Every finding on record at Dunklau Gardens

Based on observation, interview, and record review, the facility failed to ensure staff followed provider's order related to 1 (Resident 5) of 1 sampled resident's flutter valve and oxygen. The facility census was 84. Findings are:A.A record review of Resident 5's Resident Census Periods dated 06.25.2026 revealed the resident was admitted to the facility 12/10/2024. A record review of Resident 5's Client Diagnosis Report dated 06/25/2026 revealed the resident had diagnoses of Unspecified systolic (congestive) heart failure (CHF), Pneumonia, Chronic Respiratory Failure, and Chronic Obstructive Pulmonary Disease (COPD). A record review of Resident 5's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 06/19/2026 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a resident's cognitive abilities) of 15 which indicated the resident was cognitively aware (able to think and comprehend). The resident was independent on eating, required setup or clean-up assistance with oral hygiene (cleaning), required substantial/maximal assistance with upper body dressing and personal hygiene, and was dependent on staff for toileting hygiene, lower body dressing, and footwear. The resident was independent with bed mobility and substantial/maximal assistance with transfers. The resident used oxygen. A record review of Resident 5's Plan Of Care - Current dated 04/30/2026 revealed the resident had a problems/strengths area of oxygen therapy related to Chronic Obstructive Pulmonary Disease (COPD) and an intervention of flutter valve twice a day. A record review of Resident 5's Physician Orders dated 06/01/2026 - 06/30/2026 revealed the resident had an order for a Flutter Valve (device a resident blows trough that vibrates to loosen mucus) twice a day, once per shift. A record review or Resident 5's Pulmonary (Pulm) Office Note dated 08/11/2025 and the undated Multi-Disciplinary Progress Notes revealed Resident 5's Pulmonologist (lung doctor) gave the resident a flutter valve at the office visit to use twice a day, and the order was given to the facility. A record review of Resident 5's Medication Administration Record and Treatment Administration Record (MAR & TAR) dated 05/26/2026 - 06/24/2026 revealed the staff documented the staff administered the flutter valve every day except shift 2 on 06/03/2026 was marked M which indicated it was missed and shift 2 on 06/11/2026 was marked H which indicated it was held. A record review of Resident 5's MAR & TAR dated 04/25/2026 - 05/25/2026 revealed the staff documented the staff administered the flutter valve every day except shift 2 on 06/03/2026 was marked H which indicated it was held on 04/28/2026, 04/30/2026, 05/02/2026, 05/03/2026, 05/04/2026, 05/07/2026, 05/09/2026, 05/16/2026, 05/19/2026, 05/20/2026, and 05/21/2026. A record review of Resident 5's Interdisciplinary Progress Notes dated 04/28/2026 - 06/25/2026 revealed:04/28/2026 - resident was in the hospital04/30/2026 - Held due to resident does not have flutter valve 05/02/2026 - Held due to resident refused 05/03/2026 - Held due to resident refused05/04/2026 - Held due to Resident refused, resident does not have flutter valve and does not use05/07/2026 - Held due to resident refused05/09/2026 - Held due to resident refused05/16/2026 - Held due to resident refused05/19/2026 - Held due to resident refused05/20/2026 - Held due to resident refused05/21/2026 - Held due to resident refused06/03/2026 - Nothing documented06/11/2026 - Held due to Resident condition An observation on 06/25/2026 at 7:28 AM revealed Resident 5 did not have a flutter valve in the resident's room. An observation on 06/25/2026 at 7:49 AM with the facility's Assistant Director of Nursing (ADON) revealed the ADON searched the resident's room and that Resident 5 did not have a flutter valve in the room. In an interview on 06/25/2026 at 7:28 AM, Resident 5 confirmed the resident did not have a flutter valve. The resident confirmed the resident used to have one but has not had one since at least 4/28/2026. In an interview on 06/25/2026 at 7:49 AM, the ADON confirmed Resident 5 did not have a flutter valve. In an interview on 06/25/2026 at 7:52 AM, the ADON confirmed the ADON reviewed Resident 5's MAR & TAR dated 05/26/2026 - 06/24/2026 and the staff should have administered a flutter valve to the resident 2 times per day. The ADON was not sure why the MAR & TAR was marked completed when the resident did not have a flutter valve. In an interview on 06/25/2026 at 8:35 AM, the Director of Nursing (DON) confirmed Resident 5 did not have a flutter valve that was being done twice a day and should have. B.A record review of the facility's Oxygen and Equipment Protocol with a review date of 1/2026 revealed the staff would set up the oxygen (o2) per the physician's order. A record review of Resident 5's Plan Of Care - Current dated 04/30/2026 revealed the resident had a problems/strengths area oxygen therapy related to Chronic Obstructive Pulmonary Disease (COPD) and a goal of will maintain oxygen saturation (sats)(level of oxygen in the blood) oxygen at 2 liters per minute (l/m) as needed to keep sats above 88 percent (%) per Medical Doctor (MD) order. A record review of Resident 5's Physician Orders dated 06/01/2026 - 06/30/2026 revealed the resident had an order for oxygen at 2 l/m as needed to keep sats above 88 and document reason and response. A record review or Resident 5's Pulmonary (Pulm) Office Note dated 08/11/2025 revealed Resident 5's Pulmonologist documented the resident sometimes would walk around with the oxygen off and the resident said if the resident just takes it off for a couple of minutes the resident does well, but was not comfortable taking it off longer than that. The resident slept with the oxygen at 2 l/m every night. The resident's oxygen rate was 2 l/m. A record review of Resident 5's MAR & TAR dated 03/25/2026 - 06/24/2026 did not reveal that the resident used the oxygen and the staff did not document the reason and response. A record review of Resident 5's Interdisciplinary Progress Notes dated 04/01/2026 - 06/25/2026 did not reveal the staff documented the reason or response for the resident's oxygen usage. A record review of Resident 5's O2 Sats Report dated 04/28/2026 - 06/25/2026 revealed the resident's oxygen saturations were checked at least 1 time per day. 42 times the type was documented on o2, 6 times on room air (no oxygen on), and 53 times it was not marked with a type. There were only 2 times that it revealed an oxygen saturation of less than 88%, 05/15/2026 at 6:44 AM and 05/19/2026 at 6:37 AM and both were marked 85% and no type was documented. On 06/24/2026 at 7:04 AM the oxygen saturation was 100% on o2, and 06/25/2026 at 6:48 AM it was documented the resident's oxygen sat was 100% on room air. An observation on 06/24/2026 at 8:05 AM revealed Resident 5 was on oxygen set at 2 l/m. An observation on 06/25/2026 at 7:28 AM revealed Resident 5 was on oxygen set at 2 l/m. In an interview on 06/25/2026 at 7:28 AM, Resident 5 confirmed the resident used the oxygen all of the time. Sometimes it would fall off while the resident was sleeping, but the resident would put it right back on when the resident noticed it. In an interview on 06/25/2026 at 7:52 AM, the ADON confirmed Resident 5 was on oxygen set at 2 l/m, the order was for 2 l/m as needed to keep sats greater than 88%, and the resident had been on oxygen continuously at 2 l/m since admission. In an interview on 06/25/2026 at 8:35 AM, the DON confirmed Resident 5 was on oxygen and it was not documented on the TAR and should have been.

Licensure reference: 175 NAC12-006.11D Based on observation, interview and record review, the facility failed to ensure food was prepared according to the recipe to conserve the nutritive value. This had the potential to affect all residents in the facility. The facility census was 84. Findings are: Observation on 4/30/2025 at 11:39 AM revealed [NAME] A used the following procedure and ingredients: Precooked beef unmeasured Diced the celery and placed it in the pan with the meat without measuring. Obtained two onions and diced them. Placed in pan with the meat without measuring Cut open 2 bags frozen peas and 2 bags of frozen Carrots and added to pan without measuring. Added frozen diced potatoes by opening the bag and pouring out a portion of the bag and did not measure. Spices were measured by pouring an amount into the lid of the spice jar and poured into the pan. Record Review of the undated recipe titled Beef Stew Old Fashioned revealed the following ingredient list: Meat 13.88 pounds Celery fresh 1.13 Pounds Onions Yellow Fresh 1.13 pound Carrots Fresh 1.13 pounds Peas Green, Frozen Thawed and drained 1.22 Pound Potatoes Peeled Fresh Diced 2.53 Pounds Garlic Fresh chopped 1.50 Teaspoon Oregano Leaves Dried 1.50 Teaspoon Pepper [NAME] Ground 0.75 Teaspoon Interview on 4/30/2025 at 2:00 PM with the Registered Dietician revealed [NAME] A did not measure ingredients or follow the recipe instructions. This would result in a change in the nutritive value. Interview on 5/1/2025 at 10:00 AM with the Admissions Coordinator revealed all residents eat food from the kitchen.

Licensure Reference Number 175 NAC 12.006.18(B) Based on observation, interview and record review the facility failed to ensure staff performed hand hygiene (cleaning) with glove changing when going from a contaminated area to a clean area for 2 residents (Resident 47 and 62) of 4 residents sampled during cares and treatments to prevent the potential for cross contamination. The facility census was 84 at the time of the survey. Findings are: Record review of facility policy date revised 5/2024 titled Hand Hygiene revealed to complete Hand Hygiene before and after touching a patient, and immediately after glove removal. Record review of CDC.gov website Hand Hygiene for Healthcare Workers dated [DATE] stated to perform hand hygiene before donning gloves and after removing them. Record review of facility policy dated 3/2018 titled Isolation Procedures revealed gloves must be changed between tasks and procedures on the same patient if moving from a dirty site to a clean site. A. During an interview on 04/28/25 at 10:29 AM Resident 47 stated (gender) had a sore on (gender) bottom. Record review of Resident 47's Quarterly Minimum Data Set (MDS -a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) dated 3/3/25 revealed: -the resident admitted to the facility on [DATE] - St. 2 pressure ulcer, which is partial thickness skin loss and indicated not present on admission -dependent for cares. - Brief Interview for Mental Status (BIMS - a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 15, which indicated the resident is cognitively intact. Record review of Resident 47's skin interventions on Kardex revealed to apply barrier cream after each incontinence episode. Record review of Resident 47's Comprehensive Care Plan (CCP- written instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care) revealed: -problem initiated on 10/25/2023 of impaired skin integrity, always incontinent and fragile skin, and 1/1/2025 stage 2 pressure ulcer identified to coccyx. -interventions dated 10/25/2023 included proper hand washing technique before and after cares, pericare and moisture barrier after each incontinent episode, and to keep skin clean and dry. In an observation on 04/29/25 at 11:25 AM Medication Aide (MA) - D and Registered Nurse (RN) - C completed hand hygiene and applied gloves, got supplies and then began to perform incontinence cares for Resident 47. The resident was incontinent of bowels, and MA - D performed peri cares but did not change contaminated gloves before reaching into the wipes container. MA - D changed gloves when peri cares were completed but did not perform any hand hygiene. MA - D then applied the barrier cream. This observation did not reveal any hand hygiene after removing gloves. During an interview on 04/29/25 at 11:26 AM RN - C confirmed that hand hygiene should be performed when changing gloves. During an interview on 04/29/25 at 1:05 PM Unit Leader (UL) - B confirmed that hand hygiene should be performed when changing gloves. During an interview on 04/30/25 at 2:04 PM the Director of Nursing (DON) confirmed that staff should perform hand hygiene when donning (to put on) and doffing (to take off) gloves. B. During an interview on 04/28/25 at 3:20 PM Resident 62 stated there was a sore on (gender) bottom, and the nurses put ointment on it. Record review of Resident 62's Quarterly MDS dated [DATE] revealed: -resident was admitted to the facility on [DATE] - ADL's dependent with 1 assist - BIMS score of 15, which indicates the resident is cognitively intact. Record review of Resident 62's skin interventions on Kardex did not reveal that skin barrier cream needed to be applied. Record review of Resident 62's CCP revealed: -problem initiated on 12/19/2024 of impaired skin integrity and fragile skin -interventions dated 12/19/2024 included proper hand washing technique before and after cares, pericare and moisture barrier after each incontinent episode, and to keep skin clean and dry. In an observation on 04/29/25 at 10:59 AM MA - F assisted Resident 62 into the bathroom, completed hand hygiene and put on gloves and pulled the resident's pants down. MA - F changed gloves and did not perform any hand hygiene, then the MA applied barrier cream. During an interview on 04/29/25 at 11:16 AM interview with MA - F confirmed that (gender) should have washed (gender) hands when changing (gender) gloves. During an interview on 04/29/25 at 1:05 PM UL - B confirmed that hands should be washed when changing gloves. During an interview on 04/30/25 at 2:04 PM the DON confirmed that staff should perform hand hygiene when donning and doffing gloves.

Licensure Reference Number 175 NAC 12.006.09(H)(iii)(3) Licensure Reference Number 175 NAC 12.006.09(A)(ii) Based on observation, interview, and record review, the facility failed to implement pressure reducing devices for skin breakdown prevention on 2 (Residents 60 and 68) of 4 sampled residents, and failed to ensure Insulin pens were dated when opened for 2 (Residents 31 and 37) of 2 sampled residents. The facility census was 84. Findings are: A. A record review of the facility's Skin Assessment, Care and Treatment policy dated September 2001 revealed a wound was a physical injury to the body with damage to the underlying tissue. To prevent a wound the facility would develop a care plan on the Braden Subscale (an assessment to determine the risk of developing a pressure wound) areas of risk rather than total assessment score. The facility would address turning, repositioning, floating heels, and the support surface. The facility would select appropriate interventions such as floating heels off the bed with pillows under the lower portion of legs or with heel lift boots. A record review of Resident 60's Client Diagnosis Report dated 04/30/2025 revealed the resident had diagnoses of Severe Protein-Calorie Malnutrition (lack of nutrition related to low protein in the diet), Adult Failure to Thrive (global decline), Dementia (confusion), and a Stage 2 Pressure Ulcer of the Sacral Region (wound on the resident's bottom). A record review of Resident 60's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 03/19/2025 did not reveal the resident had a Brief Interview for Mental Status (BIMS)(a score of a resident's cognitive abilities) which indicated the resident was rarely/never understood. The resident was on hospice care. The resident had limited range of motion on both sides of the upper extremities (shoulder to hand or hip to toe) and the lower extremities (below the hips). The resident was dependent on staff for all Activities of Daily Living (ADLs) and needed substantial/maximal staff assistance with mobility. The MDS indicated the resident was at risk for developing pressure wounds but did not reveal the resident had one at the time the MDS was completed. The resident had skin treatments that included pressure reducing devices for bed and chair and application of dressings and ointments/medications. A record review of Resident 60's OPC Review dated 03/19/2025 revealed that a Braden Scale had been completed, and the resident had a score of 10 that indicated the resident was at high risk of developing a pressure injury. A record review of Resident 60's Pressure Injury Documentation Form dated 04/18/2025 - 04/30/2025 revealed the facility identified the resident had a 4.5 centimeter (cm) by (x) 7.8 cm unstageable pressure injury on the right heel on 4/18/2025. A record review of Resident 60's Plan Of Care-Current with an admitted [DATE] revealed the resident had a problem area of self-care deficit (unable to perform ADLs). A problem area of potential for impaired skin integrity related to fragile skin and impaired mobility. An unstageable pressure injury to the right heel. The resident had an intervention of Prevalon heel boots (padded cushions attached to feet that ensure the heels stay elevated) on bilateral (both) feet at all times except for cares, for the problem area of potential for impaired skin integrity. A record review of Resident 60's Kardex Summary dated 04/30/2025 revealed that the resident was to have Prevalon heel lift boots on at all times except for care under skin interventions. A record review of Resident 60's Physician Orders dated 05/01/2025 - 05/31/2025 revealed the resident had an order dated 04/21/2025 of HEEL - OFFLOAD HEELS USING PREVLON HEEL BOOTS ONCE PER SHIFT [Time: Shift 1, Shift 2] keep on @ (at) all x's (times), except for skin care. A record review of Resident 60's Treatment Record (TAR) dated 04/01/2025 - 04/30/2025 revealed the staff was marking the resident had Prevalon boots on each shift since 04/18/2025. An observation on 04/28/2025 at 10:11 AM did not reveal that Resident 60 was wearing Prevalon boot and heels were directly on wheelchair footrests. An observation on 04/29/2025 at 9:52 AM revealed Resident 60 was sitting in wheelchair with the Hospice nurse in the room, and the resident did not have Prevalon boots on. An observation on 04/29/2025 at 10:34 AM with the facility's Assistant Director of Nursing (ADON), Unit Leader (UL)-B, and Registered Nurse (RN)-C revealed Resident 60 was sitting in the wheelchair but did not have Prevalon boots on. In an interview on 04/30/2025 at 10:27 AM, RN-C confirmed that Resident 60 was not wearing Prevalon boots during the 04/29/2025 at 10:34 AM observation and should have had them on. In an interview on 04/30/2025 at 10:33 AM, UL-B confirmed that Resident 60 was not wearing Prevalon boots during the 04/29/2025 at 10:34 AM observation and should have had them on due to there was an order to have Prevalon boot on at all times except during cares. UL-B confirmed the Nursing Assistant (NA) thought the Prevalon boots were just to be on at night. B. A record review of the facility's Skin Assessment, Care and Treatment policy dated September 2001 revealed a wound was a physical injury to the body with damage to the underlying tissue. To prevent a wound the facility would develop a care plan on the Braden Subscale (an assessment to determine the risk of developing a pressure wound) areas of risk rather than total assessment score. The facility would address turning, repositioning, floating heels, and the support surface. The facility would select appropriate interventions such as floating heels off the bed with pillows under the lower portion of legs or with heel lift boots. A record review of Resident 68's Client Diagnosis Report dated 04/30/2025 revealed the resident had diagnoses of Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease (uncontrolled blood sugars that damaged the kidneys), Lymphedema (swelling in the body due to excess protein-rich fluid), and Atrial Fibrillation (abnormal heart rhythm). A record review of Resident 68's MDS dated [DATE] revealed it was an admission MDS and the resident was admitted [DATE]. It did not reveal BIMS score, ADLs, or skin conditions. A record review of Resident 68's 48-Hour Care Plan dated 04/23/2025 revealed the resident was verbal, alert, and cognitively intact (not confused). The resident required a staff assist of 2 with bed mobility, transfers, and toileting. The resident had a skin concerns area and the resident had other skin concerns. An intervention was to offload heels (elevate heels so not to rub against a surface). A record review of the facility's Nursing Orders dated 04/23/2025 revealed the nurse completed the form and Resident 68 was to have heels offloaded when in bed and bilateral offloading boots when in bed. A record review of Resident 68's Kardex Summary dated 04/30/2025 did not reveal that the resident was to have the heels offloaded or bilateral offloading boots. A record review of Resident 68's Braden Scale dated 04/24/2025 revealed that the resident had a score of 18 that indicated the resident was at a low risk of developing a pressure injury. A record review of Resident 68's TAR dated 04/01/2025 - 04/30/2025 revealed the resident was to have off-loading boots when in bed at bedtime and it was not marked as being completed on any days from 04/23/2025 - 04/30/2025. The staff was to offload the resident's heels when in bed and document it every shift and it had not been completed. An observation on 04/28/2025 at 9:50 AM revealed Resident 68 was lying in bed and did not have heels elevated off the mattress or off-loading boots on. No off-loading boots were observed in the room. An observation on 04/29/2025 at 9:32 AM revealed Resident 68 was lying in bed and did not have heels elevated off the mattress or off-loading boots on. The resident did have a pillow under the resident's knees. No off-loading boots were observed in the room. An observation on 04/29/2025 at 12:45 PM revealed Resident 68 was lying in bed and did not have heels elevated off the mattress or off-loading boots on. No off-loading boots were observed in the room. An observation on 04/30/2025 at 08:28 AM revealed that Resident 68 was lying in bed with a pillow under the knees, heels were not offloaded, and no heel off-loading boots observed on the resident or in the room. An observation on 04/30/2025 at 9:16 AM with Licensed Practical Nurse (LPN)-G revealed that Resident 68 was lying in bed and did not have heels elevated off the mattress or off-loading boots on. No off-loading boots were observed in the room. In an interview on 04/30/2025 at 9:52 AM with NA-H confirmed the NA uses a pillow to offload Resident 68's heels and that the resident did not have off-loading boots. In an interview on 04/30/2025 at 9:52 AM, Resident 68 confirmed the resident did not have a pillow under the resident's lower legs to keep the heels off the mattress, it was under the resident's knees, and the resident did not know where it was supposed to go. Resident 68 confirmed the NA put it there. Resident 68 confirmed the staff had not been putting off-loading boots on at night. In an interview on 04/30/2025 at 8:28 AM, Resident 68 confirmed that the resident had not been wearing any off-loading boots at night, pillow was not under the lower legs, it was under the resident's knees, and the resident has not had off-loading boots since she was readmitted to the facility on [DATE]. In an interview on 04/30/2025 at 9:16 - 9:38 AM, LPN-G confirmed that there was an order for Resident 68 to have heels offloaded and off-loading boots. LPN-G confirmed LPN-G observed the resident, the resident did not have heels offloaded, and the resident did not have off-loading boots in the room or offloaded heels and should have had. C. A record review of the facility's Insulin Pens policy dated April 2017 revealed the facility was to store insulin pens at room temperature for 1 month from date of opening. Place date opened and date pen to be thrown away on pen. A record of [NAME] Lilly's Basaglar pamphlet dated 10/2024 revealed: Storage tips: Store your opened Pen at room temperature up to 86 F (30 C) and throw it away after 28 days. https://insulins.lilly.com/basaglar A record review of the Cleveland Clinic's Insulin Pens webpage with a last reviewed date of 02/12/2024 revealed you should Write the date on the insulin pen when you first open it. Most pens are good for 28 days once you open them. (https://my.clevelandclinic.org/health/treatments/17923-insulin-pen-injections). A record review of Resident 37's Client Diagnosis Report dated 05/01/2025 revealed the resident had diagnoses of Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Lymphedema, and Weakness. A record review of Resident 37's MDS dated [DATE] revealed the resident had a BIMS of 15 which indicated the resident was cognitively intact. The resident had limited range of motion on one side of the lower extremities. The resident was independent for eating and upper body dressing, needed setup or clean-up assistance for oral hygiene (cleaning), and dependent on staff for toileting, bathing, lower body dressing, footwear, and personal hygiene. The resident required Insulin injections daily. A record review of Resident 37's Plan of Care-Current with an admitted [DATE] revealed the resident had a problem area of the resident is at risk for potential complications related to diabetes and an intervention of Insulin per physician's order. A record review of the facility's Physician Orders dated 04/01/2025 - 04/30/2025 revealed Resident 37 had an order for Basaglar Kwikpen 100 units per 1 milliliter (ml) solutions 70 units once daily for Type 2 Diabetes Mellitus. A record review of Resident 37's Medication Record and Treatment Record (MAR & TAR) dated 04/01/2025 - 04/30/2025 revealed the Basaglar Kwikpen 100 units per 1 milliliter (ml) solutions 70 units once daily for Type 2 Diabetes Mellitus was administered daily. An observation on 04/30/2025 at 8:31 AM with LPN-G revealed LPN-G administered Resident 37's Basaglar Kwikpen 100 units per 1 ml solutions 70 units once daily for Type 2 Diabetes Mellitus, but observation of the pen did not reveal a date the pen was opened, just a sticker to discard within 28 days after opened. In an interview on 04/30/2025 at 8:31 AM, LPN-G confirmed Resident 37's Basaglar Kwikpen 100 units per 1ml solutions 70 units once daily for Type 2 Diabetes Mellitus did not have an open date and should have had. In an interview on 4/30/2024 at 1:50 PM, the Director of Nursing confirmed the facility staff do not write open dates on the insulin pens when opened. They only have 2 residents in the facility that use insulin pens. The DON confirmed after record review of the facility's Insulin Pen policy, they should be dating then insulin pens when opened for Resident 37. D. A record review of the facility's Insulin Pens policy dated April 2017 revealed the facility was to store insulin pens at room temperature for 1 month from date of opening. Place date opened and date pen to be thrown away on pen. A record review of Biocon Biologics, Incorporated (Inc.) SEMGLEE - insulin glargine-yfgn injection, solution manufacturer's instruction with a revised date of 11/2024 revealed: 3 mL single-patient-use prefilled pen until expiration date was 28 days, Room temperature only (Do not refrigerate). Only use your pen for up to 28 days after its first use. Throw away the SEMGLEE pen you are using after 28 days, even if it still has insulin left in it. The box did have an area to date with an Initial Used Date. https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=8cf5544f-87d6-468b-f6ae-898b1fdb5d80&type=display#section-14 A record review of the Cleveland Clinic's Insulin Pens webpage with a last reviewed date of 02/12/2024 revealed you should Write the date on the insulin pen when you first open it. Most pens are good for 28 days once you open them. https://my.clevelandclinic.org/health/treatments/17923-insulin-pen-injections A record review of Resident 31's Client Diagnosis Report dated 05/01/2025 revealed the resident had diagnoses of Type 2 Diabetes Mellitus with Diabetic Neuropathy (uncontrolled blood sugars casing damage to the nerves), and Weakness. A record review of Resident 31's MDS dated [DATE] revealed the resident had a BIMS of 15 which indicated the resident was cognitively intact. The resident had limited range of motion on one side of the upper and lower extremities. The resident was independent for all ADLs. The resident required Insulin injections daily. A record review of Resident 31's Plan of Care-Current with an admitted [DATE] revealed the resident hand a problem area of the resident is at risk for complications related to diabetes and an intervention of Insulin per physician's order. A record review of the facility's Physician Orders dated 05/01/2025 - 05/31/2025 revealed Resident 31 had an order for SEMGLEE pen 100 units per 1 ml solution (Insulin Glargine, Recombinant) 35 units before breakfast and at bedtime for Type 2 Diabetes Mellitus. An observation on 04/30/2025 at 1:50 PM with the DON revealed the Resident 31's Insulin pen was a Biocon Biologics Insulin Glargine - YFGN Injection. Label revealed Insulin Glargine 100 units per 3 ml. Inject 35 units twice daily. Open pens good for 28 days. The pen did not have an open date. In an interview on 04/30/2025 at 1:50 PM, the DON confirmed Resident 31's Insulin pen did not have an open date and the staff do not put open dates on the pen when opening and it was not in the facility's policy. After the record review of the facility's Insulin Pen policy dated April 2017, the DON confirmed the staff were to place a date opened and date pen to be thrown away on pen when they opened a new Insulin pen.

Licensure Reference Number 175 NAC 12.006.11E Licensure Reference Number 175 NAC 12.006.11D Based on observation, interview, and record review; the facility failed to ensure recipes were followed during food preparation (prep) and clean ceiling tiles, ventilation covers, and equipment surfaces in the kitchen to prevent the potential for cross-contamination. This had the potential to affect all 72 residents that consumed food from the kitchen. Findings are: A. A record review of the facility's Food Preparation and Production policy with a revised date of 6/21 revealed standardized recipes that incorporate hazard analysis and critical control points (HACCP) procedures that protect the safety of the food supply while maintaining the nutrient content of the food and appropriate preparation techniques will be used. A record review of the Nutrition Services for Residents policy with a revised date of 5/21 revealed foods are prepared by methods that conserve nutritive value, flavor, and appearance and are attractively served at the proper temperature. A file of tested recipes adjusted to appropriate yields is maintained. A record review of the facility's undated Basil & Chive Chicken Breast Master Recipe revealed ingredients were: Basil Sweet Dried - 5 ounce Chives, Dried - 4 ounce Lemon Juice Fresh Pasteurized - 1 Quart Wine Chablis - 4 Cup Garlic Fresh (minced) - 8 Ounce Pepper Black Ground - 8 Teaspoon Oil Olive - 2 Quart Chicken Breast Boneless 4 - 96 Each 1 standard portion equals (=) 1 Breast 1. Combine basil, chives, lemon juice, white wine, garlic, black pepper and olive oil for marinade. Whisk until well-blended. 2. Pour marinade over chicken, turning to evenly coat. Hold refrigerated at internal temperature on 40 degrees Fahrenheit (F) or below for 24 hours to marinate. Drain and discard excess marinade. A record review of the facility's undated Basil & Chive Chicken Breast Master Recipe did not reveal cooking directions. An observation on 04/22/2024 at 8:46 AM revealed the Cook got a steam pan from the walk-in refrigerator and placed by the grill. The Cook used tongs and took chicken breasts from the steam pan and placed on the grill. The Cook then waited an untimed amount of time, flipped the chicken breast and grilled the breasts for an untimed amount of time. The Cook then placed the chicken breast from the grill onto a large cookie sheet. The Cook took the large cookie sheet to the food prep table and sprinkled the breasts with an unmeasured amount of basil and an unmeasured amount of chives from their containers. An observation of the steam pan of marinade did not reveal any green (chives) or flakes in the mixture. The Cook then placed the chicken breasts in the oven at 350 degrees F for 10 minutes. In an interview on 04/22/2024 at 9:02 AM the facility's Food Service Manager (FSM) confirmed the recipe did not have cooking directions so the FSM revealed a Herbed Chicken Master Recipe and said the Cook would go by that. The Herbed Chicken Master Recipe revealed a cooking temperature of 325 degrees F. In an interview on 04/22/2024 at 9:09 AM, the Cook confirmed that the steam pan only included the marinade and chicken breast, and the marinade was just Italian dressing. A record review of the Hungarian Goulash Recipe Information dated 04/22/2024 revealed the following ingredients: Noodles-Egg - 8 and 2/3 Pound Margarine - 5 and 3/4 1-pound pints Beef Stew Meat, 10% Fat, Raw - 9 and 1/8 Pound Onions - Yellow, Fresh - 4 and 1/3 Pound Garlic, Fresh (chopped fine) - 1 and 1/2 Teaspoon Granulated Sugar - 2 and 7/8 Ounce Paprika - 2 and 1/4 Ounce Pepper-White, Ground - 1 and 1/2 Teaspoon Seasoning - Bar-B-Que (BBQ) - 1 and 1/2 Tablespoon Tarragon - Leaf, Dried - 1 and 1/2 Teaspoon Tomatoes- Diced, Canned - 1 and 1/3 Gallon Sour Cream 1 and 1/2 Cup All-Purpose Flour - 1 and 1/2 Tablespoon Preparation 1. Prepare Egg Noodles according to recipe 2. In a large soup kettle heat margarine until melted 3. Add beef. saute, stirring frequently, until well-browned 4. Add onion and garlic. Cook for 8 minutes until translucent 5. Stir in sugar, paprika, white pepper, seasoning blend and tarragon 6. Add tomatoes. Mix well. Bring to boil. Reduce heat and simmer 2 to 2 and 1/4 hours or until 2/3 of liquid has been absorbed, meat is tender but not shredded and minimum internal temperature is 145 degrees F. (for 15 seconds) 7. Combine sour cream and flour. Mix until smooth. Add to meat mixture. Stir constantly until well blended. Hold hot for service An observation on 04/23/2024 at 6:55 AM revealed the facility's Cook sprayed a large steam pan with cooking spray, went to the walk-in refrigerator and got 2 packages of 2-pounds of ground beef and placed in the steam pan. The Cook then broke up the ground beef and placed in the steamer for 1 to 1.5 hours. At 8:34 AM the Cook removed the ground beef from the steamer and scraped the ground beef into a medium sized steam pan. The Cook took a pre-opened gallon can of diced tomatoes and poured an unmeasured amount of diced tomatoes in the steam pan with the ground beef. The Cook then had 3 pre-prepared cups that contained sugar, Bar-B-Que seasoning, and diced onions and added them to the mixture. The Cook then took a container of Paprika, a container of Granulated Garlic, and a container of [NAME] Pepper and added an unmeasured amount of each to the mixture and stirred with a large spoon. The Cook covered the steam pan with plastic wrap and placed in the steamer. The observation did not reveal tarragon was used. In an interview on 04/23/2024 at 8:37 AM, the Cook confirmed the paprika, granulated garlic, and white pepper was not measured, and the recipe was not followed. In an interview on 04/23/2024 at 8:40 AM, the facility's Clinical Dietician (CD) confirmed the CD observed the food prep and the Cook did not follow the recipes for 04/22/2024 Basil and Chive Chicken or the 04/23/2024 Hungarian Goulash. B. A record review of the facility's Kitchen Sanitization policy with a revised date of 6/21 revealed local and state sanitization requirements are reflected in schedules, procedures, and sanitizing compounds in use. A record review of the Planned Event Work Order Kitchen, Dishroom, [NAME] Wall & Cafe Vents log sheet dated 03/04/2024 revealed it was to be completed monthly, it was last completed on March 4th, 2024. A record review of the facility's undated Equipment/Areas to Clean log revealed the staff was to delime and clean steam oven weekly on Tuesdays and wash and clean all sides would be done weekly on Saturdays. Clean prep table would be done weekly on Saturdays. An observation on 04/17/2024 at 8:48 AM revealed the warmer cart trough below the controls contained a moderate amount of food debris, the bottom shelf of prep table appeared uncleaned with oily smears throughout the surface, scattered crust, and food debris. The square white ceiling vents all contained a gray, fuzzy substance especially above the food prep and cooking area. The ceiling tiles and thermostat above prep table contained a gray, fuzzy substance and was actually hanging from below the thermostat. The light fixture above the prep table contained an orange dried substance. The Heating Ventilation and Air Conditioning (HVAC) vents in the ceiling above the food prep and cooking area contained a gray, fuzzy substance. The vents on the back of the deli cooler contained a gray, fuzzy substance. The table under the steamer contained a white crusty substance and scattered food debris. There was food debris on the top of the steamer. The bug light located on the wall by the steamer had a yellow food splash on it. The vents above reach-in fridge contained a gray, fuzzy substance. An observation on 04/17/2024 at 9:18 AM with the CD revealed the warmer cart trough below the controls contained a moderate amount of food debris, the bottom shelf of prep table appeared uncleaned with oily smears throughout the surface, scattered crust, and food debris. The square white ceiling vents all contained a gray, fuzzy substance especially above the food prep and cooking area. The ceiling tiles and thermostat above prep table contained a gray, fuzzy substance and was actually hanging from below the thermostat. The light fixture above the prep table contained an orange dried substance. The Heating Ventilation and Air Conditioning (HVAC) vents in the ceiling above the food prep and cooking area contained a gray, fuzzy substance. The vents on the back of the deli cooler contained a gray, fuzzy substance. The table under the steamer contained a white crusty substance and scattered food debris. There was food debris on the top of the steamer. The bug light located on the wall by the steamer had a yellow food splash on it. The vents above reach-in fridge contained a gray, fuzzy substance. In an interview on 04/17/2024 at 9:18 AM, the facility's CD confirmed the above listed items were not cleaned and should have been. In an interview on 04/17/2024 at 3:50 PM, the CD confirmed the facility's Planned Event Work Order Kitchen, Dishroom, [NAME] Wall & Cafe Vents log sheet dated 03/04/2024 was last completed on 03/04/2024, it should have been completed monthly, and had not been completed in the month of April.

Based on record review and interview, the facility failed to update the PASRR (Pre-admission Screening and Resident Review) assessment for 2 of 4 sampled residents, (Residents 39 and 66) to include a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility census was 81. Findings are: A. A record review of Resident 39's PASRR dated 4/12/2019 revealed no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A record review of the pharmacy review dated 5/9/19 for Resident 39 revealed a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A record review of the History and Physical (H&P) for Resident 39 dated 11/10/2021 revealed a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A record review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] A record review of Resident 39's comprehensive Care plan (an outline of the nursing care to be provided to a resident) for Resident 39 dated 2/17/22 revealed target behaviors to include exit seeking and yelling out. A record review of Resident 39's annual MDS (Minimum Data Set - a comprehensive assessment tool used to develop a resident's care plan) dated 2/8/2022 revealed no level 2 PASSR and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 3/28/22 at 3:19PM with RN (Registered Nurse) - A confirmed the PASRR was not updated with the new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] B. A record review of Resident 66's PASRR dated 2/2/2022 revealed no mental health diagnosis. A record review of Client diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident 66's annual MDS dated [DATE] revealed a [CONDITION(S)] diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident 66's comprehensive Care Plan dated 12/14/21 revealed target behaviors for antipsychotic medication to include episodes of being uncooperative. A record review of Resident 66's H&P dated 2/11/22 does not show a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 3/28/22 at 3:08 PM with RN - A confirmed the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] &P from admission and on the recent MDS. The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER]

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on record review and interviews, the facility failed to ensure residents were free from unnecessary meds related to PRN (as needed) [MEDICATION(S)] (a medication used to treat anxiety) ordered without a frequency and with a duration of 30 days for Resident 67 and a PRN [MEDICATION(S)] (a medication used to treat anxiety with depression) order with no stop date for Resident 12. The sample size was 4. The facility identified a census of 81. FINDINGS ARE: A. A record review of the Medication Administration Record (MAR) dated 2/28/22-3/24/22 for Resident 67 revealed a PRN order for [MEDICATION(S)] with a 30 day stop date. A record review of the MAR dated 2//28/22-3/24/22 for Resident 67 revealed an order for the following: -[MEDICATION(S)] 0.5mg (milligrams) oral at bedtime for anxiety, Target behaviors: hallucinations, self isolation [MEDICATION(S)] 0.5mg 1/2 tab as needed, for 30 days. A record review of the document titled Behavior Monitoring Weekly Evaluation Summary and dated 3/5/22 through 3/19/22 for Resident 67 revealed no hallucinations, self isolation, or negative behaviors. The record review revealed every entry to read Status Stable An interview with the ADON (Assistant Director of Nursing) on 3/38/22 at 10:47 AM after review of the MAR dated 2//28/22-3/24/22 for Resident 67 confirmed the PRN [MEDICATION(S)] order did not have a frequency and should have a frequency. During the interview with the ADON, after review of the Behavior Monitoring Weekly Evaluation Summary dated 3/5/22 through 3/19/22 for Resident 67, the ADON confirmed that the behavior documentation did not support the need for the [MEDICATION(S)]. A record review of the facility policy titled Medications Dunklau Gardens with a revision date of 10/2020 revealed the following step: 1. All prescriptions are written to include drug name, dose, route, time & indication for use by a licensed practitioner. Duplicate medications will be required to have a clinical rational for use. The record review revealed that the policy did not contain guidance related to the use of PRN [CONDITION(S)] medications. Record review revealed Resident 12, was admitted [DATE] at age 63. The record revealed the resident had [CONDITION(S)], [CONDITION(S)], history [CONDITION(S)], Parkinson, essential hypertension, pain, history of transient scenic attacks, cerebral infarction without residual deficits, constipation, cardiovascular disease. Record review of a Behavior Weekly Flow sheet for February 2022, revealed there were no behaviors specific to the monitored behavior the staff were checking for, and many weekly behaviors stated no behaviors. March 24, 2022 at 9:30 AM Resident 12 in Dining Room finishing breakfast and returning to room per wheelchair. Review of Resident 12's Medication Administration record dated 2-1-22 thru 2-28-22 revealed the resident received [MEDICATION(S)] .5 mg up to three times a day, as needed for anxiety target behaviors: obsessing over things the resident cannot control. February 11th thru February 22nd, 2022 Resident 12 received [MEDICATION(S)] 19 separate times. Record review revealed that upon admission to the facility, the resident had an order for [MEDICATION(S)] .5mg ordered for 14 days, then for 30 day. The order on August 24, 2020 revealed the order by a Physician; increase [MEDICATION(S)] to .5 Three times a day as needed, no end date was found up to March 28, 2022. Interview on March 29, 2022 at 10:15 AM with the ADON confirmed there had not been an end date on the [MEDICATION(S)] since August 24, 2020.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C3a(6) Based on interview and record review, the facility failed to report a change of condition to the physician of Resident 67 related to a right heel blister. The sample size was 4. The facility identified a census of 81. FINDINGS ARE: A record review of the Progress Notes dated 2/28/22 through 3/24/22 revealed Resident 67 to have reported on 3/19/22, a right heel blister due to a new pair of shoes being too tight. The record review of the Progress Notes for Resident 6 revealed no further documentation related to the blister after 3/19/22. The review also revealed no representative or physician notification regarding a blister to the right heel. An interview with the ADON (Assistant Director of Nursing) on 3/28/22 at 10:59AM after review of the Progress Notes dated 2/28/22 through 3/24/22 for Resident 67 confirmed that no physician notification related to the right heel blister had been documented. The interview revealed that the ADON had been requested to evaluate Resident 67's right heel on 3/28/22. The interview revealed that the ADON was also the facility wound nurse. An interview with the LPN (Licensed Practical Nurse)-B on 3/38/22 at 11:25 AM revealed that usually the facility wound nurse was notified prior to 9 days post discovery of a wound or skin alteration. The interview with LPN-B confirmed that the representative notification had been completed but not documented and confirmed that no physician documentation existed A record review of the facility policy titled Skin Assessment, Care and Treatment with a revision date of 3/5/22 revealed no guidance related to physician notification of skin alterations.

Licensure Reference 175 NAC 12-006.02(8) Based on record review and interview, the facility failed to report potential neglect related to a fall with an injury that required outside treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings are: A review of the Interdisciplinary Progress Notes for Resident 5 revealed that the resident had had a fall on 3/16/22 which resulted in a head injury. Resident 5 was sent to the Emergency Department, received sutures and a computerized tomography (CT) scan, and returned to the facility. Review of the facility's incident log confirmed that the fall, injury, and need for outside treatment were documented in the log. Interview on 3/29/22 at 8:30 AM with the facility Administrator confirmed that the facility did not report this incident to the required state agencies.

Licensure Reference Number 175 NAC ,d+[DATE].16A3 Based on staff interviews, record review, facility investigation and education material, the facility failed to ensure the clinical record accurately reflected a resident's care needs by not updating the care plan when the resident went into isolation, and by not ensuring the Left Ventricular Assist Device (LVAD) was designated as a nurse-only task on the electronic Treatment Administration Record (eTAR). The facility also failed to ensure the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . As a result of the inaccurate documentation, on the evening of [DATE] when the resident went to bed, the LVAD battery was never connected to the in-house electrical supply to charge the battery, the staff did not hear the LVAD alarm, and staff did chest compressions on the resident when he was found unresponsive, contrary to LVAD instructions. This occurred for 1 of 1 (Resident 322) resident reviewed for death in the facility. The census was 70. Findings include: The facility education material for the Heartmate II LVAD, dated [DATE], specified in part: If a patient is in a Code event, place the AED on immediately and wait on what to be advised on. If shock advised, allow shock. Do not do chest compressions unless advised differently from LVAD coordinator. NO CPR (cardio-pulmonary resuscitation). and Battery sets of 2 last ,d+[DATE] hours and need [to be] charged nightly. Resident 322 had multiple co-morbidities which included in part: long term anticoagulant (blood thinner) use, ischemic [CONDITION(S)] (damaged heart muscle), [CONDITION(S)] (irregular heart rate), chronic systolic congestive heart failure (heart unable to pump blood through the body), ventricular tachycardia (high heart rate), biventricular Implantable Cardioverter-Defibrillator, and [CONDITION(S)] (blood flowing backward in the heart). The resident was originally admitted [DATE] with the LVAD, which had been placed in 2016. The resident also had a known clot near the drive shaft of the LVAD. The quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident 322 was moderately cognitively impaired. The care plan, most recently updated [DATE], specified the resident was dependent on the LVAD due to heart failure and was to be hooked up to an electrical wall outlet at night when sleeping. The Care Plan also stated the resident wished to be a Code, but do not use compressions - can use AED (automated external defibrillator). On [DATE], the Care Plan had been updated to include the potential for COVID-19 virus with intervention including screening, monitoring for symptoms and no visitation, but did not indicate when the resident had been put in isolation with the door closed, nor did it include consideration of the audibility of the LVAD system alarm. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order did not indicate that chest compressions were not to be done. Review of the eTAR for [DATE] regarding the order for the LVAD to be plugged in at night revealed, Pt (Patient) to be hooked up to red outlet wall power while sleeping. The order indicated it was to be done by the second shift, which was the 6:00 PM to 6:00 AM shift. It was not designated as a nurse only task. Other items on the eTAR such as vital signs, notifying the LVAD team if the resident's weight changed, and monitoring for COVID-19 symptoms, were identified as NURSE TO DO ONLY tasks. Resident 322 had been exposed to a COVID-19 positive staff member and was in precautionary isolation during the week of [DATE]. Staff working Resident 322's hallway wore full personal protective equipment (PPE) including face shields when in isolation rooms, which would slightly diminish one's ability to hear. Review of the facility investigation report, dated [DATE], specified the following timeline: During the early evening hours on [DATE], Licensed Practical Nurse (LPN)-A entered Resident 322's room to take vital signs. The LVAD was still on battery power because the resident wasn't yet ready for bed. Medication Aide-A (MA-A), entered Resident 322's room between 8:30 PM and 9:00 PM to administer medication. The resident had put himself to bed, which the resident often did. MA-A did not notify the nurse that Resident 322 had gotten into bed. MA-A documented on the electronic Medication Administration Record (eMAR) the medications given to Resident 322. MA-A also inadvertently signed the box on the electronic Treatment Administration Record (eTAR) for the nurse-only task of switching the LVAD from battery to an electrical wall outlet. When finished with the evening nurse tasks on [DATE], LPN-A double checked the tasks by reviewing the eMAR and eTAR. The late task notice did not highlight because the task of switching the LVAD from battery to an electrical wall outlet had been inadvertently signed on the eTAR by MA-A. Because the late task notice did not appear on the eTAR, LPN-A was not reminded and did not remember to switch the LVAD over to the electrical wall outlet for power. LPN-A was in and out of rooms on the evening of [DATE], on the hallway where Resident 322 resided, but did not hear the LVAD alarm as it began to lose power. MA-A entered Resident 322's room again sometime between 11:00 and 11:30 PM, but did not hear an alarm from the LVAD unit. MA-B also worked the hallway and was in and out of resident rooms. MA-B also reported not hearing an alarm from the LVAD unit. At approximately 1:10 AM on [DATE], MA-A was doing rounds and was unsure, but thought Resident 322 wasn't breathing. MA-A called MA-B over, who found the resident to be unresponsive and not breathing. At approximately 1:14 AM, MA-B pressed the staff assistance button which alerted LPN-A and LPN-B, who ran to Resident 322's room. Registered Nurse (RN) Supervisor-A also responded to the room and began cardiac compressions. LPN-B called the hospital Code Team and brought the facility's crash cart which contained the Automatic External Defibrillator (AED), to Resident 322's room. According to the hospital Code Team's documentation, the Code Team arrived at 1:22 AM, to find the LVAD vest had been removed, the resident was receiving respirations via an Artificial Manual Breathing Unit (AMBU) bag attached to oxygen, and the AED nodes were being applied by facility staff. The hospital team assumed responsibility for the code. The Hospital House Supervisor called the LVAD Team. A nurse's note on the hospital team's documentation said, No compressions were done by the code team. Spoke (with) on-call LVAD representative. Meds are the only thing allowed. The hospital documentation specified the resident was given three separate doses of [MEDICATION(S)], an [MEDICATION(S)] of [MEDICATION(S)] and five times the AED evaluated and said no shock. Despite efforts, Resident 322's time of death was called by the hospital Code Team's Emergency Department physician, at 1:38 AM on [DATE]. On [DATE] at 1:49 PM, the Administrator and Director of Nursing (DON) were interviewed. The Administrator said the facility had done a root-cause analysis about the processes that failed surrounding Resident 322. The DON stated the LVAD and the LVAD clinical expert team were called back to the facility to reproduce the alarms. According to the LVAD's internal record, the alarms started sounding at 9:02 PM with an intermittent alarm at ,d+[DATE] seconds. The alarm progressed to a solid tone, and last alarm sounded at 11:17 PM on [DATE]. The DON specified that at the time of the incident, Resident 322's hallway was a yellow zone (all doors were shut and staff were in full PPE including face shields) and Resident 322 was on a 14-day quarantine due to COVID-19 exposure. During the LVAD alarm test, they discovered from the hallway, the LVAD alarm could not be heard through the closed door unless one was right next to the door and listening for the alarm. The LVAD clinical expert team also pointed out that while the resident was in bed, the vest would have been covered with the resident's blanket, which would further have obscured the alarm. The Administrator stated it was the nurse's responsibility to connect the LVAD to the electrical wall outlet and the facility had since changed the eMAR/eTAR system. The DON stated the facility had also added baby monitors (wireless microphone and speaker system) for residents at risk. The DON provided an undated, unsigned statement from LPN-A. The statement indicated LPN-A saw the resident during the evening of [DATE] and took vital signs, but, resident was not ready for bed so I did not at that time hook (the resident) to the wall. The statement said, I go off of MAR (eMAR/eTAR), I check several times to make sure I was signing off and doing what I needed to do. The statement also indicated LPN-A and LPN-B were called to Resident 322's room at approximately 1:08 AM on [DATE]. At that time resident appeared to not be breathing and was gray. (LPN-B) called (RN Supervisor-A), who came to room and we started CPR. With (RN Supervisor-A) doing chest compressions, and myself bagging the resident. (LPN-B) called 222 to call a code and (RN Supervisor-A) and (MA-A) switched out [chest compressions] while I was still bagging resident. Code team arrived and took over. LPN-A no longer worked at the facility and could not be reached for an interview. MA-A was interviewed on [DATE] at 12:13 PM. MA-A stated on the evening of [DATE], the resident was given medication while MA-A was in the room between 8:30 PM and 9:00 PM. MA-A reported accidently signing the box on the eTAR for the nurse-only task of switching the LVAD from battery to an electrical wall outlet because the order did not indicate it was a nurse-only task. MA-A did not hear any alarm and said the resident was breathing when checked sometime between 11:00 to 11:30 PM. It was during the 1:00 AM rounds on [DATE], when MA-A discovered Resident 322 was not breathing. The nurses were alerted. MA-A stated that when the nurses arrived in the room, RN Supervisor-A started chest compressions and then MA-A switched and did compressions until MA-B arrived with the crash cart. MA-A stated she did not hear the LVAD alarm that night. The facility provided a written statement from LPN-B dated [DATE]. The statement indicated when LPN-B and LPN-A entered Resident 322's room there were no alarms sounding. LPN-A called for RN Supervisor-A. Upon arrival, RN Supervisor-A asked LPN-B if the resident's Code status had been checked. LPN-B checked the Code status in Resident 322's clinical record and then called the hospital Code Team. LPN-B was not interviewed during the survey. The facility provided a written statement by RN Supervisor-A, dated [DATE]. The statement indicated RN Supervisor-A was summoned to Resident 322's room at 1:14 AM on [DATE]. MA-B had been instructed to get the crash cart. I started chest compressions and (LPN-A) started rescue breathing with 3 (liters) of oxygen for the ambu bag. (LPN-B) hooked the LVAD to the wall and called for the code team. After approximately 2 min of compressions, (MA-A) started compressions. At approximately 1:17 AM, hospital code team arrived and took over the code. RN Supervisor-A no longer worked at the facility and could not be reached for an interview. On [DATE] at 12:37 PM, the DON was asked about the care plan and LVAD instructions regarding a Code versus the July physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON said, I expected my team to have clarified that. From the beginning, we knew compressions were not recommended with the LVAD so the Code order should have reflected that. The Administrator and DON were interviewed together on [DATE] at 12:51 PM about information in the clinical record, and expectations of consistent and available information to facilitate communication among staff. The Administrator stated, We have altered the process to ensure that this process does not fail again. It includes that all nurse only tasks have a definitive designation of '***Nurse Only***' so that these tasks are easily and quickly identifiable. Secondly, all nurse only tasks now require double signatures from nurses for the purpose of ensuring the nurse completes the task and it cannot be overlooked. The Administrator added, We are also doing a focus group to identify process opportunities for point of care documentation accuracy. The Administrator and DON were asked if the care plan should have been updated when Resident 332 was put into isolation because of the closed door which would have muted any alarm. The Administrator said, If we had identified that as a risk, we should have care planned that.

Licensure Reference Number 175 NAC ,d+[DATE].05 (9) Based on staff interviews and record review, the facility failed to provide essential services for a resident with heart failure by not ensuring the Left Ventricular Assist Device (LVAD) was switched from battery supply to an electrical wall outlet power supply for 1 of 1 (Resident 322) resident reviewed for death in the facility. This resulted in a power supply failure of the LVAD mechanical pump, which assisted the main blood-pumping chamber of the heart for this resident with end-stage heart failure. The resident was found with no pulse and was unable to be revived. The census was 70. Findings are: Resident 322 had multiple co-morbidities which included in part: long term anticoagulant (blood thinner) use, ischemic [CONDITION(S)] (damaged heart muscle), [CONDITION(S)] (irregular heart rate), chronic systolic congestive heart failure (heart unable to pump blood through the body), ventricular tachycardia (high heart rate), biventricular Implantable Cardioverter-Defibrillator, and [CONDITION(S)] (blood flowing backward in the heart). The resident was originally admitted [DATE] with the LVAD which had been placed in 2016. The resident also had a known clot near the drive shaft of the LVAD. The quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident 322 was moderately cognitively impaired and required limited assistance for bed mobility, transfers, and dressing. The care plan, most recently updated [DATE], specified the resident was dependent on the LVAD due to heart failure and was to be hooked up to an electrical wall outlet at night when sleeping. Resident 322 had been exposed to a COVID-19 positive staff member and was in precautionary isolation during the week of [DATE]. Staff working Resident 322's hallway wore full personal protective equipment (PPE) including face shields when in isolation rooms. Review of the facility's investigation report, dated [DATE], specified the following timeline: During the early evening hours on [DATE], Licensed Practical Nurse (LPN)-A entered Resident 322's room to take vital signs. The LVAD was still on battery power because the resident wasn't yet ready for bed. Medication Aide-A (MA-A), entered Resident 322's room between 8:30 PM and 9:00 PM to administer medication. The resident had put himself to bed, which the resident often did. MA-A did not notify the nurse that Resident 322 had gotten into bed. MA-A documented on the electronic Medication Administration Record (eMAR) the medications given to Resident 322. MA-A also inadvertently signed the box on the electronic Treatment Administration Record (eTAR) for the nurse-only task of switching the LVAD from battery to an electrical wall outlet. When finished with the evening nurse tasks on [DATE], LPN-A double checked the tasks by reviewing the eMAR and eTAR. The late task notice did not highlight because the task of switching the LVAD from battery to an electrical wall outlet had been inadvertently signed on the eTAR by MA-A. Because the late task notice did not appear on the eTAR, LPN-A was not reminded and did not remember to switch the LVAD over to the electrical wall outlet for power. LPN-A was in and out of rooms on the evening of [DATE], on the hallway where Resident 322 resided, but did not hear the LVAD alarm as it began to lose power. MA-A entered Resident 322's room again sometime between 11:00 PM and 11:30 PM but did not hear an alarm from the LVAD unit. MA-B also worked the hallway in and out of resident rooms. MA-B also reported hearing no alarm from the LVAD unit. At approximately 1:10 AM on [DATE], MA-A was doing rounds and was unsure, but thought Resident 322 wasn't breathing. MA-A called MA-B over, who found the resident to be unresponsive and not breathing. At approximately 1:14 AM, MA-B pressed the staff assistance button which alerted LPN-A and LPN-B, who ran to Resident 322's room. Registered Nurse (RN) Supervisor-A also responded to the room and began cardiac compressions. LPN-B called the hospital Code Team and brought the facility's crash cart which contained the Automatic External Defibrillator (AED), to Resident 322's room. According to the hospital Code Team's documentation, the Code Team arrived at 1:22 AM, to find the LVAD vest had been removed, the resident was receiving respirations via an Artificial Manual Breathing Unit (AMBU) bag attached to oxygen, and the AED nodes were being applied by facility staff. The hospital team assumed responsibility for the code. Despite efforts, Resident 322's time of death was called by the hospital Code Team's Emergency Department physician, at 1:38 AM on [DATE]. On [DATE] at 1:49 PM, the Administrator and Director of Nursing (DON) were interviewed. The Administrator said the facility had done a root-cause analysis about the processes that failed surrounding Resident 322. The DON stated the LVAD and the LVAD clinical expert team were called back to the facility to reproduce the alarms. According to the LVAD's internal record, the alarms started sounding at 9:02 PM with an intermittent alarm at ,d+[DATE] seconds. The alarm progressed to a solid tone, and last alarm sounded at 11:17 PM on [DATE]. The DON specified that at the time of the incident Resident 322's hallway was a yellow zone (all doors were shut and staff were in full PPE including face shields) and Resident 322 was on a 14-day quarantine due to COVID-19 exposure. They discovered from the hallway, the LVAD alarm could not be heard through the closed door unless one was right next to the door and listening for the alarm. Also, while the resident was in bed, the vest would have been covered with the resident's blanket, which would further have obscured the alarm. The Administrator stated it was the nurse's responsibility to connect the LVAD to the electrical wall outlet and the facility had since changed the eMAR/eTAR system. The Administrator said, Now the MAR (eMAR/eTAR) requires two signatures for all nurse tasks. Another enhancement was to specially identify tasks on the eMAR/eTAR for all those required to be done by the nurse. The DON stated the facility had also added baby monitors (wireless microphone and speaker system) for residents at risk. The facility had concluded the death was a result of a combinations of factors including significant and multiple diagnoses, failing nature of the resident's health, and human error of failing to switch the LVAD's power source. On [DATE] at 11:54 AM, Resident 322's primary physician was interviewed and described the resident's condition prior to the incident as tenuous (very weak) and very unstable. The primary physician stated the resident had been noted to go days without the LVAD when living at home and believed Resident 322 and the LVAD had been managed very well by the facility for two years. The primary physician did not believe the resident's death was due to the LVAD power failure. MA-A was interviewed on [DATE] at 12:13 PM. MA-A stated the Continuous Positive Airway Pressure (CPAP) mask was put on the resident while MA-A was in the room, after administering medication, between 8:30 and 9:00 PM. MA-A stated that around 11:30 PM was the next time Resident 322 was checked. MA-A specified, Resident 322 was breathing and there was no alarm sounding. It was during the 1:00 AM rounds on [DATE], when MA-A discovered Resident 322 was not breathing. LPN-A no longer worked at the facility and could not be reached for an interview. The facility provided an statement from LPN-A about the training LPN-A received regarding the LVAD. LPN-A was a contract nurse and had worked ,d+[DATE] days a week from [DATE] through [DATE]. LPN-A was oriented by the LVAD team during that first contract. LPN-A went through the facility orientation again at the beginning of a second contract from [DATE] through [DATE]. RN Supervisor-A no longer worked at the facility and could not be reached for an interview. On [DATE] at 12:37 PM, the DON provided documentation from March to [DATE], regarding the number of shifts LPN-A worked the 200 hallway where Resident 322 resided and would have provided care. During that period, LPN-A worked 35 of 36 shifts on the 200 hall. The DON stated LPN-A knew it was the nurse's responsibility to ensure the resident's LVAD was plugged into the wall outlet when the resident was in bed and had done that many times. The DON added, (LPN-A) was an exceptionally competent nurse and was well respected for clinical skills. (LPN-A) never denied it was (LPN-A's) responsibility to plug (Resident 322's LVAD) in. The Administrator was interviewed [DATE] at 12:51 PM. The Administrator stated the expectation would be without failure, Resident 322's LVAD unit should have been plugged into the electrical wall outlet when necessary. The Administrator added, We have altered the process to ensure that this process does not fail again.

Licensure Reference Number 175 NAC ,d+[DATE].09 Based on staff interviews, record review, facility investigation and education material, the facility failed to provide care in accordance with professional standards by not ensuring the Left Ventricular Assist Device (LVAD) was switched from battery supply to an electrical wall outlet power supply. This resulted in a power supply failure of the LVAD mechanical pump which assisted the main blood-pumping chamber of the heart for this resident with end-stage heart failure. The facility also failed to implement correct Code status procedure for the resident with an LVAD by performing chest compressions. This deficient practice affected 1 of 1 resident (Resident 322) reviewed with an LVAD. The resident was found with no pulse and was unable to be revived. The census was 70. Findings are: The facility education material for the Heartmate II LVAD, dated [DATE], specified in part: If a patient is in a Code event, place the AED on immediately and wait on what to be advised on. If shock advised, allow shock. Do not do chest compressions unless advised differently from LVAD coordinator. NO CPR (cardio-pulmonary resuscitation). and Battery sets of 2 last ,d+[DATE] hours and need [to be] charged nightly. Resident 322 had multiple co-morbidities which included in part: long term anticoagulant (blood thinner) use, ischemic [CONDITION(S)] (damaged heart muscle), [CONDITION(S)] (irregular heart rate), chronic systolic congestive heart failure (heart unable to pump blood through the body), ventricular tachycardia (high heart rate), biventricular Implantable Cardioverter-Defibrillator, and [CONDITION(S)] (blood flowing backward in the heart). The resident was originally admitted [DATE] with the LVAD which had been placed in 2016. The resident also had a known clot near the drive shaft of the LVAD. The quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident 322 was moderately cognitively impaired. The care plan most recently updated [DATE], specified the resident was dependent on the LVAD due to heart failure and was to be hooked up to an electrical wall outlet at night when sleeping. The Care Plan also stated the resident wished to be a Code, but do not use compressions - can use AED (automated external defibrillator) Review of the facility investigation report, dated [DATE], specified the following timeline: During the early evening hours on [DATE], Licensed Practical Nurse (LPN)-A entered Resident 322's room to take vital signs. The LVAD was still on battery power because the resident wasn't yet ready for bed. Medication Aide-A (MA-A), entered Resident 322's room between 8:30 PM and 9:00 PM to administer medication. MA-A documented on the electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . MA-A also inadvertently signed the box on the electronic Treatment Administration Record (eTAR) for the nurse-only task of switching the LVAD from battery to an electrical wall outlet. When finished with the evening nurse tasks on [DATE], LPN-A double checked the tasks by reviewing the eMAR/eTAR. The late task notice did not highlight because the task of switching the LVAD from battery to an electrical wall outlet had been inadvertently signed on the eTAR by MA-A. Because the late task notice did not appear on the eTAR, LPN-A was not reminded and did not remember to switch the LVAD over to the electrical wall outlet for power. LPN-A was in and out of rooms on the evening of [DATE], on the hallway where Resident 322 resided, but did not hear the LVAD alarm as it began to lose power. At approximately 1:10 AM on [DATE], MA-A was doing rounds and was unsure, but thought Resident 322 wasn't breathing. MA-A called MA-B over, who found the resident to be unresponsive and not breathing. At approximately 1:14 AM, MA-B pressed the staff assistance button which alerted LPN-A and LPN-B, who ran to Resident 322's room. Registered Nurse (RN) Supervisor-A also responded to the room and began cardiac compressions. LPN-B called the hospital Code Team and brought the facility's crash cart which contained the Automatic External Defibrillator (AED), to Resident 322's room. According to the hospital Code Team's documentation, the Code Team arrived at 1:22 AM, to find the LVAD vest had been removed, the resident was receiving respirations via an Artificial Manual Breathing Unit (AMBU) bag attached to oxygen, and the AED nodes were being applied by facility staff. The hospital team assumed responsibility for the code. The Emergency Department physician intubated the resident and the Hosp House Supervisor called the LVAD Team. A nurse's note on the hospital team's documentation said, No compressions were done by the code team. Spoke (with) on-call LVAD representative. Meds are the only thing allowed. The hospital documentation specified the resident was given three separate doses of [MEDICATION(S)], an [MEDICATION(S)] of [MEDICATION(S)] and the AED said no shock at 1:25, 1:27, 1:30, 1:33, 1:36 AM. Despite efforts, Resident 322's time of death was called by the hospital Code Team's Emergency Department physician, at 1:38 AM on [DATE]. The DON provided an undated, unsigned statement from the LPN-A. The statement indicated LPN-A saw the resident during the evening of [DATE] and took vital signs, but, resident was not ready for bed so I did not at that time hook (the resident) to the wall. The statement said, I go off of MAR (eMAR/eTAR), I check several times to make sure I was signing off and doing what I needed to do. The statement also indicated LPN-A and LPN-B were called to Resident 322's room at approximately 1:08 AM on [DATE]. At that time resident appeared to not be breathing and was gray. (LPN-B) called (RN Supervisor-A), who came to room and we started CPR, with (RN Supervisor-A) doing chest compressions, and myself bagging [breathing assistance with an AMBU bag] the resident. (LPN-B) called 222 to call a code and (RN Supervisor-A) and (MA-A) switched out [chest compressions] while I was still bagging resident. Code team arrived and took over. LPN-A no longer worked at the facility and could not be reached for an interview. MA-A was interviewed on [DATE] at 12:13 PM. MA-A stated on the evening of [DATE], the resident was given medication while MA-A was in the room between 8:30 PM and 9:00 PM. MA-A reported accidently signing the box on the eTAR for the nurse-only task of switching the LVAD from battery to an electrical wall outlet because the order did not indicate it was a nurse-only task. MA-A said the resident was breathing when checked sometime between 11:00 to 11:30 PM. It was during the 1:00 AM rounds on [DATE], when MA-A discovered Resident 322 was not breathing. The nurses were alerted. MA-A stated that when the nurses arrived in the room, RN Supervisor-A started chest compressions and then MA-A switched and did compressions until MA-B arrived with the crash cart. The facility provided a written statement by RN Supervisor-A, dated [DATE]. The statement indicated RN Supervisor-A was summoned to Resident 322's room at 1:14 AM on [DATE]. MA-B had been instructed to get the crash cart. I started chest compressions and (LPN-A) started rescue breathing with 3 (liters) of oxygen for the AMBU bag. (LPN-B) hooked the LVAD to the wall and called for the code team. After approximately 2 min of compressions, (MA-A) started compressions. At approximately 1:17 AM, hospital code team arrived and took over the code. RN Supervisor-A no longer worked at the facility and could not be reached for an interview. On [DATE] at 12:37 PM, the DON provided documentation from March to [DATE], regarding the number of shifts LPN-A worked the 200 hallway where Resident 322 resided and would have provided care. During that period, LPN-A worked 35 of 36 shifts on the 200 hall. When asked about expected standards of practice, the DON was clear that LPN-A knew it was the nurse's responsibility to ensure the resident's LVAD was plugged into the wall outlet when the resident was in bed and had done that many times. The DON said, (LPN-A) was an exceptionally competent nurse and was well respected for clinical skills. (LPN-A) never denied it was (LPN-A's) responsibility to plug (Resident 322's LVAD) in. The DON was also clear that from the LVAD training all the nursing staff were aware chest compressions were not recommended and should not have been done. The Administrator was interviewed [DATE] at 12:51 PM, about expected standards of practice. The Administrator stated, My expectation would be that absolutely 100% without failure, nurses would plug the resident's LVAD into AC (electrical wall outlet) power when necessary. We have altered the process to ensure that this process does not fail again. The Administrator also indicted the care plan and training about not doing compressions with the LVAD should have been followed as a standard of practice.

Licensure Reference Number 175 NAC ,d+[DATE].04C3a (5) Based on staff interviews, record review, and facility investigation, the facility failed to implement the comprehensive care plan for a resident with heart failure by not ensuring the Left Ventricular Assist Device (LVAD) was switched from battery supply to an electrical wall outlet power supply, and failed to follow the care plan to Code the resident without chest compressions. The facility also failed to update the care plan when the resident was put in precautionary isolation. This occurred for 1 of 1 resident (Resident 322) reviewed for death in the facility. The census was 70. Findings are: Resident 322 had multiple co-morbidities which included in part: long term anticoagulant (blood thinner) use, ischemic [CONDITION(S)] (damaged heart muscle), [CONDITION(S)] (irregular heart rate), chronic systolic congestive heart failure (heart unable to pump blood through the body), ventricular tachycardia (high heart rate), biventricular Implantable Cardioverter-Defibrillator, and [CONDITION(S)] (blood flowing backward in the heart). The resident was originally admitted [DATE] with the LVAD which had been placed in 2016. The resident also had a known clot near the drive shaft of the LVAD. The quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident 322 was moderately cognitively impaired. The care plan most recently updated [DATE], specified the resident was dependent on the LVAD due to heart failure and was to be hooked up to an electrical wall outlet at night when sleeping. The Care Plan also stated the resident wished to be a Code, but do not use compressions - can use AED (automated external defibrillator). On [DATE], the Care Plan was updated to include the potential for COVID-19 virus with intervention including screening, monitoring for symptoms and no visitation, but did not indicate when the resident had been put in isolation with the door closed, nor did it include consideration of the audibility of the LVAD system alarm. Resident 322 had been exposed to a COVID-19 positive staff member and was in precautionary isolation during the week of [DATE]. Staff working Resident 322's hallway wore full personal protective equipment (PPE) including face shields when in isolation rooms, which would slightly diminish one's ability to hear. Review of the facility investigation report, dated [DATE], specified the following timeline: During the early evening hours on [DATE], Licensed Practical Nurse (LPN)-A entered Resident 322's room to take vital signs. The LVAD was still on battery power because the resident wasn't yet ready for bed. Medication Aide-A (MA-A), entered Resident 322's room between 8:30 PM and 9:00 PM to administer medication. The resident had put himself to bed, which the resident often did. MA-A did not notify the nurse that Resident 322 had gotten into bed. MA-A documented on the electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . MA-A also inadvertently signed the box on the Treatment Administration Record (eTAR) for the nurse-only task of switching the LVAD from battery to an electrical wall outlet. When finished with the evening nurse tasks on [DATE], LPN-A double checked the tasks by reviewing the eMAR/eTAR. The late task notice did not highlight because the task of switching the LVAD from battery to an electrical wall outlet had been inadvertently signed on the eTAR by MA-A. Because the late task notice did not appear on the eTAR, LPN-A was not reminded and did not remember to switch the LVAD over to the electrical wall outlet for power. LPN-A was in and out of rooms on the evening of [DATE], on the hallway where Resident 322 resided, but did not hear the LVAD alarm as it began to lose power. MA-A entered Resident 322's room again sometime between 11:00 PM and 11:30 PM but did not hear an alarm from the LVAD unit. MA-B also worked the hallway in and out of resident rooms. MA-B also reported hearing no alarm from the LVAD unit. At approximately 1:10 AM on [DATE], MA-A was doing rounds and was unsure, but thought Resident 322 wasn't breathing. MA-A called MA-B over, who found the resident to be unresponsive and not breathing. At approximately 1:14 AM, MA-B pressed the staff assistance button which alerted LPN-A and LPN-B, who ran to Resident 322's room. Registered Nurse (RN) Supervisor-A also responded to the room and began cardiac compressions. LPN-B called the hospital Code Team and brought the facility's crash cart which contained the Automatic External Defibrillator (AED), to Resident 322's room. According to the hospital Code Team's documentation, the Code Team arrived at 1:22 AM, to find the LVAD vest had been removed, the resident was receiving respirations via an Artificial Manual Breathing Unit (AMBU) bag attached to oxygen, and the AED nodes were being applied by facility staff. The hospital team assumed responsibility for the code. The Hospital House Supervisor called the LVAD Team. A nurse's note on the hospital team's documentation said, No compressions were done by the code team. Spoke (with) on-call LVAD representative. Meds are the only thing allowed. The hospital documentation specified the resident was given three separate doses of [MEDICATION(S)], an [MEDICATION(S)] of [MEDICATION(S)] and five times the AED evaluated and said no shock. Despite efforts, Resident 322's time of death was called by the hospital Code Team's Emergency Department physician, at 1:38 AM on [DATE]. On [DATE] at 1:49 PM, the Administrator and Director of Nursing (DON) were interviewed. The Administrator said the facility had done a root-cause analysis about the processes that failed surrounding Resident 322. The DON stated the LVAD and the LVAD clinical expert team were called back to the facility to reproduce the alarms. According to the LVAD's internal record, the alarms started sounding at 9:02 PM with an intermittent alarm at ,d+[DATE] seconds. The alarm progressed to a solid tone, and last alarm sounded at 11:17 PM on [DATE]. The DON specified that at the time of the incident Resident 322's hallway was a yellow zone (all doors were shut and staff were in full PPE including face shields) and Resident 322 was on a 14-day quarantine due to COVID-19 exposure. During the LVAD alarm test, they discovered from the hallway, the LVAD alarm could not be heard through the closed door unless one was right next to the door and listening for the alarm. The LVAD clinical expert team also pointed out that while the resident was in bed, the vest would have been covered with the resident's blanket, which would further have obscured the alarm. The Administrator stated it was the nurse's responsibility to connect the LVAD to the electrical wall outlet and the facility had since changed the eMAR/eTAR system. The Administrator said, Now the MAR (eMAR/eTAR) requires two signatures for all nurse tasks. Another enhancement was to specially identify tasks on the (eMAR/eTAR) for all those required to be done by the nurse. The DON stated the facility had also added baby monitors (wireless microphone and speaker system) for residents at risk. The facility had concluded the death was a result of a combinations of factors including significant and multiple diagnoses, failing nature of the resident's health, and human error of failing to switch the LVAD's power source. The DON provided an undated, unsigned statement from the LPN-A. The statement indicated LPN-A saw the resident during the evening of [DATE] and took vital signs, but resident was not ready for bed, so I did not at that time hook (the resident) to the wall. The statement said, I go off of MAR (eMAR/eTAR), I check several times to make sure I was signing off and doing what I needed to do. The statement also indicated LPN-A and LPN-B were called to Resident 322's room at approximately 1:08 AM on [DATE]. At that time resident appeared to not be breathing and was gray. (LPN-B) called (RN Supervisor-A), who came to room and we started CPR. With (RN Supervisor-A) doing chest compressions, and myself bagging the resident. (LPN-B) called 222 to call a code and (RN Supervisor-A) and (MA-A) switched out [chest compressions] while I was still bagging resident. Code team arrived and took over. LPN-A no longer worked at the facility and could not be reached for an interview. MA-A was interviewed on [DATE] at 12:13 PM. MA-A stated on the evening of [DATE], the resident was given medication while MA-A was in the room between 8:30 PM and 9:00 PM. MA-A reported accidently signing the box on the eTAR for the nurse-only task of switching the LVAD from battery to an electrical wall outlet because the order did not indicate it was a nurse-only task. MA-A did not hear any alarm and said the resident was breathing when checked sometime between 11:00 to 11:30 PM. It was during the 1:00 AM rounds on [DATE], when MA-A discovered Resident 322 was not breathing. The nurses were alerted. MA-A stated that when the nurses arrived in the room, RN Supervisor-A started chest compressions and then MA-A switched and did compressions until MA-B arrived with the crash cart. The facility provided a written statement by RN Supervisor-A, dated [DATE]. The statement indicated RN Supervisor-A was summoned to Resident 322's room at 1:14 AM on [DATE]. MA-B had been instructed to get the crash cart. I started chest compressions and (LPN-A) started rescue breathing with 3 (liters) of oxygen for the AMBU bag. (LPN-B) hooked the LVAD to the wall and called for the code team. After approximately 2 min of compressions, (MA-A) started compressions. At approximately 1:17 AM, hospital code team arrived and took over the code. RN Supervisor-A no longer worked at the facility and could not be reached for an interview. On [DATE] at 12:37 PM, the DON provided documentation from March to [DATE], regarding the number of shifts LPN-A worked the 200 hall where Resident 322 resided and would have provided care. During that period, LPN-A worked 35 of 36 shifts on the 200 hall. The DON stated LPN-A knew it was the nurse's responsibility to ensure the resident's LVAD was plugged into the wall outlet when the resident was in bed and had done that many times. The DON added, (LPN-A) never denied it was (LPN-A's) responsibility to plug (Resident 322's LVAD) in. The DON was asked about the care plan's direction to not do chest compressions. The DON said all the nursing staff were aware chest compressions were not recommended and should not have been done. The Administrator and DON were interviewed together on [DATE] at 12:51 PM. The Administrator stated the expectation would be without failure, Resident 322's LVAD unit should have been plugged into the electrical wall outlet when necessary. The Administrator also said, The Care Plan and training was clear about no compressions. The Administrator and DON were asked if the care plan should have been updated because of the closed door which would have muted any alarm. The Administrator said, If we had identified that as a risk we should have care planned that. We have since gotten baby alarms (audible monitors).

Licensure Reference Number 175 NAC 12-006.11E Based on observation, interviews and facility policy review, the facility failed to date and seal opened bags of food in the walk-in refrigerator and reach-in freezer, and failed to inspect food for damage due to spoilage. This had a potential to impact all 70 residents currently in the facility. Findings are: A review of the facility policy for Food Storage, dated April 2017, read in part, Inspect foods regularly for damage due to spoilage. and 1. All items must be dated with the label gun. 2.All items dated with a Use by Date. On 08/24/20 at 8:50 AM, the facility walk-in refrigerator was observed. There was a sealed, unopened and undated plastic bag containing three heads of cabbage that were black in some areas. One cabbage head in the bag had around area approximately 4 by 5 inches that was black and slimy. There was also an undated open net bag of eight cabbages, and an opened and resealed, cooked, partial ham that was also undated. On 08/24/20 at 8:59 AM, the reach-in refrigerator was reviewed and found to have opened, unsealed and undated bags of frozen food including: a plastic bag of veggie burgers, a bag of breaded chicken strips, a package of chicken patties, two bags of chicken breasts, a plastic bag with two bread sticks, two bags of Tater Tots, one package of potato wedges, a plastic bag of breaded fish patties, and a bag of breaded onion rings. On 08/24/20 at 9:02 AM, Dietary Staff Member-A specified that all food should be dated when it is opened.The Food Services Director (FSD) was interviewed on 08/24/20 at 12:03 PM. The FSD stated the process for pulling out frozen food and refrigerated food was to date the package when it was first opened.

Based on record review and staff interview, the facility failed to conduct and document a facility-wide assessment to determine what resources were necessary to care for the resident population competently during day to day operations during the COVID-19 pandemic. This had the potential to affect all residents. The facility assessment also failed to include risks and necessary care for a resident's Left Ventricular Assist Device (LVAD) for 1 of 1 resident (Resident 322) with the LVAD who entered the facility with the device in 2018. The census was 70. Findings are: 1. Review of the facility assessment revealed it did not contain the facility's resident population, both the number of resident's and the facility's resident capacity, the care required by the resident population, staff competencies, physical environment, and cultural, ethnic, and religious factors that may affect resident's care. It also did not contain the facility's resources such as services provided, personnel, and contracts with third parties, and managing resident records during the COVID-19 pandemic. An interview with the Administrator was conducted on [DATE] at 12:51 PM regarding COVID-19 not being in the Facility Assessment. The Administrator indicated it was not done prior to the survey because they were so busy with the guidelines surrounding COVID-19. The Administrator said, we are working on that because we are in the process of changing systems. I did know the COVID piece needed to be in there. That has been assigned for a Nurse Manager to be completed. 2. Resident 322 had multiple co-morbidities which included in part: ischemic [DIAGNOSES REDACTED] (damaged heart muscle), [MEDICAL CONDITION] (irregular heart rate), chronic systolic [MEDICAL CONDITION] (heart unable to pump blood through the body), [MEDICAL CONDITION] (high heart rate), biventricular Implantable Cardioverter-Defibrillator, and [DIAGNOSES REDACTED] (blood flowing backward in the heart). The resident was originally admitted [DATE] with the LVAD, which had been placed in 2016. The LVAD was a mechanical pump which assisted the main blood-pumping chamber of the heart for this resident with end-stage heart failure. The LVAD required batteries during the day and had to be plugged into an electrical wall socket whenever the resident was in bed in order to provide the continuous blood pumping assistance. Because of the LVAD, Resident 322 also required vital signs at least three times per day including Mean Arterial Pressure (MAP). MAP is a calculation used to check if there is enough blood flow, resistance, and pressure to supply blood to all the major organs. The facility's LVAD education specified that if Resident 322 were to have a Code event, place the AED (automated external defibrillator) on immediately and wait on what to be advised on. If shock advised, allow shock. Do not do chest compressions unless advised differently from LVAD coordinator. NO CPR (cardio-pulmonary resuscitation). and Battery sets of 2 last ,[DATE] hours and need (to be) charged nightly. Review of the Facility Assessment revealed it did not contain the LVAD in the areas of population acuity of diseases, conditions and treatments or the area of potentially high-risk treatments. An interview with the Administrator was conducted on [DATE] at 12:51 PM regarding the LVAD not being in the Facility Assessment. The Administrator stated, I didn't know the LVAD system wasn't in it. The Administrator indicated she was not inclined to add the LVAD to the Facility Assessment now since the resident had expired and the facility had not made a decision to take another resident like Resident 322.

Licensure Reference Number 175 NAC ,[DATE].12E1 and ,[DATE].12E4 Based on observation, staff interviews and record review, the facility failed to store controlled substances (schedule IV medications) in a permanently affixed, locked compartment for 2 of 3 medication rooms and failed to discard an expired medication for 1 of 5 (Resident 45) residents reviewed for expired antianxiety medication. The census was 70. Findings are: 1. 483.45(h)(2) The facility must provide separately locked permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and control Act of 176 and other drugs subject to abuse. During an observation of the 200 Hall medication room on [DATE] at 4:06 PM, a box of controlled substances was observed in the medication room refrigerator. The box of controlled substances was not locked or permanently affixed to the refrigerator, and the refrigerator was not locked or permanently affixed. The controlled substances drug box contained the following: The box contained Resident 45's Schedule IV medication of [MEDICATION NAME] 2 mg/ml (milligrams/milliliter) (an anti-anxiety). There was 28.25 mg left in the bottle, after dispensed on [DATE]. The same box contained Resident 46's Schedule IV medication of [MEDICATION NAME] 2 mg/ml (milligrams/milliliter) (an anti-anxiety). There was 3.5 mg left in the bottle, with the last dispensed date of [DATE]. According to the Federal Drug Administration (www.fda.gov), [MEDICATION NAME] ([MEDICATION NAME]) is a federal controlled substance (C-IV) because it can be abused or lead to dependence. An interview with LPN-C on [DATE] on 4:10 PM indicated the scheduled nurse on the hall had a key to the medication room but there was no lock on the refrigerator containing the controlled drugs for Residents 45 and 46. During an observation of the 300 Hall medication storage room on [DATE] at 12:02 PM, a box of controlled substances was observed in the medication room refrigerator. The box of controlled substances was not locked or permanently affixed to the refrigerator, and the refrigerator was not locked or permanently affixed. The controlled substances drug box contained the following: The same box contained Resident 10's Schedule IV medication of [MEDICATION NAME] 2 mg/ml (milligrams/milliliter) (an anti-anxiety). There was 30 mg/ml left in the bottle, with the last dispensed date of [DATE]. The same box contained Resident 14's Schedule IV medication of [MEDICATION NAME] 2 mg/ml (milligrams/milliliter) (an anti-anxiety). There was 25.5 mg/ml left in the bottle, with the last dispensed date of [DATE]. The same box contained Resident 50's Schedule IV medication of [MEDICATION NAME] 2 mg/ml (milligrams/milliliter) (an anti-anxiety). There was 28.75 mg/ml left in the bottle, with the last dispensed date of [DATE]. An interview with RN-B on [DATE] at 12:02 PM, indicated the scheduled nurse on the hall had a key to medication room but there was no lock on the refrigerator containing the controlled drugs for Residents 10, 14 and 50. An interview with the Consultant Pharmacist on [DATE] at 10:45 AM, indicated that all scheduled medications should be doubled locked. An interview with the Administrator and the Director of Nursing (DON) on [DATE] at 9:22 AM, indicated that they thought only scheduled II and III drugs needed to be doubled locked and that their policy spoke to only scheduled II and III drugs needed to be doubled locked. 2. A review of the facility's policy, revised in ,[DATE], read in part: 1. All controlled medications that have been discontinued, have expired or the resident has expire will be pulled from the medication carts/medication refrigerator and placed in the Rx Destroyer bottle in the Medication Room and destroyed by 2 authorized persons (nurses only). An observation on [DATE] at 4:00 PM indicated Resident 45's Schedule IV medication of [MEDICATION NAME] 2 mg/ml (milligrams/milliliter) (an anti-anxiety), had been opened on [DATE]. There was 28.25 mg left in the bottle. During an interview on [DATE] at 8:54 AM, the Consultant Pharmacist indicated that after opening [MEDICATION NAME], it had a 90-day expiration date. During an interview on [DATE] on 4:10 PM, LPN-C indicated the [MEDICATION NAME] came from the pharmacy already opened and with a syringe in the bottle. LPN-C further stated the day the medication came to the facility, [DATE], was the day it had been opened. An interview with the Administrator and the Director of Nursing (DON) on [DATE] at 9:22 AM indicated that the [MEDICATION NAME] should have been pulled out of the refrigerator and destroyed 90 days after the medication had been opened.

Licensure Reference Number 175 NAC 12-006.06A Based on interview, record review and facility policy and procedure, the facility failed to provide timely resolution to a resident's grievance. This affected 1 of 1 (Resident 9) sampled resident reviewed for grievances. Resident 9 had been missing a clothing item since March 2020. This had the potential to affect all residents and/or residents' representatives who had grievances. The census was 70. Findings are: Resident 9 was admitted to the facility on [DATE] due to exasperation of [MEDICAL CONDITION] and type II diabetes, and compression fractures of the spine. The quarterly Minimum Data Set ((MDS) dated [DATE] documented the resident had no memory impairment and needed extensive assistance with Activities of Daily Living (ADLs). On 08/24/20 at 10:03 AM, Resident 9 stated he/she had been missing a brown, long sleeved polo shirt since approximately March 2020. The resident stated it was reported to staff, but nothing had been done. The clothing had a name label inside the collar. On 08/26/20 at 3:09 PM, Social Worker (SW-A) stated he/she was unaware of the missing shirt. SW-A stated anyone who hears about missing personal items should enter it into their system. On 08/26/20 at 3:33 PM, RN Supervisor-A stated that Resident 9 reported it back in March 2020 to her/him. RN Supervisor-A stated she/he thought she/he had entered the missing shirt into the computer system for lost items. RN Supervisor-A told Resident 9 she/he was personally going to replace the shirt but forgot about it. On 08/26/20 at 4:20 PM, the Administrator confirmed the lost shirt had not been entered into their risk management system. The Administrator stated she/he would receive a notification when something had been entered. The Administrator stated that she/he was going to take full responsibility for following up since their policy had not been followed. The Variance Reporting, Risk Management and Patient Safety policy, revision date 06/2020, under the section titled, Procedure: Variance Reporting, read in part .The variance report shall be completed by the employee who witnessed the occurrence or by one with authority to review the circumstance.

Licensure Reference Number 175 NAC 12-006.04A3d Based on record review, interview and facility policy review, the facility failed to thoroughly investigate an allegation of drug diversion, when a bottle of liquid [MEDICATION(S)] (antianxiety medication) went missing. This affected 1 of 1 resident (Resident 30) whose medications were diverted. This had the potential to affect all residents receiving an antianxiety medication. The facility identified 18 residents receiving an antianxiety. The census was 70. Findings are: Resident 30 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment, dated 07/06/20, indicated Resident 30 had a Brief Interview for Mental Status (BIMS) of 13 out of 15, which indicated minimal cognitive impairment. Resident 30 needed limited assistance for most activities of daily living (ADLs). Resident 30's plan of care documented a history of anxiety and was prescribed lorazepam. The resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 01/06/20, a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Anticipate symptom management needs with end of life process. A 90mL bottle was prescribed. On 01/07/20, the lorazepam prescription was delivered and sign in by LPN-D. The resident did not need the medication until 01/26/20. LPN-E went to administer the medication, and it could not be found. The unit manager (RN Supervisor-B) was notified and the Director of Nursing (DON) was notified. On 08/25/20 at 9:40 AM, the DON was interviewed about the facility's investigation into the missing lorazepam. The DON stated the only interviews that were conducted were with LPN-D and LPN-E. The DON admitted that it was not a thorough investigation. The DON stated the facility was not counting lorazepam at the time of the diversion, so there was no way of knowing when the medication went missing. The DON stated the facility reordered the medication from the pharmacy, so the resident did not miss the needed dose. There was no investigation to determine if the 90mL bottle of lorazepam was the only medication missing. The DON stated the policy at the time was to have a nurse sign for the medication when it was delivered from the pharmacy and then place it in the medication refrigerator in the locked medication room. It was not logged on any form nor was it counted. The facility did not expect any employees to have diverted the medication, therefore no employee interviews and/or drug tests were conducted. The DON stated LPN-D was interviewed on the phone but no formal statement was taken. LPN-E was not formally interviewed. On 08/25/20 at 11:20 AM, the Administrator stated the police were notified on 01/26/20 and felt as though the police officer would continue the investigation. The police officer asked for a printout of all employees that accessed the medication room from 01/07/20 through 01/26/20. The Administrator stated he/she struggled to do an investigation because of the time span from when the medication was delivered to when it was discovered missing. At the time, the Administrator stated the facility would only count schedule II controlled medications and not lorazepam (a scheduled IV control medication). When asked why the investigation had not continued, the Administrator stated, because no one would have been driven to touch the medication. Both the Administrator and DON were asked if they had completed reconciliation of the medication that was in the facility and they had not. On 08/26/20 at 9:14 AM, the pharmacist (from the pharmacy) was interviewed and confirmed the lorazepam, ordered on 01/06/20, was delivered on 01/07/20 and signed as received by LPN-D. On 08/25/20 at 12:57 PM, LPN-D was interviewed and confirmed it was his/her signature on the receipt from the pharmacy, signing in the lorazepam on 01/07/20. LPN-D stated he/she did not always check what was being delivered with what was on the receipt. LPN-D stated in January 2020, the facility was not counting lorazepam as a controlled medication and if it was delivered that day, it would have been put in the medication refrigerator, and not logged in or counted between shifts. LPN-D stated she/he was never formally interviewed for an investigation into the missing lorazepam. On 08/26/20 at 8:10 AM, RN Supervisor-B stated she/he had knowledge of the missing lorazepam but was not interviewed or asked to participate in an investigation, even though that unit was his/her responsibility. The facility policy titled, Abuse Investigation Protocol, dated October 2017, read as follows, in part: Purpose: All reports of resident abuse, neglect Are promptly and thoroughly investigated by facility management. Policy: (in part) 2. The facility will conduct an investigation of any alleged abuse/neglect or misappropriation or resident property in accordance with state law. 3. The facility will report such allegations within 24 hours. 4. The facility will report all investigation findings to the state within 5 working days of the incident. 5. The facility will investigate all patterns, trends or incidents that suggested the possible presence of abuse, neglect, or misappropriation of property, identified through analysis conducted by the long term care committee, with intervention, reporting or policy/procedure modification conducted as appropriate. Procedure: (in part) 3. The individual conducting the investigation will, at a minimum: a. Maintain the confidentiality of all information; b. Conduct all interviews in the presence of a witness; e. Interview the person reporting the incident f. interview any witnesses of the incident g. interview the resident h. interview the resident's attending physician i. Interview staff members (on all shifts) who have had contact with the resident . l. Interview the accused individual(s) or accused employee(s). m. Interview other residents to whom the accused employee provides care or services to determine if they have complaints about the employee. n. Interview other employees to determine if they have ever witnessed other incidents of mistreatment involving the accused employee; and o. Review all events preceding the alleged incident. 13. The administrator will provide a written report of the results of the abuse investigations and appropriate actions taken to the state survey and certification agency within 5 days of the reported incident.

Based on observation, interview, and record review, the facility failed to implement an ongoing system of surveillance designed to identify possible communicable diseases or infections in order to prevent the transmission of these diseases or infections to other persons in the facility. Findings include: An interview on 6/16/20 at 4:30pm, with the Director of Nursing showed: She watches cares regularly and addresses cross-contamination issues as they come up. She does not have a surveillance or tracking log, that is kept on an ongoing basis, for identification of infectious organisms that could be transmitted to the residents. The Infection Preventionist does the monthly tracking of infections by unit. An interview on 6/16/20 at 4:45pm, with the Infection Preventionist showed: She is the Infection Preventionist for the hospital and health center and comes to the facility part-time. She reviews infections in the facility monthly at the QAPI (Quality Assurance Performance Improvement) meeting. She looks at the central lines (intravenous line that goes into a large blood vessel near the center of the body) daily and is primarily concerned with the central lines and UTIs (urinary tract infections). The number of infections for the facility are reviewed on a monthly basis. Care is watched on an ongoing basis and staff is educated at the time of the observation. No specific surveillance, tracking, and trending of communicable diseases is in place. There is not an ongoing surveillance log of infections. Record Review of the Infection Control Policy, dated November 2017, showed: The purpose of the policy is to minimize the transmission of diseases and/or microorganisms in a long-term care setting between residents, healthcare personnel, and visitors. The Infection Control Program will be implemented, monitored, and evaluated by the Infection Control Committee. The surveillance program for the ongoing collection, review, and recommendations of health care associated infections will be maintained by the Infection Preventionist, as designated by the Infection Control Committee. The Infection Preventionist will run antibiotic reports from Keane to do surveillance of infections. Record review of the Facility Healthcare Acquired Surveillance, dated 2019, showed: No documentation of monthly infections for May, 2020 and incomplete information for April, 2020. No antibiotic reports were available for review for January, February, March, May, and June of 2020 No infection surveillance reports were available for review for April, May, or June of 2020.

Licensure Reference Number 175NAC 12-006.09D Based on observation, interview and record review; the facility failed to develop a plan to address a resident (Resident 1's) [CONDITION(S)] and gestures that required a hospitalization , who was identified with prior suicidal ideation and gestures. The facility census was 96. Findings are: Observation of Resident 1 during the survey dates 01/29/20 to 02/04/20 revealed; Resident 1 was in the hospital and had not returned to the facility unable to observe Resident 1. Record review of Resident 1's Hospital Final Report dated 4/18/19 Behavioral Medicine revealed; Resident 1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Contact was made with family who indicated this was baseline for the resident. Resident 1 was placed on one to one regarding the level of observation. Resident 1 reported that (gender) was currently residing in a SNF and that it was terrible. Resident 1 reported having recent suicidal thoughts but no previous attempts. Record review of PASARR (PreAdmission Screening Residential Review, determines whether or not an individual who has an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Medical History: Pneumonia, [CONDITION(S)], Altered Mental Status, [CONDITION(S)], Pressure Ulcer on Right Coccyx, Confusion, [CONDITION(S)], [CONDITION(S)] (Hypertension), Tachycardia, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], TBI (Traumatic Brain Injury), History of stoke. 2. Psychiatric Disability and Treatment History: [CONDITION(S)] Treatment. 3. Intellectual or Developmental Disability: NONE 4. Symptoms and Behaviors: hopelessness, aggressive behaviors, conflicts with others, and suicidal thoughts with denial of suicidal ideation. SAFETY PLAN: The nursing home should carefully assess the individual's mood and behavioral symptoms. The NF (Nursing Facility) should develop a behavior plan for staff to use to reduce the risk of harm to self and others if the behaviors start to escalate. The plan should include increased supervision as needed up to and including admission to the psychiatric hospital if the individual becomes a risk to self or others. Record review of Care Plan for Impaired behavior/altered thought process related to bi-polar disorder with PASARR level II with serious mental illness. Other Co morbidities: [CONDITION(S)] (Chronic Obstructive Pulmonary Disease), [CONDITION(S)], [CONDITION(S)], past brain trauma, and head aches, GERD (Gastro-[CONDITION(S)] Reflux Disease, Chronic Pain. BIMS (Brief Interview for Mental Status a test done to identify cognitive impairment) 15, PHQ9 (a multipurpose instrument used for screening, diagnosing, and measuring the severity of depression) was 6 indicating mild depression, and a Fall Risk 10 indicating high risk for falls. Goal: Resident 1 would remain oriented to person place and time. Approach: 1. Resident 1 calmly with soft tone 2. Allow plenty of time and allow resident 1 to vent feelings if needed. 3. Anticipate needs-works with Behavioral Health as indicated 4. Resident 1 had a PASARR level II with serious mental illness. Meds per physician order. Develop a behavior plan for staff to use to reduce the risk of harm to Resident 1 or others if the behavior escalates. Follow the facility P/P (Policy/Procedure) for admit to ED or other department if needed. Immediately report any suicidal ideation or behaviors. 5. [CONDITION(S)] behavior monitoring anxiety, restlessness, agitation, self-isolation, lack of participation in activities per order. 6. Depression screen per policy PHQ9 Score was 6 dated 6/19/19. 11/11/19 was 10. 7. Provide pleasant interaction which reassures Resident 1 if confused. 8. Explain all procedures to Resident 1 and reason prior to leaving. 9. Provide a consistent routine environment for Resident 1 10. Identify room, objects as indicated to decrease confusion if needed 11. Keep call light within reach 12. Hourly rounding 13. Non pharma logical interventions of target behaviors: Redirection, assess for pain, offer toileting, position change, allow to calm in safe environment, remove for area of excess stimulation, re-approach, monitor for root cause of behavior. 14. With increase of behaviors of anxiety, short temper, agitation and episodes of being uncooperative assess for pain receives Tylenol PRN (as needed) for pain. 2/4/2020 Record review of Abatment Plan for Residents with behaviors revealed; Instructions: Unsafe behavior (hurt self, others, or property) = 24 hour reset Once task is completed AND chart is signed off by a staff (hour and signature), a colored sticker dot associated with that task Time with staff to be used before staff scheduled to leave, off limit time occurs 30 minutes before through 30 minutes after meal time. Visit time earned each day must be used the same day, therefore the staff requested must be present that day. Red dot for calmly waiting for staff for 7 minutes after hitting call light between wake up and lunch, Green Dot for Calmly waiting for staff for 7 minutes after hitting call light between lunch and bedtime, Blue dot for communicate feelings without cuss words, Yellow dot for using coping skills (sit next to plant, listen to music, watch TV, or used computer. Behavior Plan Progression The following progression of reinforcement provided to promote the use of desired behavior to succeed in positive social interactions with staff and peers: At the end of the week he is able to earn an hour (all four 15 minute visits) 5 days a week for one week 1 day all 15 minutes could be combined together to attend a meal at the café with a staff of choice for a meal/snack. At the end of the week he is able to earn an hour (all four 15 minute visits) 5 days a week for one week and an hour at the café 1 day of an hour at the café with a peer of choice and staff of choice for a meal/snack. At the end of the week he is able to earn an hour (all four 15 minute visits) 5 days a week for one week and an hour at the café 2 day of an hour at the café with a peer of choice and staff of choice, attending part-time, for a meal/snack. At the end of the week he is able to earn an hour (all four 15 minute visits) 5 days a week for one week and 2 days at the café 2 day of an hour at the café with a peer of choice and staff of choice, attending part-time, for a meal/snack. Instructions: Must have baseline of four 15 minutes( or an hour of visits) 5 days a week to earn the café, despite if he has earned it before Once he drops down to baseline, he will get to scaffold back up each step to ensure mastery If he has one tough day, he can put effort into learned skills the rest of the time Safety Plan As the following behaviors are observed by the patient, the responses are encouraged by staff to de-escalate and redirect the patient to increase the likelihood of maintaining his safety, the safety of the other residents, and staff safety. When providing the following interventions/responses it is important to remain calm by using deep and even deep breaths to keep a calm tone of voice, relaxed shoulders, a straight but relaxed face, and able to use the word we versus you to invite a team approach for resolution. Level I. A. When observe: Resident engaged in mild cussing or excessive use of speed in wheelchair down hallway, tense body posture and facial expression paired with comments under (genders) breath. B. Response: Staff was to prompt resident the use of specific enjoyed activities (aka coping skills). These included tending to (genders) plants, listening to music, looking at birds, getting a cup of coffee or pop, going into the courtyard. It is to be noted a plant or two going to be moved to a calm spot in chapel. Level II. A. When observe: Resident was engaged in severe cussing or knocking objects off table/nearby surfaces, or throw objects staff should follow B. B. Response: Staff was to prompt Resident to go to the (genders's) chill/calm spot. This was to be in the chapel where a plant or two of (gender) would be located that (gender) would be able to tend. If (gender) was mad because of the need for assistance to the restroom, (gender) would need to be able to demonstrate ability to calm prior to being able to assist (gender) in restroom because it was unsafe to Resident 1 and staff at that time. Set up agreed upon time for Resident 1 to calm and then be able to assist (gender) to restroom. It was essential that staff had a timer set to make sure they are back there at the time that was agreed. Level III. A. When observe: Resident refused to engage in enjoyed activities/coping skills or transition to calm spot then (gender) had demonstrated that (gender) was not willing to be engaged in behaviors to promote (gender's) safety and/or the well-being of others. This may include verbalizing or demonstrating a risk to self or others by throwing themselves to the floor, use of call light cord inappropriately or in a manner of risk to self or others, other like demonstration or verbalization that indicates unanticipated risk. B. Response: Staff was to call security for further assistance. If (gender) responded to the above prompts and calm by the time security arrives then continue protocol as listed above. If the resident had not responded to above prompts by the time security has arrived (which is predicted to be approximately 30 minutes), then the Resident would be transported by security to the ED for further risk evaluation. Following an incident that progresses to a Level III leave a message for the resident's psychologist. The Administrator on 1/30/20 at 11:37AM confirmed; Resident 1 had been successful throughout the stay. The Coke thing set (gender) off and the staff had not followed the care plan and used the interventions to de-escalate the resident. The Administrator reported that the resident usually went out doors to de-escalate and had been free to roam. After the trip to the ED for the elopement the ED Provider reported that Resident 1 was in a good state and reported wants to come back to the facility. Resident 1 had came back from the ED and threw self on the floor was placed back in bed, for the first fall and then the second fall was when Resident 1 had wrapped the cord around his neck and was taken to the ED and admitted . An interview on 2/4/20 at 12:00 PM with the DON (Director of Nurses) confirmed; Social Service Worker had not created the care plans. The care plan had only addressed Resident 1 had a PASARR level II with serious mental illness. Medications were per physician order. The care plan for the Develop a behavior plan for staff to use to reduce the risk of harm to Resident 1 or others if the behavior escalates had not included a plan for suicidal ideation or gestures. The staff were to follow the facility Policy and Procedure for admit to ED or other department if needed. Immediately report any suicidal ideation or behaviors.

Licensure Reference Number 175 NAC 12-006.09D7 Based on record review and interview; the facility failed to A. Identify a resident as an elopement risk and failed to respond to a concern of a resident outside of the building and failed to ensure all residents were accounted for to prevent elopement (Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. A resident who leaves a safe area may be at risk of (or has the potential to experience) heat or cold exposure, dehydration and/or other medical complications, drowning, or being struck by a motor vehicle) this had the potential to affect 1 resident (Resident 1). B. The facility failed to implement increased supervision according to PASARR (Pre-Admission Screening and Annual Resident Review unit determines whether or not an individual how has a mental illness or developmental disabilities meet the criteria for admission to a nursing facility) recommendations and failed to implement care planned interventions to monitor a resident for escalation of behaviors and prevent a suicide attempt for 1 resident (Resident 1). C. The facility failed to provide a safe environment for 1 resident (Resident 2) who had been identified to be at risk for elopement. The facility census was 96. Findings are: A. Record review of Original Summary Dated 1/24/20 revealed; at approximately 6:08 PM received a call from EVS (Environmental Services) about Resident 1 being off the property by The Towers. Security was advised to start to call DG (Dunklau Gardens). Security called DG 300 with no answer and DG 200. Security advised staff that a resident was outside by the towers, Security described Resident 1 and the staff reported that the resident was okay because they go out to smoke. Security relayed that message to the EVS staff member. Security had received information from communication at approximately 6:48 PM 2 techs from DG were going out to get the patient and just in case security is needed they are letting them know now. At approximately 7 PM Security noticed Resident 1 in the ED (Emergency Department) and that is when Security began looking into how the resident left the building and contacted DG HS (House Supervisor) C. HS C had requested the times of which the Resident 1 had left the property and how long they had been outside. Security then began to investigate with the camera. The following time line was established with use of the camera: At Approximately 6:00 PM Resident 1 was spotted leaving the main entrance doors in the wheel chair. At approximately 6:05 PM Resident 1 was spotted rolling in the middle of the street toward The Towers staying in the middle of the road. Several cars almost struck Resident 1 or came close. At approximately 6:08 PM EVS A had followed behind Resident 1 as they moved towards The Towers, and called communications to advise security of the residents location. At approximately 6:40 PM Resident 1 was seen rolling back toward the building, and as Resident 1 crossed the street again was almost struck by a vehicle. At approximately 6:45 PM Resident 1 made it back to the property a [NAME] Police Officer stopped and observed the Resident. The Police officer assisted Resident 1 back to the building with the techs from DG via the main entrance. From approximately 7 PM to 8:32 PM Resident 1 was in the ED (Emergency Department) and escorted back to DG Resident will be on the pass port system (a system designed to monitor Residents at risk for elopement). Record review of Email dated 1/27/20 at 7:17 AM from RN (Registered Nurse) E While driving out of the parking lot, turning right out of the corner of their eye they saw a resident in a w/c across the street, headed toward the facility. As RN E was part way through the turn looked again and identified the resident as Resident 1. RN E could not tell if Resident 1 was on the side walk or in the road. RN E immediately called DG and spoke with RN C. According to cell phone record the call was placed at 6:41 PM. In the conversation with HS, known that security may have misidentified the person outside, and the person outside was Resident 1. The staff member let RN C know that Resident 1 was headed back to the facility and was nearly to the intersection, Resident 1 was using their own power. By the time the conversation ended with RN C, RN E could see Resident 1 in the review mirror and they were well into the intersection moving toward the facility. Since it sounded like RN C would make immediate arrangements to have someone assist Resident 1, Resident 1 was headed toward the facility under their own power and had normal mental status that did not restrict the ability to travel throughout the facility and RN E knew of no restrictions to be outside, the staff member did not stop. There was no traffic coming from either direction, the weather was calm with no wind and was just chilly. Record review of Quarterly MDS (Minimum Data Set a federally mandated process for clinical assessment to aid in the development of a comprehensive plan of care) dated 11/19/19 revealed; Section C Cognition- BIMS (Brief Interview for Mental Status- a test given to evaluate cognitive impairment) score of 15, Section D PHQ9 (A multipurpose instrument used for screening, diagnosing, monitoring, and measuring the severity of depression) score was 9 indicating mild to moderate depression, Section E Behaviors revealed; 1-3 days Resident 1 had verbal behaviors directed toward others and other behavioral symptoms not directed toward others. Resident 1 had rejection of care 1-3 days. An interview on 1/29/20 at 5:05 PM the Administrator reported, Resident 1 used to go out to smoke independently. The Administrator confirmed, Resident 1 had stopped smoking and had used [MEDICATION(S)] replacement. An interview on 1/30/20 at 12:17 with the DON (Director of Nurses); confirmed Resident 1 became upset after staff did not fill a request when they were asked and Resident 1 left the facility unattended and without staff knowledge. An interview on 01/30/20 at 2:17 PM with the DON revealed; Staff member D reported that Residents go over there to smoke. Staff Member D told the caller that the resident was not a member of the facility. The DON confirmed; no staff member went outside to see if the person was a Resident of DG. The DON reported the facility found out Resident 1 was outside due to a RN E leaving the facility at 6:40 PM and they called the facility to let the staff know Resident 1 was out doors. The DON confirmed; the expectation was the facility staff should have gone outdoors when they first received a call that there may have been a resident outside. The DON reported that the last time Resident 1 was seen by staff was at 6:00 PM. An interview on 2/3/20 at 4:40 PM with EVS (Environmental Services) A confirmed; at 6:00 PM they were going to Hy-[NAME] Gas Station and observed Resident 1 in-between The Towers and family care in the middle of the street. EVS A reported that the sides of the street had snow on them. EVS A drove next to the Resident 1 and told the resident that they were not to be outside. EVS A reported that they blocked Resident 1 with their vehicle, put the hazard lights on and called security, it took security a few minutes to return the call. EVS A reported that they were told it was okay to let Resident 1 go that the resident went over to The Towers to get cigarettes. EVS A confirmed, Resident 1 had traveled up to the automated doors and went inside the building at The Towers. EVS A confirmed they had known the resident and that they lived at DG, but not by name and the resident had not given EVS A their name. Record review of Police Report Summary dated 1/24/20 at 6:46 PM revealed; On January 24, 2020 the officer was patrolling in the area of [NAME] and [NAME] Street when the officer observed an elderly gentleman crossing the street in a wheel chair. The Resident was crossing at an extremely slow rate of speed, (gender) did not pay any mind to the vehicles that were approaching the area, and (gender) did not seem to be properly dressed for the weather (no hat or coat on). Once the (gender) crossed the street, they became stuck at the bottom of the driveway leading into Dunklau Gardens (so the Resident was stuck in the road way, blocking traffic). The officer assisted the resident back to Dunklau Gardens when the officer was approached by 2 staff members. The officer later identified the Resident as Resident 1, a resident of Dunklau Gardens Long Term Care Unit. The officer had taken down all the names of the staff that were responsible for the care of Resident 1. They did not seem to know that (gender) had left the facility. The officer had a hard time understanding Resident 1 when they were speaking, but the officer was able to determine that Resident 1 was unhappy at the facility. Staff told the officer that Resident 1 had multiple behavioral issues and that Resident 1 is always looking for a way to get out of the facility. However, they said that Resident 1 had never escaped before and had never been given one of the ankle monitors (something they stated they give to residents that wander away often). Record review of Police Detail Report dated : 1/24/20 On 1/24/20 Office was in uniform and on patrol working in the city of [NAME], Dodge County Nebraska. The officer was on patrol area of [NAME] and [NAME] St. The officer observed an elderly person in a wheelchair crossing the street. (Gender) appeared to be struggling to get self-wheeled across. (Gender) was crossing at an extremely slow rate of speed and did not seem to be paying attention to the vehicles piling up. The vehicles had to stop for (gender) as they approached the area. Additionally (gender) did not seem to be properly dressed for the weather. (Gender) did not have a hat or coat on. The temperature outside was about 25 degrees. As (gender) crossed the street the officer observed (gender) to be stuck at the bottom of the entrance leading into the area of Dunklau Gardens. (Gender) was sticking out in front of traffic as (gender) blocked part of the traffic lane. The officer assisted (gender) back into the parking lot. The officer had trouble understanding (gender) due to (genders) speech. So the officer asked (gender) to point where they needed to go. (Gender) pointed to Dunklau Gardens. As the officer and (gender) approached the front entrance to Dunklau Gardens a staff member stated Resident 1, what are you doing out here? The officer followed the staff members inside and was able to identify the elder as Resident 1. The officer was told (gender) was a resident of Dunklau Gardens in the long term care unit. The staff stated that Resident 1 had free roam of Dunklau Gardens, however, should not have been outside of the facility. When speaking with the staff the officer got the impression they did not seem to know that Resident 1 had left the facility. They appeared surprised when the officer came into the facility with Resident 1 and the other workers. The officer had a hard time understanding Resident 1 when (gender) spoke. However, the officer was able to understand that (gender) felt extremely unhappy being in Dunklau Gardens. Staff told the officer that Resident 1 had multiple behavioral issues, but did not go into detail. One staff member said, Resident 1 was always looking for a way to get out of the facility. The staff explained that Resident 1 had never escaped before. Resident 1 was privileged enough to get free roam of the facility. They explained to the officer that some of the residents wear ankle monitors. This is a way to prevent them from wondering off and also allows staff to know where they are. The officer was informed that Resident 1 had not met the criteria they have in place to receive an ankle monitor. Record review of Wandering Assessment for Resident 1, the facility did not provide a wandering assessment for Resident 1. An interview on 2/3/20 at 4:50 PM with RN B confirmed; that Resident 1 was upset and had escalation of behaviors on 1/24/20 and had been outside without staff knowledge. B. Record review of a Report dated 1/29/20 revealed; on 1/25/20 Resident 1 had been having escalating behaviors as a resident at Dunklau Gardens. Prior to this specific event Resident 1 had left the facility unaccompanied returned with staff, was subsequently taken to ED for evaluation and returned to DG. Upon return to the facility (gender) continued to have behaviors in a constant state throughout the night. Resident 1 was abusive to staff. These types of behaviors continued throughout the evening/night. At 8:30 PM Resident 1 placed themselves on the floor, staff assessed without injury. Then at 3:45 AM Resident 1 placed themselves on the floor, when staff entered the room Resident 1 had the call light around the neck and the dresser was pulled over on top of the resident. Resident 1 at that time stated I want to kill myself. Resident 1 was immediately assessed by charge RN and taken to the ED. Resident 1 was admitted to the hospital. Resident 1 had never made a previous attempt of suicide or made a suicidal gesture. Resident 1 was at the hospital and being evaluated for placement. PASSAR is evaluating currently to determine if NH placement is appropriate for the future. Resident 1 made a suicide attempt, sustained no injury and was transported to the hospital ED, was admitted and was being evaluated for medication management and evaluated for PASSAR. Record review of Education for Crisis Management revealed; RN B had not been educated for Crisis management. Record review of hourly rounding revealed; on 1/24/20 Resident 1 had rounding at the following times: 1. 1:04 AM, 1:56 AM, 2:25 AM, (hourly rounding missed) 3:42 AM, 4:03 AM, (hourly rounding missed) 8:29 AM, 8:34 AM, 9:39 AM, 10:38 AM, 11:29 AM , (hourly rounding missed) 1:14 PM, 2:04 PM, 2:38 PM, 3:15 PM, (hourly rounding missed) 4:31 PM ,(hourly rounding missed) 7:23 PM, 7:47 PM , (hourly rounding missed) 11:05 PM, 11:12 PM, 11: 25 PM , 11:52 PM Record review of hourly rounding revealed on 1/25/20 Resident 1 had rounding at the following times: 1. 1201 AM, 12:04 AM, 12:08 AM, 12:19 AM, (hourly rounding missed) 02:13 PM, 2:43 AM, 03:24 AM, 3:39 AM, 3:46 am. Record review of Resident 1's Care Plan revealed: Resident 1 had impaired behavior/altered thought process related to bi-polar disorder with PASARR level II with serious mental illness. Goal: Resident 1 would remain oriented to person place and time. Approach: 1. Resident 1 calmly with soft tone 2. Allow plenty of time and allow Resident 1 to vent feelings if needed. 3. Anticipate needs-works with Behavioral Health as indicated 4.**Resident 1 had a PASARR level II with serious mental illness. Meds per physician order. Develop a behavior plan for staff to use to reduce the risk of harm to Resident 1 or others if the behavior escalates. Follow the facility P/P for admit to ED or other department if needed. Immediately report any suicidal ideation or behaviors. 5. [CONDITION(S)] behavior monitoring anxiety, restlessness, agitation, self-isolation, lack of participation in activities per order. 6. Depression screen per policy PHQ9 Score was 6 dated 6/19/19. 11/11/19 was 10. 7. Provide pleasant interaction which reassures Resident 1 if confused. 8. Explain all procedures to Resident 1 and reason prior to leaving. 9. Provide a consistent routine environment for Resident 1 10. Identify room, objects as indicated to decrease confusion if needed 11. Keep call light within reach 12. Hourly rounding 13. Non pharma logical interventions of target behaviors: Redirection, assess for pain, offer toileting, position change, allow to calm in safe environment, remove for area of excess stimulation, re-approach, monitor for root cause of behavior. 14. With increase of behaviors of anxiety, short temper, agitation and episodes of being uncooperative assess for pain receives Tylenol PRN for pain. Record review of PASARR for Resident 1 dated 5/1/19 revealed; Resident 1 had Symptoms and Behaviors: hopelessness, aggressive behaviors, conflicts with others, and suicidal thoughts with denial of suicidal ideation. SAFETY PLAN: The nursing home should carefully assess the individual's mood and behavioral symptoms. The facility should develop a behavior plan for staff to use to reduce the risk of harm to self and others if the behaviors start to escalate. The plan should include increased supervision as needed up to and including admission to the psychiatric hospital if the individual becomes a risk to self or others. Record review of PN revealed; Resident 1's progress notes did not have an assessment of Resident 1's condition. Record review of Transfer form for the transfer to the ED revealed; there had not been a transfer from completed on the date of the transfer of Resident 1 to the ED. An interview on 1/30/20 at 3:00 PM with the DON confirmed; that the call times were not hourly some of the call times were over the hour. The DON confirmed; supervision had not been increased for Resident 1 during the escalation of behaviors according to the recommendations of the PASARR An interview on 1/30/20 at 11:37 AM with the Administrator confirmed; Resident 1 had an escalation in behaviors and the staff did not follow the care plan and use the interventions to de-escalate the resident. The Administrator reported that the resident usually goes out doors to de-escalate. The Administrator confirmed that the staff were to complete hourly rounding. After the resident was outside they were released and came back from the ED, threw self on the floor was placed back in bed, for the first fall and then the second fall was when Resident 1 wrapped the cord around his neck. An interview on 2/3/20 at 4:50 PM with RN B confirmed; that Resident 1 was upset and had escalation of behaviors on 1/24/20 and had been outside without staff knowledge. RN B confirmed that Resident 1 had called staff names and tossed water on RN B. RN B reported that Resident 1 had been sent to the ED after the elopement for evaluation and when returned they had called the Administrator related to concerns of the resident returning because of increased anger and behaviors. RN B had security escort for safety of staff and resident. RN B confirmed; they had not been educated for Crisis Management. /4/2020 Record review of Abatment Plan for Residents with behaviors revealed; Instructions: Unsafe behavior (hurt self, others, or property) = 24 hour reset Once task is completed AND chart is signed off by a staff (hour and signature), a colored sticker dot associated with that task Time with staff to be used before staff scheduled to leave, off limit time occurs 30 minutes before through 30 minutes after meal time. Visit time earned each day must be used the same day, therefore the staff requested must be present that day. Red dot for calmly waiting for staff for 7 minutes after hitting call light between wake up and lunch, Green Dot for Calmly waiting for staff for 7 minutes after hitting call light between lunch and bedtime, Blue dot for communicate feelings without cuss words, Yellow dot for using coping skills (sit next to plant, listen to music, watch TV, or used computer. Behavior Plan Progression The following progression of reinforcement provided to promote the use of desired behavior to succeed in positive social interactions with staff and peers: At the end of the week he is able to earn an hour (all four 15 minute visits) 5 days a week for one week 1 day all 15 minutes could be combined together to attend a meal at the café with a staff of choice for a meal/snack. At the end of the week he is able to earn an hour (all four 15 minute visits) 5 days a week for one week and an hour at the café 1 day of an hour at the café with a peer of choice and staff of choice for a meal/snack. At the end of the week he is able to earn an hour (all four 15 minute visits) 5 days a week for one week and an hour at the café 2 day of an hour at the café with a peer of choice and staff of choice, attending part-time, for a meal/snack. At the end of the week he is able to earn an hour (all four 15 minute visits) 5 days a week for one week and 2 days at the café 2 day of an hour at the café with a peer of choice and staff of choice, attending part-time, for a meal/snack. Instructions: Must have baseline of four 15 minutes( or an hour of visits) 5 days a week to earn the café, despite if he has earned it before Once he drops down to baseline, he will get to scaffold back up each step to ensure mastery If he has one tough day, he can put effort into learned skills the rest of the time Safety Plan As the following behaviors are observed by the patient, the responses are encouraged by staff to de-escalate and redirect the patient to increase the likelihood of maintaining his safety, the safety of the other residents, and staff safety. When providing the following interventions/responses it is important to remain calm by using deep and even deep breaths to keep a calm tone of voice, relaxed shoulders, a straight but relaxed face, and able to use the word we versus you to invite a team approach for resolution. Level I. A. When observe: Resident engaged in mild cussing or excessive use of speed in wheelchair down hallway, tense body posture and facial expression paired with comments under (genders) breath. B. Response: Staff was to prompt resident the use of specific enjoyed activities (aka coping skills). These included tending to (genders) plants, listening to music, looking at birds, getting a cup of coffee or pop, going into the courtyard. It is to be noted a plant or two going to be moved to a calm spot in chapel. Level II. A. When observe: Resident was engaged in severe cussing or knocking objects off table/nearby surfaces, or throw objects staff should follow B. B. Response: Staff was to prompt Resident to go to the (genders's) chill/calm spot. This was to be in the chapel where a plant or two of (gender) would be located that (gender) would be able to tend. If (gender) was mad because of the need for assistance to the restroom, (gender) would need to be able to demonstrate ability to calm prior to being able to assist (gender) in restroom because it was unsafe to Resident 1 and staff at that time. Set up agreed upon time for Resident 1 to calm and then be able to assist (gender) to restroom. It was essential that staff had a timer set to make sure they are back there at the time that was agreed. Level III. A. When observe: Resident refused to engage in enjoyed activities/coping skills or transition to calm spot then (gender) had demonstrated that (gender) was not willing to be engaged in behaviors to promote (gender's) safety and/or the well-being of others. This may include verbalizing or demonstrating a risk to self or others by throwing themselves to the floor, use of call light cord inappropriately or in a manner of risk to self or others, other like demonstration or verbalization that indicates unanticipated risk. B. Response: Staff was to call security for further assistance. If (gender) responded to the above prompts and calm by the time security arrives then continue protocol as listed above. If the resident had not responded to above prompts by the time security has arrived (which is predicted to be approximately 30 minutes), then the Resident would be transported by security to the ED for further risk evaluation. Following an incident that progresses to a Level III leave a message for the resident's psychologist. The Administrator on 1/30/20 at 11:37AM confirmed; Resident 1 had been successful throughout the stay. The Coke thing set (gender) off and the staff had not followed the care plan and used the interventions to de-escalate the resident. The Administrator reported that the resident usually went out doors to de-escalate and had been free to roam. After the trip to the ED for the elopement the ED Provider reported that Resident 1 was in a good state and reported wants to come back to the facility. Resident 1 had came back from the ED and threw self on the floor was placed back in bed, for the first fall and then the second fall was when Resident 1 had wrapped the cord around his neck and was taken to the ED and admitted . An interview on 2/4/20 at 12:00 PM with the DON (Director of Nurses) confirmed; Social Service Worker had not created the care plans. The care plan had only addressed Resident 1 had a PASARR level II with serious mental illness. Medications were per physician order. The care plan for the Develop a behavior plan for staff to use to reduce the risk of harm to Resident 1 or others if the behavior escalates had not included a plan for suicidal ideation or gestures. The staff were to follow the facility Policy and Procedure for admit to ED or other department if needed. Immediately report any suicidal ideation or behaviors. C. Resident 2 ambulates independently throughout the facility and the hospital. On 4/7/19 at 7:48 PM an alarm was activated indicating that Resident 2 was near the Café Corridor. Staff immediately responded in search of Resident 2. Rooms were checked and all of the adjacent corridors were checked. Communication/Security was notified at 7:58 PM that Resident 2 was missing from Dunklau Gardens. At 8:10 PM Resident 2 was located inside the hospital facility near the Outpatient Department of the hospital. Resident 2 did not have any injuries. This was the first time that Resident 2 had exited the Nursing Home area leaving toward the hospital. Steps to prevent this from reoccurring, the staff will do hourly rounding and the staff was instructed to redirect Resident 2 when (gender) was ambulating outside of the normal walking area for Resident 2 or when near an exit door. Passport (is used to protect memory care residents against elopement risk band was in place on resident and it sounds an alarm when the resident has breached the perimeter where it is safe for the resident to go). Record review revealed the facility had added hourly rounding for staff to complete on Resident 2. Record review of Resident 2's Care Plan revealed a self-care deficit related to Alzheimer. That Resident 2 walks without an assistive device, is at risk for leaving the facility unattended. Behavior Note date 4/5/19; Redirected Resident 2 as had set off code alert going past the hospital cafeteria. Resident was pleasant to redirect. Resident 2 stated wanted to go outside. The passport was reset and Resident 2 was returned to the unit. Interview with DON on 2/3/2020 at 2:35 PM Resident 2 and spouse would walk laps around the facility, when they were doing that the staff would turn off Resident 2's Code Alert so they were allowed to walk through the outpatient area of the hospital area and back again.