could finish the resident hit the floor. The facility documentation report revealed that a fall assessment was done. Pain medication was given and ice was placed on the resident's right shoulder. A call was placed to the physician and an order was given to x-ray the right shoulder and right clavicle. The x-ray results revealed mildly displaced acute fracture of distal clavicle. The r esident has a mild degree of osteopenia and [MEDICAL CONDITION]. Staff attempted to reach resident when she stood up but was not able to catch her on time. Resident did not call for assistance prior to getting up from the chair. The resident was eating while the staff was assisting the other resident. The resident is able to feed herself and needs encouragement to complete meals. The care plan was updated on 09/09/19 with interventions added, including bed is lowest position and floor mats as ordered. An interview was conducted with Staff C on 09/11/19 at 3:36 PM revealed that they do not update the care plan after each incident if interventions are in place already. An interview was conducted with Staff D, Risk Manager and Assistant Director of nurses on 09/12/19 at 4:30 PM, which revealed that the nurse puts in the investigation report, then Staff D speaks to the resident's nurse and the CNAs. During the morning meetings with the department heads and the unit managers, they talk about the incident and the Director of Nurses (DON) decides if the incident is reportable or not. Staff D continued to reveal that the nurses are able to update care plans. Staff D also confirmed that the care plan for Resident #38 was not updated after each fall. It was revealed that she fills out an incident follow-up and recommendation form which is attached to the incident investigation form and it stays in her office. If the intervention for the fall is already on the care plan, the care plan is not updated. An interview was conducted with the DON on 09/12/19 at 5:00 PM which revealed that one on one is never done. An interview was conducted with the Administrator on 09/12/19 at 5:20 PM and revealed that the facility purchased a new bed for Resident #38. Rehabilitation screening were done for the resident post falls. He has met with the resident's family member many times and has not come up with new interventions for the resident. 2. Review of the medical record for Resident #51 revealed an original admission date of [DATE] and a readmission date of [DATE], with [DIAGNOSES REDACTED]. The resident had two unwitnessed falls on 6/19/19 and 8/11/19. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference (ARD) date of 06/25/19 for Resident #51 revealed a Brief Interview for Mental Status (BIMS) score of 11 which revealed she was moderately cognitively impaired. Review of the facility documentation regarding follow-up and recommendations, dated 06/19/19 documented that Resident #51 was alert and oriented. Regarding her fall, she had stated she was going to the toilet and missed the seat. Recommendations/Action taken were Post-fall screening by Rehab. and instructed the resident to use call light to use restroom. Review of the facility documentation, dated 06/20/19, documented that Resident #51 was found on the bathroom floor, in a sitting position, leaning against the wheelchair. A documented full assessment was done, that indicated no injury was noted. Neuro checks were started. Vital signs were within normal limits. The resident was able to perform Range of Motion. The resident was confused and had gait imbalance. The fall was unwitnessed. Review of the facility documentation regarding follow-up and recommendations, dated 08/12/19 documented that Resident #51 attempted to walk without assistance. She stated she was trying to go to bed. Recommendations/Action taken- Redirection & monitoring of resident. Post-fall screening by Rehab. Follow-up- Staff to toilet as needed and ambulation as needed with staff assistance. Review of the facility documentation, dated 08/14/19, documented that the Resident #51 was found on the floor by the Certified Nursing Assistant (CNA). The nurse observed the resident lying on the floor, supine with a pillow under her head. Vital signs were checked, The X-ray staff person was onsite, so an X-ray was ordered right away. No injuries observed. Resident had impaired memory and gait imbalance. Reviewed of all care plans, including the fall care plan with onset date of 02/11/19 indicated all fall prevention interventions for Resident #51 were initiated on 03/29/19. There were no new fall interventions after this date to help prevent further falls. 3. Review of the medical record for Resident #119 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 05/02/19 for Resident #119 revealed a BIMS score of 13 indicating the resident is cognitively intact. Review of the quarterly MDS with an ARD date of 08/02/19 revealed a decrease of the BIMS score to 11, indicating the resident had declined cognitively to moderately impaired. Review of the facility documentation regarding follow-up and recommendations, dated 08/22/19 documented that Resident #119 ambulated with a walker and attempted to walk to the bathroom without staff assistance. She was confused and unable to follow direction. Recommendations/Action taken were: Redirection and monitoring of resident. Post-fall screening by Rehab. Resident needed to be toileted and ambulated as needed with staff assistance. Review of the facility documentation, dated 09/06/19, documented Resident #119, had an unwitnessed fall on 08/22/19, was found on the floor with no injuries, she was incontinent, was confused and had gait imbalance. Review of the care plans, including the fall care plans revealed that all of the fall prevention interventions had an onset date of her 04/25/19 admitted , and were not updated to help prevent further falls.

Based on record review, interview, and facility policy review, the facility failed to ensure 1 of 3 sampled residents (Resident #1) was free from neglect by failing to respond when the resident was experiencing a change in condition, and to provide emergency care when the resident was later found unresponsive. The facility nursing staff failed to respond to a change in a resident's condition, and provide basic life support, including Cardiopulmonary Resuscitation (CPR), to a resident who was a Full Code, and the resident died . The facility actions resulted in Immediate Jeopardy. This has the potential to affect 120 of 180 residents who are Full Code status in the facility. The Administrator was informed of the existence of the Immediate Jeopardy on [DATE] at 5:30 PM. The immediate jeopardy was on-going at the time of the exit on [DATE]. Cross Reference to F678 and F835. The findings included: A review of the facility's policy on Protection of Residents: Reducing the Threat of Abuse & Neglect, dated (MONTH) (YEAR), defines Neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect may be the result of a pattern of failures or may be the result of one or more failures involving one resident and one staff person. A review of the facility's policy Cardiopulmonary Resuscitation (CPR) Guidelines dated [DATE], documented: Personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel. An interview was conducted with the Assistant Director of Nursing (ADON) on [DATE] at 9:30 AM. The ADON stated, if a resident is unresponsive, the staff would call a Code Blue or STAT (rapid response) to the resident's room. The ADON stated, they did not have a written Code Blue policy, which designates responsibilities. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Comprehensive Minimum Data Set (MDS) Assessment, with an Assessment Reference Date of [DATE] documented Resident #1 as having mild cognitive impairment and required extensive assistance of one person for activities of daily living (ADL's). A review of Resident #1's physician orders [REDACTED]. Resident #1 was care planned on [DATE] as a Full Code, with an intervention that the resident has decided to remain a Full Code. A review of Resident #1's Progress Notes revealed, a nursing note dated [DATE] at 4:00 AM which documented: At 7:47 PM patient was picked up by family/friend to go to church. By 11:50 PM call placed by this writer (phone number) to check on pt (patient). Call was not answered and no call back. By 1:47 AM patient came accompanied by friend as per patient. Patient appeared to be lethargic and tired. Pt was assisted with ADL's and placed into bed. At 2:15 AM vital signs blood pressure: ,[DATE] (mmHg), Pulse:100 (beats/minute), Respirations: 16 (breaths/minute), temperature: 98.9 (degrees Fahrenheit) and pt. was left in bed resting. At 3:40 AM when enter the room, the patient was unresponsive, Code Blue was called and CPR performed by staff. No vital signs noted, call placed to doctor, message left to call back facility. Family member notified. Resident #1's vital signs in the clinical record revealed Resident #1's baseline blood pressure range was 131-,[DATE]-92 mmHg, and pulse rate range was ,[DATE]. Normal blood pressure is ,[DATE] and normal pulse rate is ,[DATE] beats/minute. Further review of Resident #1's clinical record did not reveal any interventions to address the resident's low blood pressure or elevated heart rate, upon her return from therapeutic leave. According to the Nursing Progress notes, Resident #1 expired 1 hour and 25 minutes after Staff A, a Registered Nurse (RN) assessed the resident's low blood pressure and elevated heart rate. A telephone interview was conducted on [DATE] at 1:45 PM with Staff E, a Certified Nursing Assistant (CNA), who worked with Resident #1 on the night she expired. Staff E stated when Resident #1 came back to facility, the resident stated she was tired and wanted to sleep. Staff E cleaned her up and put her to bed. Staff E stated, she said good night and the resident said good night at 2:05 AM. Staff E further stated, she went back to check on Resident #1 at 3:15 AM, and she did not look right. Staff E stated, she called Staff A to come and look at Resident #1. Staff E stated, Staff A came into Resident #1's room, touched the resident's hand and her stomach, and walked out of the resident's room. Staff E further stated, when Staff A did not come back to the room after about 10 minutes, she went looking for Staff A. Staff E saw Staff A heading back into Resident #1's room, and asked her what's going on with Resident #1. Staff E stated, Staff A told her Resident #1 died , and covered her up. Staff E did not witness Staff A or any other staff perform CPR on Resident #1. An telephone interview was conducted with Staff A on [DATE] at 4:45 PM. Staff A stated, Resident #1 left the faciity on [DATE] around 7:00 PM, and came back at 1:47 AM. Looked lethargic. Staff A stated, the resident was cleaned and put to bed at 2:15 AM. Staff A stated, she told Staff E to check on Resident #1 because her blood pressure was low. Staff A stated, at 3:45 AM Staff E told her Resident #1 was not breathing. Staff A stated, she called for help, started CPR, and checked vital signs, and there were none. Staff A stated, Staff B, Staff C, and Staff D, all RNs, came into the resident room and assisted with CPR. Staff A stated, she sent Staff E to check on the other residents. Staff A stated, they kept doing CPR, and nothing happened, so they stopped. Staff A acknowledged, Resident #1 was a Full Code. Staff A stated she did not call 911. Staff A stated, she must have been in shock, as she did not expect Resident #1 to code. Staff A stated, she called the doctor and left a message, then called the family. An interview was conducted with Staff B, an RN, on [DATE] at 5:00 PM. Staff B stated, she worked the night shift on [DATE]. Staff B stated, if a resident is unresponsive, they are supposed to call a Code Blue over the intercom, and everyone is to report to the room, and start CPR, and continue until Emergency Medical Services (EMS) arrived and took over. Staff B stated, she did not hear a Code Blue called on the night shift on [DATE], nor did she enter into Resident #1's room. Staff B stated, she was informed by Staff A that Resident #1 had expired. A phone interview was conducted with Staff C, an RN, on [DATE] at 10:00 AM. Staff C stated, she was not assigned to Resident #1, and worked on a different unit, on the night shift on [DATE]. Staff C stated, she did not see Resident #1, nor did she hear a Code Blue called. Staff C stated Staff A informed her a resident had died . Staff C further stated, Staff A was doing a double shift that night. Staff C further stated, the policy is CPR is to be continued until EMS arrived after calling 911. Multiple attempts were made to contact RN, Staff D. There was no return call. The facility's analysis, dated [DATE], documented: Resident was found unresponsive by CNA who then notified the nurse. The Nurse stated, she performed CPR, patient was already cold, with no pulse. The nurse did not call 911 per facility policy. An interview was conducted with the facility's Nursing Home Administrator (NHA) on [DATE] at 4:30 PM. The NHA stated, Staff A had come into the facility earlier that day to pick up her paycheck, and left the facility after being told to wait. The NHA further stated, Staff A was terminated. He also stated Staff A was reported to the Florida Board of Nursing. The NHA provided a copy of the completed healthcare practitioner form, dated [DATE], which documented: It was discovered that on [DATE] at approximately 3:40 AM, Resident #1 was found unresponsive by the C.N.A. (Staff E). She proceeded to call the nurse (Staff A) to the room. Staff A went to the room, failed to initiate CPR on a resident that was a Full Code status and failed to call 911. Staff A failed to follow regulation and facility policy. The associate was immediately suspended pending investigation, and employment has been terminated. The NHA stated all staff are CPR certified upon hire. In an interview with the NHA and ADON on [DATE] at 3:00 PM, they stated the facility did not conduct simulated mock drills to ensure that staff were competent to respond to an unresponsive resident according to facility policy and standards of practice.

Based on interview, record review, and policy review, the facility administration failed to administer the nursing home in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This affected 1 of 3 sampled residents reviewed for emergency care (Resident #1). The facility failed to monitor a resident's change in condition, neglected to provide cardiopulmonary resuscitation (CPR) to a resident who was a Full Code and the resident died . This has the potential to affect 120 of 180 residents who are Full Code status in the facility. The Administrator was informed of the existence of the Immediate Jeopardy on [DATE] at 5:30 PM. The immediate jeopardy was on-going, at the time of the exit on [DATE]. Cross reference to F600 and F678. The findings included: Per the Executive Director's (Nursing Home Administrator) Job Description Position Summary, revised [DATE]: The Executive Director provides leadership and direction for overall facility operations to provide quality patient care in accordance with all laws, regulations, and Life Care standards. Essential Functions include: Must ensure patients receive high quality care, must ensure facility is compliant with all Federal, State, and Local requirements as well as serve as the facility's Compliance Liaison, and must ensure facility is clean and safe for the comfort, convenience, and safety of patients, families, and staff. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Comprehensive Minimum Data Set (MDS) Assessment, with an Assessment Reference Date of [DATE] documented Resident #1 as having mild cognitive impairment and required extensive assistance of one person for activities of daily living (ADL's). A review of Resident #1's physician orders [REDACTED]. Resident #1 was care planned on [DATE] as a Full Code, with an intervention that the resident has decided to remain a Full Code. A review of Resident #1's Progress Notes revealed a nursing note dated [DATE] at 4:00 AM which documented: At 7:47 PM patient was picked up by family/friend to go to church. By 11:50 PM call placed by this writer (phone number) to check on pt (patient). Call was not answered and no call back. By 1:47 AM patient came accompanied by friend as per patient. Patient appeared to be lethargic and tired. Pt was assisted with ADL's and placed into bed. At 2:15 AM vital signs blood pressure: ,[DATE] (mmHg), Pulse:100 (beats/minute), Respirations: 16 (breaths/minute), temperature: 98.9 (degrees Fahrenheit) and pt. was left in bed resting. At 3:40 AM when enter the room, the patient was unresponsive, Code Blue was called and CPR performed by staff. No vital signs noted, call placed to doctor, message left to call back facility. Family member notified. Resident #1's vital signs in the clinical record revealed Resident #1's baseline blood pressure range was 131-,[DATE]-92 mmHg, and pulse rate range was ,[DATE]. Normal blood pressure is ,[DATE] and normal pulse rate is ,[DATE] beats/minute. Further review of Resident #1's clinical record did not reveal any interventions to address the resident's low blood pressure or elevated heart rate, upon her return from therapeutic leave. According to the Nursing Progress notes, Resident #1 expired 1 hour and 25 minutes after Staff A, a Registered Nurse (RN) assessed the resident's low blood pressure and elevated heart rate. Further review of Resident #1's clinical record did not reveal any documentation of the resident being pronounced deceased , or any disposition of the remains of Resident #1. An interview was conducted with the facility's Nursing Home Administrator (NHA) on [DATE] at 4:30 PM. The NHA stated Staff A had come into the facility earlier that day to pick up her paycheck, and left the facility after being told to wait. The NHA further stated Staff A was terminated. He also stated Staff A was reported to the Florida Board of Nursing. The NHA provided a copy of the completed healthcare practitioner form, dated [DATE], which documented: It was discovered that on [DATE] at approximately 3:40 AM, Resident #1 was found unresponsive by the C.N.A. (Staff E). She proceeded to call the nurse (Staff A) to the room. Staff A went to the room, failed to initiate CPR on a resident that was a Full Code status and failed to call 911. Staff A failed to follow regulation and facility policy. The associate was immediately suspended pending investigation, and employment has been terminated. The NHA stated all staff are CPR certified upon hire. On [DATE] at 5:00 PM, the NHA provided a list of five Registered Nurses (RN) and three Licensed Practical Nurses (LPN), who worked in the facility on the night shift on [DATE]. The surveyor questioned the NHA who was the charge nurse. The NHA stated, there is no charge nurse designated to serve on the night shift. The NHA further stated, there were five RN's, and any of them could be the charge nurse. In an interview with the NHA and ADON on [DATE] at 3:00 PM, they stated the facility did not conduct simulated mock drills to ensure that staff were competent to respond to an unresponsive resident according to facility policy and standards of practice. A review of the facility's policy Cardiopulmonary Resuscitation (CPR) Guidelines dated [DATE], documented: Personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel.

Based on record review, interview, and facility policy review, the facility failed to provide basic life support, including Cardiopulmonary Resuscitation (CPR), to 1 of 3 sampled residents reviewed for emergency care (Resident #1), who was found unresponsive and was a Full Code. The facility nursing staff failed to provide cardiopulmonary resuscitation to a resident and call for emergency medical services and the resident died . The facility's actions resulted in Immediate Jeopardy. This has the potential to affect 120 of 180 residents who are Full Code status in the facility. The Administrator was informed of the existence of the Immediate Jeopardy on [DATE] at 5:30 PM. The immediate jeopardy was on-going at the time of the exit on [DATE]. Cross reference to F600 and F835. The findings included: A review of the facility's policy Cardiopulmonary Resuscitation (CPR) Guidelines dated [DATE], documented: Personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Comprehensive Minimum Data Set (MDS) Assessment, with an Assessment Reference Date of [DATE] documented Resident #1 as having mild cognitive impairment and required extensive assistance of one person for activities of daily living (ADL's). A review of Resident #1's physician orders [REDACTED]. Resident #1 was care planned on [DATE] as a Full Code, with an intervention that the resident has decided to remain a Full Code. A review of Resident #1's Progress Notes revealed a nursing note dated [DATE] at 4:00 AM which documented: At 7:47 PM patient was picked up by family/friend to go to church. By 11:50 PM call placed by this writer (phone number) to check on pt (patient). Call was not answered and no call back. By 1:47 AM patient came accompanied by friend as per patient. Patient appeared to be lethargic and tired. Pt was assisted with ADL's and placed into bed. At 2:15 AM vital signs blood pressure: ,[DATE] (mmHg), Pulse:100 (beats/minute), Respirations: 16 (breaths/minute), temperature: 98.9 (degrees Fahrenheit) and pt. was left in bed resting. At 3:40 AM when enter the room, the patient was unresponsive, Code Blue was called and CPR performed by staff. No vital signs noted, call placed to doctor, message left to call back facility. Family member notified. Resident #1's vital signs in the clinical record revealed Resident #1's baseline blood pressure range was 131-,[DATE]-92 mmHg, and pulse rate range was ,[DATE]. Normal blood pressure is ,[DATE] and normal pulse rate is ,[DATE] beats/minute. Further review of Resident #1's clinical record did not reveal any interventions to address the resident's low blood pressure or elevated heart rate, upon her return from therapeutic leave. According to the Nursing Progress notes, Resident #1 expired 1 hour and 25 minutes after Staff A, a Registered Nurse (RN) assessed the resident's low blood pressure and elevated heart rate. A telephone interview was conducted on [DATE] at 1:45 PM with Staff E, a Certified Nursing Assistant (CNA), who worked with Resident #1 on the night she expired. Staff E stated when Resident #1 came back to facility, the resident stated she was tired and wanted to sleep. Staff E cleaned her up and put her to bed. Staff E stated she said good night and the resident said good night at 2:05 AM. Staff E further stated she went back to check on Resident #1 at 3:15 AM, and she did not look right. Staff E stated she called Staff A to come and look at Resident #1. Staff E stated Staff A came into Resident #1's room, touched the resident's hand and her stomach, and walked out of the resident's room. Staff E further stated when Staff A did not come back to the room after about 10 minutes, she went looking for Staff A. Staff E saw Staff A heading back into the Resident #1's room, and asked her what's going on with Resident #1. Staff E stated Staff A told her Resident #1 died , and covered her up. Staff E did not witness Staff A or any other staff perform CPR on Resident #1. An telephone interview was conducted with Staff A on [DATE] at 4:45 PM. Staff A stated Resident #1 left facility on [DATE] around 7:00 PM, and came back at 1:47 AM. Looked lethargic. Staff A stated the resident was cleaned and put to bed at 2:15 AM. Staff A stated she told Staff E to check on Resident #1 because her blood pressure was low. Staff A stated at 3:45 AM Staff E told her Resident #1 was not breathing. Staff A stated she called for help, started CPR, and checked vital signs, and there were none. Staff A stated Staff B, Staff C, and Staff D, all RNs, came into room and assisted with CPR. Staff A stated she sent Staff E to check on other residents. Staff A stated they kept doing CPR, and nothing happened, so they stopped. Staff A acknowledged Resident #1 was a Full Code. Staff A stated she did not call 911. Staff A stated she must have been in shock, as she did not expect Resident #1 to code. Staff A stated she called the doctor and left a message, then called the family. An interview was conducted with Staff B, an RN, on [DATE] at 5:00 PM. Staff B stated she worked night shift on [DATE]. Staff B stated if a resident is unresponsive, they are supposed to call a Code Blue over the intercom, and everyone is to report to the room, and start CPR, and continue until Emergency Medical Services (EMS) arrived and took over. Staff B stated she did not hear a Code Blue called on the night shift on [DATE], nor did she enter into Resident #1's room. Staff B stated she was informed by Staff A that Resident #1 had expired. A phone interview was conducted with Staff C, an RN, on [DATE] at 10:00 AM. Staff C stated she was not assigned to Resident #1, and worked on a different unit, on the night shift on [DATE]. Staff C stated she did not see Resident #1, nor did she hear a Code Blue called. Staff C stated Staff A informed her a resident had died . Staff C further stated Staff A was doing a double shift that night. Staff C further stated the policy is CPR is to be continued until EMS arrived after calling 911. Multiple attempts were made to contact RN Staff D. There was no return call. The facility's analysis, dated [DATE], documented: Resident was found unresponsive by CNA who then notified the nurse. The Nurse stated she performed CPR, patient was already cold, with no pulse. The nurse did not call 911 per facility policy. An interview was conducted with the facility's Nursing Home Administrator (NHA) on [DATE] at 4:30 PM. The NHA stated Staff A had come into the facility earlier that day to pick up her paycheck, and left the facility after being told to wait. The NHA further stated Staff A was terminated. He also stated Staff A was reported to the Florida Board of Nursing. The NHA provided a copy of the completed healthcare practitioner form, dated [DATE], which documented: It was discovered that on [DATE] at approximately 3:40 AM, Resident #1 was found unresponsive by the C.N.A. (Staff E). She proceeded to call the nurse (Staff A) to the room. Staff A went to the room, failed to initiate CPR on a resident that was a Full Code status and failed to call 911. Staff A failed to follow regulation and facility policy. The associate was immediately suspended pending investigation, and employment has been terminated. The NHA stated all staff are CPR certified upon hire. An interview was conducted with the facility's Medical Director on [DATE] at 12:30 PM. The Medical Director stated, he was aware of the incident with Resident #1. The Medical Director stated, he was aware of the facility' CPR policy. He also stated, they review policies and procedures every Wednesday in meetings in the facility. An interview was conducted with the Assistant Director of Nursing (ADON) on [DATE] at 9:30 AM. The ADON stated when a resident is unresponsive, a Code Blue is called. The ADON stated all staff report to the room of the code blue. Someone brings the crash cart, someone gets the resident's medical record, and someone calls 911. The ADON further stated they do not have a policy and procedure for Code Blue. In an interview with the NHA and ADON on [DATE] at 3:00 PM, they stated the facility did not conduct simulated mock drills to ensure that staff were competent to respond to an unresponsive resident according to facility policy and standards of practice.

Based on observation, record review and interview, the facility failed to provide the supervision necessary to prevent avoidable accidents at a level likely to allow, cause, or result in serious injury, harm, impairment, or death from burns and possible explosion as evidenced by: 1) Resident #74, whom the facility determined to be an unsafe smoker, sustained a burn of an undefined degree, that the facility failed to thoroughly investigate on 2/08/14; the resident was observed with lighters in her possession; 2) Resident #110, whom the facility determined to be as an unsafe smoker, was observed smoking unsupervised and without a smoking apron; the staff brought the resident inside the facility with a lit cigarette and placed him near the oxygen storage room on 4/08/14; the staff failed to ensure that the resident's cigarette was fully extinguished before the resident entered the facility on 4/09/14; 3) Resident #60, whom the facility determined to be an unsafe smoker and at risk for falls, was observed smoking unsupervised without a smoking apron, with lighters in his possession, and with broken/malfunctioning helmet and chair alarm; 4) Resident #41, whom the facility determined to be an unsafe smoker was observed having a lighter in his possession, which was against the facility's policy; 5) Resident #187, whom the facility initially determined to be an unsafe smoker as he kept lighters in his possession, was observed with a lighter in his possession. There are 22 smokers in the facility and on 4/10/14, the facility re-assessed the smokers and determined that 6 of 22 were unsafe smokers. 4 out of 6 unsafe smokers reviewed in the sample include Resident #74, #110, #60, and #41. The facility's practices put these four residents at immediate serious risk for potential harm, impairment and death. The Administrator was informed of the immediate jeopardy which began on 4/10/14 and the necessity of an extended survey. On 4/14/14 at approximately 2:30 PM the Administrator was informed the immediate jeopardy remained ongoing. The findings include: 1) Observation on 4/07/14 at 3:20 PM revealed, Resident #74 using a motorized wheelchair to ambulate independently inside the facility's hallways; the resident's wheelchair was equipped with a plastic tray. Further observation revealed that the resident had a pack of cigarettes, a lighter, and an ashtray on her plastic tray. In an interview conducted with the Unit Manager on 4/07/14 at 3:35 PM, the Unit Manager reported that the resident was "schizo-affective". Observation on 4/8/2014 at 9:09 AM revealed, the resident in her motorized wheelchair with a smoking apron on and a lighter and cigarettes on her wheelchair tray. The resident was observed coming inside the facility from the East Unit patio that the facility designated as a smoking area for the residents. Observation on 4/08/14 at 1:13 PM revealed, the resident in her room, in her electric wheelchair. The resident had the chair titled backwards extending all the way back and the back of her head was parallel to the floor; her legs were pointed towards the ceiling with the feet held in place by Velcro straps; there was a clear tray on the wheelchair. The resident was wearing a smoking apron. There was a pouch on her bedside table and a vehicle ashtray. The ashtray was observed to be a cup with a concave top with a small round hole in the middle of the top. The resident was looking up at the ceiling and talking to someone, but there was no one in the room. In an interview conducted with the resident at that time, the resident reported that she had been in the facility for 7 years and had no complaints. She stated that she was able to go and smoke on the patio whenever she wanted. She explained that she had cigarettes and a lighter in her possession, but the nursing staff kept the cigarette surplus. According to the resident, she was wearing a smoking apron per staff request. She acknowledged the ashtray on her bedside table and stated that she "just got it" to have it on her tray to make it "easier". Review of the Resident #74's clinical record on 4/08/14 revealed that the resident was admitted to the facility on [DATE] and readmitted on [DATE]. The resident's [DIAGNOSES REDACTED]. The clinical record revealed a PASRR/MI (Pre-admission Screening and Resident Review/ Mental Illness) Level II Determination Summary Report dated 9/27/11. The resident's clinical record included a Physician order [REDACTED]." According to a second Capacity Determination form, a Licensed Psychologist determined on 10/30/13 that the resident "does not have the capacity to make medical decisions based on informed consent." The clinical record indicated that the resident's most recent examination by her physician was on 4/03/14. The physician notes documented, "Continues to smoke as many cigarettes as she can get a hold of (mother and nursing staff trying to limit her to 2 every 2 hours but she gets some from other sources as well). When I ask her about it, she says 'I believe in it to help keep me alive with the CP ([DIAGNOSES REDACTED]). I observed her on the patio talking to herself. Upon further questioning, she says that there are studies showing the nicotine is helpful in CP, she may be willing to consider taking nicotine in a different form rather than from cigarettes. The plan included "discussed with patient re: possibility of getting nicotine from safer source such as patch, gum, lozenges, electronic cigs, etc. Discussed risks of smoking." The clinical record revealed that the resident was last seen by the Psychiatrist on 1/06/14. According to the notes, the resident had increased delusions. The clinical record included a physician order [REDACTED]. The resident's most recent Minimum Data Set Assessment (MDS), a quarterly with the assessment reference date of 1/29/14, revealed that the resident's BIMS (Brief Interview for Mental Status) score was 15, indicating lack of cognitive impairments; however, the resident had hallucinations and delusions. According to the MDS assessment, the resident needed limited assistance of one person for eating and extensive assistance of one person for personal hygiene. The assessment indicated that the resident was able to perform locomotion on and off the unit with supervision. The assessment revealed the resident had no range of motion limitations to both upper extremities; she received antipsychotic and antidepressant therapy in the 7 days prior to the assessment. Resident #74 had smoking safety assessments on 7/08/13, 8/08/13, 11/03/13, and 2/05/14. According to all the assessments, the resident did not attempt to keep smoking paraphernalia on self or in room, but dropped ashes on herself. The assessments indicated that the resident had not sustained burns to self or clothing related to cigarette smoking. According to the assessment, the resident "exhibits poor safety awareness when smoking and interventions must be placed to promote smoking safety." The assessment included, interventions to promote safe smoking practices will be placed on the resident's care plan. Interventions to consider include but are not limited to: - staff in attendance during all smoking times - smoking apron - cigarette holder - staff assistance to hold cigarette - occupational therapy intervention - social services intervention concerning compliance with smoking policies These smoking assessment failed to address the resident's ability to hold a lighter and cigarettes and her ability to use the non-portable lighter that is provided by the facility on the smoking patio. Further review of the resident's clinical record revealed a nursing note dated 2/08/14 at 1:02 PM. According to the note, "Resident alert and responsive resp (respiration) even and unlabored skin warm to touch, can express need, can feed self, good shower given this am, report to me by aid, that she noted two wounds on pt (patient's) left leg, assess it notice it was two burns marks, reported finding to pt Dr (doctor), received order to cleanse left leg burn w (with) nss (with normal saline) cover w (with) mepilex border q (every) 3 days and prn (as needed) until healed, gone out to her mom, call mom to report the incident yet to be contacted, will continue to monitor resident." There was no evidence that the facility had assessed the degree of the burn. The clinical record included a physician's orders [REDACTED]. The clinical record indicated that a wound care provider outside of the facility provided care to the resident on 2/12/14. The wound care provider notes of 2/12/14 revealed that the resident had a wound to the left anterior thigh, "origin: in-house, type: burn". The measurements were: area (sqCm): 0.16; length: 0.8; width: 0.2; dept: 0.2 estimate, with excessive necrotic tissue and mild serous drainage. According to the wound care notes of 2/12/14, "Patient educated to avoid tobacco products as it will hinder wound healing. (Resident #74) has a small necrotic wound to her left anterior thigh secondary to a cigarette burn. Treatment will be Santyl and dry dressing daily." According to subsequent notes of 2/19/14 from the wound management provider, the wound was resolved on 2/19/14. The resident's most recent social services assessment was dated 11/06/13. The assessment failed to contain any information regarding smoking, but it indicated that the resident at times, had delusions and visual and auditory hallucinations. The resident had a care plan in place, dated 11/07/13 for the problem "resident wishes to smoke". The problem was updated with: "2/05/14 - CP meeting cont poc (care plan meeting, continue with plan of care); "2/10/14 Hx (history) of unsafe smoker"; and "2/10/14 cigarette burns to leg". The goals include: "resident will smoke safely at designated area through next review date. Resident will use smoking apron safely while smoking and comply with safety measures thru next review." The interventions consisted of: "Provide resident with the following while smoking - smoking apron; Resident oriented to smoking procedures and areas (East Wing patio); Monitor for changes in smoking capabilities that require intervention/further intervention; educate resident on smoking policy; safe smoking screening completed on admission, quarterly and as needed." The care plan was updated on 2/10/14 with "Encourage resident to wear pants while smoking; encourage resident to bring smoking apron on LOA (leave of absence." The facility failed to revise the care plan to reflect the resident's need for supervision while smoking to ensure she was safe. Observation on 4/08/14 from 2:10 PM to 2:39 PM revealed the resident ambulating independently in her motorized wheelchair in the hallways of the facility. The resident had the ashtray on her wheelchair tray, visible to all who interacted with the resident. Observation on 4/08/14 at 2:39 PM revealed, the resident on the East Unit smoking patio with 3 cigarettes in her ashtray on the wheelchair tray; the resident had a smoking apron in place. Further observations at that time revealed the resident lighting a cigarette independently with a lighter and smoking independently. An automatic, non-portable lighter was observed on the patio, inside a pole that was attached to the ground. There were no staff members observed on the patio at that time. In an interview conducted on 4/08/14 at 2:45 PM with the resident's nurse, LPN#5, the nurse stated that the resident was alert and oriented; sometimes she hallucinates and has paranoia. According to the nurse, staff was trying to limit the resident's smoking, as requested by the resident's mother. However, the resident would buy cigarettes at times and the resident's mother allowed the resident to keep cigarettes in her possession. The nurse was then asked about how the resident would light her cigarettes and the nurse reported that the facility provided a non-portable lighter on the patio that was on a pole and the residents were expected to push a button to light a cigarette. The nurse then stated that she did not know whether the resident was expected or allowed to have her own lighter in her possession. She reported that she was not aware of the expectations of the facility's policy regarding residents having lighters in their possession. She reported that the surveyor would have to ask the Unit Manager regarding the policy. Observation on 4/08/14 at 2:56 PM revealed 8 residents on the smoking patio without direct facility staff supervision. The residents were observed smoking, including Resident #74. Staff was at the East Unit Nursing Station and the desk across from the nursing station, with no direct view of the residents. In an interview conducted with the East Unit Manager on 4/08/14 at 3:04 PM, the Unit Manager stated that Resident#74 was expected to wear an apron while smoking. She reported that the resident believed that smoking helped her CP ([DIAGNOSES REDACTED]) and the staff was trying to limit her smoking and give her cigarettes every "couple of hours". She reported that she was "relaxed about it" and allowed the resident to have more and the resident's mom agreed with that. According to the Unit Manager, the resident's nurse kept the resident's cigarettes in the medication room. She was asked if the resident was allowed to keep a lighter with her. She stated that she was not sure. She then asked the resident's nurse, LPN #5, who was in the area, if the resident was safe to have a lighter in her possession. The nurse replied that she did not know. The Unit Manager stated that she will "have to look at that". She stated that the resident "never has a problem if she does have a lighter." The Unit Manager stated that she did not believe that the resident had any smoking accidents. She explained that the resident had a smoking apron to prevent her from dropping cigarette ashes on herself. She was asked about the facility's policy related to residents keeping lighters in their possession. She stated that it was related to the resident's cognition if they were able to hold on to lighters. She reported that the resident "may be be schizophrenic, but may not be unsafe to keep the lighter". In an interview conducted on 4/08/14 at 3:20 PM with the Director of Nursing (DON), the DON reported that the facility tried to remove lighters from the resident, but at times she would not allow the staff to remove them. He reported that the facility had an electronic lighter in the courtyard. He stated that the facility had determined that the resident was a safe smoker, by the smoking assessment. The DON then reviewed the resident's clinical record and stated that the resident was noted as unsafe and staff had to mark that she was unsafe for the care plan to be in place. The DON stated, that he was not aware whether the resident had any accidents related to smoking. The DON then reviewed the resident's clinical record further and found the nursing note dated 2/08/14 regarding the resident's burns. He stated that he would look for the policy on smoking. Observation on 4/08/14 at 3:38 PM revealed, the resident at the nursing station, visibly upset. She stated, "someone from the state told them to take the lighters away and they took my lighters away". She stated, she has had lighters since "being here." In an interview conducted on 4/08/14 at 3:44 PM with the DON, the DON stated that he did not tell her that "the state" told the facility to take lighters away. He reported, that the resident informed him that her mom and dad told her that she could have lighters. However, he informed her that while at the facility she should not have a lighter. He stated, that in the past, the facility used to have a smoking monitor for resident supervision while smoking, but he was unsure when the facility had discontinue the practice. In an interview conducted on 4/08/14 at 11:20 AM and 2:03 PM with the Risk Manager/Assistant Director of Nursing (ADON), the ADON stated that the facility had two residents with burns in the past year; the only one related to cigarette smoke was the one for Resident #74 on 2/08/14, while the second burn occurred when a resident spilled hot coffee on himself. She reported, she had investigated the occurrence on 2/08/14 for Resident #74. According to the ADON, on 2/08/10 at 10:00 AM, the "shower staff" reported to the nurse that the resident had 2 wounds on her leg and the wounds were consistent with burn marks. The ADON stated, that the resident received treatment for [REDACTED]. She reported that the resident was unable to state how she had obtained the burns, but on 2/07/14, the resident was on an outing with her mother. The ADON was asked if the investigation included an interview with the resident's mother and interviews with other staff regarding observations of the resident smoking on 2/07/14 and 2/08/14. The ADON could not provide an answer, but stated that staff spoke with the resident's mother. She was then asked about the new interventions in the care plan, regarding wearing a smoking apron when on an outing, when the facility had not determined that the burn had occurred while the resident was on an outing. The ADON reported, the facility discussed the occurrence with the interdisciplinary team and decided on the new interventions. In an interview conducted on 4/09/14 at 2:34 PM with the MDS Coordinator, the Coordinator reported that she updated the resident's care plan for smoking on 2/10/14. According to the Coordinator, she was informed in a meeting that the resident had a burn on her leg. She stated that she spoke with the resident's mother and the mother stated that she did not know when the burn happened. She stated that she informed the ADON and the DON of the conversation and the DON asked a nurse to educate the mom regarding the smoking apron. The Coordinator acknowledged that she did not document that she spoke with the resident's mom regarding the incident. She presented a medication form that revealed a nurse educated the resident's mom on 2/11/14 and that the resident was to use a smoking apron while on outings outside of the facility. She reported, the facility included that intervention because they wanted the resident to be safe on outings, but not because they had determined that the resident sustained [REDACTED]. She then stated, the ADON initiated the intervention regarding the resident to wear pants while smoking. In a telephone interview conducted on 4/09/14 at 3:53 PM the resident's mother, stated, that she was not sure how the burn on the resident's leg occurred on 2/08/14, but that it happened while the resident was in the facility and not on the outing with her. The mother stated that the resident had lighters in her possession because she was not able to reach and use the pole lighter on the facility patio. Resident #74's mother stated that she brings cigarettes to the facility for the resident every Saturday, but would give the cigarettes to the nurse. During a further interview, she stated that the facility used to provide a smoking monitor to supervise the residents while on the smoking patio, but reported that the program ended "last year sometime or the year before". The resident's mother reported that the facility had not discussed the resident's smoking with her during the care plan conferences. However, she visits her daughter often and speaks with staff about the resident. 2) Observation on 4/08/2014 at 9:16 AM revealed Resident #110 sitting at the East Unit nurses station, in a wheelchair with a smoking apron on, awaiting his cigarettes. The Unit Manager handed the resident 2 cigarettes, adjusted the apron and the resident went out to the patio to smoke unsupervised. The resident was handed a lighted cigarette by Resident #41 to light his cigarette, then Resident#110 dropped the lit cigarette in between himself and the wheelchair. After approximately 30 seconds, the cigarette was found and was then dropped on the ground. Resident #41 then used his personal lighter and lit another cigarette for Resident #110. Observation on 4/08/14 at 2:59 PM revealed Resident#110 was smoking a cigarette, on the smoking patio by the automatic doors to the East Unit. He did not have a smoking apron in place. There was no staff present on the patio. The resident was observed waiving off another resident who was persistently asking him for a cigarette. Resident #74 was observed ambulating in his wheelchair toward the doors leading inside of the facility. The doors opened and the resident stopped on the threshold and remained there with a lit cigarette in his right hand. An aide, who was passing by the resident observed him on the threshold and pulled the resident in the wheelchair inside of the building, by the nursing station. Further observations revealed the nursing station is approximately 5 feet away from a clean storage room that had "no smoking and oxygen" signs posted on the closed entrance door and wall. The resident still had a cigarette in his right hand and smoke was observed coming from the cigarette. The resident remained there until the surveyor alerted an aide, who was at the kiosk across from the nursing station, that the resident had a lit cigarette. The aide took the resident to the smoking patio and another aide retrieved a smoking apron from the resident's room. In an interview conducted on 4/08/14 at 3:01 PM with the Unit Manager, the Manager was made aware of the observation. She stated that she "will have a talk with the resident" and explained that he was non-compliant with care. The Unit Manager was made aware that the aide assisted the resident to enter the building, while the resident had a lit cigarette in his hand. The Unit Manager then went to the patio and spoke with the aide. In a subsequent interview conducted on 4/08/14 at 3:04 PM with the Unit Manager, the Manager stated that the resident was expected to wear a smoking apron, but staff had to remind him to wear it, as the resident would take the apron off independently. She was asked how the resident was supervised when he smoked and the Manager stated that the staff "try to keep an eye on him", but explained that the resident did not have any one-to-one interventions in place. Observation of the clean utility room with "no smoking/oxygen" signs in place on 4/08/14 at 3:09 PM with the Unit Manager revealed 4 portable oxygen dispensers that were full and 2 empty oxygen dispensers. The Unit Manager acknowledged the observation. Observation on 4/09/14 at 9:19 AM revealed the resident exiting his room, independently in his wheelchair. He was wearing a smoking apron. The resident was observed then going to the nursing station and waiting by the nursing station gate. The resident then left the nursing station and returned on 4/09/14 at 9:29 AM; he was no longer wearing the smoking apron. Observation on 4/09/14 at 9:42 AM revealed the resident by the nursing station. The Unit Manager provided him with a smoking apron. The resident then went to the smoking patio independently in his wheelchair. He was observed there alone, with no other residents or staff on the East Unit smoking patio. The resident was observed searching his wheelchair, by his hips. He did not answer when asked why he was searching the wheelchair. In an interview conducted on 4/09/14 at 9:48 AM with the Unit Manager, the Manager reported that she had not provided the resident with a cigarette, as of yet. She was then observed providing him with a cigarette at 9:48 AM and assisting him to light it. The Unit Manager then stated that she needed to "keep an eye on him; he takes his smoking apron off". However, the Unit Manager then left the resident and the patio area. The resident remained unsupervised on the smoking patio. Observation on 4/09/14 at 9:58 AM revealed, the resident entering the building from the smoking patio thru the door to the A Wing hallway. The resident had a partially smoked cigarette in his mouth. There was no visible smoke observed, but there was a smell of smoke present. In an interview conducted with the resident at that time, the resident indicated that he needed a lighter, by making a gesture consistent to using a lighter to light up a cigarette. A nurse, LPN#4, was observed with a medication cart approximately 10 feet away from the resident. The nurse observed the resident with the cigarette in his mouth and stated to the surveyor, "He always does this". The nurse failed to check the resident to ensure that the cigarette was not lit and that the resident received the assistance he needed. The resident was then observed holding the cigarette in his hand and going to the hydration station. Review of Resident #110's clinical record on 4/09/14 revealed that the resident was admitted to the facility on [DATE] and readmitted on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident's current physician orders [REDACTED]. " The most recent smoking safety assessment of 3/13/14 revealed that it was determined that the resident failed to appropriately use ashtrays, dropped ashes on self, sustained burns to self or clothing related to cigarette smoking and was non-compliant with smoking regulations in the facility. He was deemed to be unsafe to smoke without supervision. The resident's most recent MDS assessment, a quarterly with the assessment reference date (ARD) of 2/28/14, revealed that the resident had unclear speech, sometimes understood others and his brief interview for mental status score was 2, which indicated severe cognitive impairment. According to the assessment, the resident rejected care and had behavioral symptoms not directed toward others (e.g. physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds)". The assessment revealed that the resident needed supervision for eating and locomotion on and off the unit; and extensive assistance of one person for personal hygiene. The resident's clinical record included a care plan dated 9/05/13. The problem was listed as "Resident wishes to smoke". The goal was for the "Resident will not experience injury or burns from smoking and be compliant with wearing smoking apron for safety thru next review." The approaches consisted of "Smoking assessment quarterly and prn (as needed) to determine abilities. Smoking area designation: East Wing patio. Monitor for changes in smoking abilities that may require additional interventions. Smoking apron to be worn for smoking." According to the document, the facility reviewed the care plan on 12/04/13 and 3/04/14, but failed to add any new interventions. It was noted that the care plan failed to specify that the resident was an unsafe smoker and failed to address supervision for the resident. In an interview conducted on 4/09/14 at 2:39 PM with CNA (Certified Nursing Assistant) #1, who brought the resident inside the East unit while he was smoking and placed him next to the oxygen storage room. CNA #1 explained that she thought she was helping the resident enter the building, but did not notice that he had a lit cigarette in his hand. An interview was conducted on 4/09/14 at 2:44 PM with LPN #4, the nurse who observed the resident entering the A Wing hallway with a cigarette in his mouth. LPN #4 explained that she had observed the resident in the facility with a cigarette in his possession, although she had not previously observe him with a cigarette in his mouth inside the facility. The LPN stated that she believed that she observed the cigarette was not lit when he entered the facility, "unless he switched it". In an interview conducted on 4/09/14 at 10:00 AM with the Unit Manager, the Manager was asked about supervision for the resident when he smoked. The Manager stated that there was no "smoking monitor" on the smoking patio but "we are doing our best" regarding supervising the resident. She reviewed the resident's care plan and stated "monitoring" addressed staff supervision of the resident. The Unit Manager reviewed the resident's care plan for smoking and reported that she did not know how the resident would be supervised. The Manager pointed to the intervention to "monitor for changes in smoking abilities that may require additional interventions" and stated that the intervention addressed supervision. However, the Manager was unable to state how the intervention was measured. 3) Upon observation of the East Wing Nurses station on 04/07/2014 at 1:02 PM, the Surveyor observed Resident #60 take a cigarette from a pack of cigarettes he had with him and place a cigarette in his mouth. The resident then wheeled himself outside to the smoking patio, unsupervised by facility staff and lit the cigarette with a personal use lighter he pulled from his pants pocket. The resident was observed to have an exposed plate to the head, underneath a safety helmet that was unsecured with the straps dangling on each side of his head; the exposed plate is located just below the safety helmet. On 04/08/2014 at 9:04 AM Resident #60 was observed sitting outside on the smoking patio unsupervised by facility staff and was smoking. The resident was sitting in the wheelchair with no smoking apron on and had a personal lighter in hand. Continued observation revealed Resident #60 lighting a second cigarette while leaning forward in his wheelchair using a personal lighter. The resident was wearing his helmet, but straps were again unsecured. Resident #60 was observed sitting outside smoking unsupervised by facility staff on 04/08/2014 at 2:20 PM; the resident was wearing his helmet, but straps were again unsecured. The resident had a lighter and a pack of cigarettes in his hand. Observation on 04/09/2014 at 9:25 AM revealed that the privacy curtain was closed to Resident #60's bedside. The surveyor then knocked on the door and after given permission to enter, it was discovered that the resident was standing next to his bed and he was not wearing his safety helmet, as the resident was putting on a smoking apron. Resident #60 had a wheelchair alarm in place, but it was not alarming. The resident stated that he was heading outside to smoke. The top drawer of his nightstand was open and it was observed to contain three lighters and a pack of cigarettes. Record review of Resident #60's clinical record on 04/09/2014 revealed that he was admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. On 03/12/2014, Resident #60 was deemed to not have the capacity to make medical decisions based on informed consent by the Licensed Psychologist. On 05/24/2012, after a fall requiring hospitalization , an order was placed for Resident #60 to wear a safety helmet when out of bed for protection of an exposed plate with screws to his right temporal lobe. The Smoking Safety Assessment that was conducted on 03/11/2014, 12/11/2013 and 09/03/2013 documents that the resident exhibits poor safety awareness when smoking and interventions must be placed to promote smoking safety. It documents that the resident drops ashes on self and he has not demonstrated ability to safely smoke cigarettes without supervision. The facility reassessed all the smoking residents in the facility on 04/09/2014 and Resident #60 was again determined to be an unsafe smoker. The Care Plan for smoking documents that the resident has poor safety awareness when smoking. Interventions for this resident include wearing a smoking apron, monitor for changes in smoking capabilities that require intervention/fu 5) A review of Resident #187's records was conducted on 4/9

Based on observation, record review and interview, the facility failed to develop, review and revise, as necessary, care plans for residents who smoke to prevent avoidable accidents at a level likely to allow, cause, or result in serious injury, harm, impairment, or death [MEDICAL CONDITION] possible explosion as evidenced by: 1) Resident #74, whom the facility determined to be an unsafe smoker, sustained a burn of undefined degree that the facility failed to thoroughly investigate on 2/08/14; the resident was observed with lighters in her possession during the survey; 2) Resident #110, whom the facility determined to be as an unsafe smoker, was observed smoking unsupervised and without a smoking apron; the staff brought the resident inside the facility with a lit cigarette and placed him near the oxygen storage room on 4/08/14; the staff failed to ensure that the resident's cigarette was fully extinguished before the resident entered the facility on 4/09/14; 3) Resident #60, whom the facility determined to be an unsafe smoker, was observed smoking unsupervised without a smoking apron, with lighters in his possession, and with a broken/malfunctioning helmet and chair alarm; 4) Resident #41, whom the facility determined to be an unsafe smoker was observed with a lighter in his possession, which was against the facility's policy; 5) Resident #187, whom the facility initially determined to be an unsafe smoker was observed with a lighter in his possession. There are 22 smokers in the facility and on 4/10/14, the facility re-assessed the smokers and determined that 6 of 22 were unsafe smokers. 4 out of the 6 unsafe smokers reviewed in the sample include Resident #74, #110, #60, and #41. The facility's practices put these four residents at immediate serious risk for potential harm, impairment and death. The Administrator was informed of the immediate jeopardy which began on 4/10/14 and the necessity of an extended survey. On 4/14/14 at approximately 2:30 PM the Administrator was informed the immediate jeopardy remained ongoing. The findings include: 1) Observation on 4/07/14 at 3:20 PM revealed Resident #74 using a motorized wheelchair to ambulate independently inside the facility's hallways; the resident's wheelchair was equipped with a plastic tray. Further observation revealed that the resident had a pack of cigarettes, a lighter, and an ashtray on her plastic tray. In an interview conducted with the Unit Manager on 4/07/14 at 3:35 PM, the Unit Manager reported that the resident was "schizo-affective". Observation on 4/08/14 at 1:13 PM revealed, the resident in her room, in her electric wheelchair. In an interview conducted with the resident at that time, the resident reported that she had been in the facility for 7 years and had no complaints. She stated that she was able to go and smoke on the patio whenever she wanted. She explained that she had cigarettes and a lighter in her possession, but the nursing staff kept the cigarette surplus. According to the resident, she was wearing a smoking apron per staff request; and it did not bother her to wear it. The resident reported that she had not had any accidents related to smoking "in a long time". She acknowledged, the ashtray on her bedside table and stated that she "just got it" to have it on her tray to make it "easier." Review of the Resident #74's clinical record on 4/08/14 revealed that the resident was admitted to the facility on [DATE] and readmitted on [DATE]. The resident's [DIAGNOSES REDACTED]. The clinical record revealed a PASRR/MI (Pre-admission Screening and Resident Review/ Mental Illness) Level II Determination Summary Report dated 9/27/11. The resident's clinical record included a Physician order [REDACTED]." According to a second Capacity Determination form, a Licensed Psychologist determined on 10/30/13 that the resident "does not have the capacity to make medical decisions based on informed consent." The clinical record indicated that the resident's most recent physician exam was 4/03/14. The physician notes documented, "Continues to smoke as many cigarettes as she can get a hold of (mother and nursing staff trying to limit her to 2 every 2 hours but she gets some from other sources as well). When I ask her about it, she says 'I believe in it to help keep me alive with the CP ([MEDICAL CONDITION]). She is still having auditory hallucinations. "Discussed risks of smoking." The resident's most recent Minimum Data Set Assessment (MDS), a quarterly with the assessment reference date of 1/29/14, revealed that the resident's brief interview for mental status score was 15, indicating lack of cognitive impairments; however, the resident had hallucinations and delusions. According to the MDS assessment, the resident needed limited assistance of one person for eating and extensive assistance of one person for personal hygiene. The assessment indicated that the resident was able to perform locomotion on and off the unit with supervision. The assessment revealed the resident had no range of motion limitations to both upper extremities. Resident #74 had smoking safety assessments on 7/08/13, 8/08/13, 11/03/13, and 2/05/14. According to all the assessments, the resident did not attempt to keep smoking paraphernalia on self or in room, but dropped ashes on herself. The assessments indicated that the resident had not [MEDICAL CONDITION] self or clothing related to cigarette smoking. According to the assessment, the resident "exhibits poor safety awareness when smoking and interventions must be placed to promote smoking safety." The assessment included, interventions to promote safe smoking practices will be placed on the resident's care plan. Interventions to consider include, but are not limited to: - staff in attendance during all smoking times - smoking apron - cigarette holder - staff assistance to hold cigarette - occupational therapy intervention - social services intervention concerning compliance with smoking policies These smoking assessment failed to address the resident's ability to hold a lighter and cigarettes and her ability to use the non-portable lighter that is provided by the facility on the smoking patio. Further review of the resident's clinical record revealed a nursing note dated 2/08/14 at 1:02 PM. According to the note, "Resident alert and responsive resp (respiration) even and unlabored skin warm to touch, can express need, can feed self, good shower given this am, report to me by aide, that she noted two wounds on pt (patient's) left leg, assessed it and noticed it was two burn marks, reported finding to pt Dr (doctor), received order to cleanse left leg burn w nss (with normal saline) cover w (with) [MEDICATION NAME] border q (every) 3 days and prn (as needed) until healed, will continue to monitor resident." There was no evidence that the facility had assessed the degree of the burn. The clinical record indicated that a wound care provider outside of the facility provided care to the resident on 2/12/14. The wound care provider notes of 2/12/14 revealed that the resident had a wound to the left anterior thigh, "origin: in-house, type: burn." The measurements were: area (sqCm): 0.16; length: 0.8; width: 0.2; dept: 0.2 estimate, with excessive necrotic tissue and mild serous drainage. According to the wound care notes of 2/12/14, "Patient educated to avoid tobacco products as it will hinder wound healing. (Resident #74) has a small necrotic wound to her left anterior thigh secondary to a cigarette burn. Treatment will be Santyl and dry dressing daily." According to subsequent notes of 2/19/14 from the wound management provider, the wound was resolved on 2/19/14. Resident #74 has a care plan in place, dated 11/07/13 for the problem "resident wishes to smoke". The problem was updated, "2/05/14 - CP meeting cont poc (care plan meeting, continue with plan of care)"; "2/10/14 Hx (history) of unsafe smoker"; and "2/10/14 [MEDICAL CONDITION] leg". The goals include: "resident will smoke safely at designated area through next review date. Resident will use smoking apron safely while smoking and comply with safety measures thru next review." The interventions consisted of: "Provide resident with the following while smoking - smoking apron; Resident oriented to smoking procedures and areas (East Wing patio); Monitor for changes in smoking capabilities that require intervention/further intervention; educate resident on smoking policy; safe smoking screen completed on admission, quarterly and as needed." According to the care plan, the licensed nurse was expected to monitor the resident for change in smoking capabilities. The care plan was updated on 2/10/14 with "Encourage resident to wear pants while smoking; encourage resident to bring smoking apron on LOA (leave of absence)." The facility failed to revise the care plan to reflect the resident's need for supervision while smoking to ensure she was safe. Observation on 4/08/14 at 2:39 PM revealed Resident 74 on the East Unit smoking patio with 3 cigarettes in her ashtray on the wheelchair tray. Further observations at that time revealed the resident lighting a cigarette independently with a green lighter and smoking independently. There were no staff members observed on the patio at that time. Observation on 4/08/14 at 2:56 PM revealed 8 residents on the smoking patio. There was no staff present. They were smoking. Staff was at the East Wing Nursing Station and the desk across from the nursing station, with no direct view of the residents. Resident #74 was one of the residents. In an interview conducted on 4/08/14 at 3:44 PM with the DON, he stated, in the past, the facility used to have a smoking monitor for resident supervision while smoking, but he was unsure when the facility discontinued the practice. 2) Observation on 4/08/2014 at 9:16 AM revealed, Resident #110 sitting at the East Unit nurses station in a wheelchair with a smoking apron on awaiting his cigarettes. The Unit Manager handed the resident 2 cigarettes, adjusted the apron and the resident went out to the patio to smoke unsupervised. The resident was handed a lighted cigarette by Resident #41 to light his cigarette. Resident #110 then dropped the lit cigarette in between himself and the wheelchair. After approximately 30 seconds the cigarette was found and was then dropped on the ground. Resident #41 then lit another cigarette for Resident #110 with his personal lighter. Observation on 4/08/14 at 2:59 PM revealed, Resident #110 smoking a cigarette while on the smoking patio, by the automatic doors to the East Unit. He did not have a smoking apron in place. There was no staff present on the patio. The resident was observed waving off another resident who was persistent about asking him for a cigarette. Resident #110 was observed ambulating in his wheelchair toward the doors. The doors opened and the resident stopped on the threshold and remained there with a lit cigarette in his right hand. An aide who was passing by the resident then pulled the wheelchair and resident, inside the building, by the nursing station. Observations revealed the nursing station is approximately 5 feet away from a clean storage room that had "no smoking and oxygen" signs present on the closed entrance door and wall. Further observations revealed the resident still had a cigarette in his right hand and smoke was observed rising from the cigarette. The resident remained there until the surveyor alerted an aide, who was at the kiosk across from the nursing station, that the resident had a lit cigarette. The aide took the resident to the smoking patio and another aide retrieved a smoking apron from the resident's room. In a subsequent interview conducted on 4/08/14 at 3:04 PM with the Unit Manager, the Manager stated that the resident was expected to wear a smoking apron, but staff had to remind him to wear it, as the resident would take the apron off independently. She was asked how the resident was supervised when he smoked and the Manager stated that the staff "try to keep an eye on him", but explained that the resident did not have any one-to-one interventions in place. Observation on 4/09/14 at 9:42 AM revealed resident #110 by the nursing station. The Unit Manager provided him with a smoking apron. The resident then went to the smoking patio independently in his wheelchair. He was observed there alone, with no other residents or staff on the East Unit smoking patio. The resident was observed searching his wheelchair, by his hips. He did not answer when asked why he was searching the wheelchair. In an interview conducted on 4/09/14 at 9:48 AM with the Unit Manager, the Manager reported that she had not provided the resident with a cigarette, but was then later observed providing him with a cigarette at 9:48 AM and assisting him to light it. The Unit Manager then stated that she needed to "keep an eye on him; he takes his smoking apron off". However, the Unit Manager then left the resident and the area. The resident remained unsupervised on the smoking patio. Review of the resident #110's clinical record on 4/09/14 revealed that the resident was admitted to the facility on [DATE] and readmitted on [DATE]. The resident's [DIAGNOSES REDACTED]. The most recent smoking safety assessment on 3/13/14 was reviewed. According to the assessment, he was found to fail to appropriately use ashtrays, dropped ashes on self, [MEDICAL CONDITION] self or clothing related to cigarette smoking and was non-compliant with smoking regulations in the facility. He was deemed to be unsafe to smoke without supervision. The resident's most recent MDS assessment, a quarterly with the assessment reference date (ARD) of 2/28/14, revealed that the resident had unclear speech, sometimes understood others and his brief interview for mental status score was 2, which indicated severe cognitive impairment. The assessment revealed that the resident needed supervision for eating and locomotion on and off the unit; and extensive assistance of one person for personal hygiene. The resident's clinical record included a care plan dated 9/05/13. The problem was listed as "Resident wishes to smoke". The goal included "Resident will not experience injury [MEDICAL CONDITION] smoking and be compliant wearing smoking apron for safety thru next review." The approaches consisted of "Smoking assessment quarterly and prn (as needed) to determine abilities. Smoking area designation: East Wing patio. Monitor for changes in smoking abilities that may require additional interventions. Smoking apron to be worn for smoking." According to the document, the facility reviewed the care plan on 12/04/13 and 3/04/14, but failed to add any new interventions. It was noted that the care plan failed to specify that the resident was an unsafe smoker and failed to address supervision for the resident. In an interview conducted on 4/09/14 at 10:00 AM with the Unit Manager, the Manager was asked about supervision for the resident when he smoked. The Manager stated that there was no "smoking monitor" on the smoking patio but "we are doing our best" regarding supervising the resident. She reviewed the resident's care plan and stated "monitoring" addressed staff supervision of the resident. The Unit Manager reviewed the resident's care plan for smoking and reported that she did not know how the resident would be supervised. The Manager pointed to the intervention to "monitor for changes in smoking abilities that may require additional interventions" and stated that the intervention addressed supervision. However, the Manager was unable to state how the intervention was measured. 3) Upon observation of the East Wing Nurses station on 04/07/2014 at 1:02 PM, the Surveyor observed Resident #60 take a cigarette from a pack of cigarettes he had with him and place a cigarette in his mouth. The resident then wheeled himself outside to the smoking patio, unsupervised by facility staff and lit the cigarette with a personal use lighter he pulled from his pants pocket. The resident was observed to have an exposed plate to the head, underneath a safety helmet that was unsecured with the straps dangling on each side of his head; the exposed plate to the head is located just below the helmet. On 04/08/2014 at 9:04 AM Resident #60 was observed sitting outside on the smoking patio unsupervised by facility staff and was smoking. The resident was sitting in the wheelchair with no smoking apron on and had a personal lighter in hand. Continued observation revealed Resident #60 lighting a second cigarette while leaning forward in his wheelchair using a personal lighter. The resident was wearing his helmet, but straps were again unsecured. Resident #60 was observed sitting outside smoking unsupervised by facility staff on 04/08/2014 at 2:20 PM; the resident was wearing his helmet, but straps were again unsecured. The resident had a lighter and a pack of cigarettes in his hand. Observation on 04/09/2014 at 9:25 AM revealed that the privacy curtain was closed to Resident #60's bedside. The surveyor then knocked on the door and after given permission to enter, it was discovered that the resident was standing next to his bed and not wearing his safety helmet, as the resident was putting on a smoking apron. Resident #60 had a wheelchair alarm in place, but it was not alarming. The resident stated that he was heading outside to smoke. The top drawer of his nightstand was open and it was observed to contain three lighters and a pack of cigarettes. Record review of Resident #60's clinical record on 04/09/2014 revealed that he was admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. On 03/12/2014, Resident #60 was deemed to not have the capacity to make medical decisions based on informed consent by the Licensed Psychologist. The Smoking Safety Assessment that was conducted on 03/11/2014, 12/11/2013 and 09/03/2013 documents that the resident exhibits poor safety awareness when smoking and interventions must be placed to promote smoking safety. It documents that he drops ashes on himself and he has not demonstrated the ability to safely smoke cigarettes without supervision. The resident's most recent MDS Assessment, an annual with the assessment reference date of 3/01/14 revealed that the resident's brief interview for mental status score was 11, which indicated moderate cognitive impairment. According to the MDS assessment, the resident needed supervision for eating and extensive assistance of one person for personal hygiene. Resident's #60's Care Plan for smoking documents that the resident has poor safety awareness when smoking. Interventions for this resident include: 1) wearing a smoking apron 2) monitor for changes in smoking capabilities that require intervention/further intervention 3) encourage resident to sit at table while smoking 4) educate resident on smoking policy 5) safe smoking screening quarterly and as needed There is no documentation in the care plan of Resident #60 being an unsafe smoker, requiring supervision by facility staff when smoking, or that the resident is not to have smoking materials. 4) Observation of the smoking patio on 04/08/2014 at 9:16 AM revealed that Resident #41 was outside smoking unsupervised and handed Resident # 110 a lit cigarette to use as a lighter to light Resident #110's cigarette. While Resident #110 was trying to light the cigarette, Resident #110 dropped the lit cigarette in-between himself and the wheelchair. Resident #110 was unsuccessful lighting the cigarette and Resident #41 removed a lighter from his pocket and lit Resident #110's cigarette for him. Record review of Resident #41's record revealed, Resident #41 was admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Resident #41 was deemed to not have capacity to make medical decisions as of 02/10/2010. The Smoking Safety Assessments that were conducted on 04/09/2014 and 01/28/2014 document that Resident #41 exhibits poor safety awareness when smoking. Interventions must be placed to promote smoking safety according to the smoking assessment of 1/28/14; the smoking assessment of 4/09/14 was incomplete and failed to specify whether smoking interventions were necessary. Both assessments documented that he dropped ashes on himself and he had [MEDICAL CONDITION] clothing related to cigarette smoking. The assessments state that the resident was non-compliant with the smoking regulations in the facility. Resident #41 had not demonstrated the ability to safely smoke cigarettes without supervision. The resident's most recent MDS Assessment, an annual with the assessment reference date of 1/21/14 revealed that the resident's brief interview for mental status score was 15, indicating lack of cognitive impairments; however, the resident had fluctuating behaviors of inattention and disorganized thinking. According to the MDS assessment, the resident needed supervision for eating and extensive assistance of one person for personal hygiene. Resident #41's Care Plan for smoking documents that the resident wishes to smoke. Interventions for this resident include: 1) Educate family/resident on smoking policy 2) Smoking assessment to determine abilities/safety 3) Smoking area designation: East Wing Patio 4) Monitor for changes in smoking abilities that may require additional interventions 5) Smoking Apron to be used when smoking There is no documentation in the care plan regarding Resident #41 being an unsafe smoker, needing supervision by facility staff when smoking or whether the resident is to have smoking materials. 5) A review of Resident #187's records was conducted on 4/9/14. Resident #187, was identified as a non-smoker on 9/14/13. On 10/2/13, the resident was identified as exhibiting poor safety awareness when smoking. The resident attempted to keep smoking paraphernalia on self or in room. On 10/2/13 a facility Registered Nurse assessed the resident on the Smoking Safety Assessment. Question 4 revealed: "Does resident attempt to keep smoking paraphernalia on self or in room?" The answer was "Yes". A (Yes) answer indicated the resident must exhibit poor safety awareness when smoking and interventions must be placed to promote smoking safety, the resident was deemed as an unsafe smoker. The resident's most recent MDS Assessment, a quarterly with the Assessment Reference Date of 3/15/14 revealed that the resident's brief interview for mental status score was 15, indicating lack of cognitive impairments; however, the resident had fluctuating behaviors of inattention and disorganized thinking. According to the MDS assessment, the resident needed supervision for eating and extensive assistance of one person for personal hygiene. A smoking care plan was initiated on 10/8/13 and updated on 12/26/13 and 3/24/14. The goals included: will smoke safely at designated area through next review date. The interventions were: "Resident oriented to smoking procedures and areas (East Wing Patio). Monitor for changes in smoking capabilities that require intervention/further intervention. Resident will demonstrate safe technique for putting out matches or lighter and disposing of ashes. Educate resident on smoking policy. Safe smoking screening completed on admission, quarterly and as needed". The care plan was updated 12/26/13 and 3/24/14. Subsequent smoking assessments 10/2/13, 12/18/13, and 3/18/14 identified the resident as a safe smoker. The facility re-assessed the resident on 4/09/14 and determined that he was a safe smoker. However, the care plan was not revised to reflect Resident #187 as a safe smoker until 4/10/14, during the survey. Review of the facility's policy and procedures regarding smoking on 4/09/14, revealed that the policy and procedure was "last revised: 9/04/12". The policy and procedures called for 3.) "A resident's ability to handle smoking material will be evaluated by the multidisciplinary team initially and quarterly using the smoking safety assessment. Each resident will be classified in one of the following categories: Resident allowed to smoke unsupervised or Resident allowed to smoke only with supervision." 4.) "Residents' smoking materials will always be kept at the nurses' station on the unit and given to residents by staff only. The use of lighters will be handled by staff only. Lighters/matches are not allowed in resident rooms or in the possession of any resident." Further review of the facility's policy and procedures for smoking revealed that the policy and procedures failed to address and define the supervision of the residents. Cross-reference to F323 and F520

Based on record review and interview, the facility's Quality Assessment and Assurance (QAA) committee failed to develop an appropriate plan of action to address facility practice following an incident in which resident experienced a possible burn from unsafe cigarette smoking. The QAA committee failed to address facility practice for allowing residents who were unsafe for independent smoking to smoke without facility staff supervision and allowing residents to keep cigarette lighters and cigarettes in their possession when they are unsafe to smoke independently. The failure to develop an appropriate action plan to address the unsafe smoking practices/situations for 5 of 22 residents who smoke and to the residents on the East unit, with a census of 48 residents as of 04/07/14, placed them at potential serious injury, harm, impairment [MEDICAL CONDITION] possible explosion and death. The Administrator was informed of the immediate jeopardy which began on 4/10/14 and the necessity of an extended survey. On 4/14/14 at approximately 2:30 PM the Administrator was informed the immediate jeopardy remained ongoing. The findings include: During the recertification survey from 4/07/14 to 4/11/14, deficient practice and immediate jeopardy was identified at F280 and F323 for the following: 1) Resident #74, whom the facility determined to be an unsafe smoker, sustained a burn that the facility failed to thoroughly investigate on 2/08/14; the resident was observed with lighters in her possession; 2) Resident #110, whom the facility determined to be as an unsafe smoker, was observed smoking unsupervised and without a smoking apron; the staff brought the resident inside the facility with a lit cigarette and placed him near the oxygen storage room on 4/08/14; the staff failed to ensure that the resident's cigarette was fully extinguished before the resident entered the facility on 4/09/14; 3) Resident #60, whom the facility determined to be an unsafe smoker, was observed smoking unsupervised without a smoking apron, with lighters in his possession, and with broken/malfunctioning helmet and chair alarm; 4) Resident #41, whom the facility determined to be an unsafe smoker was observed having a lighter in his possession, which was against the facility's policy; 5) Resident #187, whom the facility initially determined to be an unsafe smoker, due to the fact that he kept lighters in his possession was observed with a lighter in his possession. Review of the facility's policies and procedures on 4/09/14 revealed that the facility's smoking policy was last revised on 9/04/12. The policy and procedure included 3.) "A resident's ability to handle smoking material will be evaluated by the multidisciplinary team initially and quarterly using the smoking safety assessment. Each resident will be classified in one of the following categories: Resident allowed to smoke unsupervised or Resident allowed to smoke only with supervision." 4.) "Residents' smoking materials will always be kept at the nurses' station on the unit and given to residents by staff only. The use of lighters will be handled by staff only. Lighters/matches are not allowed in resident rooms or in the possession of any resident." Further review of the policy revealed that the facility failed to address how the supervision would be provided to the residents who were allowed to smoke only with supervision. The policy and procedures failed to specify how the facility would handle smoking materials and who would be in charge of monitoring that the policy was implemented. In an interview, conducted with the Interim Administrator on 4/09/14 at 4:48 PM, the Administrator reported that she has been at the facility in the current position since December 2013. She reported that the facility utilized a staff member to supervise the residents who were smoking in the past, as a "smoking monitor," but she did not know when the facility had stopped using the monitor. The Administrator reported that she had asked the Alternate Administrator to clarify when the facility had stopped using the monitor, but he was also unsure of when the facility had stopped that practice and it was the decision of the former Administrator, who was no longer working at the facility. The Administrator reported, the admissions packet for each resident specified that the residents were not allowed to have lighters, but reported no details about the facility's efforts to enforce the policy. In a subsequent interview conducted on 4/10/14 at 8:43 AM with the Administrator, the Administrator reported that since she has assumed her current role, in "mid-December" 2013, the Quality Assessment and Assurance (QAA) Committee had not discussed resident smoking concerns or practices. In a telephone interview conducted on 4/10/14 at 9:52 AM with the Medical Director, in the presence of the Administrator, the Medical Director reported that he had been in the current position for 8 years and participated in monthly QAA meetings. The Medical Director reported that in the past the facility had assigned staff to monitor the smokers and was under the impression that the facility had continued this practice to date. He stated that the QAA committee had last discussed resident smoking during the October or November 2013 QAA meeting. The Medical Director was made aware of the concerns with the sampled residents and he stated that he had not been aware of the concerns until this telephone interview. In an interview conducted on 4/10/14 at 10:52 AM with the Director of Nursing (DON), the DON stated that the facility discussed during the QAA meeting that occurred on 12/19/13 to "Consider smoking proposal to the resident council - (Former Administrator) to create a letter including cessation process". However, the issue was put on hold with a "goal of 1/14/14 for implementation." The DON was asked to clarify the details of the proposal and stated that he was not clear about the proposal and the former Administrator had been assigned to draft the proposal. However, that had not occurred. In a subsequent interview conducted on 4/10/14 at 1:38 PM with the DON and the Administrator, the participants reported that they had asked the residents who smoke to give them the lighters and they confiscated lighters from 8 residents, a total of 11 lighters were obtained from residents; 2 were from residents who were determined to be unsafe. The unsafe residents included Resident #74 and #60, but added that Resident #60's lighters, a total of 3, were not functional. The participants provided a revised smoking policy, dated 4/09/14. Review of the revised smoking policy, dated 4/09/14 revealed that the facility added to the policy "Residents' smoking materials will always be kept at the nurses' station on the unit and given to residents by staff only. The use of lighters will be handled by staff only. Lighters/matches are not allowed in resident rooms in the possession of any resident." The revised policy failed to address resident supervision. In an interview conducted on 4/11/14 at 11:46 PM with the Administrator and the DON, the participants confirmed that the facility had a monthly QAA meeting. According to the participants, the Administrator, the DON, the Assistant Director of Nursing (ADON)/Risk Manager, Medical Director and Department "Heads" participated in the monthly QAA meetings. The participants stated that the facility had scheduled a QAA meeting for 4/17/14 to discuss the resident smoking program at the facility. The DON stated that the facility had investigated the occurrence with Resident #74's cigarette burn that the aide had discovered on 2/08/14, but they were receiving different versions of the incident from the resident. The participants were asked if they assessed other residents regarding smoking safety at that time and they acknowledged that it did not occur. The DON stated "we should've done that". The DON reported that the staff would observe the residents on the smoking patio and "everyone seems to be good" during their observations so the facility did not think "there was a problem." The Administrator reported that "some areas of the smoking policy should've been reviewed further." Cross-reference to F323 and F280

Based on interviews and medical record reviews the facility failed to ensure a resident was free of any significant medication error. As evidenced by a resident receiving a controlled narcotic which was not prescribed for him, resulting in lethargy, and transfer to a local hospital for evaluation and treatment, for 1 of 4 sampled residents (Resident #1). Findings include: Medical record review conducted on 11/22/10 at 11:30 AM revealed resident #1 was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set, admission assessment with a reference date of 09/09/10 revealed resident #1 was assessed as having short and long term memory problems, modified Independence for daily decision making and the mental function was noted as varies through the course of the day. The resident was assessed as having no behavioral symptoms. The resident was assessed as requiring extensive assistance with bed mobility, transfers, locomotion off the unit, dressing, toilet use, bathing and personal hygiene. The discharge potential indicated no potential, as the resident was identified as long term care required. Review of the Medication Administration Record, [REDACTED]. Review of the nurse's notes dated 11/14/10 at 11 AM described resident #1 as alert and oriented with stable vital signs. At 1:45 PM, the nursing supervisor documented the resident was lethargic and had slurred speech. The nursing supervisor contacted the physician and received an order to transfer resident #1 to a local hospital. At 3:20 PM the nurse's notes documented a non urgent ambulance transferred the resident to the hospital. Review of the emergency room medical records revealed resident #1 arrived to the hospital and was diagnosed with [REDACTED]. Further review of the clinical notes revealed resident #1 had a positive drug screen for opiates and an additional [DIAGNOSES REDACTED]. ([MEDICATION NAME] is a medication administered to completely or partially reverse the effects of narcotics. It may also be used to diagnose overdose of narcotics). The emergency room notes documented resident #1 had a positive effect to the [MEDICATION NAME] administration and the resident became alert and responsive to staff. The emergency room notes also documented a phone conversation with the facility's nursing supervisor on 11/14/10 at 6:30 PM. The nurse's notes documented the supervisor went over the list of medications and there were no narcotics prescribed to resident #1. During an interview conducted with the resident #1's spouse on 11/22/10 at 1:33 PM, the spouse stated she arrived to the facility on [DATE] around 10 AM. She noticed the resident did not look as usual, the resident was very sleepy and the spouse had a hard time waking the resident up. She was concerned and asked the nurse to check on the resident. The spouse stated the nurse came into the room, checked the resident and the response was "he is fine, he is just sleeping". The spouse also verbalized that during the lunch meal the resident was still very sleepy. The spouse stated the nursing assistant prop the resident up in bed and the aide forced fed the resident. The spouse stated she left the facility around 1 PM with an uneasy feeling. She stated later that afternoon around 3 PM she received a phone call advising that resident #1 was going to be transferred to the hospital due to lethargy. Interview conducted with the Director of Nursing, (DON), on 11/22/10 at 1:45 PM, the DON revealed she was made aware of the incident by the nursing supervisor on 11/14/10. The DON stated the nursing supervisor received a phone call from the hospital and they were advised that resident # 1 tested positive for opiates. The DON verified that resident #1 was not prescribed any opiates or narcotics. The DON stated she had instructed the nursing supervisor to check the resident's room and to check all the medications prescribed to the resident. The DON verbalized they have started an internal investigation and they have compiled statements from the staff on duty on the night and day in question. The DON stated they have reviewed all the medication monitoring/control records and they are balanced with the actual narcotic count. The Director of Nursing was unable to answer how the resident ingested opiates while in the facility. An interview was conducted on 11/22/10 at 2:43 PM by telephone with the evening Licensed Practical Nurse, (LPN), assigned to resident #1 on 11/14/10. The nurse stated she was familiar with resident #1. The LPN verbalized that she uses the pictures in the medication administration book to identify residents prior to drug administration. The LPN verbalized some of the residents suffering with dementia remove the name bands. The LPN stated that she recalled giving resident #1's roommate the prescribed pain medication around 9 PM. An interview was conducted on 11/22/10 at 3:19 PM with the day shift Licensed Practical Nurse, (LPN), assigned to resident #1 on 11/14/10. The nurse stated she clearly recalled the medication pass on 11/14/10. The nurse verbalized that resident #1's roommate was sitting in the hallway and the roommate received the medications prescribed to him around 8 AM. The LPN also recalled that an aide reported to her that resident #1 was very sleepy and the aide wanted to put the resident back into the bed. The nurse stated that she advised the aide to feed the resident as the resident had brittle diabetes. The nurse stated she went into the resident room and took the resident's blood pressure. The nurse stated the reading was normal. The nurse stated she thought the resident did not get enough sleep over night and maybe the resident just needed to sleep longer. The nurse stated around 10 AM the resident's spouse complained that the resident was too sleepy. The nurse stated she went in the resident's room and checked the resident's blood sugar. The nurse stated she advised the spouse of the blood sugar reading and that the resident probably did not get enough sleep the night before. The nurse verbalized the resident remained sleepy but the resident was able to eat lunch. The nurse stated the aide had to feed the resident his lunch meal. The nurse stated later that afternoon, another nurse who is very familiar with the resident, noticed the resident was lethargic. The nurse, who was the manager on duty at that time, suggested to call the resident's physician and the resident was later transferred to the emergency room . The nurse was asked to explain her process for medication administration. The LPN replied that she checks the resident's picture and name band and the medication label band prior to administering any drug. The LPN was asked to clarify the documentation noted in the nurse's notes. The nurse acknowledged she did not record all the events related to the resident's condition. The nurse stated she documented at 11 AM and at that time the resident's assessment and vital signs were stable. An interview was conducted on 11/22/10 at 4:15 PM with the nursing supervisor on duty on 11/14/10. The nursing supervisor stated he was made aware of the resident's condition around 1:45 PM. The supervisor stated he had no previous knowledge that the resident was lethargic. The supervisor assessed the resident's condition and called the attending physician. The supervisor verbalized that he received an order from the physician to transfer the resident to the hospital. The supervisor verbalized that later that evening the hospital had contacted him and advised him of the resident's positive drug level for opiates. The nursing supervisor acknowledged the resident was not prescribed any narcotics or opiates. The nursing supervisor contacted the Director of Nursing and advised her of the hospital findings.

Based on interviews and medical record reviews the facility failed to meet professional standards of quality, as evidenced by a resident receiving a controlled narcotic which was not prescribed for him, resulting in lethargy, and transfer to a local hospital for evaluation and treatment, for 1 of 4 sampled residents (Resident #1). The Nurse Practice Act (Florida Chapter 464), states medications are to be administered as prescribed. Findings include: Medical record review conducted on 11/22/10 at 11:30 AM revealed resident #1 was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set, admission assessment with a reference date of 09/09/10 revealed resident #1 was assessed as having short and long term memory problems, modified Independence for daily decision making and the mental function was noted as varies through the course of the day. Review of the Physician order [REDACTED]. Review of the nurse's notes dated 11/14/10 at 11 AM described resident #1 as alert and oriented with stable vital signs. At 1:45 PM, the nursing supervisor documented the resident was lethargic and had slurred speech. The nursing supervisor contacted the physician and received an order to transfer resident #1 to a local hospital. Review of the emergency room medical records revealed resident #1 arrived to the hospital and was diagnosed with [REDACTED]. Further review of the clinical notes revealed resident #1 had a positive drug screen for opiates and an additional [DIAGNOSES REDACTED]. ([MEDICATION NAME] is a medication administered to completely or partially reverse the effects of narcotics. It may also be used to diagnose overdose of narcotics). The emergency room notes documented resident #1 had a positive effect to the [MEDICATION NAME] administration and the resident became alert and responsive to staff. The emergency room notes also documented a phone conversation with the facility's nursing supervisor on 11/14/10 at 6:30 PM. The nurse's notes documented the supervisor went over the list of medications and there were no narcotics prescribed to resident #1. During an interview conducted with the resident #1's spouse on 11/22/10 at 1:33 PM, the spouse stated she arrived to the facility on [DATE] around 10 AM. She noticed the resident did not look as usual, the resident was very sleepy and the spouse had a hard time waking the resident up. She was concerned and asked the nurse to check on the resident. The spouse stated the nurse came into the room, checked the resident and the response was "he is fine, he is just sleeping". The spouse also verbalized that during the lunch meal the resident was still very sleepy. The spouse stated the nursing assistant prop the resident up in bed and the aide forced fed the resident. The spouse stated she left the facility around 1 PM with an uneasy feeling. She stated later that afternoon around 3 PM she received a phone call advising that resident #1 was going to be transferred to the hospital due to lethargy. Interview conducted with the Director of Nursing, (DON), on 11/22/10 at 1:45 PM, the DON revealed she was made aware of the incident by the nursing supervisor on 11/14/10. The DON stated the nursing supervisor received a phone call from the hospital and they were advised that resident # 1 tested positive for opiates. The DON verified that resident #1 was not prescribed any opiates or narcotics. The Director of Nursing was unable to answer how the resident ingested opiates while in the facility. An interview was conducted on 11/22/10 at 2:43 PM by telephone with the evening Licensed Practical Nurse, (LPN), assigned to resident #1 on 11/14/10. The nurse stated she was familiar with resident #1. The LPN verbalized that she uses the pictures in the medication administration book to identify residents prior to drug administration. The LPN verbalized some of the residents suffering with dementia remove the name bands. The LPN stated that she recalled giving resident #1's roommate the prescribed pain medication around 9 PM. An interview was conducted on 11/22/10 at 3:19 PM with the day shift Licensed Practical Nurse, (LPN), assigned to resident #1 on 11/14/10. The nurse verbalized that resident #1's roommate was sitting in the hallway and the roommate received the medications prescribed to him around 8 AM. The LPN also recalled that an aide reported to her that resident #1 was very sleepy and the aide wanted to put the resident back into the bed. The nurse stated that she advised the aide to feed the resident as the resident had brittle diabetes. The nurse stated she thought the resident did not get enough sleep over night and maybe the resident just needed to sleep longer. The nurse stated around 10 AM the resident's spouse complained that the resident was too sleepy. The nurse stated she went in the resident's room and checked the resident's blood sugar. The nurse stated she advised the spouse of the blood sugar reading and that the resident probably did not get enough sleep the night before. The nurse verbalized the resident remained sleepy but the resident was able to eat lunch. The nurse stated the aide had to feed the resident his lunch meal. The nurse stated later that afternoon, another nurse who is very familiar with the resident, noticed the resident was lethargic. The nurse, who was the manager on duty at that time, suggested to call the resident's physician and the resident was later transferred to the emergency room . The nurse was asked to explain her process for medication administration. The LPN replied that she checks the resident's picture and name band and the medication label band prior to administering any drug. The LPN was asked to clarify the documentation noted in the nurse's notes. The nurse acknowledged she did not record all the events related to the resident's condition. The nurse stated she documented at 11 AM and at that time the resident's assessment and vital signs were stable. An interview was conducted on 11/22/10 at 4:15 PM with the nursing supervisor on duty on 11/14/10. The nursing supervisor stated he was made aware of the resident's condition around 1:45 PM. The supervisor stated he had no previous knowledge that the resident was lethargic. The supervisor assessed the resident's condition and called the attending physician. The supervisor verbalized that he received an order from the physician to transfer the resident to the hospital. The supervisor verbalized that later that evening the hospital had contacted him and advised him of the resident's positive drug level for opiates. The nursing supervisor acknowledged the resident was not prescribed any narcotics or opiates.