Every finding on record at Forest Park Nursing & Rehabilitation

Based on interview and record review, the facility failed to ensure within 14 days after the facility determined, or should have determined, that there had been a significant change assessment completed for the resident's mental condition for 1 (Resident #2) of 5 residents reviewed for resident assessments. The facility failed to ensure a comprehensive MDS significant change assessment was completed for Resident #2, after he made suicidal ideation statements on 05/07/26, 05/18/26 and 05/25/26, 06/03/26 and 06/22/26. This failure could place residents at risk of not getting all of their medical needs met, which could cause residents to harm themselves resulting in decreased health and psycho-social well-being. The findings included:Record review of Resident #2's admission MDS assessment dated [DATE] and signed by the DON on 05/18/26 revealed, a [AGE] year-old male who admitted [DATE], his BIMS score was 14 (cognition intact). For section D. Resident mood interview (Say to resident: Over the last 2 weeks, have you been bothered by any of the following problems?) was coded 0 for not having any interest or pleasure in doing things and feeling down, depressed, or hopeless. He used a wheelchair and had upper and lower extremity impairments and needed Partial/moderate assistance and substantial/maximal assistance for most ADLs. His primary active diagnosis were stroke, and his other diagnoses[SH4.1] were hypertension (high blood pressure), benign prostatic hyperplasia (non-cancerous enlarged gland), diabetes mellitus (high blood sugar level), hyperlipidemia (high levels of fat lipids), thyroid disorder (abnormal hormone gland), and aphasia (neurological language disorder). Record review of Resident #2's Quarterly MDS assessment dated [DATE] and signed by the DON 06/02/26 revealed, a [AGE] year-old male who admitted [DATE], he had a BIMS score of 12 (moderately impaired cognition). For section D. Resident mood interview (Say to resident: Over the last 2 weeks, have you been bothered by any of the following problems?) . it was coded 0 for not having any interest or pleasure in doing things and feeling down, depressed, or hopeless. He used a wheelchair and walker and had upper extremity impairment and no lower extremity impairment and needed supervisory or touch assistance and Partial/moderate assistance for most ADLs. His primary active diagnoses were stroke, and his other diagnoses were hypertension, benign prostatic hyperplasia, diabetes mellitus, hyperlipidemia, thyroid disorder, and aphasia. Record review of Resident #2's Care Plans revealed Resident #2 had a behavioral problem related to ongoing suicidal ideations, date initiated 06/23/26 and revised 06/25/26 Resident #2 has a behavior problem related to suicidal thoughts. Date initiated and revised 06/05/26 The resident needs in room socialization and sensory stimulation. Date initiated and revised 05/06/26 the resident has had an actual fall related to poor balance. Record review of Resident #2's Hospital Discharge summary dated [DATE] revealed, resident was assessed and cleared of suicidal ideation and Melatonin was ordered to promote sleep. Record review of Resident #2's Psychiatric Subsequent Assessment by Psychiatric NP C dated 06/08/26 revealed, reason for referral: Depression, worrying, irritability, delusions, suicidal/homicidal, resident was sent out for suicidal ideation with a plan. Physical examination: speech slow, soft, sad, flat affect, no plan for suicidal ideation, no risk of aggression, moderate depression. No medication changes and assessment plan: Primary insomnia and unspecified mood disorder. Revisit in 2 weeks. Record review of Resident #2's June 2026 MAR revealed, 88 mcg Levothyroxine sodium 1 tablet for morning, 3 mg. Melatonin 2 tablet at bedtime, 40 mg Pantoprazole 1 tablet 1 x D, 0.4 mg Tamsulosin 1 capsule at bedtime, 400 mg Magnesium Oxide 2 tablets 2 x D, 500 mg Metformin 2 tablets 2 x D, 40 mg Propranolol 1 tablet 2 x D, 1 gm Sucralfate 1 tablet 4 x D, 50 mg Armodafinil 1 tablet 1 x D, 2 mg Imodium A-D, 4% Lidocaine to lower back topically for morning, 4 mg Ondansetron 1 tablet every 6 hours, as needed, Resident exhibits depressive target behavior (each shift chart the number of episodes the targeted behavior occurred, intervention used and the outcome of the intervention), 325 mg Acetaminophen 1 tablet every 6 hours, as needed. Record review of Resident #2's Nurse Progress notes dated 05/07/26 at 11:34 am, by ADON D revealed, Change in condition reported on this change in condition were behavioral symptoms.Nursing evaluations, evaluation and recommendations are: Resident reported to IDT team that he was planning suicide by jumping out the window and/or wrapping cords around his neck and rolling out of bed. MD notified. Transfer to emergency room for suicidal ideation. Record review of Resident #2's Social Worker note by SW B dated 05/18/26 at 1:07 pm, Late Entry: SW sent psychiatric referral due to resident's suicidal ideations. Resident will be evaluated today. Record review of Resident #2's Social services note by SW B dated 05/25/26 at 9:55 am revealed, PHQ-2 to 9: Little interest or pleasure in doing things - symptom presence: no. little interest or pleasure in doing things - symptom frequency: never or 1 day, feeling down, depressed, or hopeless - symptoms presence: No. feeling down, depressed, or hopeless - symptom frequency - never or 1 day. Score: 0.0. Record review of Resident #2's Nurse Progress note dated 05/25/26 at 11:24 am, change in condition: Behavioral status evaluation: Danger to self and others suicide potential.primary provider feedback, recommendations: sent to emergency room and new testing orders. Record review of Resident #2's Nurse progress note dated 05/25/25 at 1:50 pm by ADON D revealed, Psychiatrist came to visit resident, and he told her he want [sic] to kill himself, the doctor advised the ADON of the situation, so this nurse called 911 and went to sit with patient until EMT arrived. Patient told EMT that he planned to kill himself on a certain day, but he will not tell them the date because they would try to stop him, patient said that he would jump out the window so he could die. Patient sent to psychiatric hospital. Record review of Resident #2's Nurse Progress notes dated 06/03/26 at 12:13 pm by LVN E revealed, This nurse call 911 because patient was saying he wanted to kill himself. Psychiatric (through 911) came out to evaluate and said that they would not take him because he can't walk and they just came and got him and returned back to the facility after a couple of days. Record review of Resident #2's Nurse Progress notes dated 06/22/26 at 1:44 pm by LVN E revealed, Patient called 911 and told them he was planning to kill himself at 6 pm today, this nurse was at the dining room when patient called 911. Patient placed on continuous observation and safety precautions initiated per facility protocol. Potential hazards removed from patient's environment Provider notified of assessment findings and recommendation for emergent psychiatric evaluation. Interview and observation on 06/25/26 at 11:28 am, Resident #2 was lying in bed and appeared calm and not in any distress. His wheelchair was next to his bed. He stated he did not feel sad or depressed, and had no plan on jumping out of the window, but a couple of days ago, he felt that way. He stated he took medications for depression that worked he believed because right now he did not want to kill himself. He stated he would love to get shaved by the staff before he left this facility. He stated he saw the psychologist at this facility, and had been sent to the hospital's psychiatric ward several times because of not wanting to live anymore. He stated he was currently getting ready to go to a rehabilitation hospital for therapy. Interview on 06/25/26 at 12:47 pm, the DON stated Resident #2 had been suicidal since becoming a resident at the facility last month. She stated the nurses called Resident #2's doctor when he had suicidal thoughts, and was transferred to the hospital for psychiatric services. She stated once he was cleared for safety, he was sent back to this facility. She stated Resident #2 received psychiatric services from their provider and SW B talked to him a lot, when he had a bad day. She stated the Hospital had a team that also came out to evaluate him with two LE and a psychiatric nurse for his crisis moments. She stated the hospital team gave Resident #2 tacos and assessed and cleared him. She stated the nurse's communication for each shift and staff training was done to ensure Resident #2 was safe. She stated the staff made sure he had plastic ware, encouraged him to come out of his room and 1:1 when he had a bad day. She stated they also care planned this and added Resident #2 was scheduled to go to a rehabilitation hospital today. She stated the plan was for him to return to this facility since he could not return home. She stated Resident #2 was his own RP and she had not spoken to his family about his suicidal thoughts, but was sure SW B had spoken to them about it. She stated she would have to go through his notes to see if he had any plan to kill himself or just made the statements of wanting to die. She stated she did not know how often Resident #2 made suicidal statements off the top of her head and would follow-up with HHS after reviewing his records. She stated Resident #2 did not want to be in any nursing home at all and said she would ensure SW B to talk to him about his options to return here or go to another facility. Interview on 06/25/26 at 2:20 pm, the DON stated after she reviewed Resident #2's records, she said on 05/07/26 he made a suicidal statement, and he was sent to the hospital for evaluation and he returned after clearance. Interview on 06/25/26 at 3:13 pm, the DON stated Resident #2 also made suicidal statements on 05/18/26 and 05/25/26 and was sent to the hospital both times and he was cleared and returned. And on 06/03/26 he made suicidal statements and the hospital psychiatric team came to evaluate and cleared him at this facility. Then on 06/23/26 he made suicidal statements and was sent to the hospital and was cleared. She stated his 06/24/26 hospital discharge planning paperwork, said he wanted to go somewhere else and so he was sent to the rehabilitation hospital today (06/25/26). Interview on 06/25/26 at 4:36 pm, SW B stated Resident #2's first suicidal statements started on 05/07/26 during their IDT meeting and shortly after they put procedures in place to keep him safe. They put him on 1:1 monitoring then he was sent to the hospital for a psychiatric evaluation. She stated he was also seen by this facility's psychiatrist and counselor, and they checked on him often to make sure he was not feeling suicidal anymore. She stated that week, Resident #2 made a suicidal statement 06/22/26 and he was sent to the hospital and he just returned yesterday 06/23/26. She stated Resident #2 said he wanted to go back to the rehabilitation hospital, so he went back there today. She stated he was pretty good with talking to her when she went to check on him daily, when she worked. She stated when MDS assessments were not accurate the residents may not get full access to their rights. She stated for suicidal statements, it could affect the resident (she did not go into detail after re-questioning) and said she was not aware that the MDS was linked to the care plans. She stated the MDS assessments had what the resident's care needs were. She stated she knew how to do the MDS assessments, and no one had told her they were wrong. Interview on 06/25/26 at 5:19 pm, MDS F stated she was on vacation and was not aware Resident #2 made suicidal statements in May 2026. She stated Resident #2 was identified by the IDT as being suicidal on 06/02/26, and they discussed the plan to address it. She stated she was responsible for having accurate MDS assessments. She stated the MDS assessments were important because they were a reflection of the care provided to the residents. She stated if the MDS assessments were not accurate, the staff may not provide all the care for the residents. She stated for MDS Assessment they were supposed to interview the residents and review their medical records for the MDS sections to complete. Interview on 06/25/26 at 6:48 pm, the Administrator stated he was informed about Resident #2's first suicidal ideation on 05/07/26 and he was sent to the hospital. He stated Resident #2 had been sent to the hospital for making suicidal statement since then. He stated Resident #2 was alert and oriented X 3, and he did not want to be at this facility. He stated there was nowhere to put suicidal ideation on the MDS assessment, section D. for Mood and would have to talk more to the nursing department. He stated there were no problems with Resident #2's MDS assessments, and the care plans were based on what the MDS data was. He stated CMS just recently changed and now the MDSs were based on what the care plan data was. He stated they had a QAPI meeting in April 2026, about the MDS software issue with their signature sheets not transmitted properly and not with what was coded for the residents. He stated the MDS Coordinator was responsible for accurate MDS assessments.Record review of SW B's Inservice Training Report dated 06/25/26 revealed, Subject: MDS Accuracy - Check and review RAI manual for additional guidance. The instructor was MDS C and summary of the meeting: Review MDS sections - verbalize understanding and accuracy. And signed by SW B. Record review of the facility's Minimum Data Set policy version 1.17 undated revealed, Purpose: To utilize the most current version of the RAI manual to guide all IDT members on the proper procedure for coding items on MDS assessments, completing of Care Area Assessments (CAAs), and other instructions relating to MDS procedures. Policy: The facility will follow RAI guidelines for all areas related to MDS processes. Procedure: 1. IDT to utilize RAI for all processes pertaining to MDS. 2. MDS Nurse or IDT member to produce section of RAI referenced to support coding or other MDS processes as indicated.

Based on observation, interview, and record review, the facility failed to respect the resident's right to personal privacy for one (Residents #1) of 5 residents reviewed for resident rights. The facility failed to ensure CNA A did not leave her computer tablet unattended on a bedside table that was located on the 200 hall. It was unlocked and displayed Resident #1 was incontinent for bowel movements. This failure could place residents at risk of having their medical information disclosed by residents and visitors which could cause embarrassment, frustration, and feelings of decreased privacy, resulting in a decline in their health and psycho-social well-being. The findings included: Record review of Resident #1's Quarterly MDS assessment dated [DATE] and signed by the DON revealed, a [AGE] year-old male who admitted [DATE]. He had a BIMS score of 10 (moderately impaired cognition), walked without assistance and needed supervisory with touch assist for all ADLs. He was always continent of bowel and bladder and had active diagnoses of stroke and diagnoses of hypertension (high blood pressure), heart failure (heart muscle too weak to pump blood), renal failure (kidney lose ability to filter waste and excess fluid), hyperlipidemia (high levels of fat lipids), CVA, non-Alzheimer's dementia (cognitive loss), hemiplegia (one sided paralysis), anxiety (persistent worrying causing stress) depression (serious mood disorder). He had shortness of breath and at risk of developing pressure sores but had no skin issues. Record review of Resident #1's Care Plan dated 03/18/24 revealed, [Resident #1] had functional bowel and bladder incontinence related to activity tolerance, impaired mobility, physical limitations. Goal: Will remain free from skin breakdown due to incontinence and brief use through review dateObservation on 06/25/26 at approximately 11:52 am revealed Resident #2 pressed his call light. CNA A entered his room to assist Resident #2 with looking for his wallet that was eventually found. Observation on 06/25/26 at 11:54 am revealed, on the hall, there was a computer tablet on a bedside table by room [ROOM NUMBER]. This computer tablet displayed Resident #1's plan of care showing he was incontinent of his bowel. (No one was observed around this computer tablet. Observation and interview on 06/25/26 at 11:55 am, CNA A walked out of Resident #2's room and quickly grabbed the computer tablet and started walking away very fast. She was stopped and agreed to have an interview. CNA A said she went to answer a resident's call light. She stated the call light was on and she went to answer it and she should not have left the tablet open because it was a HIPAA violation. She stated the tablet disclosed resident information. She stated she was in Resident #2's room for about two to three minutes to help Resident #2 find his wallet. She stated she was in his room a little longer than she thought she would be. She stated she had just finished charting on a resident and was about to start charting Resident #1's ADLs. She stated she was moving too fast, and she was trying to answer the call light, but she knew she was not supposed to leave the resident info displayed on the computer tablet. She stated other people could use the resident's medical information for their own benefit or a family or resident could have taken pictures and read the resident's information. She stated for future reference she would slow down and lock the screen before she walked away from it. Interview on 06/25/26 at 6:06 pm, the DON stated they were good with the confidentiality of the resident's records. She stated she was not aware CNA A left the computer tablet unlocked and showing Resident's #1's ADL records for anyone to see. She stated if CNA A's computer was up, then yes, that was a problem. She stated incontinent care status was private information especially if the residents were incontinent. She stated the DON and Administrator were responsible for ensuring the facility was HIPAA complaint. She stated they needed to make sure computer screens were locked and they were not available for anyone to see Resident Information. Interview on 06/25/26 at 6:48 pm, the Administrator stated HIPAA compliance was expected to keep personal healthcare information protected at all times. He stated he was not aware CNA A left the computer tablet open on the hallway with a resident's information disclosed. He stated they were absolutely going to do a 1:1 training session with her about HIPAA compliance that day. He stated, ultimately, he was responsible for ensuring the facility had no HIPAA compliance issues. Record review of the facility's Resident Rights policy dated August 2020 revealed, Purpose: To promote and protect the rights of all residents at the facility. Procedure: I. Stated and federal laws guarantee certain basic rights to all residents of the facility. These rights include, but are not limited to, a resident's right to: E. Privacy and confidentiality including the right to privacy in his/her specific oral, written, and electronic communications. Record review of the facility's Medical Records policy dated June 2020 revealed, Purpose: To ensure the accurate documentation and maintenance of medical records by the facility. Policy: Clinical records, paper or electronic, will be kept for each resident admitted for care. Content will be in compliance with licensing and certifying governmental agency requirements and professional standards. Procedures: V. Protected health information contained in the record is confidential and will only be released in accordance with the Facility's HIPAA policies. VII. Unlawful or unauthorized access to, use or disclosure of protected health information will be reported in accordance with the Facility's HIPAA polices.

Based on interview and record review, the facility failed to ensure the resident's assessments accurately reflected their statuses for 1 (Resident #2) of 5 residents reviewed for resident assessments. 1) The facility failed to ensure SW B correctly completed Resident #2's 05/07/26 MDS assessment. SW B did not review and capture his suicidal ideations in the prior 14 days. SW B failed to ask this resident if in the past 14 days did, he have suicidal ideations; subsequently Resident #2 made suicidal statements which were within 14 days of this assessment and not included in Section D.0500 (i).2) The facility failed to ensure SW B correctly completed Resident #2's 06/02/26 Quarterly MDS assessment. SW B did not review and capture his suicidal ideations. SW B failed to ask this resident if in the last 14 days did, he have suicidal ideations; subsequently Resident #2 made suicidal statements which were within 14 days of this assessment and not included in Section D.0500 (i).These failures could place residents with mood disorders at risk of not getting all of their medical needs met for mental health issues, which could cause residents to harm themselves resulting in decreased health and psycho-social well-being. The findings included:Record review of Resident #2's admission MDS assessment dated [DATE] and signed by the DON on 05/18/26 revealed, a [AGE] year-old male who admitted [DATE], his BIMS score was 14 (cognition intact). For section D. Resident mood interview (Say to resident: Over the last 2 weeks, have you been bothered by any of the following problems?) was coded 0 for not having any interest or pleasure in doing things and feeling down, depressed, or hopeless. He used a wheelchair and had upper and lower extremity impairments and needed Partial/moderate assistance and substantial/maximal assistance for most ADLs. His primary active diagnosis were stroke, and his other diagnoses were hypertension (high blood pressure), benign prostatic hyperplasia (non-cancerous enlarged gland), diabetes mellitus (high blood sugar level), hyperlipidemia (high levels of fat lipids), thyroid disorder (abnormal hormone gland), and aphasia (neurological language disorder). Record review of Resident #2's 05/07/26 MDS - Version 3.0 Resident assessment and care screening nursing home comprehensive item set revealed, Section D 0150.i. thoughts that you would be better off dead, or hurting yourself in some way. Record review of Resident #2's Quarterly MDS assessment dated [DATE] and signed by the DON 06/02/26 revealed, a [AGE] year-old male who admitted [DATE], he had a BIMS score of 12 (moderately impaired cognition). For section D. Resident mood interview (Say to resident: Over the last 2 weeks, have you been bothered by any of the following problems?) . it was coded 0 for not having any interest or pleasure in doing things and feeling down, depressed, or hopeless. He used a wheelchair and walker and had upper extremity impairment and no lower extremity impairment and needed supervisory or touch assistance and Partial/moderate assistance for most ADLs. His primary active diagnoses were stroke, and his other diagnoses were hypertension, benign prostatic hyperplasia, diabetes mellitus, hyperlipidemia, thyroid disorder, and aphasia. Record review of Resident #2's 06/02/26 MDS - Version 3.0 Resident assessment and care screening nursing home comprehensive item set revealed, Section D 0150.i. thoughts that you would be better off dead, or hurting yourself in some way.Record review of Resident #2's Care Plans revealed, Resident #2 had a behavioral problem related to ongoing suicidal ideations, date initiated 06/23/26 and revised 06/25/26 Resident #2 has a behavior problem related to suicidal thoughts. Date initiated and revised 06/05/26 The resident needs in room socialization and sensory stimulation. Date initiated and revised 05/06/26 the resident has had an actual fall related to poor balance. Record review of Resident #2's Hospital Discharge summary dated [DATE] revealed, resident was assessed and cleared of suicidal ideation and Melatonin was ordered to promote sleep. Record review of Resident #2's Psychiatric Subsequent Assessment by Psychiatric NP C dated 06/08/26 revealed, reason for referral: Depression, worrying, irritability, delusions, suicidal/homicidal, resident was sent out for suicidal ideation with a plan. Physical examination: speech slow, soft, sad, flat affect, no plan for suicidal ideation, no risk of aggression, moderate depression. No medication changes and assessment plan: Primary insomnia and unspecified mood disorder. Revisit in 2 weeks. Record review of Resident #2's June 2026 MAR revealed, 88 mcg Levothyroxine sodium 1 tablet for morning, 3 mg. Melatonin 2 tablet at bedtime, 40 mg Pantoprazole 1 tablet 1 x D, 0.4 mg Tamsulosin 1 capsule at bedtime, 400 mg Magnesium Oxide 2 tablets 2 x D, 500 mg Metformin 2 tablets 2 x D, 40 mg Propranolol 1 tablet 2 x D, 1 gm Sucralfate 1 tablet 4 x D, 50 mg Armodafinil 1 tablet 1 x D, 2 mg Imodium A-D, 4% Lidocaine to lower back topically for morning, 4 mg Ondansetron 1 tablet every 6 hours, as needed, Resident exhibits depressive target behavior (each shift chart the number of episodes the targeted behavior occurred, intervention used and the outcome of the intervention), 325 mg Acetaminophen 1 tablet every 6 hours, as needed. Record review of Resident #2's Nurse Progress notes dated 05/07/26 at 11:34 am, by ADON D revealed, Change in condition reported on this change in condition were behavioral symptoms.Nursing evaluations, evaluation and recommendations are: Resident reported to IDT team that he was planning suicide by jumping out the window and/or wrapping cords around his neck and rolling out of bed. MD notified. Transfer to emergency room for suicidal ideation. Record review of Resident #2's Social Worker note by SW B dated 05/18/26 at 1:07 pm, Late Entry: SW sent psychiatric referral due to resident's suicidal ideations. Resident will be evaluated today. Record review of Resident #2's Social services note by SW B dated 05/25/26 at 9:55 am revealed, PHQ-2 to 9: Little interest or pleasure in doing things - symptom presence: no. little interest or pleasure in doing things - symptom frequency: never or 1 day, feeling down, depressed, or hopeless - symptoms presence: No. feeling down, depressed, or hopeless - symptom frequency - never or 1 day. Score: 0.0. Record review of Resident #2's Nurse Progress note dated 05/25/26 at 11:24 am, change in condition: Behavioral status evaluation: Danger to self and others suicide potential.primary provider feedback, recommendations: sent to emergency room and new testing orders. Record review of Resident #2's Nurse progress note dated 05/25/25 at 1:50 pm by ADON D revealed, Psychiatrist came to visit resident, and he told her he want [sic] to kill himself, the doctor advised the ADON of the situation, so this nurse called 911 and went to sit with patient until EMT arrived. Patient told EMT that he planned to kill himself on a certain day, but he will not tell them the date because they would try to stop him, patient said that he would jump out the window so he could die. Patient sent to psychiatric hospital. Record review of Resident #2's Nurse Progress notes dated 06/03/26 at 12:13 pm by LVN E revealed, This nurse call 911 because patient was saying he wanted to kill himself. Psychiatric (through 911) came out to evaluate and said that they would not take him because he can't walk and they just came and got him and returned back to the facility after a couple of days. Interview and observation on 06/25/26 at 11:28 am, Resident #2 was lying in bed and appeared calm and not in any distress, his wheelchair was next to his bed. He stated he did not feel sad or depressed and had no plan on jumping out of the window, but a couple of days he felt that way. He stated he took medications for depression that worked he believed because right now he did not want to kill himself. He stated he would love to get shaved before he left this facility. He stated he saw the psychologist at this facility and had been sent to the hospital psychiatric ward several times because of not wanting to live anymore. He stated he was currently getting ready to go to a rehabilitation hospital for therapy. Interview on 06/24/26 at 12:10 pm, LVN E stated Resident #2 has made statements of self-harm a month ago. She stated each time he had suicidal ideation his Doctor and 911 was called and he was taken to the hospital for evaluation and cleared for safety and returned back to this facility. She stated when he returned back to this facility they tried to get him up to go to activities and explained to him how important it was to do activities. He was taking psychotropic medication, but he refused to take them or go to activities. She stated Resident #'2 Doctor told the staff to continue to monitor him for signs of suicidal ideation. She stated the Psychiatric NP C who visited him regularly, to ensure he was safe. She stated two weeks ago she spoke to the DON about Resident #2 made suicidal ideation statements almost every other day that 'He doesn't want to live and wants to kill himself and the DON said they were working on a care plan for him. She stated she had not seen Resident #2 trying to hurt himself, but she and the other staff still kept an eye on him. Interview on 06/25/26 at 12:23 pm, ADON D stated Resident #2 had been suicidal three or four times since being admitted to this facility. She stated in the past he was going to kill himself but did not reveal the date or time for anyone to stop him. She stated Resident #2 said on occasion he was going to jump out of the window for the past month. She stated the LA and Hospital psychiatric services came out at times and he was also transferred to the hospital a few times in the past 30 to 45 days. She stated Resident #2 was cleared for safety after his evaluations, but they were still monitoring him closely. She stated the last time he went to the hospital was 06/22/26 for suicidal thoughts and said they were trying to encourage him to get up for activities to get him out more and sometimes he would get up and sometimes not. She stated the staff continued to check Resident #2 more often and documented in his MAR his mood. She stated he had no Suicidal thoughts today (06/25/26) but yesterday (06/24/26) he did. She stated she went and talked to him, and he was up this morning and was doing fine today (06/25/26). She stated today he planned to go to a rehabilitation hospital for more therapy. She stated Resident #2 had a care plan for suicidal thoughts and he received counseling from their psychiatric provider. She stated Resident #2 took propanol for psychiatric and Depakote for his psychiatric issue and was getting psychology and psychiatric services. She stated they have had IDT meetings on a regular basis and Resident #2 was discussed for his suicidal thoughts. She stated their IDT meetings included the DON, both ADON's, Administrator, MDS and SW. Interview on 06/25/26 at 12:47 pm, the DON stated Resident #2 had been suicidal since being a resident at this facility, last month. She stated the nurses called Resident #2's Doctor when he had suicidal thought and was transferred to the hospital for psychiatric services. She stated once he was cleared for safety he was sent back to this facility. She stated Resident #2 received psychiatric services from their provider and their SW B talked to him a lot, when he had a bad day. She stated the Hospital had a team that also came out to evaluate him with two LE and a psychiatric nurse for his crisis moments. She stated this hospital team gave Resident #2 tacos and assessed and cleared him. She stated the nurse's communication for each shift and staff training was done to ensure Resident #2 was safe. She stated the staff made sure he had plastic ware, encouraged him to come out of his room and 1:1 when he had a bad day. She stated they also care planned this and added Resident #2 was scheduled to go to a rehabilitation hospital today. She stated the plan was for him to return to this facility since he could not return home. She stated Resident #2 was his own RP and she had not spoken to his family about his suicidal thoughts, but was sure SW B had spoken to them about it. She stated she would have to go through his notes to see if he had any plan to kill himself or just made the statements of wanting to die. She stated she did not know how often Resident #2 made suicidal statements off the top of her head and would follow-up with HHS after reviewing his records. She stated Resident #2 did not want to be in any nursing home at all and said she would ensure SW B to talk to him about his options to return here or go to another facility. Observation on 06/25/25 at 1:20 pm, Resident #2's was not in the room and his belongings were gone. (ADON D stated he had just left the facility to go to the rehabilitation hospital). Interview on 06/25/26 at 1:24 pm, the Administrator stated Resident #1 admitted last month and he had no suicidal statements prior to his admission [DATE] but would review his notes to be sure. He stated Resident #2 was his own RP and was cognitively intact. He stated Resident #2 made suicidal statements for which they were sending him to the hospital for and was seen by their psychiatric provider. He stated he knew Resident #2 had been sent out several times for suicidal thoughts and went to the hospital and they cleared him saying he was safe and was no longer a harm to himself. He stated Resident #2 said he did not want to be in a nursing home, but he could not return home with his family. He stated Resident #2 made a statement to put him out on the street, and he told him No they could not do that. He stated Resident #2 was transferred to a rehabilitation hospital for therapy today (06/25/26). He stated he was taken there to increase his functional ability. He stated if he returned to this facility, they would have to have a care plan meeting with Resident #2 and his family to see if there was anything else that could be done to help Resident #2. He stated he spoke to Resident #2 with AD E and SW B, and they asked what could be done to make it better for him, because he stayed in his room most of the time. He stated Resident #2 said he liked coffee, so they made sure he received his coffee every morning. Interview on 06/25/26 at 2:20 pm, the DON stated after she reviewed Resident #2's records, she said on 05/07/26 he made a suicidal statement, and he was sent to the hospital for evaluation and he returned after clearance. Interview on 06/25/26 at 3:13 pm, the DON stated Resident #2 also made suicidal statements on 05/18/26 and 05/25/26 and was sent to the hospital both times and he was cleared and returned. And on 06/03/26 he made suicidal statements and the hospital psychiatric team came to evaluate and cleared him at this facility. Then on 06/23/26 he made suicidal statements and was sent to the hospital and was cleared. She stated his 06/24/26 hospital discharge planning paperwork, said he wanted to go somewhere else and so he was sent to the rehabilitation hospital today (06/25/26). Interview on 06/25/26 at 4:36 pm, SW B stated Resident #2's first suicidal statements started on 05/07/26 during their IDT meeting and shortly after they put procedures in place to keep him safe. They put him on 1:1 monitoring then he was sent to the hospital for a psychiatric evaluation. She stated he was also seen by this facility's psychiatrist and counselor, and they checked on him often to make sure he was not feeling suicidal anymore. She stated this week Resident #2 made a suicidal statement 06/22/26 and he was sent to the hospital and he just returned yesterday 06/23/26. She stated Resident #2 said he wanted to go back to the rehabilitation hospital, so he went back there today. She stated he was pretty good with talking to her when she went to check on him daily, when she worked. She stated she planned to work with the rehabilitation hospital on his discharge plans before his therapy was completed. She stated she coded Resident #2's 06/02/26 MDS assessment for not being depressed and not having little interest in doing things because he said he felt fine that day for the 05/07/26 MDS assessment and 06/02/26 MDS assessment. She stated when she interviewed him, he was not suicidal. She stated she did not talk to the nursing staff or reviewed his progress notes to see that on 05/25/26 he made suicidal statements and was sent to the hospital. She stated she did not know she was supposed to ask him about his mood for the past 14 days of the MDS Assessment Section D. Mood. She stated when MDS assessments were not accurate the residents may not get full access to their rights. She stated for suicidal statements, it could affect the resident (she did not go into detail after re-questioning) and said she was not aware that the MDS was linked to the care plans. She stated the MDS assessments had what the resident's care needs were. She stated she knew how to do the MDS assessments, and no one had told her they were wrong. Interview on 06/25/26 at 5:19 pm, MDS F stated she was on vacation and was not aware Resident #2 made suicidal statements in May 2026. She stated Resident #2 was identified by the IDT as being suicidal on 06/02/26 and they discussed the plan to address it. She stated she completed the Mood section of Resident #2's admission MDS 05/18/26 and she coded that he had no mental health issues when she interviewed him, he said he was not suicidal at that time. She stated she reviewed his nurse's notes, then said she did not remember on the top of her head if she reviewed them. She stated she needed to see if he had any suicidal ideation in May 2026 by looking at his records. She stated she was not aware Resident #2 wanted to kill himself on 05/07/25 and was not sure if the IDT discussed it in the meeting. She stated sometimes she was busy with assessments or other tasks and could not remember if she was in any May 2026 IDT meetings. She stated she remembered on 06/02/26 they had an IDT meeting about his suicidal statements, then said she did not remember when she found out he was suicidal. She stated she would have to get her computer to review his records. She stated after review, she read that Resident #2 made suicidal statements on 05/07/26 and went to the hospital, but was not aware of it until today (06/25/26). She stated she was aware of his 06/02/26 suicidal statement and he had a psychiatric evaluation and was cleared. She stated there was not a place on the MDS for her to have coded his suicidal statements for the 05/18/26 MDS Assessment. And after it was pointed out where, by the HHS investigator, she stated it was greyed out because Resident #2 said he had no mood issues at that time. She stated she was responsible for having accurate MDS assessments. She stated the MDS assessments were important because they were a reflection of the care provided to the residents. She stated if the MDS assessments were not accurate, the staff may not provide all the care for the residents. She stated for MDS Assessment they were supposed to interview the residents and review their medical records for the MDS sections to complete. Interview on 06/25/26 at 6:06 pm, the DON stated some of the MDS assessments were not accurate and they had a QAPI meeting over that one as well. She stated there was no section for suicidal ideation on the MDS assessments and said that the MDS assessments for Resident #2 was done correctly. (The facility was asked for proof of the MDS issues they identified and they were unable to provide it for inaccurate MDS coding).Interview on 06/25/26 at 6:48 pm, the Administrator stated he was informed about Resident #2's first suicidal ideation on 05/07/26 and he was sent to the hospital. He stated Resident #2 had been sent to the hospital for making suicidal statement since then. He stated Resident #2 was alert and oriented X 3 and he did not want to be at this facility. He stated there was nowhere to put suicidal ideation on the MDS assessment, section D. for Mood and would have to talk more to the nursing department. He stated there were no problems with Resident #2's MDS assessments and said the care plans were based on what the MDS data was. He stated CMS just currently changed and now the MDSs were based on what the care plan data was. He stated they had a QAPI meeting in April 2026, about the MDS software issue with their signature sheets not transmitted properly. He stated the MDS Coordinator was responsible for accurate MDS assessments. Record review of SW B's Inservice Training Report dated 06/25/26 revealed, Subject: MDS Accuracy - Check and review RAI manual for additional guidance. The instructor was MDS C and summary of the meeting: Review MDS sections - verbalize understanding and accuracy. And signed by SW B. Record review of the facility's Minimum Data Set policy version 1.17 undated revealed, Purpose: To utilize the most current version of the RAI manual to guide all IDT members on the proper procedure for coding items on MDS assessments, completing of Care Area Assessments (CAA's), and other instructions relating to MDS procedures. Policy: The facility will follow RAI guidelines for all areas related to MDS processes. Procedure: 1. IDT to utilize RAI for all processes pertaining to MDS. 2. MDS Nurse or IDT member to produce section of RAI referenced to support coding or other MDS processes as indicated.

Based on interviews and record reviews the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #1) of 3 residents, reviewed for medications. The facility failed to ensure Resident #1's order for Wellbutrin 300 mg was not duplicated on the MAR.The facility failed to ensure the staff signed off on the MAR correctly. Staff signed off that they administered 600 mg when they only administered 300 mg. This failure placed residents at risk for medication related errors and medication overdose.Findings included: Review of Resident #1's Quarterly MDS Assessment, dated 02/12/26, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her BIMS score was 15, indicating her cognitive skills were intact. Her diagnoses included heart failure and end-stage kidney disease. There were no diagnoses for anxiety disorder or depression listed. Review of Resident #1's Face Sheet, dated 04/16/26, reflected her diagnoses included blindness, generalized anxiety disorder, and major depressive disorder. Review of Resident #1's Comprehensive Care Plans, dated 02/19/26, reflected Resident #1 was non-compliant with medication administration and facility interventions included talk to the resident to determine reasons for refusal of care.Review of Resident #1's Medication Administration Record for March 2026 reflected two separate orders for Wellbutrin 300 mg daily was administered 03/01/26 - 03/23/26. Review of Resident #1's Psychiatric Subsequent Assessment, dated 03/09/26, reflected the NP had documented the resident was receiving Wellbutrin 600 mg daily. Review of Resident #1's Psychiatric Subsequent Assessment, dated 03/23/26, reflected the NP had documented the resident was receiving Wellbutrin 600 mg daily and changed the dose to 450 mg daily. An interview on 04/16/26 at 11:42 AM with Resident #1 revealed she was not receiving her medications correctly. She said the facility was overdosing her by giving her 600 mg of Wellbutrin instead of 300 mg daily. She said she would tell the nurse who said they had already spoken to the doctor about the dose. Resident #1 said she would refuse the dose when they tried to give her 600 mg instead of 300 mg. In an interview on 04/16/26 at 1:40 PM, LVN A revealed she would administer medications to Resident #1 if the medication aide called in. LVN A said Resident #1 would refuse medication including Wellbutrin. LVN A said she did not know why the resident would refuse Wellbutrin. In an interview on 04/16/26 at 1:55 PM, the DON revealed she did not know if Resident #1 received Wellbutrin 600 mg daily from 03/01/26-03/23/26 as ordered. In an interview on 04/16/26 at 3:30 PM, the ADON revealed Resident #1 had an order for Wellbutrin 600 mg daily in March 2026 but did not receive 600 mg. She said it was a duplicate order listed on the Medication Administration Record. The ADON said the NP found the error. The ADON said she spoke with staff who said they only administered 300 mg, not 600 mg. In an interview on 04/16/26 at 3:50 PM, the NP said she identified Resident #1 had an order for Wellbutrin 600 mg daily on 03/23/26. The NP said she lowered the dose to 450 mg daily. The NP said Resident #1 never asked her for a dose reduction of the medication. The NP said Resident #1 would see an outside NP and maybe they ordered the additional order for Wellbutrin 300 mg daily to total 600 mg. The NP said if a resident received 600 mg of Wellbutrin, they could experience stomach upset, diarrhea, stomach pain, insomnia, and increased anxiety. The NP said Resident #1 never reported those symptoms to her. In an interview on 04/16/26 at 4:00 PM, the Physician said he oversaw the care provided by the NP. He said he did not know why Resident #1 had an extra order for Wellbutrin 300 mg daily to total 600 mg. Interviews on 04/16/26 from 4:10 PM to 4:55 PM with MA B, MA C, MA D, MA E, and LVN F revealed they administered Wellbutrin 300 mg daily instead of Wellbutrin 600 mg as ordered on the Medication Record for 03/01/26 - 03/23/26. They said they signed they gave 600 mg in error. They said they had been trained to sign only the medications they administered. In an interview on 04/16/26 at 5:15 PM, the DON revealed the facility had a QAPI meeting to put a system in place to ensure the Medication Administration Record was correct. The DON said she was made aware of the issue on 04/16/26 when it was brought to her attention by the Surveyor. She said the ADON was responsible for checking Medication Administration Records occasionally. The DON said Resident #1 would have been at risk for side effects including seizures and agitation if she received 600 mg of Wellbutrin daily. The DON said the resident did not report those side effects. The DON said she did not know why Resident #1 refused Wellbutrin. Record review of the facility policy, Medication Administration, not dated, reflected: .Nursing staff will keep in mind the [seven] rights of medication when administering medication:A. The right medicationB. The right dose.

Based on observation, interview and record review, the facility failed to maintain an effective pest control program for 1 of 1 facility for 119 residents reviewed for pests, Gnats were observed in rooms and hallways on Hall A (first floor), Hall B, (secured unit), and Hall C (second floor), in the facility. This failure could place residents at risk of an increased exposure to pests and vector-borne diseases and infections.Findings included: During an observation on 02/17/2026 at 9:17 a.m., Hall A (first floor) room [ROOM NUMBER] had three gnats crawling in the bathroom sink. During an observation on 02/17/2026 at 9:18 a.m., Hall A (first floor) room [ROOM NUMBER] had five gnats crawling in the bathroom sink. During an observation on 02/17/2026 at 9:30 a.m., a medication cart on Hall A (first floor) had three gnats crawling on top of the cart. During an observation on 02/17/2026 at 9:32 a.m., Hall A (first floor) room [ROOM NUMBER]-2 (bed next to the window) had six gnats crawling on the bedside table. During an observation on 02/17/2026 at 10:07 a.m., Hall B (secured unit) room [ROOM NUMBER] a gnat flew in the room. During an observation on 02/17/2026 at 10:23 a.m., Hall B (secured unit) a gnat in the hallway flew outside of room [ROOM NUMBER]. During an observation on 02/17/2026 at 10:45 a.m., Hall C (second floor) three gnats were on the wall near the doorway to room [ROOM NUMBER]. Further observation revealed three gnats crawling on the wall, next to the window in room [ROOM NUMBER]. During an observation on 02/17/2026 at 10:52 a.m., Hall C (second floor) a gnat flew outside room [ROOM NUMBER]. During a confidential group meeting on an undisclosed date and time with eleven residents revealed eleven residents stated there was a pest control problem concerning gnats. The Gants were in their bathrooms and rooms. The eleven-resident stated they reported to staff and the pest control man treated the drains, but the gnat problem did not improve. During an interview on 02/18/2026 at 8:15 a.m., MA A revealed she had not seen any gnats. MA A stated if she saw pest, she would report to the Maintenance Man. MA A stated there was no book at the nurses' station to write your sightings in, but tell the Maintenance man. During an interview and record review on 02/19/2026 at 8:22 a.m., the Plant Operations Manager and a review of the pest control book revealed the pest control company comes two times a week. The Plant Operations Manager stated the pest control company told him as long as the residents had plants and food in their rooms there would be gnats. The Plant Operations Manager stated he would call the pest control company back out again. Record review of the Pest control logs, dated 12/2025 through 02/2026, revealed one mention of gnats. There was no further documentation to review, only one log. During an interview on 02/18/2026 at 11:10 a.m. with the Administrator he revealed he was aware of a pest problem in the residents' rooms and in other parts of the facility. The Administrator stated he would see that the problem was addressed now that he was aware of the pest still in the facility. Record review of facility provided pest control log revealed, in part, dates and treatments as follows:Treatment dates and services performed: 12-14-2025-Kitchen and Nurse's station had accumulation of food product from damaged goods noted. Instructed staff to remove food product to prevent attraction by pests. evidence of employees eating outside of cafeteria noted and my attract pests. Please instruct the staff, do not to take food outside of cafeteria area, and no open top drinks. 1-11-2026-treated hallways, reception, breakroom, conference room, kitchen, and restrooms. There is a small fly issue (gnats coming from the drains in the dish sink. Instructed employees to regularly clean this sink out to help. Also, rooms need to be better cleaned. Several residents' rooms have food and snacks with open containers in the rooms. 2-13-2026-treated kitchen, dining room, break rooms, resident rooms, nurse's station, and exterior parameters. Serviced insect light stations in the hallways.Species listed in treatment: Flies, rodents, gnats, and occasional invaders. Review of the policy and procedure Pest Control dated revised 08/2020 reflected: To ensure the facility is fress of insects, rodents, and other pests that could compromise the health, safety, and comfort of residents, facility staff, and visitors. The facility maintains an ongoing pest control program to ensure the building and grounds are kept free of insects, rodents, and other pests.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's 1 of 1 kitchen reviewed for food safety. The facility failed to ensure food items in the dry storage room were properly stored, sealed, and protected from exposure to air in accordance with professional food service standards. The facility failed to ensure food items in the walk-in refrigerator were properly stored, sealed, and protected from exposure to air in accordance with professional food service standards. The garbage receptacle at the #1 handwashing sink contained items other than paper towels. These failures could place residents at risk for food-borne illness, cross contamination, and infection.During an observation of the #1 handwashing sink's garbage receptacle on 02/17/2026 at 9:29 a.m., the following was revealed: 1 of 2 handwashing sinks had garbage receptacles that contained items other than disposable paper towels, including plastic cups and several tin cans. During an observation of the dry storage room on 02/17/2026 at 9:37 a.m., the following was revealed: 1-large clear plastic press-and-seal bag of colored circled-shaped cereal was exposed to air, had no label identifying the item, had an open date of 02/12/2026, and had a best-by date of 02/28/2026.1 previously opened bag of sandwich bread (1 lb. 8 oz.) had no label identifying the item, had no open date, and had a best-by date of 02/28/2026. The Dietary Manager handled the clear plastic press-and-seal bags; the bags separated without the application of force or resistance. She stated the seals are defective, as they opened with minimal contact. One previously opened bag of hamburger buns (1 lb. 8 oz.) had no open date and had a best-by date of 02/19/2026. 1-large clear plastic press-and-seal bag of edible cake confetti was exposed to air, had an open date of 10/30/2025, and had a best-by date of 01/30/2026. 1-large clear plastic press-and-seal bag of spiral shaped pasta was exposed to air, had no label identifying the item, had an open date of 02/15/2026, and had no best-by date. 4 unopened loaves of bread had no label identifying the item and had no best-by date. The manufacturer's name was the only identifiable information on the label. During an observation of the walk-in refrigerator on 02/17/2026 at 9:54 a.m. revealed the following: 1-large clear plastic press-and-seal bag containing shredded cheese was exposed to air, had an open date of 02/10/2026, and had no best-by date. During an interview on 02/17/2026 at 10:18 a.m., the Dietary Manager stated the two dates on food stored in the dry storage room and walk-in refrigerator reflected the date the product was opened and the best-by date. She reported that all kitchen staff were responsible for labeling and properly sealing food items after opening them. She further stated that serving residents food that was exposed to air or expired could cause them to become sick. During an interview on 02/17/2026 at 10:24 a.m., the Dietary Aide stated the two dates on the food reflected the day it was received and the best-by date. She stated the best-by date was three days after the product was opened. She further stated if improperly sealed or expired food was served to residents, the food could be contaminated with bacteria and residents could become sick. During an observation of the #1 handwashing sink garbage receptacle on 02/18/2026 at 10:06 a.m. the following was revealed: 1 of 2 handwashing sinks had garbage receptacles that contained items other than disposable paper towels, including insulated foil, plastic shrink wrap, and a large empty tin can. During an observation of the walk-in refrigerator on 02/18/2026 at 10:18 a.m. the following was revealed: The large clear plastic press-and-seal bag from the day prior was no longer in the walk-in refrigerator. During an interview on 02/18/2026 at 10:24 a.m., the Dietary Manager stated the facility received a shipment of supplies on 02/17/2026 and large clear plastic zip-top bags were included in the shipment. During an observation of the #1 handwashing sink garbage receptacle on 02/19/2026 at 12:23 p.m. revealed the following: 1 of 2 handwashing sinks had garbage receptacles that contained items other than disposable paper towels, including styrofoam cups, plastic shrink wrap, and a large empty apple juice carton. During an interview on 02/19/2026 at 12:46 p.m., the Corporate Dietitian stated the two dates recorded on food items stored in the dry storage room and walk-in refrigerator represented the date the product was opened by staff and the manufacturer's Best By date. She reported all dietary staff were responsible for appropriately labeling and sealing food items upon opening. She said that serving food items exposed to air or beyond the manufacturer's expiration date presented a risk for contamination and potential foodborne illness for residents. She added that she oversaw the training of all kitchen staff, and they receive training monthly and as needed. Their last training was a couple of weeks ago. In a record review of the facility's Food Labeling and Dating policy, dated 01.02.2026, revealed VI. Opening a food item can change the storage life of a product. Once a package or container is opened, the item must be labeled with an open by date and use-by date or dated with the use-by or expired on the manufacturer's recommended shelf-life. Section VI A. If the manufacturer does not include a recommended use by or expire date, the dietary staff must determine a use by date for the food item based on the Storage Period table or 7 days. Label the original packaging, Ziplock bag, bin, or container appropriate use by date. Review of the U.S. FDA Food Code 2022 reflected: Definitions 3. Food Receiving and Storage - When food, food products or beverages are delivered to the nursing home, facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all PHF/TCS foods stored in the refrigerator or freezer as indicated. Section 6-301.20 Disposable Towels, Waste Receptacle. Waste receptacles at handwashing sinks are required for the collection of disposable towels so that the paper waste will be contained, will not contact food directly or indirectly, and will not become an attractant for insects or rodents.

Based on observation, interview and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #78, and #124) of four residents reviewed for infection control. The facility MA A failed to disinfect the blood pressure cuff in between vital sign checks for Resident #78, and Resident #124. The facility MA A failed to wash hands prior to eye drops administration to Resident #78. This failure could place residents at risk for spread of infection through cross-contamination. Findings included: Record review of Resident #78's quarterly MDS assessment, dated 11/24/2025, reflected a [AGE] year-old female, admitted [DATE], diagnoses included hypertension (high blood pressure), diabetes (high sugar), and heart failure (weak heart). Resident #78's BIMs score of 14 indicated the resident was cognitively intact and required assistance from one staff for activities of daily living. Record review of Resident #78's consolidated physician orders, dated January 2026 reflected an order dated 01/09/2025, metoprolol Tartrate (high blood pressure) tablet 25mg one tablet by mouth two times a day. Further review revealed physician orders to check blood pressure every shift. Record review of Resident #124's admission MDS assessment, dated 12/12/2026, reflected a [AGE] year-old male, admitted [DATE], diagnoses included hypertension (high blood pressure) and end stage renal disease (kidneys do not function completely). Resident #124's BIMs score of 15 indicated the resident was cognitively intact and required assistance from one staff for activities of daily living. Record review of Resident #124's consolidated physician orders, dated February 2026 reflected an order dated 02/18/2026, losartan potassium (blood pressure) 25mg give one tablet by mouth one time a day, and amlodipine besylate (for high blood pressure) 5mg give one tab by mouth daily. Further review revealed physician orders to check blood pressure every shift, prior to giving blood pressure medications. During an observation on 02/17/2026 at 9:20 a.m., MA A, during medication pass, went to the medication cart and started preparing to perform medication administration for Resident #78. MA A took the blood pressure cuff (machine to check blood pressure) to check Resident #78's blood pressure. MA A did not clean the machine prior to or after using on Resident #78, with germicidal proposal wipes. MA A left the room, went back to the cart, used hand sanitizer documented on the resident's clinical record and began to prepare for the medication pass. MA A prepared the medications after taking the blood pressure, reentered the room of Resident #78 carrying a medicine cup, a box of nasal spray, and a box of eye drops. MA A administered the cup of medications to Resident #78, then administered the nasal spray and, without cleansing her hands, administered the eyes drops to both eyes of Resident #78. MA A collected the boxes and left the room, returned to the medication cart, using hand sanitizer after. During an observation on 02/17/2026 at 9:59 a.m., MA A, during medication pass, went to the medication cart and started preparing to perform medication administration for Resident #124. MA A took the blood pressure cuff to check his blood pressure. MA A did not clean the machine prior to or after used on Resident #78 or Resident #124. MA A left the room, went back to the medication cart, used hand sanitizer, documented on the resident's clinical record and began to prepare for the medication pass. During an interview on 02/17/2026 at 10:30 a.m., MA A stated she was to clean all equipment used before and after use on each resident, to prevent the spread of infection. MA A stated the blood pressure cuff must be cleaned after each usage. MA A stated she guessed she did not clean it in front of you, just got to talking and forgot. MA A stated she used hand sanitizer before and after using the blood pressure cuff. MA A stated she should have cleaned her hands before giving eye drops, she thought about it after the drops were administered. During an interview on 02/18/2026 at 2:24 p.m., the DON stated all direct care staff must clean equipment, including blood pressure cuffs, after having contact with each resident. The DON stated germicidal proposal wipes were available on all medication and treatment carts. The DON stated if the staff were not cleaning the equipment appropriately this could spread germs to themselves and the residents. Further interview with the DON revealed the staff should always wash their hands and put on gloves before administering eye drops. The DON stated if they did not, it could spread infection to themselves and others. Record review of the in-services given in the past three months (11/2025 through 01/2026) reflected an in-service dated 01/09/2026, for infection control and cleaning of equipment and MA A attended the meeting. Record review of the facility's policy titled, Cleaning & Disinfection of Environmental Surfaces and Equipment, dated revised June 2020, reflected, The following categories are used to distinguish the levels of sterilization/disinfection necessary for items used in the resident's environment. C. non-critical items are those that come in contact with intact skin but not mucous membranes. ii. Non-critical equipment items include bed pans, blood pressure cuffs. iii. Most non-critical items can be decontaminated where they are used . Record review of the facility's policy titled, Hand Hygiene, dated revised June 2020, reflected, . policy: the facility considers hand hygiene the primary means to prevent the spread of infections. Procedure: III. Facility staff follow the hand hygiene procedures to help prevent the spread of infections to other staff, residents, and visitors. V. Facility staff and volunteers must perform hand hygiene procedures in the following circumstances including but not limited to. A. Wash hands with soap and water: . iv. After unprotected (ungloved.) contact with blood, other body fluids, secretions, excretions, mucous membranes, non-intact skin, intact skin. v. after contact with intact and non-intact skin .

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 3 residents (Resident #1) reviewed for care plans:The facility failed to ensure Resident #1's comprehensive care plans reflected that she had refused her medications on and off for the past 2 months. This failure could affect residents by placing them at risk of not receiving care and services to meet their needs. Findings included: Record review of Resident #1's face sheet dated 02/19/2026 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included congestive heart failure, chronic kidney disease, blindness in right and left eye, chronic obstructive pulmonary disease and chronic viral hepatitis C. Record review of Resident #1's most recent admission MDS dated [DATE] revealed Resident had a BIMS of 15 indicating she was cognitively intact and needed partial to moderate assistance with activities of daily living. Record Review of Resident #1's nurses notes revealed the following: On 01/09/2026, it was documented at 8:19 PM that Resident #1 refused her anti-biotic Cefuroxime for a Urinary tract infection and other scheduled pills for the medication aide. On 01/14/2026, it was documented at 10:58 AM that Resident #1 refused morning medications with the medication aide, but accepted medications from the nurse.On 02/01/2026, it was documented at 6:21 AM that Resident #1 refused all morning medications.On 02/04/2026 it was documented at 8:31 PM that Resident #1 refused all evening medications except Amitriptyline HCI Oral Tablet 25 milligrams. Educated resident on the importance of taking medications, Resident verbalized understanding but refused. On 02/06/2026 it was documented at 8:50 AM that Resident #1 continued to refuse scheduled morning medications from yesterday, nurse provided education and encouraged the resident to adhere to taking her medication, but she continues to refuse. Record Review of Resident #1's comprehensive care plan dated 12/15/2025 revealed there was no care plan to address the refusal of medications until 02/19/2026 when it was brought to the attention of the facility by the surveyor. In an interview on 02/19/2026 at 11:20 AM with MDS Nurse A revealed that she had worked for the facility since September of 2025. She stated that she was notified in the morning clinical meeting of any issues that needed to be care planned. She stated that if the behavior only occurred one time, it should be added to the care plan. She was not aware that Resident #1 had refused her medication. She stated the risk to the residents would be the care plan was not personalized and would not show a true reflection of the resident. In an interview on 02/19/2026 at 11:33 AM with ADON B revealed that she would notify the Physician and the Director of Nurses of any refusals, and she would add it to the care plan but was unsure what the policy was regarding refusals. She was aware that Resident #1 had been refusing her medications. She stated the risk to the resident was that staff wouldn't know if the resident had been educated on the risks of refusing the medication. In an interview on 02/19/2026 at 12:56 PM with DON C revealed that if a resident was refusing medications, her expectation was that it should be reported in the morning meeting so that everyone is aware of the refusal. She stated the risk to the resident was that if it wasn't care planned, then staff were not aware and cannot monitor the resident. Review of the undated facility policy on Care Planning reflected in part, A licensed nurse will initiate the care plan and update as indicated for change of condition, onset of new problems. The IDT (Interdisciplinary Team) will revise the comprehensive care plan as needed at the following intervals:B: As dictated by changes in the residents' conditionD: To address changes in behavior and care

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 1 (Resident #1) of 7 residents reviewed for infection control. 1.LVN B and CNA C failed to wear PPE gown during incontinence care for Resident #1 who was on Enhanced Barrier Precautions for G-tube and Wounds. 2. LVN B failed to change her gloves and failed to perform hand hygiene when she did not remove her dirty gloves after finishing incontinence care for Resident #1 before connecting her feeding tube back to the feeding. These failures could place residents at risk of infectious disease. Resident #1 Record review of Resident #1's admission record dated 02/03/26 revealed a [AGE] year-old female with an initial admission to the on 12/11/23 and readmitted to the facility on [DATE]. Her diagnoses included senile degeneration of Brain (this is a brain condition that progressively destroys memory and other important mental functions and causes state of confusion and forgetfulness), gastrostomy status (this is a feeding tube that is placed through the abdominal cavity area into the stomach for nutritional purpose and medication for individual who have a difficulty swallowing) and non-pressure chronic ulcers to both ankles. Record review of Resident #1's quarterly MDS dated [DATE] indicated Resident #1 had severe cognitive impairment. The MDS indicated she had a feeding tube and received 51 percent or more of her total calories through tube feeding. MDS also indicated she was always incontinent with bowels and bladder and dependent on toileting, showers, and transfers. MDS did not indicate any wounds or pressure sore Record review of Resident #1's care plan initiated 07/18/24 revealed Resident #1 was on enhanced barrier precautions related to wounds and device care. The goal was to follow enhanced barrier precautions. Interventions included staff wearing clean gowns and gloves while performing high contact care. Observation on 02/03/26 at 3:05 PM, revealed Resident #1 had a sign outside the resident's door which indicated the resident was on EBP. LVN B and CNA C did not wear gowns while providing incontinent care to Resident #1. Continuous observation of Resident #1's incontinent care also revealed that LVN B did not change her dirty gloves or wash her hands after wiping Resident #1's bottom before reconnecting Resident #1 back to her feeding via g-tube. Interview with LVN B on 02/03/26 at 3:27 PM, she said she had already washed her hands before starting care. She said she was not aware that a g-tube was considered an indwelling medical device which would require EBP. She said unless a resident had secretions that were bloody, she did not need to wear a gown. She said she had not been trained on EBP in a while and was thinking that EBP was only for wounds and foley catheter. She stated now she understood anyone with a g-tube or anything invasive would require PPE. She stated the risk was contamination. She said that she should have changed her gloves before connecting back the feeding as that was infection control and contamination. Interview with CNA C on 02/03/26 at 3:37 PM, she stated if a resident was on any type of isolation, and she did not understand the precautions then she would ask the nurse. She said that she did not wear a gown because the nurse (LVN B) was not wearing a gown and was in the room with her, so she did not think it was required to wear a gown. She said she was not sure what the risk was. In an interview with the DON on 02/04/26 at 11:19 AM, revealed if a resident was on EBP isolation it meant staff were to wear gloves and gowns while providing care. She stated all staff were expected to wear PPE to prevent the spread of infection. She said that the nurse should have changed her gloves and completed hand hygiene before moving on to connect the G-tube. She said the risk was contamination and spread of infection Interview with the administrator on 02/04/26 at 11:20 AM, he said he expected staff to follow the policy and procedures that were in place. He said all staff were expected to prevent spreading of infection. Record review of facility in-service titled Enhanced Barrier Precautions dated 02/03/26 led by DON revealed one on one completion for LVN B and CNA C. Review of the facility policy titled Standard and Enhanced Precautions revised 10/24/22 revealed.D. Gownsi. A gown is worn to protect skin and prevent soiling of clothing during proceduresand resident care activities that are likely to generate splashes or sprays of blood,body fluids, secretions, or excretions or cause soiling of clothing G. Lineni. Transport and processing of used linen soiled with blood, body fluids, secretions,and excretions is handled in a manner that prevents skin and mucous membraneexposures, contamination of clothing, and avoids transfer of microorganisms toother residents and environments. Review of policy Implementation of Standard and Transmission-Based Precautions dated 03/24, revealed, .EBP are indicated for residents with any of the following: 1. Infection or colonization with a CDC-targeted MDRO .Wounds and/or indwelling medical devices even if a resident is not known to be infected or colonized with a MDRO .post signage .high-contact resident care activities requiring gown and glove use .

Based on observation, interview and record review the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys for one (Hall C Nurse Cart) of five medication carts reviewed. LVN A failed to ensure that Hall C nurse cart was not left unlocked and unattended with the keys still in the lock mechanism in between rooms [ROOM NUMBERS]. This failure placed residents at risk of having access to medications not ordered for them or more than recommended doses.Observation and interview on 02/03/26 at 3:48 PM, revealed a medication cart on C hall was left unlocked and unattended with the keys still in the lock mechanism in the middle of C hall between rooms [ROOM NUMBERS]. The MDS nurse walked toward the cart while surveyor was standing by the unlocked and unattended medication cart, and she pushed the lock mechanism in (indicating locking position) and she pulled the keys out of the lock mechanism. She stated, this cart should be locked. She said the nurse should not have left the cart unlocked when unattended. The Surveyor asked the MDS nurse who the unlocked medication cart belonged to, and she stated the medication cart belonged to LVN A. In an interview with LVN A on 02/03/26 at 4:11 PM, revealed the unattended and unlocked medication cart on C Hall belonged to her and it was a nurse cart. She said she had just finished cleaning the medication cart and she dashed into the med room to get some blood sugar strips. She said she forgot to lock the cart, and she forgot to take the keys with her. She stated it was important to keep the med cart locked, and keys safely removed and within nurse's position. She stated the risk was medication safety of the residents' obtaining narcotics medications because keys were left in the cart and to prevent them or anyone from getting into the cart. In an interview with the DON on 02/04/26 at 11:19 AM, revealed she expected her staff to lock their medication carts and take the keys with them. She said that she had already started an Inservice, and the nurse (LVN A) was suspended for the incident. She said all nurses were responsible for securing their medication carts. She said she was responsible for monitoring that staff were following medication safety. She said the risk was that anyone could access get into the medication cart. Review of facility policy titled Medication Storage, revised 01/2026, reflected: Medication carts must be locked and always secured unless under direct and continuous supervision of authorized personnel during medication administration. These standards are required to ensure resident safety and regulatory compliance. 2. Key Security: keys must always remain on the authorized staff member person. Keys must not be left in the cart locked, placed on cart, left on surfaces, given to unlicensed personnel or left unattended.

Based on observation, interview and record review the facility failed to ensure medications were secured and inaccessible to unauthorized staff and residents for one medication cart on the second floor reviewed for medication storage.The facility failed to ensure the 2nd floor medication cart was locked when unattended. This failure could place residents at risk for drug diversion, drug overdose, and accidental administration of medications to the wrong residents. Findings included:During an observation and interview, on 01/13/2026 at 2:30 p.m., the second-floor nurse's station medication cart was unlocked. Observation of the unattended cart revealed the surveyor opened the top drawer and it contained biological and medications for residents. The MDS Coordinator walked up, said shit, closed the drawer, locked the cart, and walked behind the nurse's station. When asked who was responsible for the medication cart, LVN A denied the cart was observed unlocked. When informed the cart was observed unlocked and unattended and the MDS coordinator locked the cart, LVN A provided an interview. During an observation on 01/03/2026 at 2:29 p.m., revealed an in-house security camera located above the 2nd floor nurse's station and was reviewed at: 2:29:04 medication cart was observed unlocked and the top drawer was then opened by surveyor.2:29:07 MDS Coordinator approached, closed the drawer, and locked the cart. 2:29:13 MDS Coordinator walked behind the nurse's station.2:29:40 MDS Coordinator approached LVN A. 2:30:05 LVN A approached the medication cart, pushed on the lock, and stated it is locked.Durning an interview on 01/13/2026 at 2:35 p.m., LVN A revealed the risk of not locking the medication cart was a resident could open it. LVN A continued to deny the medication cart was observed unlocked. During an interview on 01/13/2026 at 3:10 p.m., the MDS Coordinator revealed she locked the medication cart because it was unlocked. She revealed the medication cart was unlocked, unattended, and able to be opened by someone other than the nurse responsible for the cart. She stated that a medication cart should be locked when the person responsible was not standing in front of the cart. She stated the risk could be a danger to residents and others and in no situation should a medication cart be left unlocked and unattended. During an interview on 01/13/2026 at 3:35 p.m., the Administrator revealed the expectation was medication carts were to be locked when not in use. The risk to the residents was they could get medications they were not supposed to have. During an interview on 01/13/2026 at 3:56 p.m., the DON revealed the mediation cart should never be unlocked without the nurse standing in front of it giving care to a resident. The expectation was as state regulation stated once you turn from the cart, it should be locked. The risk to the residents was the patient could access things [medications] in the cart. During a record review of policy titled Storage of Medications revision date 08-2020 revealed. Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. 2. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications are permitted to access medications, mediation room, carts and medication supplies are locked when they are not attended by persons with authorized access.

Based on interview and record review the facility failed to ensure that each resident received adequate supervision and assistive devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for supervision. The facility failed to provide adequate supervision for Resident #1 during a routine incontinent change which involved CNA A and CNA B which led to Resident #1 hitting their head on the bedside table. This failure could place residents at risk of injury. Findings include: Record review of Resident #1's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #1's Care Plan dated 6/19/2025 reflected Resident #1 had diagnoses which included Dementia (Decline in cognitive abilities such as memory, thinking, problem solving, judgment), Hypertension (High blood pressure), Chronic Kidney Disease (Kidneys lose the ability to filter waste), Osteo Arthritis (Joint disease that causes pain in the joints), Neuropathy (Damaged nerves), Constipation (Difficulty passing stool), Depression (Mental health disorder that significantly impacts mood, thought, behavior), Anxiety Disorder (Mental health disorder of excessive worry, fear, or nervousness), Alzheimer's (Neurodegenerative disorder that affects memory, thinking, behavior), Hyperparathyroidism (Parathyroid gland produce too much hormone), Muscle Weakness (Decrease in muscle strength and function), Cognitive Communication Deficit (Difficulty communicating because of memory, attention, function) and Tinea Unguium (Fungal infection of the nails). Resident #1 required 2 person assist. Resident #1 had Activities of Daily Living self care performance deficit related to Alzheimer's, confusion, and dementia. Interventions were listed as bed mobility, roll left to right-partial/moderate assist, sit to [NAME]-substantial/maximum assist, [NAME] to sit-substantial/maximum assist, Sit to stand-substantial/maximum assist. Personal Hygiene was documented as substantial/maximum assist. Bowel and bladder incontinent related to Alzheimer's and Dementia. 10/17/2025 documented Resident #1 had Right eyebrow laceration. 10/17/2025 documented to maintain proper alignment while turning and repositioning. Record review of CNA B's, undated, employee witness statement, reflected she was performing care on Resident #1 with CNA A. Resident #1 hit her head on the bedside table as she was being turned over. Record review of Resident #1's MDS record dated 10/4/2025 revealed Resident #1 had a bims of 00 (severe cognitive impairment). Resident #1 had a score of 01 (Dependent) for Toileting Hygiene and Roll left and right. Record review of CNA A's employee witness statement, dated 10/14/2025, reflected she was performing perineal care (cleaning or washing of the genitals) on Resident #1 with CNA B. Resident #1 began to fall out of the bed while they were in the middle of turning her over. They were able to prevent the fall by keeping her in a secure position on the bed but were unable to prevent her from hitting her head on the bedside table. The injury caused bleeding. Record review of Resident #1's weekly skin check, dated 10/14/2025, reflected Resident #1 had injuries to the following: Bruise to the right eye, and Laceration to the right eyebrow. Record review of the incident report, completed on 10/14/2025, by LVN C, reflected Resident #1 was being assisted by CNA A and CNA B when the accident occurred. During her assessment she observed a straight line injury on top of the right eyebrow and a swollen black eye. She cleansed with normal saline, pat dry and applied dressing. She administered pain medication, Tylenol 325 mg 2 tablets. Vitals were taken with normal ranges. Blood Pressure 120/80, Temperature 97.3, Pulse 80, Oxygen 97% on room air. She repositioned Resident #1. Notifications were made to the responsible party, Medical Director, and Director of Nursing. She documented Resident #1 as being alert and oriented. Record review of Resident #1's X-Ray results, dated 10/15/2025, reflected Resident #1 had an X-Ray to the facial bones which showed no serious injury. The reason the X-Ray was performed was because of localized swelling, mass, and lump. The radiology results reflected Resident #1 did not have fracture. The osseous structure was intact. The sinus appeared clear. Soft tissues appeared unremarkable. Record review of Neuro Evaluation Check, completed on 10/15/2025, reflected Resident #1 had normal vitals and was alert and oriented. Record review of Resident #1's weekly skin check, dated 10/16/2025, reflected Resident #1 had injuries to the following: Right eye discoloration from the incident on 10/14/2025, Right eyebrow laceration from the incident on 10/14/2025. Observation of Resident #1 on 10/23/2025 at 11:00 AM revealed Resident #1's had a large discolored yellow bruise about 3 inches by 4 inches on the upper right side of her face. Interview was attempted but unsuccessful due to Resident #1's cognitive function. Interview on 10/23/2025 at 10:10 AM with Director of Nursing E, revealed Resident #1 received a black eye as result of her injury on 10/14/2025. She stated Resident #1 was assessed by both a skin assessment and a neuro assessment. She stated an incident report was completed and Resident #1 had normal vital signs. She stated the physician ordered imaging which showed the resident did not have any fracture to her facial bones. She stated there was bruising because the resident hit her head on a bedside table during incontinent care. She stated the Resident had a gash above her right eye. She stated Resident #1 was monitored and assessed at every single shift after the incident. At first it was just a gash. Then it became a black eye. Then they did the assessment and X-ray. The physician came in and did a head to toe assessment himself with the nurse practitioner. She stated Resident #1 hit her eye on the bedside table because the table was too close to the bed. She stated she received statements from staff and performed inservices accordingly. There were 2 staff in the room, CNA A and CNA B. The staff made notifications at the time of injury to the Physician, ADON, DON, and POA. Then inservices were performed on incontinent care, and environment. The resident was not verbal. She stated the staff should not have assumed the table was not that close. She stated they should have moved the table further away but the resident moved in the middle of them turning her over. She stated that the facility has inserviced care staff on Safety Environment Training, Incontinent Care Assistance, Abuse/Neglect, Incidents and Accidents. Interview on 10/23/2025 at 11:15 AM with ADON F, revealed the facility performed inservices for incontinent care, positioning, abuse/neglect, and decluttered rooms (physical environment). The X-ray was done within 24 hours of the incident occurring. The bruise on the resident's face showed up when the incident occurred. The bruising was a result of a staff member turning Resident #1 over during incontinent changing. The face had no fracture. The soft tissue was unremarkable. Resident #1 is 2 person assist and there were 2 staff members in the room at the time assisting with Resident #1's incontinent care. They injury occurred because Resident #1 hit her head on the bedside table when they rolled her over. During the turn Resident #1 made a sudden movement. Interview on 10/23/2025 at 11:30 AM with Physician H, revealed the facility did not have to send Resident #1 to the hospital as long as there was not a change in her neuro status and if the incident was witnessed and not suspicious. He stated the bruise looks like a laceration on the eye-lid. Sometimes blood trickled down and could make it look worse than it actually was. An injury could look worse later. Interview on 10/23/2025 at 12:30 PM with Nurse Practitioner G revealed he was the one who ordered the X-rays after the facility notified him of the incident. He stated he did a complete check on Resident #1 after it was reported to him. He stated her injury was the result of hitting the bedside table. He stated the injury looked worse than it was because of the way a bruise could develop over time. He stated she shouldn't have any lasting effects as a result of this injury. He stated, it's basically just a bad bruise around her eyes and a little bit of swelling. It shouldn't have any long-lasting effect. He stated there was harm, but it was not a significant injury. The X-ray showed no acute fracture . Once the incident happened the facility did everything they were supposed to do after the incident had already occurred. He stated he knew there were inservices that were completed so the staff didn't have this incident again moving forward. Interview on 10/23/2025 at 2:00 PM with CNA B, revealed she was turning Resident #1 with CNA A assisting her when mid turn Resident #1 began to move unpredictably. She stated that was what caused the accident. She stated Resident #1 almost fell off of the bed, but since there were two of them in the room on each side of the bed they were able to make sure she didn't fall. She stated Resident #1 hit the bedside table hard with the side of her face. She stated she immediately reported it to the nurse. She stated she was sorry it happened. She stated the night table was very close to her bed and when Resident #1 leaned over in that direction she hit her head on the bedside table. She stated Resident #1 began to bleed a little bit above her eye. She stated that the bedside table was beside the bed but it was not touching the bed or hovering over the bed. Resident #1 leaned over the side of the bed and hit the table. She stated that the facility has inserviced care staff on Safety Environment Training, Incontinent Care Assistance, Abuse/Neglect, Incidents and Accidents. Interview on 10/23/2025 at 3:00 PM with LVN C, revealed she assessed Resident #1 after the CNA notified her of the incident. She stated CNA A and CNA B tried to change the resident and during the rotation of the turn, Resident #1 pushed against them with her upper half. The resident almost fell off of the bed because she flung her upper torso against the direction the staff were rotating her. She stated CNA A and CNA B did not drop the resident nor did Resident #1 fall. She stated CNA B realized there was blood on Resident #1's forehead. She stated she took vitals and performed a neuro check. She stated everything was okay. She stated she contacted the responsible party, director of nursing, and physician. She stated that the facility has inserviced care staff on Safety Environment Training, Incontinent Care Assistance, Abuse/Neglect, Incidents and Accidents. Interview on 10/23/2025 at 3:15 PM with Administrator D revealed she had already investigated the case and assessed the environment. She stated CNA A and CNA B both told her what had happened. She stated she was told Resident #1 began to move while they were turning her. She stated she already educated the staff and performed inservices. Resident #1 was 2 person assisted and the staff successfully followed the facility policies. The facility investigation determined that it was an accident. Record review of Inservice Training Report completed on 10/15/2025 reflected 23 care staff received Safety Environment Training on 10/15/2025. Record review of Inservice Training Report, completed on 10/16/2025, reflected 18 care staff received Incidents and Accidents Training on 10/16/2025. Record review of Inservice Training Report, completed on 10/17/2025, reflected 25 care staff received Incontinent Care Assistance Training on 10/17/2025. Record review of Inservice Training Report, completed on 10/17/2025, reflected 23 care staff received Abuse and Neglect Training on 10/17/2025. Record Review of the facility Abuse/Neglect policy reflected the facility successfully followed their policies for Abuse/Neglect. Record Review of the facility Perineal Care policy stated the staff are to turn residents to their side and reposition resident. Record Review of the facility Care policy stated all residents receive the necessary care and services based on an individualized comprehensive assessment process. Residents are provided with the necessary care and services to maintain the highest practicable physical, mental, and social well-being level of an environment that enhances quality of life in the scope of a long-term care facility. Care and services are provided in a manner that consistently enhances self-esteem and self-wroth. The police stated the facility provides care and services to residents with reasonable accommodations of each resident's individual needs and preferences. Record Review of the facility Quality of Life policy stated the facility staff provides care and services that ensure that resident's abilities in activities of daily living, including: hygiene, mobility, elimination, dining, communication, speech, language and other methods of communication do not diminish while in the care of the facility, except when unavoidable as evidence by clinical condition.

Based on interviews and record reviews the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administer of all drugs and biologicals to meet the needs of 1 (Resident#1) out of 3 residents reviewed. The facility failed to ensure Resident#1 medication were administered all drugs and biological via G-Tube administration and/or orally. This failure could place residents at risk of not receiving medications as prescribed. Findings include: Record review of Resident#1 face sheet reflected, she was a [AGE] year-old female originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident#1 was diagnosed with but not limited to, Type 1 diabetes mellitus with ketoacidosis with coma (body lacks significant insulin), altered mental status, urinary tract infection, site not specified and cognitive communication deficit. Resident#1 MDS dated [DATE] reflected, Resident #1 had a BIMS of 03 which indicated severed impaired cognition. Record review of Resident#1 October TAR and MAR reflected: *Phenytoin oral suspension 125mg/ml Give 5ml via G-Tube three times a day related to unspecified convulsions, started 09/25/25 and DC 10/07/25. *Polyethylene Glycol powder Give 17mg via G-Tube two times a day for constipation, started 09/25/25 and DC 10/07/25. *Peg 3350 17gm/scoop powder-Give 17 gram via G-Tube every 24 hours as needed for constipation, started 09/25/25 and DC 10/07/25. Record review of Resident#1 November TAR and MAR reflected: *Phenytoin oral suspension 125mg/ml/ml Give 5ml via G-Tube three times a day related to unspecified convulsions, started 10/09/25 and DC 11/07/25. *Resident#1 was hospitalized [DATE] and 10/07/25. *Resident#1 refused phenytoin oral suspension 125mg/ml on 10/19/25 at 1:00 pm. *Peg 3350 17gm/scoop powder-Give 17 gram via G-Tube every 24 hours as needed for constipation. started 10/09/25 and DC 11/07/25. *Phenytoin Oral Suspension 125 MG/5ML- Give 5 ml by mouth three times a dayrelated to unspecified convulsion, started 11/07/25 and DC 11/13/25. *Lactulose Oral Solution 10 GM/15ML -Give 30 ml by mouth every 12 hours asneeded for Constipation, started 11.07.25 and DC 11.13.25 *PEG 3350 17 GM/scoop Powder - Give 17 gram by mouth every 24 hoursas needed for Constipation, started 11/07/25 and DC 11/13/25 Record review of Resident#1 hospital records dated 11/12/25 reflected: Resident#1 was admitted to the hospital on [DATE] at 12:53 pm. Resident #1 chief complaint was vomiting. Resident#1 visit diagnosis was Diabetic ketoacidosis without coma associated with type 1 diabetes mellitus (Without enough insulin, the body begins to break down fat as fuel. This causes a buildup of acids in the blood (primary). Note dated 11/10/25. *Brief neurology notes [Resident#1] with seizure disorder on Phenytoin 125mg TID previously but level < 1.8 as she has not been receiving it at the facility [Resident#1] has been given unknown time.[Resident#1] would re-start as below: Start 100mg TID for 5 days, then check through level subtherapeutic (being a dose that is below what is used for treating disease), then increase to the 125 TID as [Resident#1] was on previously. *Internal medicine and psychiatry notes reflected, stool ball seen on image, large BM in the am after Bisacodyl suppository.CTAP showing distended rectum due to stool burden with stercoral colitis (inflammation of the colon due to fecal impaction,) *Hospital laboratory results dated [DATE] reflected Phenytoin value level of < 1.8 and a reference range of 10.0-20.0., flagged for low level. During an interview and observation on 11/12/25 at 4:50 pm revealed Resident#1 did not recall why she was in the hospital. Resident#1 stated she received her insulin shots at the facility, and she took her medications. Surveyor observed HPCT feeding Resident#1 through G-tube. Surveyor observed HN take Resident#1 BS and Resident#1 BS was 170. During an interview on 11/12/25 at 5:15pm the Hospital physician stated Resident#1 Phenytoin levels were extremely low and showed that she was not getting the medication. The Hospital physician stated Resident#1 had pending lab results for infection and she would provide that information. During an interview on 11/13/25 at 9:58 am CNA C stated Resident#1 BMs were documented on the POC daily and every shift. CNA A stated Resident#1 was in and out the hospital and did not recall the last time she had a BM. CNA C stated if a resident did not have a BM the information would be shared with the ADON. During an interview on 11/13/25 at 10:10 am LVN D stated Resident#1 medication was given through the G-Tube. LVN D stated Resident#1 did not like the G-Tube and would sometimes refuse medication. During an interview over the phone on 11/13/25 at 10:24 am LVN E stated he gave Resident#1 all her medications through the G-Tube. During an interview over the phone on 11/13/25 at 12:40 pm Resident#1's PCP stated Resident#1 would refuse medications and this was a continuous struggle with Resident#1. The PCP stated Resident#1 Phenytoin levels were low and he was trying to see why they were low. The PCP stated if the Resident were not getting medication she could have seizure. Record review of Hospital Physician email to surveyor reflected on 11/13/25 at 5:30 pm: [Resident#1] imaging showed a large fecal stool ball which would only arise in imaging if she were not getting MiraLAX and not having regular bowel movements. During an interview and record review on 11/14/25 at 8:50 am Resident#1's PCP stated Resident#1 Phenytoin levels being in the 1's could possibly mean Resident#1 was not getting the medication as prescribed. The PCP stated the presence of stool cannot be avoided because Resident#1 does not move around a lot. The PCP stated that he did not have Resident#1 chart in front of him and could not say if Resident#1 medications could interact with one another. During an interview and record review on 11/14/25 at 9:00am, Surveyor and the ADON went through the MAR and TAR together. The ADON stated Resident#1 received all her medications in October and November expect for the days Resident#1 was at the hospital. The ADON stated sometimes Resident#1 refused medications and was in and out of the hospital a lot. Record review of Resident#1 MAR/TAR revealed Resident#1 refused phenytoin oral suspension 125mg/ml on 10/19/25 at 1:00 pm and was hospitalized [DATE] and 10/07/25 for the month of October. Record review of November MAR revealed Peg 3350 17gm/scoop powder as needed for constipation showed not administered. Record review of the Phenytoin oral suspension 125mg/ml was not administered 11/10/25 and 11/11/25 because of Resident#1 hospitalization. The ADON stated medications were D/C when Resident#1 went to the hospital and restarted her medication when she returned to the facility with PCP approval. During an interview over the phone on 11/14/25 at 9:45am CMA A stated Resident#1 medications had been transferred to G-Tube and she did not give her medications from the MAR in a long time. CMA A stated prior to the change she administered Resident#1 medication and sometimes she would refuse. CMA A stated when resident#1 refused medication, CMA A would attempt to administer medication again, let the charge nurse know and document on the MAR. During an interview over the phone on 11/14/25 at 9:50 am CMA B stated Resident#1 used to take medications by mouth, sometimes Resident#1 would refuse medications. CMA B stated when resident#1 refused medication, CMA B would attempt to administer medication again, let the charge nurse know and document on the MAR. During an interview on 11/14/25 from 9:53 am to 10:10 am, CNA F, CNA G and CNA H stated Residents BMs are documented every shift and if resident does not have a BM the ADON was notified. Residents who received peri care and catheter bags are drained daily on every shift and documented in the POC. Attempted to call Medical Director on 11/14/25 at 10:30 am, surveyor not able to leave voicemail. During an interview and record review on 11/14/25 at 11:30 am the DON stated Resident#1 received all her POC for the month of October and November. Record review of Resident#1 POC for October and November revealed Resident#1 BM was monitored on three shifts. Record review revealed Resident#1 had a BM every day expect on 10/6/25, 10/07/2 and 11/11/25, which were days that Resident#1 was hospitalized . Record review of email from Hospital Physician to surveyor revealed on 11/14/25 at 4:11pm, Phenytoin levels should be greater than 10 on lab work for a patient who is getting the medication. Her level was less than 1.6 which means she has not been receiving the medication. The concern of not receiving this medication is that it puts her at a greater seizure risk given her prior history of seizures. And if she were to have seizures, it would cause electrolyte abnormalities and then could cause neurological dysfunction or cardiac issues. Record review Hospital Physician email to surveyor revealed on 11/14/25 at 7:22pm, There is no way to say a specific time for sure however it's takes at least several days (3-5) of constipation to be able to show up on a CT scan. Record review of facility policy Medication Administration, undated reflected, .iv. The licensed nurse must know the following information about any medication they are administering .D. The drug's indication for use and desired outcome, E. The drug's usual dosage .documentation A. The time the dose of the drug or treatment administered to the resident will be recorded in the resident's individual medication record by the person who administers the drug or treatment.

Based on interviews and record reviews, the facility failed to provide and document sufficient preparation and orientation of resident to ensure safe and orderly transfer or discharge from the facility and ensure the orientation was provided in a form and manner that the resident could understand for one (Resident #1) of three residents reviewed for discharge.1. On 09/26/2025, the facility failed to ensure Resident #1's post-discharge destination and continued care provider could meet Resident #1's needs. Resident #1 required medication management and supervision with activities of daily livings, which the shelter did not provide. 2. On 09/26/2025 the facility failed to ensure Resident #1 was admitted to the shelter, as Resident #1 was left standing in line. On 10/03/2025 Resident #1 was found by a high school security guard approximately 14 miles away from the shelter where he had been dropped off to.This deficient practice could place residents at risks of accidents, and could result in serious harm, injury, impairment, and death.An Immediate Jeopardy was identified on 10/29/2025 at 2:26 p.m., while the IJ was removed on 10/30/2025 at 3:38 p.m., the facility remained out of compliance at a at a severity level of potential for more than minimal harm and a scope of isolated due to the facility still monitoring the effectiveness of their Plan of Removal. Record Review of Resident #1's face sheet, dated 10/29/2025, revealed a [AGE] year-old man originally admitted on [DATE]. Resident #1 had diagnoses which included anoxic brain damage (brain does not receive enough oxygen), major depressive disorder serious mental health condition that significantly impacts a person's mood, thoughts, and behavior), anxiety disorder (excessive fear or anxiety), seizures (sudden, uncontrolled electrical discharges in the brain), lack of coordination, muscle weakness,, difficulty walking, sever protein-calorie malnutrition (does not consume enough protein and calories to meet their body's needs), chronic viral hepatitis C long-term infection of the liver caused by the hepatitis C virus), hyperlipidemia (high levels of lipids (fats) in the blood, including cholesterol and triglycerides), chronic pain syndrome, essential hypertension (high blood pressure without an identifiable underlying cause), and gastro-esophageal reflux disease without esophagitis ( condition where stomach contents flow back into the esophagus (reflux) but do not cause inflammation or damage to the esophageal lining ). Record review of Resident #1's discharge MDS assessment, dated 09/26/2025, revealed Resident #1 had a BIMS score of 7, which indicated severe impairment. Resident #1's functional abilities required supervision for all self-care needs. Record review of Resident #1's Care Plan, dated 06/19/2025, revealed Resident #1 had an ADL self-care performance deficit r/t impaired balance, required antidepressant medication for diagnosis of major depressive disorder, had potential for complications diagnosis of hypertension, was a risk for falls, had impaired cognitive function/dementia or impaired thought processes r/t anoxic brain injury, and was incontinent at times due to confusion, inability to communicate needs.Record review on 10/28/2025 of Resident #1's social services progress note revealed Resident #1 was discharged on 9/26/2025 to shelter. Record review on 10/28/2025 through 10/30/2025 of Resident #1's electronic health records from revealed no documentation of referral for alternate placement for Resident #1. Record review on 10/28/2025 through 10/30/2025 Resident #1's electronic health records revealed no documentation of verbal or written notice of intent to leave the facility. Record review on 10/28/2025 through 10/30/2025 Resident #1's electronic health records revealed no documentation that Resident #1 representative refused to pick Resident #1 up from the facility. [SP3] During an interview on 10/27/2025 at 3:28 p.m., the complainant revealed that she had received a call from Resident #1's family member who stated the nursing facility allegedly dropped Resident #1 off at a shelter (date unknown) and he was found at a school 14 miles away from the alleged shelter, by security. Resident #1 was currently at his family members home and will stay there until they find him placement.During an interview on 10/27/2025 at 3:33 p.m., Resident #1's assigned case manager revealed that she was assigned to Resident #1 case on 10/06/2025. She stated that Resident #1's family member was contacted by law enforcement on 10/03/2025 and stated that Resident #1 was located at or near a school. Resident #1's family went and picked him up on 10/03/2025. The case manager stated she had spoken with Resident #1's family and was told that Resident #1 was allegedly dropped off at a shelter (date unknown) and was found on 10/03/25 by law enforcement and someone Resident #1 was able to provide his brothers phone number, Resident #1 family was contacted, and the family member went to get Resident #1. The case manager stated that the family member had contacted Resident #1 and APS was involved also. She stated that APS had assisted with clinical records on 10/25/2025 after APS went to the nursing facility to sign the release form, but the records were incomplete. The case worker stated that she needed more recent clinical documentation to place Resident #1, what she had received stopped in April 2025. During an interview on 10/27/2025 at 3:55 p.m., Resident #1's family member revealed that Resident #1 was found by a school security on 10/03/2025. The family member stated that Resident #1 stated he had walked to the school, and that he would sleep on the street. The family member stated when Resident #1 was picked up he looked like he had slept on the streets for a few days. The Family member said they called APS. The Family member stated they would take care of Resident #1 until placement was found for him as he needed assistance because he cannot cook, required help with bathing, and putting clothes on and off. During an interview on 10/27/2025 at 4:04 p.m., Resident #1 revealed that the facility had provided him with a notice of discharge because he was caught smoking in the facility. Resident #1 stated that he did not ask to go to a shelter. Resident #1 stated the nursing facility dropped him off at the shelter. He was tired of waiting for a bed at the shelter, so he started walking. Resident #1 said that he walked to the school but wasn't aware how long it took him but thought it was a couple of days. During an interview on 10/28/2025 at 9:50 a.m., with the APS worker stated she had received a report from Resident #1's Parole Officer on 10/04/2025 that Resident #1 had been picked up by his family member and needed placement. The APS worker stated that she had talked to Resident #1's family member and was told that the nursing facility dropped Resident #1 off to the shelter and he got tired of waiting on a bed and started walking and was found on 10/03/2025 by school security. The APS worker stated she worked with the case manager to find placement and she had received clinicals on or about 10/24/2025 and forwarded to the case manager but required more recent clinicals as the clinicals that were sent ended in April 2025, but to place Resident #1 they required most up to date records. During an interview on 10/28/2025 at 2:39 p.m., with the facility SW revealed Resident #1 was discharged on 09/26/2025 after Resident #1 had been provided a 30-day discharge notice on 08/26/2026 for failure to follow facility smoking policy to a shelter. The SW stated that the shelter had a nurse on staff, provided day and night shelter, so she thought it was safe for Resident #1 to discharge there. The SW stated the ADM told her it was okay to discharge Resident #1 to the shelter. The SW stated she gave Resident #1's paperwork to the shelter security guard after she confirmed she did not have to stay with Resident #1. The security guard told her since it was his first time there should be no issues with him admitting to the shelter and she did not have to stay. The SW stated she did not do any referrals for alternate placement for the resident. The SW revealed that there was no documentation that the resident representative refused to pick him up and there was no documentation that resident intent was to leave the facility and go to a shelter. During an interview on 10/28/2025 at 4:42 p.m., with the facility Nurse Practitioner who revealed he was informed by the facility that Resident #1 had a bed at the shelter and there was nurse staff that would assist him with his medication management. The nurse practitioner stated that if the shelter could not provide the medication management that it would not be a safe discharge. During an interview on 10/29/2025 at 9:10 a.m., with the shelter intake specialist revealed that the shelter was open from 7am to 5pm daily and night shelter was available depending on availability. The shelter intake specialist stated individuals who have proof of income, birth certificate and social security cards were first priority for beds, then woman and finally men, but currently there were no beds available and that there were women who have been waiting for approximately 3 months for a bed. The shelter intake specialist stated that there were no 24-hour medical staff. The shelter intake specialist stated that there were care managers to assist individuals, but it was not a requirement for them to do so and would depend on their case load if they would be able to assist. During an interview on 10/29/2025 at 9:57 a.m., the ADM revealed that she had provided Resident #1 with a 30-day notice for a second offense of violation of facility smoking policy. The ADM stated that Resident #1 was caught smoking illegal substance on two occasions. The ADM stated on the first offense Resident #1 was placed on a behavior contract that he acknowledged and signed on 8/16/25. The ADM stated the 30-day notice was provided to Resident #1 as well as contacted Resident #1 family member to inform them that the notice was provided and what caused the 30-day notification. The ADM stated the family member understood and agreed to take Resident #1 home. The ADM stated that the IDT met and agreed that Resident #1 was safe to discharge home with family members. The ADM stated the day Resident #1 family member was supposed to pick Resident #1 up they did not show up and did not answer the phone. The ADM stated Resident #1 still wanted to leave the facility and the SW had found the shelter that provided day/night services had a nurse on staff so felt that was a safe place for Resident #1. The ADM stated she was not aware if any alternate nursing home placement referrals were made, did not believe there was any documentation that the representative refused to pick the resident up, and there was no documentation that the resident expressed his intent to leave the facility and go to a shelter. The ADM stated that she felt the shelter was a safe place to discharge Resident #1 because their website stated they offered/night shelter and that there were nurses there to provide medication management and to assist with ADLs for him. The ADM stated that she did not call the shelter to verify bed availability or if there was 24-hour nurse care at the shelter. The ADM stated that it was her responsibility to ensure that residents had a safe discharge location. During an interview on 10/29/2025 at 11:44 a.m., the Ombudsman revealed that he was notified on 8/27/2025 that Resident #1 had received a 30- day discharge but was not aware that the facility discharged Resident #1 to a shelter until 10/06/20025 when he spoke to a family member. The Ombudsman stated that they advocate homeless shelters because they cannot provide the level of care residents need. The Ombudsman stated he was not aware if the facility made any alternate nursing home referrals for Resident #1 or if Resident #1 requested to go to the shelter. During interview on 10/29/2025 at 12:37 p.m., with the SW, she revealed that the ADM made the final determination to send Resident #1 to the shelter. Record review of the facility Discharge or Transfer policy undated stated Purpose To ensure that resident are transferred and discharges from the facility in compliance with state and federal laws and to provide complete, safe, and appropriate discharge planning and necessary information to the continuing care provider. Procedures under Documentation. A. When the facility anticipates a resident's discharge to a lower level of care (e.g., private resident, group home or board or care or assisted living) tor to another nursing care facility, the IDT with assistance of the resident and his/her personal representative, will develop a discharge summary and posit discharge plan to assist the resident to adjust to his or her new living environment. A. i. Appropriate IDT members will educate the resident or his/her personal representative regarding the discharge plan issues and will assist the resident with discharge plansG. If the resident is transferred because needs cannot be met, the facility must document attempts to [NAME] the residents needs and the services available at the receiving facility to meet the needsXV. Documentation and education provided to a resident or to his/her personal representative in preparation for transfer/discharge will be provided in a language he/she understands. This was determined to be an Immediate Jeopardy (IJ) on 10/29/25 at 2:26 p.m. The ADM, RDO and RCN were notified. The ADM was provided with the IJ template on 10/29/25 at 2:2:26 p.m. The facility's POR for Immediate Jeopardy was accepted on 10/30/25 at 3:38 p.m. and reflected the following: Date: 10/30/2025 PLAN OF REMOVAL FORIMMEDIATE JEOPARDYSummary of Details which lead to outcomes: Resident #1 had been discharged from the facility on 09/26/2025 and dropped off at a homeless shelter by the social worker but did not get checked in. On 10/29/2025 received an IJ Template notification that the Survey Agency had determined that this discharge was unsafe and constitutes immediate jeopardy. Identified areas for improvement include:- Lack of consistent IDT oversight on discharge decisions.- Inadequate documentation verifying safe placement and discharge readiness.- Facility did not verify that the resident was admitted safely to the discharged location.- Missed opportunities to seek other alternative placement prior to discharge.The notification of the alleged immediate jeopardy states as follows:F627 Transfer and discharge.The facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly discharge from the facility.Identify residents who could be affected: All residents set to discharge from the facility have the potential to be affected.Actions Taken to Prevent Serious Adverse Outcome from Occurring or Recurring1. On 10/29/2025, Resident #1's Power of Attorney was contacted by the Regional Director of Operations and offered the option to have resident #1 readmit to the facility to which she agreed. On 10/29/2025, resident #1 was picked up from his family members home and re-admitted to the facility.2. On 10/29/2025, Resident #1 was assessed by the Medical Director and was determined to be at Medically stable with prior level of functioning.3. On 10/29/2025, Regional Social Service Director initiated and completed an audit of all resident discharges from August 1, 2025, to present to ensure safe resident discharges. All audited residents were confirmed to have been safely discharged from the facility. A review by DON of residents with smoking violations did not reveal any residents with smoking violation related discharges.4. Nursing facility Administrator employment was terminated effective 10/29/2025 and the Regional Director of Operations will provide oversite until a new Administrator is appointed.5. The facility social worker was educated by the regional Director of Social Services regarding Inadequate documentation verifying safe placement and discharge readiness. Training and post test was conducted on 10/29/2025.6. Once a new Administrator is hired, they will be educated by the Regional Director of operations on resident safe discharge before being allowed to work.7. IDT team members which includes: the Administrator, DON, social service director, MDS coordinator, Therapy Director, Activity Director, Dietary services and 2 ADON's were educated by regional Director of Operations, Regional Nurse Consultant and Regional Social Service Director on safe resident discharge process, the education was followed by a post test on 10/29/2025. All IDT members who were not present at the facility at the time of the education were educated and completed a post test over the phone. Education was initiated and completed on 10/29/2025.8. Charge nurses were educated by ADON's on safe resident discharge process; the education was followed by a post test. All nurses who were not present at the facility at the time of the education were educated ADON's and completed a post test over the phone. Education was initiated and completed on 10/29/2025.9. New staff will receive this training during onboarding and annually thereafter from the Administrator/DON or designee.10. No IDT team members or charge nurses will be allowed to work until they complete education on safe resident discharge. Training will be completed by the DON or designee. In-Services conducted: Initiated and completed 10/29/20251. Resident safe discharge process: All IDT team members and charge nurses. Training conducted by Regional Nurse Consultant, Regional Director of Operations and Regional Social service Director. Each IDT team member and charge nurse also completed post test.2. Discharge Safety Verification Checklist: All IDT team members. Training conducted by Regional Nurse Consultant, Regional Director of Operations and Regional Social service Director. Each IDT team member and charge nurse also completed post test.11. No IDT team members or charge nurses will be allowed to work until they complete this education. Training will be completed by the DON or designee.Implementation of changes:A new Discharge Safety Verification Checklist will be completed with on all resident discharges. Each IDT member will check and sign off on this verification checklist before any resident discharges from the facility.Checklist requires verification of:- Reason for discharge- Interdisciplinary Team (IDT) Involvement- Placement and safety verification- Notice and documentation- Resident Preparation- Final IDT review and Authorization.Each IDT team member or designee will document in PCC under progress notes to include information relevant to their disciplines on discharge planning. Form will be managed by the social worker in a binder stored behind the 1st floor nurses station and accessible to the IDT members. Completed discharge verification checklist form will be uploaded to PCC and verified by the Regional Director of Operations and Regional Nurse Consultant.Monitoring Effective 10/29/2025, Each resident discharge will be reviewed and a Discharge Safety Verification Checklist completed by the IDT team members daily (Monday through Friday) and by the weekend supervisor during the weekends. The discharge safety verification checklist will be emailed to the Regional Director of Operations, Regional Nurse Consultant and Regional Social Service Director for review and approval before any resident discharges.Monitoring and review for approval will continue with each scheduled discharge for two months and then periodically thereafter.Involvement of Medical Directorhe Medical Director met with the Interdisciplinary team on 10/29/2025 and conducted an Ad HOC QAPI regarding safe resident discharge process. The Medical Director was notified about the immediate Jeopardy on 10/29/2025, the Plan of removal was reviewed and accepted by the Medical Director on 10/29/2025.Who is responsible for implementation of process? The Regional Director of Operations (RDO) and Regional Nurse Worker (RNC) will be responsible for the implementation and monitoring of the new process. RDO and RNC will review scheduled discharges with social worker Daily x4 weeks, bi-weekly x4 weeks and monthly thereafter to monitor for process implementation. The New Process/system was started on 10/29/2025.Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued 10/29/2025. Monitoring of the plan of removal included:Administrator Termination effective on 10/29/2025, verified via nursing facility employee termination form.Observation of Resident #1 readmitted at the facility on 10/29/25 at 12:56pmRecord review of a one-on-one in-service titled Resident Safe Discharge, dated10/29/2025 reflected Social Worker was educated by Regional Area of DirectorRecord review of in-service titled Discharge planning process - Safe discharge, dated 10/29/25 reflected the DON and 2 ADONS were educated by the Regional Nurse Record review of in-service titled on Discharge Process - Safe Discharge Planning, dated 10/29/25 reflected the facility IDT staff members (Social Worker, Human Resources, Admissions, Director of Rehabilitation, 2 MDS coordinators, medical records, dietary Manager, staffing and central supply and 2 ADONs) were educated by Regional Nurse, Area Director and Regional Social Worker Record review of the IDT posttest on discharge process reflected they had 100% accuracy.Record review of in-service titled Discharge Instructions, Compliance, Regulations, dated 10/29/25, reflected 18 Licensed Nurses were educated by Regional NurseRecord review of 30-Day Discharges revealed no other residents were discharged to the homeless shelter. Record review of facility discharge audit dated 10/29/25, reflected no other residents were discharged to an unsafe location. Record review of the AD HOC QA meeting held on 10/29/25 reflected the meeting consisted of RDO, RCN, RSW, DON, MDS, Medical Director, and DORInterview with the DON, on 10/30/25 at 10:19 a.m., The DON stated that she was not aware that Resident #1 did not discharge home with his family member until his parole officer called a week later. The DON stated that she was a member of the IDT and was present for the meeting but did not recall a discussion for Resident #1 to go to a shelter. The DON stated that her role in the IDT was to ensure that the location for the residents was safe and that the location could provide the medical care requirements for each resident and she did not recall an IDT meeting to discuss Resident #1 going to a shelter. The DON thought Resident #1 had discharged his to his family member house planned. Interview with the RDO on 10/30/25 at 11:15 a.m., he stated he trained the SW on the discharge planning process and documentation. Additionally, the RDO stated that the RCN and RSW re-educated the IDT team on discharge process and safe discharges. This was verified via record review of social service in-service dated 10/29/25.An interview with the RCN on 10/30/25 at 11:30 a.m., she stated she had trained the DON, ADON A and ADON B on the discharge planning process and documentation. This was verified via record review of IDT training in-service dated 10/29/25. During an interview on 10/30/25 at 12:20 p.m., Resident #2's family member revealed that the discharge process at the facility went smooth, the SW has set up home health and only thing left to do was pick up Resident #2. This was verified via record review that the SW had placed order for home health.Interviews held on 10/30/25 from 1:11 p.m., to 5:45 p.m. which covered staff who work morning, day, night shifts, PRN staff and double weekend staff conducted with the DON, ADON A (Sunday through Thursday), ADON B (Tuesday through Saturday), LVN C (1st shift/weekdays), LVN D (weekdays), LVN E (PRN), LVN F (overnight/morning), LVN G (overnight/morning), LVN H (double weekends), LVN I (Overnight), LVN J (morning), LVN K (second shift), LVN L (second shift), MDS N, MDS O, and DOR indicated they all participated in in-services on Discharge Process - Safe Discharge, documentation and proficiency test prior to starting their shifts. All staff knew their responsibilities. All staff were knowledgeable, who were a part of the IDT. All staff were able to state that the facility's discharge process to ensure all residents' discharges were safe, all know what was required to be documented and who was responsible for each task and understood that the ADO and RCN would oversee the entire process to make sure it was complete.The ADM, RDO and RCN were notified that the IJ was removed on 10/29/2025 at 3:38 p.m. The facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of isolated due to the facility still monitoring the effectiveness of their Plan of Removal.

Based on interview and record review the facility failed to ensure that each resident received adequate supervision and assistive devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for supervision. The facility failed to provide adequate supervision for Resident #1 during a routine incontinent change which involved CNA A and CNA B which led to Resident #1 hitting their head on the bedside table. This failure could place residents at risk of injury. Findings include: Record review of Resident #1's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #1's Care Plan dated 6/19/2025 reflected Resident #1 had diagnoses which included Dementia (Decline in cognitive abilities such as memory, thinking, problem solving, judgment), Hypertension (High blood pressure), Chronic Kidney Disease (Kidneys lose the ability to filter waste), Osteo Arthritis (Joint disease that causes pain in the joints), Neuropathy (Damaged nerves), Constipation (Difficulty passing stool), Depression (Mental health disorder that significantly impacts mood, thought, behavior), Anxiety Disorder (Mental health disorder of excessive worry, fear, or nervousness), Alzheimer's (Neurodegenerative disorder that affects memory, thinking, behavior), Hyperparathyroidism (Parathyroid gland produce too much hormone), Muscle Weakness (Decrease in muscle strength and function), Cognitive Communication Deficit (Difficulty communicating because of memory, attention, function) and Tinea Unguium (Fungal infection of the nails). Resident #1 required 2 person assist. Resident #1 had Activities of Daily Living self care performance deficit related to Alzheimer's, confusion, and dementia. Interventions were listed as bed mobility, roll left to right-partial/moderate assist, sit to [NAME]-substantial/maximum assist, [NAME] to sit-substantial/maximum assist, Sit to stand-substantial/maximum assist. Personal Hygiene was documented as substantial/maximum assist. Bowel and bladder incontinent related to Alzheimer's and Dementia. 10/17/2025 documented Resident #1 had Right eyebrow laceration. 10/17/2025 documented to maintain proper alignment while turning and repositioning. Record review of CNA B's, undated, employee witness statement, reflected she was performing care on Resident #1 with CNA A. Resident #1 hit her head on the bedside table as she was being turned over. Record review of Resident #1's MDS record dated 10/4/2025 revealed Resident #1 had a bims of 00 (severe cognitive impairment). Resident #1 had a score of 01 (Dependent) for Toileting Hygiene and Roll left and right. Record review of CNA A's employee witness statement, dated 10/14/2025, reflected she was performing perineal care (cleaning or washing of the genitals) on Resident #1 with CNA B. Resident #1 began to fall out of the bed while they were in the middle of turning her over. They were able to prevent the fall by keeping her in a secure position on the bed but were unable to prevent her from hitting her head on the bedside table. The injury caused bleeding. Record review of Resident #1's weekly skin check, dated 10/14/2025, reflected Resident #1 had injuries to the following: Bruise to the right eye, and Laceration to the right eyebrow. Record review of the incident report, completed on 10/14/2025, by LVN C, reflected Resident #1 was being assisted by CNA A and CNA B when the accident occurred. During her assessment she observed a straight line injury on top of the right eyebrow and a swollen black eye. She cleansed with normal saline, pat dry and applied dressing. She administered pain medication, Tylenol 325 mg 2 tablets. Vitals were taken with normal ranges. Blood Pressure 120/80, Temperature 97.3, Pulse 80, Oxygen 97% on room air. She repositioned Resident #1. Notifications were made to the responsible party, Medical Director, and Director of Nursing. She documented Resident #1 as being alert and oriented. Record review of Resident #1's X-Ray results, dated 10/15/2025, reflected Resident #1 had an X-Ray to the facial bones which showed no serious injury. The reason the X-Ray was performed was because of localized swelling, mass, and lump. The radiology results reflected Resident #1 did not have fracture. The osseous structure was intact. The sinus appeared clear. Soft tissues appeared unremarkable. Record review of Neuro Evaluation Check, completed on 10/15/2025, reflected Resident #1 had normal vitals and was alert and oriented. Record review of Resident #1's weekly skin check, dated 10/16/2025, reflected Resident #1 had injuries to the following: Right eye discoloration from the incident on 10/14/2025, Right eyebrow laceration from the incident on 10/14/2025. Observation of Resident #1 on 10/23/2025 at 11:00 AM revealed Resident #1's had a large discolored yellow bruise about 3 inches by 4 inches on the upper right side of her face. Interview was attempted but unsuccessful due to Resident #1's cognitive function. Interview on 10/23/2025 at 10:10 AM with Director of Nursing E, revealed Resident #1 received a black eye as result of her injury on 10/14/2025. She stated Resident #1 was assessed by both a skin assessment and a neuro assessment. She stated an incident report was completed and Resident #1 had normal vital signs. She stated the physician ordered imaging which showed the resident did not have any fracture to her facial bones. She stated there was bruising because the resident hit her head on a bedside table during incontinent care. She stated the Resident had a gash above her right eye. She stated Resident #1 was monitored and assessed at every single shift after the incident. At first it was just a gash. Then it became a black eye. Then they did the assessment and X-ray. The physician came in and did a head to toe assessment himself with the nurse practitioner. She stated Resident #1 hit her eye on the bedside table because the table was too close to the bed. She stated she received statements from staff and performed inservices accordingly. There were 2 staff in the room, CNA A and CNA B. The staff made notifications at the time of injury to the Physician, ADON, DON, and POA. Then inservices were performed on incontinent care, and environment. The resident was not verbal. She stated the staff should not have assumed the table was not that close. She stated they should have moved the table further away but the resident moved in the middle of them turning her over. She stated that the facility has inserviced care staff on Safety Environment Training, Incontinent Care Assistance, Abuse/Neglect, Incidents and Accidents. Interview on 10/23/2025 at 11:15 AM with ADON F, revealed the facility performed inservices for incontinent care, positioning, abuse/neglect, and decluttered rooms (physical environment). The X-ray was done within 24 hours of the incident occurring. The bruise on the resident's face showed up when the incident occurred. The bruising was a result of a staff member turning Resident #1 over during incontinent changing. The face had no fracture. The soft tissue was unremarkable. Resident #1 is 2 person assist and there were 2 staff members in the room at the time assisting with Resident #1's incontinent care. They injury occurred because Resident #1 hit her head on the bedside table when they rolled her over. During the turn Resident #1 made a sudden movement. Interview on 10/23/2025 at 11:30 AM with Physician H, revealed the facility did not have to send Resident #1 to the hospital as long as there was not a change in her neuro status and if the incident was witnessed and not suspicious. He stated the bruise looks like a laceration on the eye-lid. Sometimes blood trickled down and could make it look worse than it actually was. An injury could look worse later. Interview on 10/23/2025 at 12:30 PM with Nurse Practitioner G revealed he was the one who ordered the X-rays after the facility notified him of the incident. He stated he did a complete check on Resident #1 after it was reported to him. He stated her injury was the result of hitting the bedside table. He stated the injury looked worse than it was because of the way a bruise could develop over time. He stated she shouldn't have any lasting effects as a result of this injury. He stated, it's basically just a bad bruise around her eyes and a little bit of swelling. It shouldn't have any long-lasting effect. He stated there was harm, but it was not a significant injury. The X-ray showed no acute fracture . Once the incident happened the facility did everything they were supposed to do after the incident had already occurred. He stated he knew there were inservices that were completed so the staff didn't have this incident again moving forward. Interview on 10/23/2025 at 2:00 PM with CNA B, revealed she was turning Resident #1 with CNA A assisting her when mid turn Resident #1 began to move unpredictably. She stated that was what caused the accident. She stated Resident #1 almost fell off of the bed, but since there were two of them in the room on each side of the bed they were able to make sure she didn't fall. She stated Resident #1 hit the bedside table hard with the side of her face. She stated she immediately reported it to the nurse. She stated she was sorry it happened. She stated the night table was very close to her bed and when Resident #1 leaned over in that direction she hit her head on the bedside table. She stated Resident #1 began to bleed a little bit above her eye. She stated that the bedside table was beside the bed but it was not touching the bed or hovering over the bed. Resident #1 leaned over the side of the bed and hit the table. She stated that the facility has inserviced care staff on Safety Environment Training, Incontinent Care Assistance, Abuse/Neglect, Incidents and Accidents. Interview on 10/23/2025 at 3:00 PM with LVN C, revealed she assessed Resident #1 after the CNA notified her of the incident. She stated CNA A and CNA B tried to change the resident and during the rotation of the turn, Resident #1 pushed against them with her upper half. The resident almost fell off of the bed because she flung her upper torso against the direction the staff were rotating her. She stated CNA A and CNA B did not drop the resident nor did Resident #1 fall. She stated CNA B realized there was blood on Resident #1's forehead. She stated she took vitals and performed a neuro check. She stated everything was okay. She stated she contacted the responsible party, director of nursing, and physician. She stated that the facility has inserviced care staff on Safety Environment Training, Incontinent Care Assistance, Abuse/Neglect, Incidents and Accidents. Interview on 10/23/2025 at 3:15 PM with Administrator D revealed she had already investigated the case and assessed the environment. She stated CNA A and CNA B both told her what had happened. She stated she was told Resident #1 began to move while they were turning her. She stated she already educated the staff and performed inservices. Resident #1 was 2 person assisted and the staff successfully followed the facility policies. The facility investigation determined that it was an accident. Record review of Inservice Training Report completed on 10/15/2025 reflected 23 care staff received Safety Environment Training on 10/15/2025. Record review of Inservice Training Report, completed on 10/16/2025, reflected 18 care staff received Incidents and Accidents Training on 10/16/2025. Record review of Inservice Training Report, completed on 10/17/2025, reflected 25 care staff received Incontinent Care Assistance Training on 10/17/2025. Record review of Inservice Training Report, completed on 10/17/2025, reflected 23 care staff received Abuse and Neglect Training on 10/17/2025. Record Review of the facility Abuse/Neglect policy reflected the facility successfully followed their policies for Abuse/Neglect. Record Review of the facility Perineal Care policy stated the staff are to turn residents to their side and reposition resident. Record Review of the facility Care policy stated all residents receive the necessary care and services based on an individualized comprehensive assessment process. Residents are provided with the necessary care and services to maintain the highest practicable physical, mental, and social well-being level of an environment that enhances quality of life in the scope of a long-term care facility. Care and services are provided in a manner that consistently enhances self-esteem and self-wroth. The police stated the facility provides care and services to residents with reasonable accommodations of each resident's individual needs and preferences. Record Review of the facility Quality of Life policy stated the facility staff provides care and services that ensure that resident's abilities in activities of daily living, including: hygiene, mobility, elimination, dining, communication, speech, language and other methods of communication do not diminish while in the care of the facility, except when unavoidable as evidence by clinical condition.

Based on observations, interviews, and record reviews the facility failed to ensure the resident's environment remained as free of accident hazards as is possible and received adequate supervision and assistance for one (Resident #1) of five residents reviewed for Incident and accidents. 1.The facility failed to provide adequate supervision for Resident #1 to prevent her from having injuries and falls from 02/02/25 to 02/08/25; subsequently Resident #1 sustained a left wrist fracture of unknown origin on 02/02/25, fell on [DATE] sustained a lip bleed, found on the floor next to her bed on 02/07/25 and on 02/08/25 she had left sided facial bruising, a swollen chin, and dark reddish gums. She was later diagnosed at the hospital on 02/08/25 with a hematoma of her jaw and previously diagnosed left wrist fracture. 2. The facility failed to provide supervision in the B Hall Memory Care unit when 2 CNA's were discovered asleep in the unit at the nurses station with the light off on 03/05/25. 3. The facility failed to ensure the staff worked their complete 8-hour shifts (not including 30-minute lunch breaks), did not clocked in to work late or clocked out early and there was no evidence to show who worked in their places if staff called out, which resulted in a lack of supervision of the residents as evidenced by: a. Employees either clocked in late or clocked out early during their shifts for halls A and halls B (Memory Care Unit) on 01/31/25, 02/01/25, 02/02/25, 02/03/25, 02/04/25, 02/05/25, 02/06/25, 02/07/25 and 02/08/25. b. There was no second staff scheduled to work Sunday 02/02/25 from 6:00 am to 2:00 pm that cared for the Memory Care residents where Resident #1 resided. And after the DON reviewed it she said MA P worked from 9:33 am to 2:00 pm, but MA P said she only cleaned the resident's rooms in the Memory Care unit. c. The facility failed to ensure the nursing department employees worked their 8 hours shift (minus 30 minutes for lunch) for dates: 03/02/25, 03/03/25, 03/04/25, 03/05/25, 03/06/25. An IJ (Immediate Jeopardy) was identified on 03/05/25. The IJ template was provided to the facility on [DATE] at 2:34 pm. While the IJ was removed on 03/07/25 at 5:43 pm, the facility remained out of compliance at a scope of no actual harm and a severity level of pattern because all staff had not been trained on their plan to prevent re-occurrences and due to the facility's continued monitoring the implementation and effectiveness of their plan of removal. These failures could place fall risk residents in the memory care unit, at risk of continued falls or possible abuse, which could result in more injuries and pain and cause the residents to experience a health decline and decreased psycho-social well-being. The findings included: A) Record review or Resident #1's Admission MDS Assessment completed by MDS Coordinator R on 02/06/25 revealed, a [AGE] year-old female who admitted on [DATE] with a BIMS score of 02 (Severe cognitive impairment). She was admitted to the 100 hall (memory care unit). She had disorganized thinking and inattention that fluctuated and no assistance for mobility needed and did not have any mood or behaviors. She needed partial to moderate assistance with toileting, bathing, upper and lower body dressing, personal hygiene and partial to moderate assistance with transfers. She was always continent with urine and bowel and she had other neurological conditions. She had diagnoses of hypertension (high blood pressure), viral hepatitis (liver infection and damage), hyperlipidemia (high level of fat particles), thyroid disorder (gland dysfunction), non -Alzheimer's - Dementia (cognitive loss), malnutrition (nutritional deficit), encephalopathy (brain disease) , insomnia (poor sleep habit), muscle weakness (weak muscles), difficulty walking, other lack of coordination, cognitive communication deficit. She had a history of falling with no injury and for the past seven days took antipsychotic and antidepressant medications. (The MDS did not address her combative behaviors) Record review of Resident #1's Care Plan dated 01/30/25 revealed, the resident had impaired cognitive function/dementia or impaired thought processes related to dementia. On 01/23/25 she was at risk for elopement related to elopement evaluation risk score and required a secured unit environment for safety and at risk for falls related to decreased safety awareness, impaired cognition, wandering and will often lay on the floor. With interventions: Anticipate and meet the resident's needs and to be sure the resident's call light was within reach and encouraged the resident to use it for assistance as needed. Educated the resident/family/caregivers about safety reminders and what to do if a fall occurred. Encouraged the resident to participate in activities that promoted exercise, physical activity for strengthening and improved mobility. Ensured that the resident was wearing appropriate footwear examples included nonskid socks, closed footed shoes and other safe footed coverings when ambulating or mobilizing in w/c. On 01/25/25 she was dependent on staff for activities, cognitive stimulation, social interaction related to cognitive deficits. Interventions: Introduced the resident to residents with similar background, interests, and encourage/facilitate interaction. Invited the resident to scheduled activities and provided the resident with materials for individual activities as desired the resident liked the following independent activities and to Provide with activities calendar. Notify resident of any changes to the calendar of activities. The resident needed 1 to 1 bedside/in-room visits and activities if unable to attend out of room events On 02/04/25 had an actual fall with major injury (wrist fracture) with Interventions: For no apparent acute injury, determine and address causative factors of the fall. And to monitor/document /report PRN x 72 hours to Medical Doctor for signs/symptoms: Pain, bruises, Change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation. Provided activities that promoted exercise and strength building where possible. And to Provide 1:1 activities if bedbound On 02/05/25 alteration in musculoskeletal status related to fracture of the left wrist. (The Care plans did not address her combative behaviors). Record review of all of Resident #1's Incidents by incident type printed 02/14/24 revealed: Falls with no injury incidents: 02/02/25 at 8:23 pm, 02/06/25 at 10:22 pm, 02/07/25 at 11:30 pm. Skin tear incidents: 02/02/25 at 8:23 pm and 8:36 pm. Other incidents (observed swelling to left wrist): 02/02/25 at 8:58 pm. Record review of Resident #1's Fall Assessments since she admitted revealed: 01/23/25 score was 2 Low risk 02/03/25 score was 7 Moderate risk 02/06/25 score was 13 High risk 02/08/25 score was 26 High risk Record review of Resident #1's Progress Note dated 01/26/2025 at 4:57 pm Type: Skilled Evaluation by RN Q revealed, .Teaching and Training;, assessed behavior, assess for pain, assess for anxiety , provided redirection, Neurological: Resident is Alert: Oriented to Person; Oriented to Place; Resident has Impaired decision making ability; Resident is Confused; Resident has Delusions: Difficulty understanding others, Skin/Skin Conditions: No changes in skin integrity, Cardiovascular .Muscular: Resident has an unsteady gait requiring supervision; Resident has had a change in ADL functional ability, Resident is Ambulatory, Walks Independently, Mood/Behavior: Changes noted in behavior, Resident intentionally lay herself to the floor; uncooperative to be provided assistance to her safety, or to be redirected, and combative to the staff. Record review of Resident #1's Progress Note dated 01/27/2025 at 11:33 a.m., by ADON F revealed, Type: Skilled Evaluation LATE ENTRY Teaching and Training; assessed behavior, assess for pain, assess for anxiety , provided redirection, Neurological: Resident is Alert; Oriented to Person; Oriented to Place; Resident has Impaired decision-making ability; Resident is Confused; Resident has Delusions. Difficulty understanding others; Skin/Skin Conditions: No changes in skin integrity, Gastrointestinal: ,Continent of Bowel, Bowel Sounds: Present; Gastro-urinary: Continent of Bladder, Urine Color: Amber, Urine Clarity Clear, No foul odor noted . Muscular: Resident has an unsteady gait requiring supervision; Resident has had a change in ADL functional ability, Resident is Ambulatory, Walks Independently; Mood/Behavior: Changes noted in behavior, Resident intentionally lay herself to the floor; uncooperative to be provided assistance to her safety, or to be redirected, and combative to the staff. Record review of Resident #1's Progress note: Skilled Nursing documentation dated 01/31/25 at 11:35 am by ADON F revealed, Receiving both Skilled Nursing and Skilled Therapy Services with skilled diagnosis: ENCEPHALOPATHY (brain disease), Mood/Behavior: Changes noted in behavior, Res continues to refuse medications, this nurse explained to Res that it is important to adhere to medication regimen as prescribed by her MD, nurse attempted reproach, Res refused. Res has no s/s of distress. Record review of Resident #1's Progress note: Alert note dated 02/01/25 at 5:30 pm, Resident c/o hip pain while the FM was present. requests the nurse to ask NP G to increase the Tylenol 500 to the Tylenol Arthritis 650mg. NP G approve the request. Record review of Resident #1's Progress note: Change of condition dated 02/02/25 at 7:57 pm by LVN A revealed, Observed resident L wrist/hand swollen. Resident stated it hurts during assessment. Ice pack applied. The FM was present during the assessment. NP G notified. STAT X-ray ordered for the L wrist/hand. Record review of Resident #1's Incident Report by LVN A dated 02/02/25 at 4:41 pm revealed, Incident Description Nursing Description: observed swelling to left wrist. Incident was unwitnessed. Resident Description: Resident was unable to specify. Was this incident witnessed: No. Immediate Action Taken: Description: Attempted to do ROM exercises. Resident stated it is too painful. Picture taken and sent to NP G. STAT X-RAY was ordered. Ice applied to the Left wrist/hand. PRN Tylenol given for the pain. Resident Taken to Hospital? No. Mental status: oriented to person, lack of safety awareness, forgetful, Predisposing physiological factors: confused, gait imbalanced, Administrator, [Weekend Supervisor E] and the [FM] notified. Record review of Resident #1's left wrist and hand 2 D (dimensional) X-ray results, dated 02/03/25, revealed, Final Reason for Study: R22.32 LOCALIZED SWELLING, MASS, AND LUMP, LEFT UPPER LIMB - WRIST 2V (view), LEFT See Note FINDINGS: There is a dorsal impaction fracture (wrist bone break)involving the distal radius (broken wrist) with modest callus (bone cartilage) and mild displacement. There is associated soft tissue swelling. Diffuse osseous demineralization (decreased bone density) is noted. Moderate degenerative changes are seen. See Note CONCLUSION: Impacted wrist fracture (wrist bone driven into another bone, compression damage) as described. Correlation is needed with history, symptomatology, and physical exam to determine precise acuity. CT or MRI examination follow-up is advised if clinical ambiguity remains. Record review on Resident #1's Nurses note dated 02/03/25 by LVN B revealed, [NP G] n/o to send resident to ER for evaluation, the FM requests that resident be sent to Hospital ER. Record review of Resident #1's Hospital Discharge Record dated 02/03/25 revealed, Diagnosis: wrist Mildly displaced intra-articular fracture of the distal radius (break in wrist bone) with mild apex volar angulation (small degree tilt or bending of fracture point). Surrounding soft tissue swelling. The carpal arcs are preserved (wrist bones were intact). Orders: Fracture non-mobile under fluoro (medical imaging technique), placed in volar (palm side of hand) resting splint, weight bearing status: NWB LUE, Ortho clinic 2 weeks, pain control per ER Record review of Resident #1's Nurses Note dated 02/03/25 by RN H revealed, Returned from the ER Hospital. Was sent there for left wrist fx. Returned with dx closed fx of distal end of left radius (broken bone at the wrist), unspecified fx morphology(shape/form) . A splint immobilizer was applied, wrapped with ace wrap. Plan is for surgical procedure - closed reduction (realign of fracture without surgery) for the wrist at surgical center. The center will call for further information. The [FM] aware. Assessed for pain continuing. Denied pain on arrival to reassess. Record review of Resident #1's Provider Investigation Report incident dated 02/08/25 at 2:30 pm, revealed the [FM] alleged that the nurse supervisor (Weekend Supervisor E) had hit Resident #1 in her mouth. There was a bruise on the right side of her chin and redness inside her mouth on the bottom gums. The resident denied any pain or discomfort. Treatment was provided and the resident was taken to the hospital. Statements, interviews, and resident safe surveys were completed and determined the facial bruising and swelling was from her fall 02/07/25. Findings: Unfounded. Record review of Resident #1's Hospital Report dated 02/18/25 revealed, She admitted [DATE]: Review of systems: Jaw bruising and pain, Physical exam: Bruising on chin and swelling of left side of cheek, Bruising gums, patient has negative popsicle test (fractured jaw test). Assessment plan: Recurrent falls: 1:1 sitter in place, follow-up x-ray neck, head, perimandibulbar hematoma: supportive care and outpatient dental, Left distal radius fracture, osteoarthritis, vascular dementia, debility. Pertinent Items Requiring Follow-up Post-Discharge 1. Adjust psychiatric medications PRN, 2. Monitor thyroid function, 3. Follow up w/ hand clinic, 4. Follow up w/ dentist. Record review of the facility's Daily Staffing sheet dated 01/31/25 for the 10:00 pm - 6:00 am shift for five halls revealed, they had 1 RN, 2 LVN's, 0 MA and 5 CNA's total at the facility. (The census section was blank). Record review of the facility's Daily Staffing sheet dated 02/01/25 for the 10:00 pm - 6:00 am shift for five halls revealed, they had 1 RN, 2 LVN's, 0 MA and 5 CNA's total at the facility. (The census section was blank). Record review of the facility's Daily Staffing sheet dated 02/02/25 for the 6:00 am - 2:00 pm shift for five halls revealed, they had 1 RN, 4 LVN's, 3 MA and 4 CNA's. (The census section was blank) Record review of the facility's schedule sheet dated Friday 01/31/25 revealed CNA J was the only staff scheduled to work in the Memory care Unit Hall B during the 10:00 pm - 6:00 am shift. Record review of CNA J's Timesheet dated Friday 01/31/25 revealed she clocked in at 10:25 pm and clocked out at 5:52 am - 7.45 total hours. Record review of the facility's schedule sheet dated 01/31/25 revealed RN H was scheduled to work the A Hall from 10:00 pm - 6:00 am. Record review of the RN H's Timesheet dated 01/31/25 revealed RN H clocked in at 10:35 pm and clocked out at 7:29 am - 8.91 hours. Record review of the facility's schedule sheet dated Friday 01/31/25 on the 10:00 pm - 6:00 am shift, revealed LVN O was scheduled to work the E Hall (2nd floor). Record review of LVN O's Time sheet dated Friday 01/31/25 revealed she clocked in at 10:14 pm and clocked out at 6:25 am - 7.69 total hours. Record review of the schedule sheet dated 02/01/25 revealed CNA T was scheduled to work the B Hall Memory care from 2:00 pm - 10:00 pm. Record review of CNA T's Timesheet sheet dated 02/01/25 revealed she clocked in at 3:31 pm and clocked out at 10:08 pm - 6.61 hours. Record review of the facility's schedule sheet dated 02/01/25 revealed CNA J was scheduled to work the B Hall Memory Care unit from 10:00 pm - 6:00 am. Record review of CNA J's Timesheet dated 02/01/25 revealed she clocked in at 10:30 pm and clocked out at 6:11 am - 7.68 hours. Record review of the facility's schedule sheet dated Saturday 02/01/25 revealed CNA K was scheduled to work the A Hall from 2:00 pm - 10:00 pm and Hall B Memory care unit from 10:00 pm - 6:00 am. Record Review of CNA K's Timesheet dated 02/01/25 revealed she clocked in at 2:21 pm and clocked out at 6:36 am - 15.38 hours. Record review of the Facility's schedule sheet dated Saturday 02/01/25 revealed LVN N was scheduled to work the A Hall unit on the 10:00 pm - 6:00 am. Record review of the Facility's Timesheet sheet dated Saturday 02/01/25 for LVN N was requested but not provided by the facility. Record review of the facility's Schedule sheet dated Saturday 02/01/25 for the 10:00 pm - 6:00 am shift revealed, LVN O was schedule to work the D Hall (2nd floor). LVN O's Timesheet was requested for Saturday 02/01/25 but the DON gave the HHSC surveyor LVN's 01/31/25 timesheet. Record review of the facility's schedule sheet dated Saturday 02/01/24 revealed LVN A was scheduled to work 02/01/25 from 6:00 am to 2:00 pm. Record review of LVN A's Timesheet dated 02/01/25 revealed she clocked in at 6:17 am and clocked out at 2:08 pm, clocked in at 2:40 pm, clocked out 9:18 pm, clocked in at 9:50 pm and clocked out at 10:06 pm - 14.75 hours. Record review of the facility's schedule sheet dated Sunday 02/02/25 revealed LVN A was the only staff scheduled to work in the Memory care unit Hall B during the 6:00 am - 2:00 pm shift. Record review of LVN A's Timesheet revealed on Sunday 02/02/25 she clocked in at 6:20 am and clocked out at 10:09 pm - 23.81 total hours. Record review of the facility's schedule sheet dated Sunday 02/02/25 revealed MA P was scheduled to work A Hall from 6:00 am - 2:00 pm and 2:00 pm to 10:00 pm. Record review of MA P's Time sheet dated Sunday 02/02/25 revealed she clocked in at 9:33 am and clocked out at 12:27 pm for lunch and clocked back in at 1:02 pm and clocked out at 10:11 pm - 12.06 total hours. Interview and observation of Resident #1 on 02/13/25 at 7:10 pm at the hospital revealed, she had 1:1 monitoring (constant observation of the resident). A hospital sitter was in the room with her and she was watching TV and she had a beige bandage wrapped around her left wrist and forearm and cotton was underneath the bandage. She stated she had not fallen that she knew of and that her arm was broken because she was always picking up something too heavily. Her lower left chin and face was not swollen, discolored, or bruised. She stated she had no pain of her mouth or left wrist and said she could not remember where she lived prior to coming to this hospital. She stated she could not remember if anyone had been abusive to her and the people should know if they were abusive because she did not have time for that. She stated the IV port and hospital ID band on her right arm got on her nerves more so than the bandage around her left wrist. Record review of Resident #1's Incident report dated 02/06/25 at 10:22 p.m., by LVN D revealed, Resident was seen walking slumped over when she tripped over her socks, this nurse and on shift CNA attempted to assist Resident to floor when she became combative and physically aggressive with staff, hitting herself in the mouth with her splinted left wrist. Resident was eased to the floor by staff and allowed to rest before being helped back to her feet and assisted to her room. Full head to toe assessment was completed resulting vital signs within normal limits, no apparent bruising, no s/s of respiratory distress. Resident had a complaint of pain in her lip where she hit her mouth with wrist. PRN pain medication administered, and pain has since subsided upon recheck. Resident seen lying in bed resting. Hydration and call light are within reach, bed is in lowest position possible. Care continues. Resident Description: She lost her footing because her socks were too slippery and did not need help getting up. Resident was eased to the floor by staff and allowed to rest before being helped back to her feet and assisted to her room. Full head to toe assessment was completed resulting vital signs within normal limits, no apparent bruising, no s/s of respiratory distress. Res had a complaint of pain in her lip where she hit her mouth with wrist. PRN pain medication administered, and pain has since subsided upon recheck. MD notified, DON/ADON notified. RP notified. Resident seen lying in bed resting. Hydration and call light are within reach, bed is in lowest position possible. Care continues. Resident taken to hospital: No. Injury location: face. Pain level 5 (moderate pain level), Alert, ambulatory with assistance. Mental status: Oriented to person, impulsiveness, lack of safety awareness, forgetful. Res the inside of her lip, Resident taken to rest room to rinse her mouth, given PRN pain med which was effective at recheck. Res resting in bed with eyes closed at this time. Confused, impaired memory, sundowning. Interview on 02/13/25 at 4:39 pm, CNA C stated Resident #1 was a new admit and walked without assistance and needed assistance to the toilet. She stated on Saturday 02/01/25 or Sunday 02/02/25, the dinner trays came out and as she helped Resident #1 lean up in her chair, she noticed her left wrist was swollen. She stated she told LVN B, and LVN B went to assess Resident #1 and later on she heard it was fractured and she was sent to the hospital. She stated she was not sure what happened to her wrist and the previous CNA (CNA I) said she did not know what happened or noticed any swelling or bruising of Resident #1's wrist. She stated LVN A said she did not know what happened to Resident #1's wrist either. She stated on Thursday 02/06/25 during the 2 pm - 10 pm shift, Resident #1 was walking down the hall, leaned backwards, and she and LVN D ran and guided Resident #1 down to the floor. She stated during that process Resident #1 got agitated and started swinging her arms and hit herself in her mouth with the soft cast. She stated Resident #1's mouth bled a little on the right side of her lip; it was a little swollen. She stated she did not hit her head on the wall or rail, and at that time, she had no bruising to her face. She stated she worked Saturday 02/08/25 and asked LVN A to help reposition Resident #1 but Resident #1 said she did not want to be bothered. She stated Resident #1 was sleeping sideways in the bed and she asked could she reposition her better in bed and Resident #1 said to leave her alone. She stated around 10:00 am, Weekend Supervisor E and LVN A went in Resident #1's room and she heard Resident #1 hit Weekend Supervisor E. She stated after the incident, she did not see any bruising on Resident #1's face all the way up to the end of her shift at 10:00 pm. She stated she had not seen anyone being abusive to Resident #1. She stated when she returned to work, she heard Resident #1 was taken to the hospital. She stated the facility had enough staff working in the dementia care unit Resident #1 was in. She stated their dementia care unit currently had 21 residents with one CNA and one LVN working per shift. She stated most of the residents walked without assistance. She stated Resident #1 was not good with expressing her needs. Interview on 02/13/25 at 5:30 pm, LVN D stated Resident #1 admitted [DATE] and she discharged last weekend 02/08/25. She stated Resident #1 was ambulatory without assistance and used to work at a hospital because she always said she had to go to work. She stated Resident #1 had the typical dementia behavior and she was verbally and physically abusive to the staff. She stated Resident #1's mindset was that she was always at work and she required a lot of redirecting. She stated she heard Resident #1 went the hospital on 02/03/25 after her x-ray results showed she had a fractured wrist. She stated they were not sure how her wrist got fractured. She stated Resident #1 had a splint with an ace bandage around it to keep it in place. She stated Thursday 02/06/25, Resident #1 was walking around 10:00 pm or 11:00 pm down the hallway, by the dining room and she appeared to be unsteady. She stated she and CNA C tried to keep her from falling but Resident #1 said she did not want any help. She stated Resident #1 kept leaning backwards and they lowered Resident #1 to the floor and in the process Resident #1 hit the right side of her mouth with her soft cast. She stated Resident #1 never hit the floor, and she and CNA C turned Resident #1 around and eased her down to the floor. She stated she had one arm under Resident #1's arm and CNA C was on the other side under Resident #1's other arm. She stated she had minimum bleeding and her lip had a skin tear for which she gave her PRN Tylenol. She stated she called Resident #1's doctor and got a doctor's order for a skull series x-ray as a precaution. She stated she went to check on Resident #1 later and she was fine and with no bleeding or bruising. She stated she spoke to the FM about Resident #1 stumbling like she was about to fall and they tried to catch her before she fell . She stated on Friday 02/07/25, the x-ray tech came to do the x-rays but the FM told the x-ray tech to come back another time. She stated the last time she saw Resident #1 was Friday 02/07/25 around 10:30 pm and she was fine and had no signs or symptoms of distress, pain, or bleeding. She stated Resident #1 was her normal self, walking around with her juice saying she was getting her people together. She stated she informed the FM about seeing Resident #1 hit her mouth with her soft cast by mistake. She stated measures to prevent Resident #1 from falling was to continue with a lot of redirection and anticipating her needs. She stated after 5:00 pm, they did showers and got the residents ready for bed. She stated she reported Resident #1's fall on 02/07/25 to ADON F and added guided falls were considered falls that was why she did an incident report and contacted Resident #1's doctor, the FM, and the ADON. She stated she was not aware of Resident #1 having any other falls. Interview on 02/14/25 at 10:13 am, LVN B stated she worked Monday 02/03/25 and she sent Resident #1 to the hospital. She stated LVN A said they noticed Resident #1's arm was slightly swollen with no change in bone structure. She stated Resident #1 did not want her wrist touched and she explained to Resident #1 she needed to check to see how she was doing. She stated she kept Resident #1's wrist elevated with ice on it while she waited for the x-ray results. She stated Resident #1 had no signs of pain and slept most of the night. She stated Resident #1 got up once to use bathroom with the CNA's assistance while they were waiting for the x-ray results. She stated around 7:00 am, the doctor said to send Resident #1 to the ER, and she passed the information to the Administrator, DON, the FM, and the next nurse. She stated Resident #1's x-ray result showed she had an impacted wrist fracture and LVN A and no one else knew what caused her fractured wrist. She stated she informed the FM about the need to transfer her to the hospital and when she was being transferred, she had no bruises on her face or bleeding or swollen lip. She stated Resident #1 was laughing and said It sucks getting old when being transported to the hospital. She stated she contacted management for injuries of unknown origin because it was their protocol. She stated she notified the Administrator, DON, and ADON about Resident #1's x-ray results and the Administrator responded to call her (the FM). She stated she called and spoke to the Administrator about Resident #1's wrist fracture x-ray result. Interview on 02/14/25 at 10:39 am, LVN A stated she worked double weekends. She stated Resident #1 admitted about three weeks ago, and she was very familiar with Resident #1. She stated Resident #1 normally walked but had an unsteady gait and they always made sure her bed was in the lowest position. She stated they also increased monitoring of Resident #1 and anticipated her needs and that she was A/O x1 (person). She stated Resident #1 was doing well walking without assist, but once or twice she was sent to the hospital (for the swollen wrist and bruised and swollen face). She stated she worked Saturday 02/01/25, and Resident #1 did not have any falls, unusual occurrences ,or wrist swelling, but she did have generalized and hip pain. She stated she called Resident #1's doctor and her Tylenol 300 mg was increased to 650 mg which was effective. She stated the FM said she did not want Resident #1 on narcotics and the hip pain was probably due to a fall she had at home. She stated she did not remember Resident #1 having a fall the weekend of Saturday 02/01/25 or Sunday 02/02/25. She stated on Sunday 02/02/25, Resident #1 was not a morning person and they would let her sleep in. She stated Resident #1 woke up around 9:00 am or 10:00 am on 02/02/25 and she had no swelling of her left wrist, but later that afternoon the FM visited and reported Resident #1's left wrist was swollen. She stated when she assessed Resident #1, she saw the swelling of her left wrist, but the FM said her left wrist was not swollen the previous day. She stated she took a picture of Resident #1's left wrist to show the DON and ADON F and to her doctor. She stated she asked Resident #1 to flex her arm, Resident #1 said it hurt, and her doctor ordered a STAT x-ray. She stated she was confused as to how Resident #1's left wrist got swollen even though Resident #1 said she fell a couple of days of ago. She stated the FM said Resident #1 could be saying she fell , but she could have fallen the night prior 02/01/25 or that day 02/02/25. She stated Resident #1 was fine on 02/02/25 and few hours later her left wrist was swollen then she did Resident #1's full body assessment. She stated Resident #1's left kneecap and left elbow had STs and Resident #1 said she fell but could not say how. She stated if she had a fall who could have helped her off the floor, because she did not have a lot of strength. She stated they could not say if Resident #1 was able to get up without assist after falling, and they did not know what caused Resident #1's swollen broken left wrist. She stated on 02/02/25, Resident #1's left wrist x-ray was done, and LVN B sent her to the hospital on 02/03/25. She stated when she returned to work Saturday 02/08/25, she noticed Resident #1 had a soft wrap bandage across Resident #1's left middle fingers up to her middle arm. On Saturday 02/08/25, Resident #1 was lying horizontally off the bed. She said she asked Weekend Supervisor E to help reposition the resident. She stated Resident #1 swung at and hit Weekend Supervisor E's head and they both stepped back and stopped trying to reposition Resident #1. She stated Resident #1 did not have any bruises or swelling to her face. She stated she called the FM about the incident regarding trying to turn her and noticed she was taking the cast wrapping around her arm apart. She stated the FM came to the facility around 1:00 pm and said, she was just frustrated and Resident #1 was sitting on the floor and calm in her room. She stated the FM said she would get Resident #1 off of the floor, cleaned up, and did not want the staff to assist her. She stated 30 to 45 minutes later, the FM asked her to go to Resident #1's room, said Resident #1's face and chin were swollen and Resident #1 was in pain. She stated that was when she noticed Resident #1 had slight swelling and a bruise on the right side of her chin. She stated Resident #1 was assessed and her vitals were checked. They were within normal limits, and she had no pain. She stated she was not sure but thought maybe the bruises were due to the fall she had 02/06/25. She stated she sent pictures of the bruise and video of the inside of her mouth to Resident #1's doctor, the ADON, and DON. She stated she received a doctor's order to send Resident #1 to the hospital, per the family's re [TRUNCATED]

Based on interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident #1) of five residents reviewed for care plans. The facility failed to ensure Resident #1's care plan addressed her combative behavior (aggressive and eager to fight or argue) as documented by RN Q on 01/26/25 and ADON F on 01/27/25. Subsequently, on 02/06/25 at 10:22 pm, LVN D and CNA I said Resident #1 was about to fall and as they tried to stop her from falling, Resident #1 became combative and hit her lip which caused her lip to bleed. And on 02/08/25, Resident #1 hit the Weekend Supervisor E's face when she was trying to reposition Resident #1. This failure could place all residents with aggressive and combative behaviors, at risk of their individual needs not being met, which could cause falls and injuries and result in a decline in the resident's health and psycho-social well-being. Findings included: Record review or Resident #1's Admission MDS Assessment completed by MDS Coordinator R on 02/06/25 revealed, a [AGE] year-old female who admitted on [DATE] with a BIMS score of 02 (Severe cognitive impairment). She was admitted to the 100 hall (memory care unit). She had disorganized thinking and inattention that fluctuated and no assistance for mobility needed and did not have any mood or behaviors. She needed partial to moderate assistance with toileting, bathing, upper and lower body dressing, personal hygiene and partial to moderate assistance with transfers. She was always continent with urine and bowel and she had other neurological conditions. She had diagnoses of hypertension (high blood pressure), viral hepatitis (liver infection and damage), hyperlipidemia (high level of fat particles), thyroid disorder (gland dysfunction), non -Alzheimer's - Dementia (cognitive loss), malnutrition (nutritional deficit), encephalopathy (brain disease) , insomnia (poor sleep habit), muscle weakness (weak muscles), difficulty walking, other lack of coordination, cognitive communication deficit. She had a history of falling with no injury and for the past seven days took antipsychotic and antidepressant medications. (The MDS did not address her combative behaviors) Record review of Resident #1's Care Plan dated 01/30/25 revealed, the resident had impaired cognitive function/dementia or impaired thought processes related to dementia. On 01/23/25 she was at risk for elopement related to elopement evaluation risk score and required a secured unit environment for safety and at risk for falls related to decreased safety awareness, impaired cognition, wandering and will often lay on the floor. With interventions: Anticipate and meet the resident's needs and to be sure the resident's call light was within reach and encouraged the resident to use it for assistance as needed. Educated the resident/family/caregivers about safety reminders and what to do if a fall occurred. Encouraged the resident to participate in activities that promoted exercise, physical activity for strengthening and improved mobility. Ensured that the resident was wearing appropriate footwear examples included nonskid socks, closed footed shoes and other safe footed coverings when ambulating or mobilizing in w/c. On 01/25/25 she was dependent on staff for activities, cognitive stimulation, social interaction related to cognitive deficits. Interventions: Introduced the resident to residents with similar background, interests, and encourage/facilitate interaction. Invited the resident to scheduled activities and provided the resident with materials for individual activities as desired the resident liked the following independent activities and to Provide with activities calendar. Notify resident of any changes to the calendar of activities. The resident needed 1 to 1 bedside/in-room visits and activities if unable to attend out of room events On 02/04/25 had an actual fall with major injury (wrist fracture) with Interventions: For no apparent acute injury, determine and address causative factors of the fall. And to monitor/document /report PRN x 72 hours to Medical Doctor for signs/symptoms: Pain, bruises, Change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation. Provided activities that promoted exercise and strength building where possible. And to Provide 1:1 activities if bedbound On 02/05/25 alteration in musculoskeletal status related to fracture of the left wrist. (The Care plans did not address her combative behaviors). Record review of Resident #1's Progress Note dated 01/26/2025 at 4:57 pm Type: Skilled Evaluation by RN Q revealed, .Teaching and Training;, assessed behavior, assess for pain, assess for anxiety , provided redirection, Neurological: Resident is Alert: Oriented to Person; Oriented to Place; Resident has Impaired decision making ability; Resident is Confused; Resident has Delusions: Difficulty understanding others, Skin/Skin Conditions: No changes in skin integrity, Cardiovascular .Muscular: Resident has an unsteady gait requiring supervision; Resident has had a change in ADL functional ability, Resident is Ambulatory, Walks Independently, Mood/Behavior: Changes noted in behavior, Resident intentionally lay herself to the floor; uncooperative to be provided assistance to her safety, or to be redirected, and combative to the staff. Record review of Resident #1's Progress Note dated 01/27/2025 at 11:33 a.m., by ADON F revealed, Type: Skilled Evaluation LATE ENTRY Teaching and Training; assessed behavior, assess for pain, assess for anxiety , provided redirection, Neurological: Resident is Alert; Oriented to Person; Oriented to Place; Resident has Impaired decision-making ability; Resident is Confused; Resident has Delusions. Difficulty understanding others; Skin/Skin Conditions: No changes in skin integrity, Gastrointestinal: ,Continent of Bowel, Bowel Sounds: Present; Gastro-urinary: Continent of Bladder, Urine Color: Amber, Urine Clarity Clear, No foul odor noted . Muscular: Resident has an unsteady gait requiring supervision; Resident has had a change in ADL functional ability, Resident is Ambulatory, Walks Independently; Mood/Behavior: Changes noted in behavior, Resident intentionally lay herself to the floor; uncooperative to be provided assistance to her safety, or to be redirected, and combative to the staff. Record review of Resident #1's Incident report dated 02/06/25 at 10:22 p.m., by LVN D revealed, Resident was seen walking slumped over when she tripped over her socks, this nurse and on shift CNA attempted to assist Resident to floor when she became combative and physically aggressive with staff, hitting herself in the mouth with her splinted left wrist. Resident was eased to the floor by staff and allowed to rest before being helped back to her feet and assisted to her room. Full head to toe assessment was completed resulting vital signs within normal limits, no apparent bruising, no s/s of respiratory distress. Resident had a complaint of pain in her lip where she hit her mouth with wrist. PRN pain medication administered, and pain has since subsided upon recheck. Resident seen lying in bed resting. Hydration and call light are within reach, bed is in lowest position possible. Care continues. Resident Description: She lost her footing because her socks were too slippery and did not need help getting up. Resident was eased to the floor by staff and allowed to rest before being helped back to her feet and assisted to her room. Full head to toe assessment was completed resulting vital signs within normal limits, no apparent bruising, no s/s of respiratory distress. Res had a complaint of pain in her lip where she hit her mouth with wrist. PRN pain medication administered, and pain has since subsided upon recheck. MD notified, DON/ADON notified. RP notified. Resident seen lying in bed resting. Hydration and call light are within reach, bed is in lowest position possible. Care continues. Resident taken to hospital: No. Injury location: face. Pain level 5 (moderate pain level), Alert, ambulatory with assistance. Mental status: Oriented to person, impulsiveness, lack of safety awareness, forgetful. Res the inside of her lip, Resident taken to rest room to rinse her mouth, given PRN pain med which was effective at recheck. Res resting in bed with eyes closed at this time. Confused, impaired memory, sundowning. Record review of Resident #1's Provider Investigation Report incident dated 02/08/25 at 2:30 p.m., revealed the [FM] alleged that the nurse supervisor (Weekend Supervisor E) had hit Resident #1 in her mouth. There was a bruise on the right side of her chin and redness inside her mouth on the bottom gums. The resident denied any pain or discomfort. Treatment was provided and the resident was taken to the hospital. Statements, interviews, and resident safe surveys were completed and determined the facial bruising and swelling was from her fall 02/07/25. Findings: Unfounded. Interview on 02/13/25 at 5:30 p.m., LVN D stated Resident #1 used to say she worked at the hospital and was the typical dementia resident with behaviors. She stated she was verbally and physically aggressive to the staff and her mindset was that she was always working and she required a lot of redirecting. She stated Resident #1 had a splint with an ace bandage to keep it in place since 02/03/25. She stated Thursday 02/06/25 around 10:00 p.m. or 11:00 p.m., Resident #1 was walking down the hallways by the dining room. She stated she and CNA C saw Resident #1 looking like she was about to fall but Resident #1 said no she did not want any help. She stated they tried to lower Resident #1 to the floor and in the process Resident #1 hit the right side of her mouth (lip) with her cast. She stated Resident #1 had minimum bleeding from her lip and after she assessed Resident #1 she had a skin tear on her lip. She stated she gave her PRN Tylenol and called her Doctor and the FM. She stated she was pending an x-ray of right chin and a skull series as a precaution. She stated she went to check on Resident #1 and she was fine and had no bleeding. Interview on 02/14/25 at 10:39 am, LVN A stated she worked double weekends. She stated Resident #1 admitted about three weeks ago, and she was very familiar with Resident #1. She stated Resident #1 normally walked but had an unsteady gait and they always made sure her bed was in the lowest position. She stated they also increased monitoring of Resident #1 and anticipated her needs and that she was A/O x1 (person). She stated Resident #1 was doing well walking without assist, but once or twice she was sent to the hospital (for the swollen wrist and bruised and swollen face). She stated she worked Saturday 02/01/25, and Resident #1 did not have any falls, unusual occurrences ,or wrist swelling, but she did have generalized and hip pain. She stated she called Resident #1's doctor and her Tylenol 300 mg was increased to 650 mg which was effective. She stated the FM said she did not want Resident #1 on narcotics and the hip pain was probably due to a fall she had at home. She stated she did not remember Resident #1 having a fall the weekend of Saturday 02/01/25 or Sunday 02/02/25. She stated on Sunday 02/02/25, Resident #1 was not a morning person and they would let her sleep in. She stated Resident #1 woke up around 9:00 am or 10:00 am on 02/02/25 and she had no swelling of her left wrist, but later that afternoon the FM visited and reported Resident #1's left wrist was swollen. She stated when she assessed Resident #1, she saw the swelling of her left wrist, but the FM said her left wrist was not swollen the previous day. She stated she took a picture of Resident #1's left wrist to show the DON and ADON F and to her doctor. She stated she asked Resident #1 to flex her arm, Resident #1 said it hurt, and her doctor ordered a STAT x-ray. She stated she was confused as to how Resident #1's left wrist got swollen even though Resident #1 said she fell a couple of days of ago. She stated the FM said Resident #1 could be saying she fell , but she could have fallen the night prior 02/01/25 or that day 02/02/25. She stated Resident #1 was fine on 02/02/25 and few hours later her left wrist was swollen then she did Resident #1's full body assessment. She stated Resident #1's left kneecap and left elbow had STs and Resident #1 said she fell but could not say how. She stated if she had a fall who could have helped her off the floor, because she did not have a lot of strength. She stated they could not say if Resident #1 was able to get up without assist after falling, and they did not know what caused Resident #1's swollen broken left wrist. She stated on 02/02/25, Resident #1's left wrist x-ray was done showing it was fractured, and LVN B sent her to the hospital on 02/03/25. She stated when she returned to work Saturday 02/08/25, she noticed Resident #1 had a soft wrap bandage across Resident #1's left middle fingers up to her middle arm. On Saturday 02/08/25, Resident #1 was lying horizontally off the bed. She said she asked Weekend Supervisor E to help reposition the resident. She stated Resident #1 swung at and hit Weekend Supervisor E's head and they both stepped back and stopped trying to reposition Resident #1. She stated Resident #1 did not have any bruises or swelling to her face. She stated she called the FM about the incident regarding trying to turn her and that noticed she was taking the cast wrapping around her arm apart and picking at the cotton underneath it. She stated the FM came to the facility around 1:00 pm and said, she was just frustrated and Resident #1 was sitting on the floor and calm in her room. She stated the FM said she would get Resident #1 off of the floor, cleaned her up, and did not want the staff to assist her. She stated 30 to 45 minutes later, the FM asked her to go to Resident #1's room, said Resident #1's face and chin were swollen and Resident #1 was in pain. She stated that was when she noticed Resident #1 had slight swelling and a bruise on the right side of her chin. She stated Resident #1 was assessed and her vitals were checked. They were within normal limits, and she had no pain. She stated she was not sure but thought maybe the bruises were due to the fall she had 02/06/25. She stated she sent pictures of the bruise and video of the inside of her mouth to Resident #1's doctor, the ADON, and DON. She stated she received a doctor's order to send Resident #1 to the hospital, per the family's request. She stated, on 02/08/25, she spoke to the Administrator about Resident #1's dark purple and reddish-purple chin bruises and dark red gums. She stated she told the Administrator she was not sure if Resident #1 had new injuries or delayed bruises from a previous fall. She stated the Administrator said how unfortunate things keep happening to [Resident #1] then she went to talk to the FM. She stated the Administrator and the FM spoke to one another prior to the resident going to the hospital. She stated Resident #1 was picked up by the EMT on 02/08/25 with no signs or symptoms of distress. She stated she charted Resident #1's information in the nurse's notes and did an incident report. She stated if residents continued to have injuries of unknown origin that could cause new medical conditions or bleeding internally. She stated they had to be especially watchful of the memory care residents which could turn into neglect. She stated if the facility was not able to stop a resident from falling or curing the problem could cause more complications in the resident's life. Interview on 02/14/25 at 12:49 pm, Weekend Supervisor E stated on 02/08/25, LVN A asked her to assist with repositioning Resident #1 because she was laying crooked in bed. She stated during the process of trying to reposition her, Resident #1 swung out and hit her right eye. She stated she then stepped back and did not move her, then the FM was called. Interview on 03/04/25 at 2:46 pm, the DON stated their last fall prevention training was 01/25/25, and they had not had a behavioral management training recently. She stated the last customer service, which was similar to behavioral management, training was 01/24/25. She stated the therapy department did verbal trainings with the nursing staff about how to care for Resident #1 after she had the wrist fracture. She stated she was not sure which staff received the training and would have to talk to the therapist about who she trained. (The DON was not able to provide documentation of the therapy trainings with the staff). Interview on 03/06/25 at 9:42 a.m., MDS Coordinator R stated Resident #1 was resistive to care and bathing and remembered hearing the FM helped with her care. She stated she was not sure how many falls Resident #1 has had but stated as a team they reviewed the residents falls. She stated Resident #1 had a wrist fracture and she believed she had a care plan and could not remember off the top of her head if Resident #1 had a fall on 02/06/25. She stated the care plan was the POC the staff went by to take care of the residents. She stated Resident #1 was still a one person assist and ambulated without assistance and able to help with her own ADL care. She stated she was in charge of completing the comprehensive care plans and the two ADON's did the Care plan revisions. She stated the IDT reviewed the resident's falls daily and stated she would check to see if Resident #1had a care plan for combativeness. She stated the IDT team consisted of all the department heads. Interview on 03/06/25 at 10:32 a.m., MDS Coordinator R stated she reviewed Resident #1's progress notes and saw that she was resistant to medications and pocketed meds and resisted care. She stated she was not aware Resident #1 was combative and ADON F was responsible for revising Resident #1's Care plan. Interview on 03/06/25 at 10:57 a.m., ADON F stated Resident #1 was resistant to care and her protectiveness of her receiving care she became combative. She stated Resident #1 was not combative all the time and it was associated when the staff provided care to her. Interview on 03/06/25 at 3:50 p.m., ADON F stated Resident #1 had no care plan for combativeness or for her behavior lying in bed sideways. She stated they had no thoughts to move her closer to the nurses station and was not sure why. Interview on 03/07/25 at 12:12 pm, MDS Coordinator R stated she had trainings yesterday 03/06/25 and today 03/07/25. She stated they trained about the Kardex being used for plan of care, behaviors and understanding residents with dementia. She stated the staff needed to let the supervisor know if a resident had behaviors and how to redirect to try get the residents to comply. She stated also stepping back and giving the resident time calm down. She stated they were trained on making sure the residents had on appropriate foot ware like nonskid socks when they were up ambulating. She stated she was not delegated to make sure the care plans were accurate but the IDT team was responsible for ensuring care plans were accurate for high risk fall residents. She stated combativeness was physical aggression and if the care plans were not right could cause the staff to not know how to care for the residents and the residents could fall or get hurt. Interview on 03/07/25 at 1:43 p.m., ADON F stated she had trainings on dementia care and behavioral management and customer service. She stated they trained the aides on how to use the Kardex for how to care for the residents. She stated the training covered combativeness with dementia residents and how to redirect the behavior, remove self from the behavior and if that failed report going by the chain of command. She stated she did not need to add combative to Resident #1's care plan because she already had a resistance to care, care plan. She stated the education with the staff was ongoing with spot checks for knowledge comprehension. She stated she was trained on the IDT needed to ensure care plan accuracy by updating the resident's care plan during the meeting. She stated the Care plan was related to the Kardex the CNA's used to provide the resident's care. Interview on 03/07/25 at 5:14 p.m., the Administrator stated yesterday 03/06/25, they educated the IDT staff about making sure they reviewed the resident's falls, times of the falls and incidents. She stated during the IDT meeting the IDT were responsible for making changes to the residents care plans during that time of the meeting. She stated the two ADON's and MDS Coordinator R were responsible for ensuring the care plans were accurate and updated. Record review of the Facility's Care Plan policy dated 06/2020 revealed, Purpose: To ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs. Policy The Facility will provide the highest quality care in the safest environment for the residents residing in the Facility. Policy I. The Facility's Interdisciplinary Team (IDT) will develop a Baseline and/or Comprehensive Care Plan for each resident in accordance with OBRA and MOS guidelines. II. The Care Plan serves as a course of action where the resident (resident's family and/or guardian or other legally authorized representative), resident's Attending Physician, and IDT work to help the resident move toward resident-specific goals that address the resident's medical, nursing, mental and psychosocial needs. III. A Licensed Nurse will initiate the Care Plan, and the plan will be finalized in accordance with OBRA/NDS guidelines and updated as indicated for change in condition, onset of new problems, resolution of current problems, and as deemed appropriate by clinical assessment and judgment on an ass [sic] needed bases. V. The IDT will revise the Comprehensive Care Plan as needed at the following intervals: A. Per RAI schedules; B. As dictated by changes in the resident's condition; C. In preparation for discharge; D. To address changes in behavior and care; and E. Other times as appropriate or necessary. Record review of the facility's Behavioral Management Policy dated 06/2020 revealed, Behavioral Management: Purpose: To implement the most desirable and effective interventions to change, modify, decrease, or eliminate behaviors that are distressing to the resident, and/or are decreasing or negatively impacting the residents' quality of life. Policy: The concept of behavioral management is an interdisciplinary process. The key components of this process are: Identifying residents whose behaviors pose a risk to self and others; Developing individual and practical care strategies based on assessment needs; Implementing the behavior management program; and ongoing assessment, monitoring, and evaluation of the effectiveness of the behavior management program including the effectiveness of the psychoactive drugs.

Based on observations, interviews and record reviews the facility failed to ensure all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for one (Resident #1) of five residents reviewed for injury of unknown origin reporting. The facility failed to ensure on 02/02/25 Resident #1's injury of unknown origin was reported to HHSC when the staff did not know why she had a swollen left wrist that was later diagnosed as fractured (broken). This failure could place fall risk residents of getting more injuries, bruises, and pain which could result in emotional turmoil and cause decreased health and psycho-social well-being. Findings included: Record review or Resident #1's Admission MDS Assessment completed by MDS Coordinator R on 02/06/25 revealed, a [AGE] year-old female who admitted on [DATE] with a BIMS score of 02 (Severe cognitive impairment). She was admitted to the 100 hall (memory care unit). She had disorganized thinking and inattention that fluctuated and no assistance for mobility needed and did not have any mood or behaviors. She needed partial to moderate assistance with toileting, bathing, upper and lower body dressing, personal hygiene and partial to moderate assistance with transfers. She was always continent with urine and bowel and she had other neurological conditions. She had diagnoses of hypertension (high blood pressure), viral hepatitis (liver infection and damage), hyperlipidemia (high level of fat particles), thyroid disorder (gland dysfunction), non -Alzheimer's - Dementia (cognitive loss), malnutrition (nutritional deficit), encephalopathy (brain disease) , insomnia (poor sleep habit), muscle weakness (weak muscles), difficulty walking, other lack of coordination, cognitive communication deficit. She had a history of falling with no injury and for the past seven days took antipsychotic and antidepressant medications. Record review of Resident #1's Care Plan dated 01/30/25 revealed, Impaired cognitive function/dementia or impaired thought processes related to dementia. On 01/23/25 At risk for elopement related to elopement evaluation risk score and requires a secured unit environment for safety and at risk for falls related to decreased safety awareness, impaired cognition, wandering, will often lay on the floor. On 01/25/25 was dependent on staff for activities, cognitive stimulation, social interaction related to cognitive deficits. On 02/02/25 had an actual fall with major injury (wrist fracture). On 02/05/25 alteration in musculoskeletal status related to fracture of the left wrist. Record review of Resident #1's Incident Report by LVN A dated 02/02/25 at 4:41 pm revealed, Incident Description Nursing Description: observed swelling to left wrist. Incident was unwitnessed. Resident Description: Resident was unable to specify. Was this incident witnessed: No. Immediate Action Taken: Description: Attempted to do ROM exercises. Resident stated it is too painful. Picture taken and sent to NP G. STAT X-RAY was ordered. Ice applied to the Left wrist/hand. PRN Tylenol given for the pain. Resident Taken to Hospital? No. Mental status: oriented to person, lack of safety awareness, forgetful, Predisposing physiological factors: confused, gait imbalanced, Administrator, [Weekend Supervisor E] and the [FM] notified. Record review of Resident #1's left wrist and hand 2 D (dimensional) X-ray results, dated 02/03/25, revealed, Final Reason for Study: R22.32 LOCALIZED SWELLING, MASS, AND LUMP, LEFT UPPER LIMB - WRIST 2V (view), LEFT See Note FINDINGS: There is a dorsal impaction fracture (wrist bone break)involving the distal radius (broken wrist) with modest callus (bone cartilage) and mild displacement. There is associated soft tissue swelling. Diffuse osseous demineralization (decreased bone density) is noted. Moderate degenerative changes are seen. See Note CONCLUSION: Impacted wrist fracture (wrist bone driven into another bone, compression damage) as described. Correlation is needed with history, symptomatology, and physical exam to determine precise acuity. CT or MRI examination follow-up is advised if clinical ambiguity remains. Record review on Resident #1's Nurses note dated 02/03/25 by LVN B revealed, [NP G ]n/o to send resident to ER for evaluation, FM requests that resident be sent to Hospital ER. Record review of Resident #1's Hospital Discharge Record dated 02/03/25 revealed, Diagnosis: wrist Mildly displaced intra-articular fracture of the distal radius (break in wrist bone) with mild apex volar angulation (small degree tilt or bending of fracture point). Surrounding soft tissue swelling. The carpal arcs are preserved (wrist bones were intact): Ortho clinic 2 weeks. Record review of Resident #1's Nurses Note dated 02/03/25 by RN H revealed, Returned from the ER Hospital. Was sent there for left wrist fx. Returned with dx closed fx of distal end of left radius (broken bone at the wrist), unspecified fx morphology(shape/form). A splint immobilizer was applied, wrapped with ace wrap. Plan is for surgical procedure - closed reduction (realign of fracture without surgery) or the wrist at surgical center. The center will call for further information. The [FM] aware. Assessed for pain continuing. Denied pain on arrival to reassess. Interview and observation on 02/13/25 at 7:10 pm at the hospital revealed Resident #1 had 1:1 hospital sitter in the room with her and she was watching TV. Resident #1had a beige elastic bandage wrapped around her left wrist and forearm and cotton was underneath the bandage. She stated she had not fallen that she knew of and that her arm was broken because she was always picking up something too heavy. Resident #1 said she had no pain of her mouth or left wrist and said she could not remember where she lived prior to coming to the hospital. She stated she could not remember if anyone had been abusive to her, and the people should know if they were abusive because she did not have time for that. She stated the IV port and hospital ID band on her right arm got on her nerves more so than the elastic bandage around her left arm. Interview on 02/14/25 at 10:39 am, LVN A stated she worked double weekends. She stated Resident #1 admitted about three weeks ago and she was very familiar with Resident #1. Resident #1 normally walked but had an unsteady gait and they always made sure her bed was in the lowest position. She stated they also increased monitoring of Resident #1 and anticipated her needs and that she was A/o x1 (person). She stated Resident #1 was doing well walking without assist but once or twice she was sent to the hospital. She stated she worked Saturday 02/01/25 and Resident #1 did not have any falls, unusual occurrences or wrist swelling but she did have generalized and hip pain. She stated she called Resident #1's doctor and her Tylenol 300 mg was increased to 650 mg which was effective. She stated the FM said she did not want Resident #1 on narcotics and the hip pain was probably due to a fall she had at home. She stated she did not remember Resident #1 having a fall the weekend of Saturday 02/01/25 or Sunday 02/02/25. She stated on Sunday 02/02/25 Resident #1 was not a morning person and they would let her sleep in. She stated Resident #1 woke up around 9:00 am or 10:00 am on 02/02/25 and she had no swelling of her left wrist but later that afternoon the FM visited and reported Resident #1's left wrist was swollen. She stated when she assessed Resident #1, she saw the swelling of her left wrist and the FM said her left wrist was not swollen the previous day. She stated she took a picture of Resident #1's left wrist to show the DON and ADON F and to her doctor. She stated she asked Resident #1 to flex her arm and Resident #1 said it hurt and her doctor ordered a STAT x-ray. She stated she was confused as to how Resident #1's left wrist got swollen even though Resident #1 said she fell a couple of days of ago. She stated the FM said Resident #1 could be saying she fell but she could have fallen the night prior 02/01/25 or that day 02/02/25. She stated Resident #1 was fine on 02/02/25 and few hours later her left wrist was swollen then she did Resident #1's full body assessment. She stated Resident #1's left kneecap and left elbow had STs and Resident #1 said she fell but could not say how. She stated if she had a fall who could have helped her off the floor, because she did not have a lot of strength. She stated they could not say if Resident #1 was able to get up without assist after falling, and they did not know what caused Resident #1's swollen broken left wrist. She stated on 02/02/25 Resident #1's left wrist x-ray was done and LVN B sent her to the hospital on 02/03/25. Interview on 02/24/25 at 3:02 pm, the Administrator stated she was manager on duty on 02/02/25 and heard Resident #1 had fallen. She stated she was making rounds on 02/02/25 around 10:30 am and talked to Resident #1 who was sitting in a chair in the dining room and she was fine. She stated later seeing Resident #1's wrist was swollen and she asked LVN A to let her know when the FM came to the facility. She stated she spoke to the staff from the night before and who were on duty on 02/02/25 and no one said she had fallen. She stated even though Resident #1's BIMS score was low they went by what Resident #1 said that she had fallen, which was why she did not report the incident to HHSC. She stated she believed Resident #1 had fallen and the nurses did their incident and reporting process. Record review of the facility's Abuse and Neglect policy date revised 10/24/24 revealed, Purpose: To ensure the facility establishes, operationalizes, and maintains an Abuse prevention and prohibition program designed to screen and train employee, protect residents and to ensure a standardized methodology for the prevention, identification, investigation and reporting of abuse in accordance with federal and state requirements. Policy: Each resident has the right to be free from mistreatment, abuse .The facility has zero tolerance for abuse .Procedure: IX. Reporting/Response: D. The facility will report allegations of injuries of unknown source i. Immediately, but no later than 2 hours after forming the suspicion if the alleged violation results in serious bodily injury to the state survey agency .

Based on observations, interviews, and record reviews the facility failed to ensure In response to allegations of abuse, neglect, or mistreatment, have evidence that all alleged violations were thoroughly investigated to prevent further potential abuse, neglect, or mistreatment while the investigation was in progress. And report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for one (Resident #1) of five residents reviewed for Abuse and Neglect. The facility failed to ensure on 02/02/25 Resident #1's injury of unknown origin was investigated and report sent to HHSC when the staff did know why she had a swollen left wrist that was later diagnosed as fractured (broken). This failure could place residents at risk of getting more injuries, bruises, and pain which could result in emotional turmoil and cause decreased health and psycho-social well-being. Findings included: Record review or Resident #1's Admission MDS Assessment completed by MDS Coordinator R on 02/06/25 revealed, a [AGE] year-old female who admitted on [DATE] with a BIMS score of 02 (Severe cognitive impairment). She was admitted to the 100 hall (memory care unit). She had disorganized thinking and inattention that fluctuated and no assistance for mobility needed and did not have any mood or behaviors. She needed partial to moderate assistance with toileting, bathing, upper and lower body dressing, personal hygiene and partial to moderate assistance with transfers. She was always continent with urine and bowel and she had other neurological conditions. She had diagnoses of hypertension (high blood pressure), viral hepatitis (liver infection and damage), hyperlipidemia (high level of fat particles), thyroid disorder (gland dysfunction), non -Alzheimer's - Dementia (cognitive loss), malnutrition (nutritional deficit), encephalopathy (brain disease) , insomnia (poor sleep habit), muscle weakness (weak muscles), difficulty walking, other lack of coordination, cognitive communication deficit. She had a history of falling with no injury and for the past seven days took antipsychotic and antidepressant medications. Record review of Resident #1's Care Plan dated 01/30/25 revealed, Impaired cognitive function/dementia or impaired thought processes related to dementia. On 01/23/25 At risk for elopement related to elopement evaluation risk score and requires a secured unit environment for safety and at risk for falls related to decreased safety awareness, impaired cognition, wandering, will often lay on the floor. On 01/25/25 was dependent on staff for activities, cognitive stimulation, social interaction related to cognitive deficits. On 02/02/25 had an actual fall with major injury (wrist fracture). On 02/05/25 alteration in musculoskeletal status related to fracture of the left wrist. Record review of Resident #1's Incident Report by LVN A dated 02/02/25 at 4:41 pm revealed, Incident Description Nursing Description: observed swelling to left wrist. Incident was unwitnessed. Resident Description: Resident was unable to specify. Was this incident witnessed: No. Immediate Action Taken: Description: Attempted to do ROM exercises. Resident stated it is too painful. Picture taken and sent to NP G. STAT X-RAY was ordered. Ice applied to the Left wrist/hand. PRN Tylenol given for the pain. Resident Taken to Hospital? No. Mental status: oriented to person, lack of safety awareness, forgetful, Predisposing physiological factors: confused, gait imbalanced, Administrator, Weekend Supervisor E and the [FM] notified. Record review of Resident #1's left wrist and hand 2 D (dimensional) X-ray results, dated 02/03/25, revealed, Final Reason for Study: R22.32 LOCALIZED SWELLING, MASS, AND LUMP, LEFT UPPER LIMB - WRIST 2V (view), LEFT See Note FINDINGS: There is a dorsal impaction fracture (wrist bone break)involving the distal radius (broken wrist) with modest callus (bone cartilage) and mild displacement. There is associated soft tissue swelling. Diffuse osseous demineralization (decreased bone density) is noted. Moderate degenerative changes are seen. See Note CONCLUSION: Impacted wrist fracture (wrist bone driven into another bone, compression damage) as described. Correlation is needed with history, symptomatology, and physical exam to determine precise acuity. CT or MRI examination follow-up is advised if clinical ambiguity remains. Record review on Resident #1's Nurses note dated 02/03/25 by LVN B revealed, [NP G ] n/o to send resident to ER for evaluation, the [FM] requests that resident be sent to Hospital ER. Record review of Resident #1's Hospital Discharge Record dated 02/03/25 revealed, Diagnosis: wrist Mildly displaced intra-articular fracture of the distal radius (break in wrist bone) with mild apex volar angulation (small degree tilt or bending of fracture point). Surrounding soft tissue swelling. The carpal arcs are preserved (wrist bones were intact): Ortho clinic 2 weeks . Record review of Resident #1's Nurses Note dated 02/03/25 by RN H revealed, Returned from the ER Hospital. Was sent there for left wrist fx. Returned with dx closed fx of distal end of left radius (broken bone at the wrist), unspecified fx morphology(shape/form) . A splint immobilizer was applied, wrapped with ace wrap. Plan is for surgical procedure - closed reduction (realign of fracture without surgery)or the wrist at surgical center. The center will call for further information. The [FM] aware. Assessed for pain continuing. Denied pain on arrival to reassess. Interview and observation on 02/13/25 at 7:10 p.m., at the hospital revealed Resident #1 had 1:1 hospital sitter in the room with her and she was watching TV. Resident #1 had a beige elastic bandage wrapped around her left wrist and forearm and cotton was underneath the bandage. She stated she had not fallen that she knew of and that her arm was broken because she was always picking up something too heavy. Resident #1 said she had no pain of her mouth or left wrist and said she could not remember where she lived prior to coming to the hospital. She stated she could not remember if anyone had been abusive to her, and the people should know if they were abusive because she did not have time for that. She stated the IV port and hospital ID band on her right arm got on her nerves more so than the elastic bandage around her left arm. Interview on 02/14/25 at 10:39 am, LVN A stated she worked double weekends. She stated Resident #1 admitted about three weeks ago and she was very familiar with Resident #1. Resident #1 normally walked but had an unsteady gait and they always made sure her bed was in the lowest position. She stated they also increased monitoring of Resident #1 and anticipated her needs and that she was A/o x1 (person). She stated Resident #1 was doing well walking without assist but once or twice she was sent to the hospital. She stated she worked Saturday 02/01/25 and Resident #1 did not have any falls, unusual occurrences or wrist swelling but she did have generalized and hip pain. She stated she called Resident #1's doctor and her Tylenol 300 mg was increased to 650 mg which was effective. She stated the FM said she did not want Resident #1 on narcotics and the hip pain was probably due to a fall she had at home. She stated she did not remember Resident #1 having a fall the weekend of Saturday 02/01/25 or Sunday 02/02/25. She stated on Sunday 02/02/25 Resident #1 was not a morning person and they would let her sleep in. She stated Resident #1 woke up around 9:00 am or 10:00 am on 02/02/25 and she had no swelling of her left wrist but later that afternoon the FM visited and reported Resident #1's left wrist was swollen. She stated when she assessed Resident #1, she saw the swelling of her left wrist and the FM said her left wrist was not swollen the previous day. She stated she took a picture of Resident #1's left wrist to show the DON and ADON F and to her doctor. She stated she asked Resident #1 to flex her arm and Resident #1 said it hurt and her doctor ordered a STAT x-ray. She stated she was confused as to how Resident #1's left wrist got swollen even though Resident #1 said she fell a couple of days of ago. She stated the FM said Resident #1 could be saying she fell but she could have fallen the night prior 02/01/25 or that day 02/02/25. She stated Resident #1 was fine on 02/02/25 and few hours later her left wrist was swollen then she did Resident #1's full body assessment. She stated Resident #1's left kneecap and left elbow had STs and Resident #1 said she fell but could not say how. She stated if she had a fall who could have helped her off the floor, because she did not have a lot of strength. She stated they could not say if Resident #1 was able to get up without assist after falling, and they did not know what caused Resident #1's swollen broken left wrist. She stated on 02/02/25 Resident #1's left wrist x-ray was done and LVN B sent her to the hospital on 02/03/25. Interview on 02/24/25 at 3:02 pm, the Administrator stated she was manager on duty on 02/02/25 and heard Resident #1 had fallen. She stated she was making rounds on 02/02/25 around 10:30 am and talked to Resident #1 who was sitting in a chair in the dining room and she was fine. She stated later seeing Resident #1's wrist was swollen and she asked LVN A to let her know when the FM came to the facility. She stated she spoke to the staff from the night before and who were on duty on 02/02/25 and no one said she had fallen. She stated even though Resident #1's BIMS score was low they went by what Resident #1 said that she had fallen, which was why she did not investigate this 02/02/25 incident to HHSC. She stated she believed Resident #1 had fallen and the nurses did their incident and reporting process. Record review of the facility's Abuse and Neglect policy date revised 10/24/24 revealed, Purpose: To ensure the facility establishes, operationalizes, and maintains an Abuse prevention and prohibition program designed to screen and train employee, protect residents and to ensure a standardized methodology for the prevention, identification, investigation and reporting of abuse in accordance with federal and state requirements. Policy: Each resident has the right to be free from mistreatment, abuse .The facility has zero tolerance for abuse .Procedure: VI. Investigation: A. The facility promptly and thoroughly investigates reports of .injuries of unknown source. B. The Administrator receives the report of an incident or suspected incident of resident .injuries of unknown source. VII. Special consideration for investigation of injuries of unknown origin (unexplained injuries): A. Unexplained injuries are promptly and thoroughly investigated by the Director of Nursing Services and/or other staff person designated by the Administrator, to ensure that resident safety is not compromised and action is taken whenever possible, to avoid future occurrences.

Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for one (Resident #2) of five residents reviewed for medications errors in that: The facility administered Clonidine to Resident #2 on multiple occasions outside of the ordered blood pressure parameters. This failure could place residents receiving blood pressure medications at risk for low blood pressure. Findings include: Review of Resident #2's Face Sheet and Minimum Data Set (MDS) dated [DATE] reflected Resident #2 was a was a [AGE] year-old male admitted on [DATE] with diagnoses in part including End Stage Renal Disease (final, permanent stage of chronic kidney disease where kidneys no longer function on their own), and Essential Hypertension (high blood pressure not caused by another medical condition). Review of Care Plan dated 10/15/24 reflected Resident #2 had hypertension which included an intervention to give antihypertensive medications as ordered. Review of Physician G's physician order dated 12/30/24 reflected Resident #2 was ordered to receive Clonidine 0.2 milligrams by mouth three times daily if systolic blood pressure was greater than 170, diastolic blood pressure greater than 100. This order was open-ended (had no stop date). Review of Resident #2 Medication Administration Record (MAR) reflected Resident #2 received Clonidine 0.2 mg on two occasions in February 2025, 49 occasions in January 2025, and 68 occasions in December 2024 when Resident #2's blood pressure was less than 170 systolic and less than 100 diastolic. A review of Resident #2's blood pressures for February 2025, January 2025, and December 2024 reflected no episodes of hypotension requiring intervention. In an interview on 02/05/25 at 09:10 am, Medication Aide H stated she had received in-service training on 02/04/25 regarding the need to give blood pressure medications according to ordered parameters. She reported Resident #2 took two blood pressure medications. One medication if the blood pressure was not below 110/60, and an additional medication if blood pressure was above 170/100 and she had been in a routine of taking the blood pressure and giving the medication without necessarily reading the parameters. She stated it was human error and she took responsibility. She reported that giving Clonidine outside of the scheduled parameters could cause the resident to have low blood pressure. In an interview on 02/05/25 at 09:55 am, the DON reported that she was notified on 02/05/25 of Clonidine being given to Resident #2 outside of the ordered blood pressure parameters. She reported the nurse practitioner was notified and the ordered was changed from scheduled to PRN (as needed) so that nurses would give this medication instead of the medication aides. She reported all other medication aide carts were audited and no other orders for scheduled Clonidine with ordered parameters were found. She reported the facility would review all blood pressure medications including ordered parameters during, stand up report in the mornings. The DON reported that Resident #2 did not experience any known adverse effects due to this medication error. The DON reported that if a resident received Clonidine outside of the scheduled blood pressure parameters, they could potentially code (cardiac arrest), pass away, or end up in the emergency room . In an interview on 02/05/25 at 11:37 am, Nurse Practitioner E reported that the facility notified him that Resident #2 had received Clonidine outside of the ordered blood pressure parameters and that he had come to the facility to evaluate Resident #2 on 02/05/25. He reported that Resident #2 had no negative impact that he could find, and that hypotension was the only side effect that could have happened. In an interview on 02/05/25 the Medical Director reported that most dialysis patients including Resident #2 required antihypertensive medications, and that after reviewing Resident #2's chart, it looked like Resident #2 receiving Clonidine 0.2 mg outside of the scheduled blood pressure parameters had actually helped his blood pressure. He reported the risk of giving an antihypertensive medication outside of the ordered parameters is that the resident could have low blood pressure. In an interview on 02/04/25 at 16:30 pm, Resident #2 reported that the medication aides always took his blood pressure, and he had not experienced any issues with his medications or his blood pressure. He reported that his medications were given accurately to the best of his knowledge. He denied any symptoms of hypotension, and none were noted. The facility policy titled, Medication-Administration (Policy no. -NP-310, undated) states, The resident's MAR will be reviewed for allergies and/or special considers for administration including: C. vital sign parameters and lab results as appropriate.

Based on observation, interviews and record reviews, the facility failed to immediately consult with the resident's physician when there was a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) for one (Resident #1) of eight residents reviewed for change in condition. LVN A failed to contact Resident #1's Dr. on 06/08/24, for his drastically decreased BP and he was not transferred to the hospital until 06/09/24. Subsequently, Resident #1 was currently at the hospital diagnosed with septic shock and on a ventilator machine (mechanical life support). An Immediate Jeopardy (IJ) was identified on 06/13/24. An IJ Template was provided to the facility on [DATE] at 10:00 am. While the Immediate Jeopardy was removed on 06/14/24 at 5:00 pm, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that was not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure could place all residents at risk of not being assessed and treated in a timely manner and appropriately, with PA/MD interventions, which could result in a decline in their health and psycho-social well-being or death. Findings included: Record review of the facility's census revealed they had 114 residents. Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a male who admitted to this facility 08/03/23 with a BIMS Score of 10 (moderate cognitive impairment). He had 1 sided upper extremity impairment and 2 sided lower extremity impairment and substantial maximal assist with ADL's. He was frequently incontinent to bladder and always incontinent to bowel. He had medically complex conditions with diagnoses anemia (low red blood cells and hemoglobin), hypertension (high blood pressure), peripheral vascular disease (circulatory condition/reduced blood flow). And he had diagnoses renal insufficiency (kidney failure), diabetes mellitus (high blood sugar), hyperlipidemia (high level fat particles), malnutrition (lack of nutrients), depression (lowered mood), and generalized muscle weakness (muscle weakness). Record review of Resident #1's Order Summary Report dated 06/12/24 revealed orders for: regular diet with thin liquids, 2.0 supplement 120cc 3xd, Amlodipine besylate oral tab 10 mg, 1-tab 1xd for HTN, hold SBP <110, DBP <60, HR 60, and Ondansetron HCI (hydrochloride) Oral tab 4 mg 1 tab by mouth every 6 hours a needed for nausea and vomiting, etc. Record review of Resident #1's Care Plan printed 06/12/24 revealed, date initiated: 08/08/23: dialysis due to chronic kidney disease, altered respiratory status/difficulty breathing related to history of respiratory failure, impaired cognitive function or thought processes. And had bladder incontinence, communication problem and dialysis and diabetes. Date initiated: 01/25/24: potential for fluid overload related to kidney failure: will remain free of signs/symptoms of fluid overload through review date, as evidenced by . changes in mood or behavior, nausea/vomiting . Monitor/document/report to MD PRN signs/symptoms of fluid overload. Hypertension related to Norvasc - Oral. Date Initiated: 08/09/2023, Revision on: 08/09/2023: will maintain a blood pressure within the following parameters: (110/60) through review date. Revision on: 03/03/2024, Target Date: 07/21/2024. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow Record review of Resident #1's Progress note by LVN A dated 06/08/24 at 9:13 am revealed, Resident noted with abnormal vital signs: BP 93/44, O2:88% room air . Weakness, vomiting, poor eating. Resident offered 120 ml of orange juice, elevated head of bed, and more fluid. (There was not any documentation showing LVN A checked Resident #1's BP on 06/08/24 from 12:09 pm to 10:00 pm. And there was no documentation LVN A notified Resident #1's PA/MD on 06/08/24 about Resident #1's change in condition). Record review of Resident #1's Progress note by LVN A dated 06/09/24 at 9:15 am revealed, Resident noted with abnormal vital signs: BP 83/44, O2:88% RA . Resident very weak, nausea, vomiting, poor eating. Resident is alert. PA notified and ordered resident to be sent to hospital using 911. 911 called and took resident to hospital. Family member informed that resident is sent to hospital. DON notified. Record review of Resident #1's SBAR Communication Form dated 06/09/24 by LVN A revealed, Before calling MD/NP/PA evaluate the resident, check vital signs, review record, review an INTERACT (Interventions to Reduce Acute Care Transfers) care path or acute change in condition file card. Have relevant information when reporting. Situation: This started on 06/08/24, since this started it has gotten worse, BP 83/44, altered level of consciousness, weakness, Full Code review and notify: Primary Care Clinician notified yes 06/09/24 8:15 am. Record review of Resident #1's Hospital H&P (history & physical) dated 06/09/24 revealed, Upon arrival to the ED (emergency department), the patient was noted to be minimally responsive with poor oral care .he was hypotensive (low blood pressure) and tachycardiac (fast irregular heartrate), which was only transiently responsive to 1 L fluid bolus (single large dose medicine) .admitted to MICU. Vitals: BP 108/60, pulse 100, SP O2 92%. Labs: WBC (white blood cell) 13.64 (high), Assessment: admitted to MICU for shock of likely mixed etiology, requiring pressors (life support). Problem list: presumed septic shock (widespread infection causing organ failure), AMS (altered mental status), SOB (shortness of breath), Left calcareous wound (ulcer infection), history of osteomyelitis (bone inflammation), hyperbilirubinemia (liver disfunction) and abdominal pain, hypoglycemia (low blood sugar), ESRD (End Stage Renal Disease), hyponatremia (low sodium level), hypothyroidism (underactive thyroid) and HTN (high blood pressure). Addendum at 06/09/2024: Following arrival to the ICU, the patient was noted to have large volume emesis (vomit) that progressed to possible coffee ground emesis. Due to concern for inability to protect airway, the patient was intubated as per procedure note. Record review of Resident #1's Hospital follow-up note dated 06/11/24 revealed, BP 116/66, SP O2 100%, labs: WBC 13.43 (high), IV antibiotic for ESBL and VRE for sacral wound, placed on CRRT (continuous renal replacement therapy) and palliative care consult. Note: Assumed respiratory care of patient with ventilator settings. Interview on 06/11/24 at 3:06 pm with Hospital Representative stated Resident #1 admitted with AMS (altered mental status) and septic shock (widespread infection causing organ failure) and was currently on a ventilator in MICU. He stated Resident #1's prognosis was poor and he was still the same since he admitted . Observation on 06/11/24 at 5:05 pm, Resident #1 was at the hospital's MICU, he was nonresponsive and using a ventilator machine. Interview by phone on 06/12/24 at 12:28 pm, LVN A stated he worked double shift weekends and on 06/08/24 Resident #1 had a change in condition. LVN A said he was good and talking, but then around 7:00 am or 7:30 am he noticed his vitals were low 93/something. He stated he checked Resident #1's vitals again and it was 101/something and kept monitoring the resident and at 9:00 pm he forgot to document those vital signs in the EMR. He stated he checked his vitals several times throughout the day and was not sure why he did not document those readings and not call Resident #1's PA/MD. He stated he left on 06/08/24 around 10:00 pm and gave a report to LVN B to continue monitoring Resident #1 for his low BP. Then stated he did not contact the Dr. because he was able to get Resident #1's vitals up. He stated at the end of his shift he succeeded in getting Resident #1's vitals increased and he was stable. He stated he returned to work on 06/09/24 and checked Resident #1's BP and his vital signs were getting worse and his O2 sats were going down. He stated he called PA D and she told him to send Resident #1 to the hospital because he was having nausea/vomiting, poor eating, low blood sugar and low BP. He stated Resident #1 was able to respond but he was not drinking fluids like he was the day before. He stated he was doing everything he could for Resident #1. He stated he spoke to the corporate nurse and the DON this morning (06/12/24) from 8:00 am - 10:00 am about what he did when Resident #1's BP dropped. He stated they told him he was suspended because of his actions of not calling PA/MD. He stated in hindsight Resident #1 was stable and there was no need for him to go to the hospital until the next day 06/09/24. Interview on 06/12/24 at 2:20 pm, LVN B stated she was Resident #1's night shift nurse on 06/08/24 from 10:00 pm to 06/09/24 at 6:00 am and she usually did her rounds between 4:00 am to 6:00 am. She stated the previous nurse LVN A did not say Resident #1 had a change in condition. She stated if he did, she would have called his Dr. and did another BP check to see what the Dr. wanted to do. She stated she would not play around with someone's life and did what she needed to do to take care of the residents properly. She stated if Resident #1's BP was too low she would have rechecked it and checked his orders to see if anything could have been given by talking to his Dr. She stated if a resident's BP were 93/44, she replied Oh yes she would have called the Dr. about that. She stated she would not play around with the resident's BP because she was there to help the residents. She stated if a resident's BP dropped, they could shut down and go into respiratory distress especially if their BP was low. She stated a resident might end up dying and pass away. Interview on 06/12/24 at 2:44 pm, CNA C stated on 06/09/24 she was doing her rounds and around 6:30 am - 6:45 am Resident #1's speech was slurred like he was tired. She stated she spoke to LVN A and he said he was aware and was making arrangements to send him to the hospital then he was sent to the hospital. She stated the previous time she saw him was 06/06/24 and he appeared to be fine. Interview on 06/12/24 at 4:15 pm, the Administrator stated they had an AD HOC meeting because Resident #1's BP dropped and it was not reported timely to the physician. He stated LVN A got focused on one thing, the vital signs and missed documenting the BP checks. He stated they had a meeting with their Medical Director and they were taking this matter seriously. He stated he had suspended some staff and currently doing countless in-service trainings with the other staff. Interview on 06/12/24 at 5:52 pm, PA D stated she was temporarily filling in working for the regular PA for this facility. She stated she received a call from a nurse that Resident #1's vitals were off on 06/09/24 and she told the LVN to send the resident to the hospital. She stated she had not received any calls from anyone about Resident #1 abnormal vitals on 06/08/24. She stated she expected the nurse to call her or the Dr. when the resident's BPs were low. She stated with Resident #1 being a dialysis patient, she would have ordered him Midodrine to bring his BP back up depending on his pulse and fluid buildup. She stated the treatment depended on the person because everybody was different. She stated if a resident's BP dropped, sepsis or dehydration could occur. She stated she had not spoken to the Administrator about any issues with Resident #1. Interview 06/12/24 at 6:10 pm, the DON stated LVN A said Resident #1 went to the hospital for his irregular vital signs on 06/09/24. She stated the first time she heard about his irregular vitals was 06/09/24 and since finding out LVN A did not call Resident #1's Dr. they started staff trainings. She stated the staff were trained on change of condition and for the on-call person to start reviewing change of condition on the weekends. She stated after review of Resident #1's records he did not complete his dialysis treatment 06/07/24. She stated she saw on Saturday 06/08/24 Resident #1 had a low BP of 93/something then LVN A did another BP check again and it was 101/something. She stated LVN A said he felt like Resident #1's BP was fine so he did not call the Dr. and just gave him fluids and Zofran (prevents nausea). She stated she tried to call LVN A Monday 06/10/24 and spoke to him this morning 06/12/24 and educated him on reporting change of condition, reviewing the 24-hour report on EMR dashboard (EMR overview of all resident information), completing audits on vital signs and went over doing his documentation. She stated he told her he rechecked Resident #1's vital signs but did not document the results. She stated she wrote him up because he failed to follow their change of condition protocol and they reviewed what was a change of condition and abnormal vs. all vital sign types. She stated she spoke to LVN B who also did not do any BP checks and monitoring of Resident #1, because she said, She was not told Resident #1 had abnormal vitals. She stated LVN B said, She did not follow-up with Resident #1's vitals or contacted the Doctor because LVN A did not notify her of his abnormal vitals. She stated LVN B said, had she known she would have asked the PA/MD to get further direction. She stated had LVN A called the Doctor maybe the Doctor would have put Resident #1 on supplemental O2, to get his O2 sats greater than 90% or offer a 120-cc supplemental shake. She stated Resident #1's BP being 93/44 was not his baseline and the Doctor should have definitely been notified after LVN A received that BP reading on 06/08/24. She stated Resident #1 was currently at the hospital intubated with and elevated white blood cell count. She stated they started Inservice trainings with the nurses, CNAs, and MAs on change of condition, knowing when to contact the PA/MD and they had a QAPI meeting today (06/12/24) with the Medical Director. She stated he went over what should be done to prevent this from happening again. She stated she was not sure why every two-hour checks of Resident #1 had not been done because they should have been done on 06/08/24 and 06/09/24. She stated they needed to make sure the nurses looked at the vital audits screen, to review the EMR dashboard. Interview on 06/12/24 at 6:58 pm, the Administrator stated since finding out about Resident #1's condition they had an AD HOC meeting today (06/12/24) about the immediate interventions to put in place. He stated they started re-educating all nursing staff on physician notification, change in condition, and vital signs. He stated they suspended LVN A and gave him a corrective action memo. He stated they put in audit tools right now and the whole team was reviewing the residents' records to ensure vital sign abnormalities were done properly. He stated Resident #1 was currently at the hospital and the marketing director said he was intubated and that was the extent of what he was privy to. He stated the two ADONs and DON was responsible for ensuring change in conditions were being communicated to the PA/MD. In a group interview on 06/13/24 at 10:00 am, the RNC stated they were aware of the issues involving LVN A not notifying the PA/MD when Resident #1 had a change in condition. The RDO stated they were aware of what happened to Resident #1, prior to the HHSC investigator arriving on 06/11/24, but he was not able to say how many employees they had and how many had the in-service trainings. He stated he would follow up with HHSC investigator and provide their internal investigation later. Interview on 06/13/24 at 10:32 am, RN E stated if a resident's BP were to get too low, it could cause the resident to have a significant declination and become lethargic, confused and beyond their baseline. Interview on 06/13/24 at 12:08 pm, the RDO stated all the nurses who worked Monday 06/10/24 were trained on change in condition, before their shifts started. He stated he was not sure who else had been trained and would have to check. He stated as of this day (06/13/24) the Monday-Friday staff were trained on change in condition but the weekend staff had not been yet. He stated LVN A was suspended on Monday 06/10/24 and they had their AD HOC meeting on Monday with the Medical Director. He stated the DON and ADON's did audits and said he was not sure if any other residents were negatively affected. He stated they implemented the Change in condition and using the interact tool stop and watch and notified the physician. He stated the PA/MD had to answer and nursing had to fully assess the residents. He stated they dropped the ball and wanted to ensure the staff were highly trained, to understand how to care for the residents. He stated he would provide the facility's Incident report and Internal investigation. Interview on 06/13/24 at 1:39 pm, the DON stated they spoke to LVN A about what occurred with Resident #1 on 06/08/24 and he was written up this morning 06/13/24 with a warning due to failure to not contact Resident #1's PA/MD when his BP dropped. Interview on 06/13/24 at 3:20 pm, the DON stated she was not sure how many staff had the change in condition training. She stated all staff who worked Monday 06/10/24 had the training but the PRN and weekend staff had not been trained yet. Interview on 06/13/24 at 4:52 pm, the DON stated she received Resident #1's updated hospital report today (06/13/24) and his condition was still the same with a sepsis diagnosis. Record review of the facility's Change in condition policy dated 06/2020 - revealed, Purpose: To ensure residents, family, legal representative, and physicians are informed of changes in the resident's condition in a timely manner. Procedure: The licensed nurse will notify the resident's attending physician, Reporting information to the attending physician, family notification and documentation. An Immediate Jeopardy (IJ) was identified on 06/13/24. An IJ Template was provided to the facility on [DATE] at 10:00 am. While the Immediate Jeopardy was removed on 06/14/24 at 5:00 pm, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. Record review of the facility's Plan of Removal provided to the HHSC investigator on 06/14/24 at 10:45 am and approved at 11:00 am revealed, PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it may concern, Summary of Details which lead [sic] to outcomes: On 6/11/2024, a complaint was initiated at [This facility]. On 6/13/2024 a surveyor provided an IJ Template notification that the Survey Agency has determined that a condition at the center constitute immediate jeopardy to resident health. The notification of the alleged immediate jeopardy states as follows: F580 Change of Condition LVN A failed to contact Resident #1's Dr. after his BP decreased to 93/44 on 06/08/24 at 10:23 am. LVN A checked Resident #1's BP again 06/08/24 at 12:08 pm and it was 101/54 and did not do any further BP checks during the remainder of his shift. On 06/08/24 between 10p - 6 a there was no evidence LVN B checked on Resident #1 during her shift. Interviews with LVN A and LVN B revealed they had not notified the DON or Dr. about Resident #1's condition. Resident #1's NP C and the DON stated they had not received any calls about Resident #1's decreased BP until 06/09/24 when he went to the hospital. Identify residents who could be affected: All residents have the potential to be affected. Identify responsible staff/ what action taken: 1. Licensed Nurses, RNs and LVNs received a re-education by the DON on the facility policy and procedure regarding documentation, notification on following parameters for abnormal BPs. Initiated on 6/10/24 with a completion of 6/14/24. 2. LVN received a 1:1 re-education and disciplinary action including suspension by the DON on the facility policy and procedure notification of changes of condition to the charge nurse promptly. Completed on 6/12/24. 3. Training for licensed Nurses, RNs and LVNs and Medication aides on notification changes of condition to physician and nurse management with proper documentation was initiated on 6/10/2024 by the Director of Nursing with a completion date of 6/14/24. 4. Medication aides and Licensed nurses, LVNs and RNs were also re-educated to follow up on abnormal vital signs by the Director of Nursing on 6 /10/2024 with a completion date of 6/14/24. 5. An audit of all BP medications with parameters was initiated on 6/10/24 by the DON and ADON with a completion date of 6/14/24. 6. Audit of all vitals including BPs to identify any abnormalities from baseline was initiated on 6/10/24 by the DON and ADON. With a completion date of 6/14/24. 7. Post test given to all licensed nurses RN/LVN on change of condition, vitals, notification, and documentation. Initiated 6/10/24 with a completion date of 6/14/24. In-Services conducted: 1. Change in condition. 2. Documentation 3. Notification 4. Vitals The in-service was attended by licensed caregivers which include Registered Nurse, Licensed Vocational Nurse, and Certified Medication Aid [sic], Certified Nurse Aide, and staff from all other departments. Understanding of the in service was verbalized and confirmed by written/ verbal post test. This in-service was initiated on 6/10/24 with a completion date of 6/14/24 and all staff must be in-service before they are allowed to work. New staff will be educated about resident change in condition, documentation, notification and vitals before their floor orientation. Implementation of changes: The changes which include monitoring of vitals (BP) and change in condition of residents through 24 reports [sic] were started by the Director of Nursing. The changes were implemented effective on 6/10/24 with a completion date of 6/14/24 and will be ongoing until all staff are re-educated. The Director of Nursing will ensure competency through verbalization of understanding by staff and in servicing. Monitoring The Administrator/Director of Nursing/Assistant Director of Nursing will be responsible for monitoring the implementation and effectiveness of in-service on 6/10/24. o The Administrator/Director of Nursing/Designee will monitor/review vitals daily and review 24-hour report for change in condition x4 weeks, then weekly x2 weeks, then monthly and report any adverse finding during QAPI o Director of Nursing/Designee will conduct a daily audit of vitals and change in condition daily x4 weeks, then weekly x 2 weeks, then monthly and report any adverse findings during QAPI o Director of Nursing/Designee will conduct a daily audit of vitals daily x4 weeks, then weekly x 2 weeks, then monthly and report any adverse findings during QAPI Involvement of Medical Director The Medical Director met with the Interdisciplinary team on 6/10/24 and conducted an Ad HOC QAPI regarding physician notification, documentation, change in condition, and vitals. The Medical Director was notified about the immediate Jeopardy on 6/13/24, the Plan of removal was reviewed and accepted by Doctor. Involvement of QA An Ad Hoc QAPI meeting was held with the Medical Director, Facility Administrator, Director of Nursing and Assistant Director of Nursing to review plan of removal on 6/10/24 [sic] Who is responsible for the implementation of process? The Director of Nursing will be responsible for the implementation of the new process. The New Process/system was started on 6/10/2024. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy verbally issued on 6/13/2024. [END] In a group meeting on 06/14/24 at 11:00 am, The Administrator, DON, RDO and RNC was notified that the POR was accepted and this facility was in the monitoring phase to ensure their POR was implemented. Interview on 06/14/24 at 11:10 am, RNC stated they were still working on their investigation summary. Interview on 06/14/24 at 2:55 pm, the DON stated they would start having the on-call weekend nurse review the 24-hour EMR dashboard for any changes of the resident's vital signs. She stated she was responsible for ensuring the staff followed their change in condition policy. She stated her expectations were for the staff to monitor the residents and if anything was different from their baseline, they needed to notify the PA/MD and RP. She stated not monitoring the residents and notifying the PA/MD could cause the staff to miss something that could delay care. She stated it could further delay getting the resident evaluated resulting in a number of things such as a worsening condition or death. Interview on 06/14/24 at 4:00 pm, the Administrator stated based on what occurred with Resident #1, they planned on terminating LVN A, and complete the Inservice trainings with everyone. He stated the DON and two ADON's would continue reviewing the residents' vital signs daily with his oversight over the nurse management team. He stated the weekend nurse supervisor would be doing the monitoring of the vitals on the weekends to ensure the nurses were notifying the PA/MD. He stated all staff had to do their change in condition trainings with the post tests before they were able to work on the floor. He stated they had 117 employees total and was not sure how many more staff needed to be trained then said maybe one or two staff. He stated in the QA (Quality Assurance) Meeting they reviewed with the medical director Resident #1's change in condition and what could be done to prevent this from happening again. He stated if residents had a change in condition and the PA/MD was not notified, could result in the deterioration of the resident and exacerbation of the resident's symptoms. He stated his expectation for resident care was for PA/MD notifications and documentation were done. Record review of the Facility's Investigation undated provided by the Administrator on 06/14/24 at 1:24 pm revealed, Internal Investigation Re: Resident #1 Patient Information: Resident is a [AGE] year-old male who admitted to facility on xx/xx/xxxx under the care of Dr. XXX. Resident is cognitively intact as evidenced by a BIMS score of 15. Primary diagnosis: osteomyelitis, left ankle and foot. Additional diagnosis: PVD, major depressive disorder, type 2 diabetes, acute and subacute infective endocarditis (heart infection), anemia (low iron), and hypertension. Incident: On 6/8/2024 LVN A documented Resident #1 to have the following vital signs: BP 93/44, O2:88% room air, P106, FSBS 67 mg/dl. Weakness, vomiting, poor eating. LVN A did not document notification of these abnormal vital signs to Physician. On 6/9/2024 LVN A documented Resident #1 to have the following vital signs: BP83/44, P111, O2:88% RA, R21/min, T97.8, FSBS 85mg/dl LVN A called physician's PA and resident was sent to acute care hospital via EMS. Investigation: Interview with LVN A revealed the following: LVN A said he was concerned about the blood sugar level and that is why he gave the patient 120 mL of orange juice. He said that he repositioned the patient in the bed to address the other abnormal vital signs. He says that he had remeasured his BP and that it had started going up into the normal ranges. Review of the Medication Aides charting she had recorded a BP high enough that BP reducing medication according to parameters was administered. The medication aide said that the patient seemed stable and normal with no signs of distress during medication administration, and he received medications well. LVN A admits that he did not notify the physician of the abnormal vitals on Saturday. He also admits that he did not document the later vital signs that he had taken in the medical record. Actions to Address: LVN A was given one on one in-service by DON on expectations for physician notification for any abnormal vital signs and medication administration. Employee suspended pending investigation. [END] Interviews on 06/13/24 between 10:32 am - 11:40 am with RN E, RN F, LVN G, MA H, CNA I revealed they were trained between 06/10/24 and 06/13/24 on change in condition, notifying PA/MD of drops in resident's BPs., Interviews on 06/14/24 between 11:44 am - 3:34 pm revealed, LVN K, Medical Record L, MA M, Housekeeper/Laundry aide N, Housekeeper O, Dietary aide P, Dietary cook Q, Laundry aide R, Laundry aide S, RN T, ADON U, OT (Occupational Therapy) V, PTA (Physical Therapy Assistant) W, CNA X, MA Y, RN Z stated they were trained between 06/10/24 and 06/14/24 on change in condition, notifying the PA/MD, stop and watch and notifying the nurses, the DON and ADONs when a resident had a change in condition. Record review on 06/13/24 of the facility's Supporting documents emailed by the Administrator on 06/12/24 at 9:10 pm revealed, Inservice trainings on 06/10/24 with mostly administrative/department head staff and some floor staff. And on 06/11/24 and 06/12/24 more floor staff were trained on change in condition and stop and watch reporting. Record review on 06/13/24 of the facility's Supporting documents emailed by the Administrator on 06/13/24 at 2:22 pm, revealed three duplicate in service signature sheets dated 06/10/24. There was signed training sheets from the 8:00 am to 5:00 pm staff on 06/10/24 on topics change in condition and. And signature sheets on 06/12/24, posttests from 06/10/24 - 06/13/24 and resident chart audits from 06/10/24 to 06/13/24 revealed staff were proficient in change in condition procedures. Record review of signage posting currently being put at all nurses stations: NOTIFY MD/NP OF LOW BLOOD PRESSURES . SYSTOLIC LESS THAN 95 DIASTOLIC LESS T:HAN . SYSTOLIC GREATER THAN 170 AND DIASTIC GREATER THAN 90 . ASSESS YOUR PATIENT AND DOCUMENT. Record review of LVN A's Corrective Action Memo dated 06/12/24 by DON revealed, Violation of policy and procedure, carelessness, Employer Statement: Acute change in condition is a sudden, clinically important deviation from the patient's baseline in physical, cognitive, behavioral, or functional domains. Clinically important means a deviation that, without intervention, may result in complications or death. Alert charting is documentation done to track a medical event for a period of 72 hours or longer. Events may include but not necessarily limited to suspected or actual change in condition. Action being taken Suspension Objective/Solution: Employee will understand the importance of communicating change of condition with MD, NP, DON, ADON, on call phone. Employee will review abnormal vital signs and verbalize values in EMR Failure to document indicates task was not completed. Employee will be suspended pending investigation. Employee statement: blank. Signed by LVN A and DON. Record review of LVN B's Corrective Action memo dated 06/13/24 by DON revealed, Violation of policy and procedure Employer Statement: Treatments completed and documented as per physician's order. Documentation will be completed by the end of the assigned shift. Failure to document means task was not completed. Written warning. Objective/Solution: Employee will document task completed by the end of assigned shift. Employee Statement: Blank. Signed by LVN B and DON. An Immediate Jeopardy (IJ) was identified on 06/13/24. An IJ Template was provided to the facility on [DATE] at 10:00 am. While the Immediate Jeopardy was removed on 06/14/24 at 5:00 pm, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effecti [TRUNCATED]

Based on observation, record reviews and interviews the facility failed to ensure that based on the comprehensive assessment of a resident, residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of eight residents reviewed for quality of care. 1. LVN A failed to provide appropriate treatment and care on 06/08/24 as indicated: a. Did not monitor and check Resident#1's BP after 12:08 pm. b. Did not notify the DON and LVN B, about Resident #1's change in condition and need for continued BP monitoring. c. Did not follow Resident #1's Nephrologist's Doctor order and this facility's Care Plan to ensure the resident did not experience possible fluid overload. 2. LVN B failed to check on Resident #1 throughout her shift and she said she did a BP check on Resident #1 at 5:00 am on 06/09/24 but failed to document it. An Immediate Jeopardy (IJ) was identified on 06/13/24. An IJ Template was provided to the facility on [DATE] at 10:00 am. While the Immediate Jeopardy was removed on 06/14/24 at 5:00 pm, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. These failures could place residents at risk of harm which could cause a decline in their health and psycho-social well-being and lead to need for hospital intervention or death. Findings included: Observation on 06/11/24 at 5:05 pm, Resident #1 was at the hospital's MICU, he was nonresponsive and using a ventilator machine (life support). Record review of the facility's census revealed they had 114 residents. Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a male who admitted to this facility 08/03/23 with a BIMS Score of 10 (moderate cognitive impairment). He had 1 sided upper extremity impairment and 2 sided lower extremity impairment and substantial maximal assist with ADL's. He was frequently incontinent to bladder and always incontinent to bowel. He had medically complex conditions with diagnoses anemia (low red blood cells and hemoglobin), hypertension (high blood pressure), peripheral vascular disease (circulatory condition/reduced blood flow). And diagnosed with renal insufficiency (kidney failure), diabetes mellitus (high blood sugar), hyperlipidemia (high level fat particles), malnutrition (lack of nutrients), depression (lowered mood), and generalized muscle weakness (muscle weakness). Record review of Resident #1's Order Summary Report dated 06/12/24 revealed orders for: regular diet with thin liquids, 2.0 supplement 120cc 3xd, Amlodipine besylate oral tab 10 mg, 1-tab 1xd for HTN, hold SBP <110, DBP <60, HR 60, and Ondansetron HCI (hydrochloride) Oral tab 4 mg 1 tab by mouth every 6 hours a needed for nausea and vomiting. And there was not any standing orders for renal diet wirh fluid restrictions. Record review of Resident #1's Care Plan printed 06/12/24 revealed, date initiated: 08/08/23: dialysis due to chronic kidney disease, altered respiratory status/difficulty breathing related to history of respiratory failure, impaired cognitive function or thought processes. And had bladder incontinence, communication problem and dialysis and diabetes. Date initiated: 01/25/24: potential for fluid overload related to kidney failure: will remain free of signs/symptoms of fluid overload through review date, as evidenced by . changes in mood or behavior, nausea/vomiting . Date Initiated: 01/25/2024: Monitor/document/report to MD PRN signs/symptoms of fluid overload Hypertension related to Norvasc - Oral. Date Initiated: 08/09/2023, Revision on: 08/09/2023: will maintain a blood pressure within the following parameters: (110/60) through review date. Revision on: 03/03/2024, Target Date: 07/21/2024. Record review of Resident #1's Progress note by LVN A dated 06/08/24 at 9:13 am revealed, Resident noted with abnormal vital signs: BP 93/44, O2:88% room air . Weakness, vomiting, poor eating. Resident offered 120 ml of orange juice, elevated head of bed, and more fluid. (There was not any documentation showing LVN A monitored or checked Resident #1's BP on 06/08/24 from 12:09 pm to 10:00 pm. And there was no documentation LVN A notified the DON and LVN B on 06/08/24 about Resident #1's change in condition and fluid amounts given). Record review of Resident #1's Progress note by LVN A dated 06/09/24 at 9:15 am revealed, Resident noted with abnormal vital signs: BP 83/44, O2:88% RA . Resident very weak, nausea, vomiting, poor eating. Resident is alert. PA notified and ordered resident to be sent to hospital using 911. 911 called and took resident to hospital. Family member informed that resident is sent to hospital. DON notified. Record review on Resident #1's Progress note from 06/08/24 from 10:00 pm to 06/09/24 at 6:00 am, revealed LVN B did not document she checked on Resident #1 every two hours or at all during her shift. Record review of Resident #1's SBAR Communication Form dated 06/09/24 by LVN A revealed, Before calling MD/NP/PA evaluate the resident, check vital signs, review record, review an INTERACT(Interventions to Reduce Acute Care Transfers) care path or acute change in condition file card. Have relevant information when reporting. Situation: This started on 06/08/24, since this started it has gotten worse, BP 83/44, altered level of consciousness, weakness, Full Code review and notify: Primary Care Clinician notified yes 06/09/24 8:15 am. Record review of Resident #1's Hospital H&P (history & physical) dated 06/09/24 revealed, Upon arrival to the ED (emergency department), the patient was noted to be minimally responsive with poor oral care .he was hypotensive (low blood pressure) and tachycardiac (fast irregular heartrate), which was only transiently responsive to 1 L fluid bolus (single large dose medicine) .admitted to MICU. Vitals: BP 108/60, pulse 100, SP O2 92%. Labs: WBC (white blood cell) 13.64 (high), Assessment: admitted to MICU for shock of likely mixed etiology, requiring pressors (life support). Problem list: presumed septic shock (widespread infection causing organ failure), AMS (altered mental status), SOB (shortness of breath), Left calcareous wound (ulcer infection), history of osteomyelitis (bone inflammation), hyperbilirubinemia (liver disfunction) and abdominal pain, hypoglycemia (low blood sugar), ESRD (End Stage Renal Disease), hyponatremia (low sodium level), hypothyroidism (underactive thyroid) and HTN (high blood pressure). Addendum at 06/09/2024: Following arrival to the ICU, the patient was noted to have large volume emesis (vomit) that progressed to possible coffee ground emesis. Due to concern for inability to protect airway, the patient was intubated as per procedure note. Record review of Resident #1's Hospital follow-up note dated 06/11/24 revealed, BP 116/66, SP O2 100%, labs: WBC 13.43 (high), IV antibiotic for ESBL and VRE for sacral wound, placed on CRRT (continuous renal replacement therapy) and palliative care consult. Note: Assumed respiratory care of patient with ventilator settings. Interview on 06/11/24 at 3:06 pm with Hospital Representative stated Resident #1 admitted with AMS and septic shock and was currently on a ventilator in MICU. He stated Resident #1's prognosis was poor and he was still the same since he admitted . Interview by phone on 06/12/24 at 12:28 pm, LVN A stated he worked double shift weekends and stated on 06/08/24 Resident #1 had a change in condition. LVN A said he was good and talking, but then around 7:00 am or 7:30 am he noticed his vitals were low 93/something. He stated Resident #1 was alert/orient and drank his Orange Juice then he vomited and then gave him Zofran (prevent nausea/vomiting) He stated he checked Resident #1's vitals again and it was 101/something and kept monitoring the resident and at 9:00 pm he forgot to document those vital signs in the EMR. He stated he checked his vitals several times throughout the day and was not sure why he did not document those readings. He stated he left on 06/08/24 around 10:00 pm and gave a report to LVN B to continue monitoring Resident #1 for his low BP. He stated at the end of his shift he succeeded in getting Resident #1's vitals increased and he was stable. He stated he forgot to document checking Resident #1's BP throughout the duration of his shift on 06/08/24, because it was the end of the shift but knew he should have documented that. He stated not documenting resident's vitals could make it very hard to follow up and compare previous conditions and limit communication because the documentation was missing. He stated he spoke to the corporate nurse and the DON this morning (06/12/24) from 8:00 am - 10:00 am about what he did when Resident #1's BP dropped. He stated they told him he was suspended because of his actions of not calling the DON. Interview on 06/12/24 at 2:20 pm, LVN B stated she was Resident #1's night shift nurse on 06/08/24 from 10:00 pm to 06/09/24 at 6:00 am and she usually did her rounds between 4:00 am to 6:00 am. She stated on 06/09/24 she saw Resident #1 at 5:00 am and took his BP and it was normal and he had no fever, he was stable. She stated she put his vital signs on his dialysis paper and not the EMR. She stated he said good morning to her and was talking and she gave him some water. She stated there was only two nurses that worked upstairs on her shift and she had a lot to do and wrote Resident #1's BP reading on her pad. She stated the previous nurse LVN A did not say Resident #1 had a change in condition. She stated if he did, she would have called his Dr. and did another BP check to see what the Dr. wanted to do. She stated she would not play around with someone's life because she would ensure the residents were properly cared for. She stated if Resident #1's BP was too low she would have rechecked it and checked his orders to see if anything could have been given and by talking to his Dr. She stated if a resident's BP were 93/44, she replied Oh yes she would have called the Dr. about that. She stated she would not play around with the resident's BP and would check it more often because it could drop. She stated upstairs they only had two nurses on the night shift and she and other nurse had to split one of the halls (Hall E) for which Resident #1 was on. She stated she was not able to complete all her documentation at night, because they really needed a third night nurse upstairs to cover Hall E. She stated she asked about getting another nurse and the administrator said they would once they were full upstairs. She stated if a resident's BP dropped, they could shut down and go into respiratory distress especially if their BP was low. She stated a resident might end up dying and pass away. Interview on 06/12/24 at 4:15 pm, the Administrator stated LVN A got focused on one thing, the vital signs and missed documenting the BP checks. He stated they had a meeting with their Medical Director and they were taking this matter seriously. He stated he suspended some staff and currently doing countless in-service trainings with the other staff. Interview on 06/12/24 at 5:52 pm, PA D stated if a resident's BP dropped, sepsis or dehydration could occur. Interview on 06/12/24 at 6:10 pm, the DON stated LVN A said Resident #1 went to the hospital for his irregular vital signs on 06/09/24. She stated the first time she heard about Resident #1's irregular vitals was 06/09/24. She stated on 06/08/24 they started staff trainings on change of condition and for the on-call person to start reviewing change of condition on the weekends. She stated she saw on Saturday 06/08/24 Resident #1 had a low BP of 93/something then LVN A did another BP check again and it was 101/something. She stated LVN A said, He felt like Resident #1's BP was fine and just gave him fluids and Zofran. She stated she tried to call LVN A Monday 06/10/24 and spoke to him this morning 06/12/24 and educated him on reporting change of condition, reviewing the 24-hour report on EMR dashboard, completing audits on vital signs, and went over doing his documentation. She stated she wrote him up because he failed to follow their change of condition protocol and they reviewed what was a change of condition and abnormal vs. all vital sign types. She stated LVN B said she did not follow-up with Resident #1's vitals because LVN A did not notify her of his abnormal BP. She stated LVN B said had she known she would have asked the MD/NP to get further direction. She stated Resident #1 was currently at the hospital intubated (tube place down throat to assist with breathing) and elevated white blood cell count. She stated they started Inservice trainings with the nurses, CNAs, and MAs on change of condition and they had a QAPI meeting today (06/12/24) with the Medical Director. She stated the Medical Director went over what should be done to prevent this from happening again. She stated they had enough nurses working upstairs, because they had roughly 80 residents on the 2nd floor and from 10:00 pm - 6:00 am there was two nurses because only PRN medications were given. She stated she was not sure why every two-hour checks of Resident #1 had not been done because they should have been done on 06/08/24 and 06/09/24. She stated they needed to make sure the nurses looked at the vital audits screens by reviewing the EMR dashboard for any abnormal vital readings. Resident #1 did not have any fluid restriction standing orders but could see LVN A gave Resident #1 120 cc of orange juice. She stated she was not aware the documentation showed LVN A gave the resident 'more fluids'. Interview on 06/12/24 at 6:58 pm, the Administrator stated since finding out about Resident #1's condition they had an AD HOC meeting today (06/12/24) about the immediate interventions to put in place. He stated they started re-educating all nursing staff on change of condition, and vital signs. He stated they suspended LVN A and gave him a corrective action memo. He stated they put in audit tools right now and the whole team was reviewing the residents' records to ensure vital sign abnormalities were done properly. He stated Resident #1 was currently at the hospital and the marketing director said he was intubated and that was the extent of what he was privy to. In a group interview on 06/13/24 at 10:00 am, the RNC stated they were aware of the issues involving LVN A not notifying the PA/MD when Resident #1 had a change in condition. The RDO stated they were aware of what happened to Resident #1, prior to the HHSC investigator arriving on 06/11/24, but he was not able to say how many employees they had and how many had the in-service trainings. He stated he would follow up with HHSC investigator and provide their internal investigation later. Interview on 06/13/24 at 10:32 am, RN E stated if a resident's BP were to get too low, it could cause the resident to have a significant declination and become lethargic, confused and beyond their baseline. Interview on 06/13/24 at 10:50 am, RN F stated if a resident who was on dialysis had a drop in their BP, she would never give them fluids because they could retain the fluids and could get fluid overload. She stated especially if the Doctor did not order additional fluids. She stated if a resident's BP were too low or high, she would give them the PRN medication and check their BP within 30 minutes to an hour. She stated all of her focus would be on that resident. She stated she would get more BP readings to ensure the resident was stable. Interview on 06/13/24 at 11:16 am, LVN G stated if a resident's BP dropped, they could pass out and said she would not just give a resident fluids because she was just a nurse who worked based off of Dr. orders. She stated if a dialysis resident who was on dialysis had a 93/44 BP, she would never give them fluids without a Dr. order. Interview on 06/13/24 at 12:08 pm, the RDO stated all the nurses who worked Monday 06/10/24 were trained on change in condition and stop and watch reporting, before their shifts started. He stated he was not sure who else had been trained and would have to check. He stated as of this day (06/13/24) the Monday - Friday staff were trained on change in condition but the weekend staff had not been yet. He stated LVN A was suspended on Monday and they had their AD HOC meeting on Monday (06/10/24) with the Medical Director. He stated the DON and ADONs did audits and said he was not sure if any other residents were negatively affected. He stated they implemented the Change in condition interact tool stop and watch. He stated they dropped the ball and wanted to ensure the staff were highly trained, to understand how to care for the residents. Interview on 06/13/24 at 1:39 pm, the DON stated they were going to audit every resident getting BP medications. She stated they spoke to LVN A about what occurred with Resident #1 on 06/08/24. And LVN B was written up this morning (06/13/24) due to failure to not document Resident #1's vital signs. Interview on 06/13/24 at 3:20 pm, the DON stated she was not sure how many staff had the change in condition training. She stated all staff who worked Monday 06/10/24 had the training but the PRN and weekend staff had not been trained yet. Interview on 06/13/24 at 4:52 pm, the DON stated she received Resident #1's updated hospital report today (06/13/24) and his condition was still the same with a sepsis diagnosis. Record review of the facility's Care and Services Policy dated 06/2020 revealed, To ensure through an interdisciplinary team (IDT) process, that all residents receive the necessary care and services based on an individualized comprehensive assessment process. Policy: Residents are provided with the necessary care and services to maintain the highest practicable. physical, mental, and social well-being level of in an environment that enhances quality of life in the scope of a long-term care facility. Care and services are provided in a manner that consistently enhances self-esteem and self-worth. Procedure: I. The Facility will have sufficient staff to provides services to residents with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being as determined by individualized resident assessments and plans of care. An Immediate Jeopardy (IJ) was identified on 06/13/24. An IJ Template was provided to the facility on [DATE] at 10:00 am. While the Immediate Jeopardy was removed on 06/14/24 at 5:00 pm, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. Record review of the facility's Plan of Removal provided to the HHSC investigator on 06/14/24 at 10:45 am and approved at 11:00 am revealed, PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it may concern, Summary of Details which lead to outcomes: On 6/11/2024, a complaint was initiated at [This facility]. On 6/13/2024 a surveyor provided an IJ Template notification that the Survey Agency has determined that a condition at the center constitute immediate jeopardy to resident health. The notification of the alleged immediate jeopardy states as follows: F 684 Quality of Care - Based on observation, interviews, and record reviews LVN A failed to contact the resident's Doctor after Resident #1's BP decreased to 93/44 on 06/08/24 at 10:23 am. LVN A checked Resident #1's BP again 06/08/24 at 12:08 pm and it was 101/54 and did not do any further BP checks during the remainder of his shift. There's no documentation of the 10p - 6 a LVN B checking Resident #1 or doing vitals. Then on 06/09/24 at 8:37 am LVN A returned to work and checked Resident #1's BP was 83/44 then Resident #1 was sent to the hospital. Identify residents who could be affected: All residents have the potential to be affected. Identify responsible staff/ what action taken: 1. Director of Nurses were re-educated by the Regional Nurse Consultant on the facility policy on monitoring, documenting, and reporting abnormal signs or symptoms on 6/10/2024. Understanding was verified by a written posttest. 2. Licensed Nurses received a re-education by the DON on the facility policy and procedure on physician notification and documentation initiated on 6/10/2024. Knowledge of education was verified by written signatures and verbalization of understanding completed on 6/14/2024. 3. Training for licensed nurses and medication aides on notification of changes in condition to physician and nurse management with proper documentation was initiated on 6/10/2024 by the Director of Nursing. Knowledge of education was verified by written signatures and verbalization of understanding completed on 6/14/2024. 4. Training for non-clinical staff on notification of changes in condition to the charge nurse or nurse manager 6/10/2024 by the Director of Nursing. Knowledge of education was verified by written signatures and verbalization of understanding completed on 6/14/2024. 5. Training for licensed nurses on Physician notification on critical lab results and abnormal vital signs with proper documentation was initiated on 6/10/2024 by the Director of Nursing. Knowledge of education was verified by written signatures and verbalization of understanding completed on 6/14/2024. 6. An audit of all resident vital signs was initiated on 6/10/2024 by DON and ADON. To verify that physician was notified of any abnormal reading. Audit was completed on 6/10/2024. In-Services conducted: 1. Change in condition. 2. Medication administration 3. Physician notification 4. Labs and Vitals 5. Documentation of care provided The in-services were attended by licensed caregivers which include Registered Nurse, Licensed Vocational Nurse, Certified Medication Aide, Certified Nurse Aides and staff from all other departments. Understanding of in-services was verified with a written/and or verbal posttest. This in-service was initiated on 6/10/2024 and completed on 06/14/2024. All staff must be in-serviced before they are allowed to work. New staff will be educated about resident change in condition, medication administration, physician notification before their floor orientation and monitoring will be continued ongoing by the DON/Designee. Implementation of changes (Monitoring all or any medication not given and change in condition of residents through 24-hour report). The changes which include daily monitoring of lab results, vital sign readings, change in condition and physician notification of residents through 24-hour reports were started by the Director of Nursing. The changes of monitoring of all residents with a change in condition and abnormal vital signs or labs /imaging results over 24hr were implemented effective on 6/10/2024 and completed on 06/14/2024. No staff will be allowed to work before completion of these in-services. The Director of Nursing will ensure competency through verbalization of understanding by staff and in servicing. Monitoring The Administrator/Director of Nursing/Assistant Director of Nursing will be responsible for monitoring the implementation and effectiveness of in-service on 6/10/2024. o The Director of Nursing/Designee will monitor/review vital signs daily and review 24-hour reports for change in condition and physician notification x4 weeks, then weekly x2 weeks, then monthly and report any adverse finding during QAPI. o Director of Nursing/Designee will conduct a daily audit of resident vital signs and change in condition daily x4 weeks, then weekly x 2 weeks, then monthly and report any adverse findings during QAPI. Involvement of Medical Director The Medical Director met with the Interdisciplinary team on 6/10/2024 and conducted an Ad HOC QAPI regarding physician notification and change in condition. The Medical Director, Doctor was notified about the immediate Jeopardy on 6/13/2024, the Plan of removal was reviewed and accepted by Doctor. Involvement of QA An Ad Hoc QAPI meeting was held with the Medical Director, facility administrator, director of nursing, and social services director to review plan of removal on 6/13/2024. Who is responsible for the implementation of the process? The Director of Nursing will be responsible for the implementation of the new process. The New Process/system was started on 6/10/2024. The Administrator will ensure DON implements the new process. Regional Nurse Consultant will audit the implementation of the new process. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy verbally issued on 6/13/2024. [END] In a group interview on 06/14/24 at 11:00 am, The Administrator, DON, RDO and RNC was notified that the POR was accepted and this facility was in the monitoring phase to ensure their POR had been implemented. Interview on 06/14/24 at 11:10 am, RNC stated they were still working on their investigation summary. She stated LVN A gave Resident #1 120 cc of orange juice from his meal tray and was not aware more fluids was given as reported in the progress notes, she said Resident #1 was not on a fluid restriction or renal diet and they just recently scheduled a meeting with Resident #1's dialysis staff to get fluid restriction and renal diet and go over other dialysis orders to ensure their accurate. Interview on 06/14/24 at 2:33 pm, RN Z stated the nurses needed to give treatments to the residents that were PA/MD ordered and he would ensure checking the resident's BP for the remainder of the shift if they had a change in condition. Interview on 06/14/24 at 2:55 pm, the DON stated they would start having the on-call weekend nurse review the 24-hour EMR dashboard for any changes of the resident's vital signs and nurses' documentation. She stated she was responsible for ensuring the staff followed their change in condition policy. She stated her expectations was for the staff to monitor the residents and if anything was different from their baseline, . She stated not monitoring the residents and could cause the staff to miss something that could delay care. She stated it could further delay in getting the resident evaluated resulting in a number of things such as a worsening condition or death. Interview on 06/14/24 at 4:00 pm, the Administrator stated based on what occurred with Resident #1, they planned on terminating LVN A and completed Inservice trainings with almost everyone. He stated the DON and two ADONs would continue reviewing the residents' vital signs daily with his oversight over the nurse management team. He stated the weekend nurse supervisor would be doing the monitoring of the vitals on the weekends to ensure the nurses were He stated all staff had to do their change in condition trainings with the post tests before they were able to work on the floor. He stated they had 117 employees total and was not sure how many more staff needed to be trained. He stated in the QA (Quality Assurance) Meeting they reviewed with the medical director about Resident #1's change in condition and what could be done to prevent this from happening again. He stated if residents had a change in condition and not documented timely, could result in the deterioration and exacerbation of the resident's symptoms. He stated his expectation for resident care was for documentation of the residents were done. He stated they have a care meeting scheduled with the resident's dialysis center next week to ensure the Doctor order were correct. He stated the Medical Doctor agreed the meeting with dialysis was a good idea. Interviews on 06/13/24 between 10:32 am - 11:40 am with RN E, RN F, LVN G, MA H, CNA I revealed they were trained between 06/10/24 and 06/13/24 on change in condition, of drops in resident's BP and documentation residents vital signs. Interviews on 06/14/24 between 11:44 am - 3:34 pm revealed, LVN K, Medical Record L, MA M, Housekeeper/Laundry aide N, Housekeeper O, Dietary aide P, Dietary cook Q, Laundry aide R, Laundry aide S, RN T, ADON U, , CNA X, MA Y, RN Z stated they were trained between 06/10/24 and 06/14/24 on change in condition, documentation, stop and watch and notifying the nurses, the DON and ADONs when a resident had a change in condition. Record review on 06/13/24 of the facility's Supporting documents emailed by the Administrator on 06/12/24 at 9:10 pm revealed, Inservice trainings on 06/10/24 with mostly administrative/department head staff and some floor staff. And on 06/11/24 and 06/12/24 more floor staff were trained on change in condition and stop and watch reporting. Record review on 06/13/24 of the facility's Supporting documents emailed by the Administrator on 06/13/24 at 2:22 pm, revealed three duplicate in service signature sheets dated 06/10/24. There was signed training sheets from the 8:00 am to 5:00 pm staff on 06/10/24 on topics change in condition and documentation. And signature sheets on 06/12/24, posttests from 06/10/24 - 06/13/24 and resident chart audits from 06/10/24 to 06/13/24 revealed staff were proficient in change in condition and documentation procedures. Record review of signage posting currently being put at all nurses stations: NOTIFY MD/NP OF LOW BLOOD PRESSURES . SYSTOLIC LESS THAN 95 DIASTOLIC LESS T:HAN . SYSTOLIC GREATER THAN 170 AND DIASTIC GREATER THAN 90 . ASSESS YOUR PATIENT AND DOCUMENT. Record review of LVN A's Corrective Action Memo dated 06/12/24 by DON revealed, Violation of policy and procedure, carelessness, Employer Statement: Acute change in condition is a sudden, clinically important deviation from the patient's baseline in physical, cognitive, behavioral, or functional domains. Clinically important means a deviation that, without intervention, may result in complications or death. Alert charting is documentation done to track a medical event for a period of 72 hours or longer. Events may include but not necessarily limited to suspected or actual change in condition. Action being taken Suspension Objective/Solution: Employee will understand the importance of communicating change of condition with DON, ADON, on call phone. Employee will review abnormal vital signs and verbalize values in EMR Failure to document indicates task was not completed. Employee will be suspended pending investigation. Employee statement: blank. Signed by LVN A and DON. Record review of LVN B's Corrective Action memo dated 06/13/24 by DON revealed, Violation of policy and procedure Employer Statement: Treatments completed and documented as per physician's order. Documentation will be completed by the end of the assigned shift. Failure to document means task was not completed. Written warning. Objective/Solution: Employee will document task completed by the end of assigned shift. Employee Statement: Blank. Signed by LVN B and DON. Record review of the facility Dialysis Care policy dated 06/2020 revealed, To provide care for residents diagnosed with renal disease requiring ongoing dialysis treatments. Policy: I. The Facility will be responsible for the overall care delivered to the resident, monitoring of the resident prior to and after the completion of each dialysis treatment, and providing for all nondialysis needs of the resident including during the time period when the resident is receiving dialysis. II. The Facility maintains a contract with a dialysis service provider which addresses communications between the Facility and Provider. Record review of the facility's Licensed

Based on interview and record review, the facility failed ensure residents were free of any significant medication errors for one (Residents #1) of three residents reviewed for medications. Nurse C failed to give the PRN Clonidine as ordered by the physician for Resident #1 on 10/17/23, 10/27/23, 11/08/23, and 11/09/23, when Resident #'s systolic blood pressure was over 170. Resident #1 was sent to the hospital on 11/16/23 after a change of condition, when Resident #1's initial blood pressure was documented as 214/117, Resident #1 did not eat breakfast, could not swallow, and jaws shifted to the left. Resident #1's hospital admission diagnoses was a hemorrhagic stroke. Resident #1 passed away at the hospital on 11/18/23. An immediate Jeopardy was identified on 12/29/23. While the Immediate Jeopardy was removed on 01/02/24, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not Immediate Jeopardy, due to the facility continuation of in-servicing and monitoring the Plan of Removal. This failure could affect residents by placing them at risk for a delay in medical treatment, worsening in condition, or possible death. Findings included: Record review of Resident #1' face sheet, dated 01/02/24, revealed a [AGE] year-old female, who admitted to the facility on [DATE], with a readmitted [DATE]. Her diagnoses included Seizures, Cerebral Infarction (stroke), Vitamin D deficiency, Long-term use of anticoagulants (blood thinners), Dysphagia (difficulty swallowing), Difficulty in walking, Cognitive Communication Deficit (difficulty thinking and how someone uses language), Conversion Disorder with Seizures or convulsions (physical and sensory problems), Hyperlipidemia (high cholesterol), and Essential Hypertension (high blood pressure). Record review of the active physician's order dated 10/30/22, revealed the following: Clonidine HCI tablet 0.1 MG. Give 1 tablet by mouth every 12 hours as needed for elevated B/P related to essential (primary) hypertension. Give clonidine 0.1 MG if the systolic blood pressure is > 170. Record review of Resident #1's Care Plan, dated 11/09/23, revealed the following, [Resident Name] will remain free from s/sx of hypertension through the next review date. Give anti-hypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension (blood pressure issues when standing up or sitting down) and increased heart rate and effectiveness. Monitor for and document any edema. Notify MD. Monitor/Document/Report to MD PRN any s/sx of malignant hypertension: Headache, visual problems, confusion, disorientation, lethargy, nausea and vomiting, irritability, seizure activity, difficulty breathing. Obtain blood pressure readings per order. Take blood pressure readings under same condition each time. Record review of Resident #1's Medication Administration Record dated, October 2023, revealed a blood pressure reading on 10/17/23 of 200/108 and another blood pressure reading on 10/27/23 of 196/113. There was no documentation of the blood pressure rechecked after these readings. There was no evidence documented that the PRN clonidine was administered to Resident #1 on either of these dates. Record review of Resident #1's Medication Administration Record, dated, November 2023, revealed a blood pressure reading on 11/08/23 of 185/30 and another blood pressure reading on 11/09/23 of 181/111. There was no documentation of the blood pressure rechecked after these readings. There was no evidence documented that the PRN clonidine was administered to Resident #1 on either of these dates. Record review of Resident #1's Progress Notes/Nurses Notes on the electronic record, revealed no documentation on 10/17/23, 10/27/23, 11/08/23, or 11/09/23. There was no documentation on Resident #1' electronic record regarding, rechecked blood pressure, administration of clonidine, or a consultation with the physician. There was no documentation that Resident #1's physician was contacted on either of these days. Record review of the progress note on 11/16/23, revealed the resident's physician was contacted regarding the change in condition. Record review of Resident #1's Progress Notes/Nurse Notes on the electronic record, revealed on 11/16/23, resident was checked on at 6:02 AM by Nurse G, she appeared stable, then 8:30 AM, Nurse G noticed she was not eating her breakfast, did not respond when her name was called, but just looked at the nurse. It was noted Nurse G noticed resident could not swallow, vitals were taken, and Resident #1's blood pressure was 214/117. The PRN Clonidine was noted as given, Nurse G rechecked vital signs at 10:03 AM and Resident #1's blood pressure was 161/89. It was noted that Nurse G noticed resident's jaws shifting to one side. Per the progress/nurse notes, the doctor and family were notified, and Resident #1 was sent to the hospital via ambulance at 10:25 AM. Record review of Resident #1's hospital record dated 12/28/23, revealed an admitted [DATE] with an admission diagnosis of hemorrhagic stroke. Resident #1's blood pressure was documented as 240/158 at admission, after intubation. The hospital record noted, She was hypertensive to the 240s systolic upon arrival and was minimally responsive. The death pronounced at 12:31 PM on 11/18/23. The preliminary cause of death was intraventricular hemorrhage. In an interview on 12/28/23 at 4:59 PM, Corporate Nurse stated typically, the staff, typically the med aide, would give a resident their scheduled blood pressure medication to see if that would help lower the resident's blood pressure. She stated in Resident #1's situation, if the scheduled high blood pressure medication was given, and her blood pressure was checked later, the blood pressure was still elevated, then a nurse should have given the PRN Clonidine medication. Corporate Nurse stated someone should have documented on the resident's electronic record if the blood pressure was elevated, needed to be rechecked, and if the PRN medication was given or not. In an interview on 12/29/23 at 10:12 AM, Med Aide B stated she was the med aide who gave Resident #1 her medication on 10/17/23 and 10/27/23. Med Aide B stated she verbally notified Nurse C of Resident #1's high blood pressure. She stated Nurse C said okay, and she would handle it. Med Aide B stated most med aides don't document in the progress notes in the electronic record. She stated that most nurses would complete the documentation. Med Aide B stated she was told last night by DON, Administrator, and Corporate Nurse that she should have documented the high blood pressure and her verbal notification to Nurse C. She stated she was trained to document the blood pressures when she took them and to notify the nurse if there were any concerns. In an interview on 12/29/23 at 10:54 AM, Med Aide A stated she was one of the med aides that gave medications to Resident #1. She stated when Resident #1's blood pressure was high she gave Resident #1 her scheduled medications and let Nurse C know about the blood pressure. Med Aide A stated the nurses handled PRN medications and documentation regarding PRN medications given. Med Aide A stated the med aides would tell the nurses about the high blood pressure and the nurses would document in PCC and contact the doctor if needed. On 12/29/23 at 11:15 AM, an attempt was made to contact Nurse G via telephone, but there was no answer or returned call. In an interview on 12/29/23 at 11:28 AM, Nurse C stated she was not told by any med aide that Resident #1 had a systolic reading over 170 on 10/17/23, 10/27/23, or 11/09/23, so she was not aware that the resident might have needed the PRN medication. Nurse C stated Med Aide A told her about Resident #1's systolic blood pressure being over 170 on 11/08/23. She stated they rechecked Resident #1's blood pressure, it was lower, but she failed to document it on Resident #1's electronic record. She stated she did not give the PRN blood pressure medication on that day either. Nurse C stated she failed to document the blood pressure after she rechecked it, and did not remember what the last blood pressure reading was specifically. She stated she remembered the blood pressure went down, so she did not administer the PRN Clonidine. She stated she failed to note the PRN medication was not given due to Resident #1's blood pressure decreasing. Nurse C stated at the time there was no risk of not giving the PRN medication to Resident #1 on 11/08/23, because the resident's blood pressure went down. In an interview on 12/29/23 at 2:47 PM, DON stated the nurse should recheck the blood pressure levels after the med aide voiced any concern. She stated if there were no concerns after rechecking, then the nurses do not have to document anything regarding rechecking and if any PRN medications were given. DON stated Nurse C should have followed the physician's orders for PRN medications, if the systolic blood pressure was over 170. DON stated she considered it a problem if a nurse rechecked a resident's blood pressure and it was still high, and the PRN medication was not given. DON stated the nurses were responsible for giving PRN medication. DON stated since Nurse C did not document on the days in question, she could only take the word of Nurse C when she told her Resident #1's blood pressure was rechecked and went down on the day she was informed by the medication aides of any concerns. DON stated all staff should follow the care plan and all orders. She stated the risk of not following the care plan or orders is possible changes with the resident. Record review of The American Heart Association's article titled, The Facts About High Blood Pressure, dated 05/25/23, revealed the following: Most of the time there are no obvious symptoms. Blood pressure cannot be cured. But it can be managed effectively through life style changed and, when needed, medication. When left untreated, the damage that high blood pressure does to your circulatory system is a significant contributing factor to heart attack, stroke and other health threats. Record review of the facility's undated policy titled, Medication- Administration, Nursing Manual- Nursing Care, revealed the following: Purpose To Provide practice standards for safe administration of medications for residents in the facility. I. Medication will be administered by a licensed nurse per the order of an attending physician or licensed independent practitioner, or as consistent with state law. An Immediate Jeopardy was identified on 12/29/23. Corporate Nurse, Administrator, DON, Regional Director of Operations, and Director of Clinical Education were notified of the Immediate Jeopardy on 12/29/23 at 4:18 PM and were provided with the Immediate Jeopardy Template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Plan of Removal was accepted on 01/02/23 at 10:35 AM and reflected the following: Date: 12/29/23 PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it may concern, Summary of Details which lead to outcomes: On 12/29/23, a complaint was initiated at (Facility Name and Address). A surveyor provided an IJ Template notification that the Survey Agency has determined that a condition at the center constitute immediate jeopardy to resident health. The notification of the alleged immediate jeopardy states as follows: F760 Residents Are Free of Significant Med Errors The facility failed to remain free of significant medication errors. Identify residents who could be affected: All residents have the potential to be affected. Identify responsible staff/ what action taken: 7. Director of Nurses was re-educated by the Regional Nurse Consultant on the facility medication administration policy on 12/29/23. Understanding was verified by a written post test. 8. Licensed Nurses received a re-education by the DON on the facility policy medication administration on 12/29/23. Understanding of education was verified by written post test. 9. Training for licensed nurses and medication aides on notification of changes in condition to physician and nurse management with proper documentation was initiated on 12/29/2023 by the Director of Nursing. Understanding of education was verified by written signatures and verbalization of understanding. 10. Medication aides were re-educated on the process of notification to the nurse by medication aides for PRN medications by the Director of Nursing on 12/29/23. Understanding of education was verified by written signatures and verbalization of understanding. 11. An audit of all blood pressure medications with parameters was initiated on 12/29/2023 by the DON and ADON. Resulting in parameters being adjusted by physician and orders updated. 12. Audit of all PRN blood pressure medication with parameters was initiated on 12/29/2023 by the DON and ADON. In-Services conducted: 4. Change in condition. 5. Medication administration 6. Following plan of care The in-services were attended by licensed caregivers which include Registered Nurse, Licensed Vocational Nurse, and Certified Medication Aide. Understanding of in-services will be verified with a written/and or verbal post test. This in-service was initiated on 12/29/23 and all staff must be in-service before they are allowed to work. New staff will be educated about resident change in condition, medication administration before their floor orientation and monitored will be continued ongoing by the DON/Designee. Implementation of changes (Monitoring all or any medication not given and change in condition of residents through 24 hour report). The changes which include monitoring of all or any medications not given and change in condition of residents through 24 hr. reports were started by the Director of Nursing. The changes of monitoring of all or any medications not given and change in condition of residents through 24hr were implemented effective on 12/29/23 and will be ongoing until all staff are re-educated. The Director of Nursing will ensure competency through verbalization of understanding by staff and in servicing. Monitoring The Administrator/Director of Nursing/Assistant Director of Nursing will be responsible for monitoring the implementation and effectiveness of in-service on 12/29/23. The Director of Nursing/Designee will monitor/review vital signs daily and review 24-hour report for change in condition x4 weeks, then weekly x2 weeks, then monthly and report any adverse finding during QAPI. Director of Nursing/Designee will conduct a daily audit of missing medications and change in condition daily x4 weeks, then weekly x 2 weeks, then monthly and report any adverse findings during QAPI. Director of Nursing/Designee will conduct a daily audit of scheduled and PRN blood pressure medications with parameters daily x4 weeks, then weekly x 2 weeks, then monthly and report any adverse findings during QAPI. The Regional Nurse Consultant will audit the implementation process 3x per week x4weeks, then weekly x4weeks, then monthly ongoing and report any adverse findings during QAPI. Involvement of Medical Director The Medical Director met with the Interdisciplinary team on 12/29/23 and conducted an Ad HOC QAPI regarding physician notification and change in condition. The Medical Director, (Doctor's Name) was notified about the immediate Jeopardy on 12/29/23, the Plan of removal was reviewed and accepted by (Doctor's Name). Involvement of QA An Ad Hoc QAPI meeting was held with the Medical Director, facility administrator, director of nursing, and social services director to review plan of removal on 12/29/23. Who is responsible for the implementation of process? The Director of Nursing will be responsible for the implementation of the new process. The New Process/system was started on 12/29/23. The Administrator will ensure DON implements the new process. Regional Nurse Consultant will audit the implementation of the new process. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy verbally issued on 12/29/23. Monitoring: In an interview on 01/02/24 at 12:01 PM, Social Worker stated she had received some in-services since 12/29/23. She stated she received an in-service on change of condition, protocols related to changes in residents, and how those changes should be reported. Social Worker stated she also completed an in-service on taking vital signs as well. In an interview on 01/02/24 at 12:22 PM, Med Aide B stated she received in-services since Friday, 12/29/23. She stated she received an in-service on resident blood pressures, what and when to check and when it needs to be reported to a nurse. Med Aide B stated the in-services covered documenting the blood pressure and any changes and documenting that nurse was notified. She stated she also received an in-service on change of condition. In an interview on 01/02/24 at 12:35 PM, Charge Nurse stated she received in-services last Thursday that covered medication administration, change of condition, taking blood pressure, physician's orders, what nurses should do if med aides report any changes of conditions, how to document change of condition in residents, blood pressure medications, care plans, vital signs, what to do when there is irregular vitals, and PRN blood pressure medications, if it's ordered to go ahead and give the medication according to the doctor's orders. In an interview on 01/02/24 at 1:05 PM, Med Aide D stated she was in-serviced yesterday, 01/01/24, that covered medications and residents changes of condition. She stated during the in-service she was told to notify the nurse with any changes of any resident. Med Aide D stated the in-service also covered how to take blood pressures and when to know there were issues with a resident's blood pressure. In an interview on 01/02/24 at 1:14 PM, ADON stated she received in-services last Thursday (12/28/23), and it covered medication administration, elevated blood pressures, change of condition in residents, notifying the resident's physician and family, following the care plan, and proper documentation. She stated she was in-serviced by DON. In an interview on 01/02/24 at 1:20 PM, DON stated she in-serviced all of the staff in the facility that reported to her, and Corporate Nurse in-serviced her. She stated she was in-serviced on change of condition, medication administration, when and how to notify the doctor and family, how to review the 24-hour reports to monitor for a change in condition, and how to ensure nurses are documenting and reporting changes in blood pressure. In a telephone interview on 01/02/24 at 1:30 PM, Med Aide E stated he was in-serviced on change of condition, PRN medications, notifying the nurse when there are concerns, and blood pressures. In an interview on 01/02/24 at 1:36 PM, Nurse C stated she was in-serviced since last Thursday on PRN medications, vitals, change of conditions, and notifying the physician of any changes. In a telephone interview, on 01/02/24 at 1:52 PM, Nurse F stated he received additional training last week, around 12/28/23, that covered notification on changes, how the med aide should notify a nurse of any issues, how a nurse should contact the physician, or the DON/ADON if there are concerns of if the nurses are not able to reach the doctor. He stated the in-service also covered PRN medications, and checking vitals, including blood pressure. In an interview on 01/02/24 at 1:58 PM, Administrator stated he was in-serviced by Corporate Nurse. He stated he was in-serviced on change of condition, medication errors, physician notification, blood pressure, who needs to notify who of a change in condition with a resident, what the nurses should do once they are notified of a change in condition, and what the med aides are required to do in the process. A record review of the following was completed on 01/02/24: Blood Pressure medication audit of all residents, including all revisions since 12/28/23. There were no concerns. An in-service for Medication Administration, Documentation of rechecked Vitals, Documentation when all medications are given, Documentation of notifications to nurse and doctor, Change of Condition, and Following Physician's Orders, dated 12/29/23, instructor noted as DON, and instructor for DON was Corporate Nurse All post tests for all in-services completed Sign-off Verification that all vitals were checked on all residents and audits were completed on calendar for 12/28/23, 12/29/23, 12/30/23, 12/31/23, 01/01/24, and 01/02/24, and signed-off by Administrator, DON, and Corporate Nurse. An untitled, undated, facility document with review of all vitals for residents on 12/28/23, 12/29/23, 12/30/23, 12/31/23, 01/01/24, and 01/02/24, which included weight, respiration, blood pressure, temperature, pulse, blood sugar, height, O2 saturation, and pain levels for each resident. Document of verification of all active orders reviewed and updated if needed. Administrator was notified on 01/02/24, the Immediate Jeopardy was removed. While the immediacy was removed on 01/02/24, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not Immediate Jeopardy due to the facility continuing in-servicing and monitoring of the Plan of Removal.

Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for one resident (Resident #1) of three residents reviewed for change in physical, mental, or psychosocial status. The facility failed to give Resident #1 her PRN anti-hypertensive medication as ordered and noted on the care plan. The facility failed monitor and document signs and symptoms of malignant hypertension as noted on the care plan for Resident #1. Resident #1 was sent to the hospital on 11/16/23 after a change of condition, when Resident #1's initial blood pressure was documented as 214/117, Resident #1 did not eat breakfast, could not swallow, and jaws shifted to the left. Resident #1's hospital admission diagnoses was a hemorrhagic stroke. Resident #1 passed away at the hospital on 11/18/23. An immediate Jeopardy was identified on 12/29/23. While the Immediate Jeopardy was removed on 01/02/24, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not Immediate Jeopardy, due to the facility continuation of in-servicing and monitoring the Plan of Removal. This failure could affect residents by placing them at risk for a delay in medical treatment and worsening in condition, hospitalization , and/or death. Findings included: Record review of Resident #1' face sheet, dated 01/02/24, revealed a [AGE] year-old female, who admitted to the facility on [DATE], with a readmitted [DATE]. Her diagnoses included Seizures, Cerebral Infarction (stroke), Vitamin D deficiency, Long-term use of anticoagulants (blood thinners), Dysphagia (difficulty swallowing), Difficulty in walking, Cognitive Communication Deficit (difficulty thinking and how someone uses language), Conversion Disorder with Seizures or convulsions (physical and sensory problems), Hyperlipidemia (high cholesterol), and Essential Hypertension (high blood pressure). Record review of the active physician's order dated 10/30/22, revealed the following: Clonidine HCI tablet 0.1 MG. Give 1 tablet by mouth every 12 hours as needed for elevated B/P related to essential (primary) hypertension. Give clonidine 0.1 MG if the systolic blood pressure is > 170. Record review of Resident #1's Care Plan, dated 11/09/23, revealed the following, [Resident Name] will remain free from s/sx of hypertension through the next review date. Give anti-hypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension (blood pressure issues when standing up or sitting down) and increased heart rate and effectiveness. Monitor for and document any edema. Notify MD. Monitor/Document/Report to MD PRN any s/sx of malignant hypertension: Headache, visual problems, confusion, disorientation, lethargy, nausea and vomiting, irritability, seizure activity, difficulty breathing. Obtain blood pressure readings per order. Take blood pressure readings under same condition each time. Record review of Resident #1's Medication Administration Record dated, October 2023, revealed a blood pressure reading on 10/17/23 of 200/108 and another blood pressure reading on 10/27/23 of 196/113. There was no documentation of the blood pressure rechecked after these readings. There was no evidence documented that the PRN clonidine was administered to Resident #1 on either of these dates. Record review of Resident #1's Medication Administration Record, dated, November 2023, revealed a blood pressure reading on 11/08/23 of 185/30 and another blood pressure reading on 11/09/23 of 181/111. There was no documentation of the blood pressure rechecked after these readings. There was no evidence documented that the PRN clonidine was administered to Resident #1 on either of these dates. Record review of Resident #1's Progress Notes/Nurses Notes on the electronic record, revealed no documentation on 10/17/23, 10/27/23, 11/08/23, or 11/09/23. There was no documentation on Resident #1' electronic record regarding, rechecked blood pressure, administration of clonidine, or a consultation with the physician. There was no documentation that Resident #1's physician was contacted on either of these days. Record review of the progress note on 11/16/23, revealed the resident's physician was contacted regarding the change in condition. Record review of Resident #1's Progress Notes/Nurse Notes on the electronic record, revealed on 11/16/23, resident was checked on at 6:02 AM by Nurse G, she appeared stable, then 8:30 AM, Nurse G noticed she was not eating her breakfast, did not respond when her name was called, but just looked at the nurse. It was noted Nurse G noticed resident could not swallow, vitals were taken, and Resident #1's blood pressure was 214/117. The PRN Clonidine was noted as given, Nurse G rechecked vital signs at 10:03 AM and Resident #1's blood pressure was 161/89. It was noted that Nurse G noticed resident's jaws shifting to one side. Per the progress/nurse notes, the doctor and family were notified, and Resident #1 was sent to the hospital via ambulance at 10:25 AM. Record review of Resident #1's hospital record dated 12/28/23, revealed an admitted [DATE] with an admission diagnosis of hemorrhagic stroke. Resident #1's blood pressure was documented as 240/158 at admission, after intubation. The hospital record noted, She was hypertensive to the 240s systolic upon arrival and was minimally responsive. The death pronounced at 12:31 PM on 11/18/23. The preliminary cause of death was intraventricular hemorrhage. In an interview on 12/28/23 at 4:59 PM, Corporate Nurse stated typically, the staff, typically the med aide, would give a resident their scheduled blood pressure medication to see if that would help lower the resident's blood pressure. She stated in Resident #1's situation, if the scheduled high blood pressure medication was given, and her blood pressure was checked later, the blood pressure was still elevated, then a nurse should have given the PRN Clonidine medication. Corporate Nurse stated someone should have documented on the resident's electronic record if the blood pressure was elevated, needed to be rechecked, and if the PRN medication was given or not. In a telephone interview on 12/29/23 at 10:37 AM, Nurse Practitioner stated the blood pressure being high and not addressed could have contributed to Resident #1 going to the hospital, but he stated he could not say because he did not know all the specifics. He stated the PRN clonidine should have been given to Resident #1 as ordered. He stated the facility staff should have given the scheduled blood pressure medications, if the systolic was high, the staff should have rechecked the blood pressure, and if it was still high, the facility staff should have given Resident #1 the PRN medication. He stated if the blood pressure was still high after that, or if resident had any change in condition, he or the resident's physician should have been notified. Nurse Practitioner stated he did not recall being contacted on 10/17/23, 10/27/23, 11/08/23, or 11/09/23. In a telephone interview on 12/29/23 at 11:00 AM, Resident #1's Physician stated Resident #1's high blood pressure on 11/16/23, could have contributed to her having to go to the hospital. He stated he could not say if the high blood pressure on the other dates could have contributed to her going to the hospital on 11/16/23. He stated he did not recall being contacted by any facility staff regarding Resident #1's change in condition on 10/17/23, 10/27/23, 11/08/23, or 11/09/23. He stated he may have made changes to Resident #1's orders, but he stated he could not say for certain, because he did not know the specifics of what occurred. On 12/29/23 at 11:15 AM, an attempt was made to contact Nurse G via telephone, but there was no answer or returned call. In an interview on 12/29/23 at 11:28 AM, Nurse C stated she was not told by any med aide that Resident #1 had a systolic reading over 170 on 10/17/23, 10/27/23, or 11/09/23, so she was not aware that the resident might have needed the PRN medication. Nurse C stated Med Aide A told her about Resident #1's systolic blood pressure being over 170 on 11/08/23. She stated they rechecked Resident #1's blood pressure, it was lower, but she failed to document it on Resident #1's electronic record. She stated she did not give the PRN blood pressure medication on that day either. Nurse C stated she contacted the doctor and nurse practitioner, but did not receive a response. She stated she failed to document her attempt to reach the doctor or nurse practitioner. Nurse C stated at the time there was no risk of not giving the PRN medication to Resident #1 on 11/08/23, because the resident's blood pressure went down. Nurse C stated that the staff should follow the care plan of a resident, and that care plan can be located on the resident's electronic record. Nurse C stated she failed to document the blood pressure after she rechecked it, and did not remember what the last blood pressure reading was specifically. She stated she remembered the blood pressure went down, so she did not administer the PRN Clonidine. She stated she failed to note the PRN medication was not given due to Resident #1's blood pressure decreasing. She stated a risk of not following the plan could be issues with the resident. In an interview on 12/29/23 at 2:47 PM, DON stated the nurse should recheck the blood pressure levels after the med aide voiced any concern. She stated if there were no concerns after rechecking, then the nurses do not have to document anything regarding rechecking and if any PRN medications were given. DON stated Nurse C should have followed the physician's orders for PRN medications, if the systolic blood pressure was over 170. DON stated she considered it a problem if a nurse rechecked a resident's blood pressure and it was still high, and the PRN medication was not given. DON stated the nurses were responsible for giving PRN medication. DON stated since Nurse C did not document on the days in question, she could only take the word of Nurse C when she told her Resident #1's blood pressure was rechecked and went down on the day she was informed by the medication aides of any concerns. DON stated all staff should follow the care plan and all orders. DON stated Nurse G was the one that cared for Resident #1 on 11/16/23, but Nurse G's last day working at the facility was on 12/26/23. She stated Nurse G resigned. She stated the risk of not following the care plan or orders is possible changes with the resident. Record review of The American Heart Association's article titled, The Facts About High Blood Pressure, dated 05/25/23, revealed the following: Most of the time there are no obvious symptoms. Blood pressure cannot be cured. But it can be managed effectively through life style changed and, when needed, medication. When left untreated, the damage that high blood pressure does to your circulatory system is a significant contributing factor to heart attack, stroke and other health threats. Review of the facility's policy titled, Care Planning, revised on 06/20, and titled Care Planning stated the following: IX. Each resident's Comprehensive Care Plan will describe the following: A. Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychological well-being . An Immediate Jeopardy was identified on 12/29/23. Corporate Nurse, Administrator, DON, Regional Director of Operations, and Director of Clinical Education were notified of the Immediate Jeopardy on 12/29/23 at 4:18 PM and were provided with the Immediate Jeopardy Template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Plan of Removal was accepted on 01/02/23 at 10:35 AM and reflected the following: Date: 12/29/23 PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it may concern, Summary of Details which lead to outcomes: On 12/29/23, a complaint was initiated at (Facility name and address). A surveyor provided an IJ Template notification that the Survey Agency has determined that a condition at the center constitute immediate jeopardy to resident health. The notification of the alleged immediate jeopardy states as follows: F684 Quality of Care The facility failed to follow Resident #1's care plan regarding hypertension. The plan stated to monitor, document, and report signs or symptoms of malignant hypertension, and it was not documented as monitored on all days, the doctor was not notified of all signs or symptoms. Identify residents who could be affected: All residents have the potential to be affected. Identify responsible staff/ what action taken: 13. Director of Nurses were re-educated by the Regional Nurse Consultant on the facility policy on monitoring, documenting, and reporting abnormal signs or symptoms on 12/29/23. Understanding was verified by a written post test. 14. Licensed Nurses received a re-education by the DON on the facility policy and procedure regarding documentation and following parameters for elevated blood pressures initiated on 12/29/23. Knowledge of education was verified by written signatures and verbalization of understanding. 15. Training for licensed nurses and medication aides on notification of changes in condition to physician and nurse management with proper documentation was initiated on 12/29/2023 by the Director of Nursing. Knowledge of education was verified by written signatures and verbalization of understanding. 16. Medication aides and nurses were also re-educated to follow the resident plan of care regarding interventions to maintain the resident's medication regime by the Director of Nursing on 12/29/23. Knowledge of education was verified by written signatures and verbalization of understanding. 17. An audit of all blood pressure medications with parameters was initiated on 12/29/2023 by the DON and ADON. Resulting in parameters being adjusted by physician and orders updated. 18. Audit of all PRN blood pressure medication with parameters was initiated on 12/29/2023 by the DON and ADON. In-Services conducted: 7. Change in condition. 8. Medication administration 9. Following plan of care The in-services were attended by licensed caregivers which include Registered Nurse, Licensed Vocational Nurse, and Certified Medication Aide. Understanding of in-services will be verified with a written/and or verbal post test. This in-service was initiated on 12/29/23 and all staff must be in-service before they are allowed to work. New staff will be educated about resident change in condition, medication administration before their floor orientation and monitored will be continued ongoing by the DON/Designee. Implementation of changes (Monitoring all or any medication not given and change in condition of residents through 24 hour report). The changes which include monitoring of all or any medications not given and change in condition of residents through 24 hr. reports were started by the Director of Nursing. The changes of monitoring of all or any medications not given and change in condition of residents through 24hr were implemented effective on 12/29/23 and will be ongoing until all staff are re-educated. The Director of Nursing will ensure competency through verbalization of understanding by staff and in servicing. Monitoring The Administrator/Director of Nursing/Assistant Director of Nursing will be responsible for monitoring the implementation and effectiveness of in-service on 12/29/23. The Director of Nursing/Designee will monitor/review vital signs daily and review 24-hour report for change in condition x4 weeks, then weekly x2 weeks, then monthly and report any adverse finding during QAPI. Director of Nursing/Designee will conduct a daily audit of missing medications and change in condition daily x4 weeks, then weekly x 2 weeks, then monthly and report any adverse findings during QAPI. Director of Nursing/Designee will conduct a daily audit of scheduled and PRN blood pressure medications with parameters daily x4 weeks, then weekly x 2 weeks, then monthly and report any adverse findings during QAPI. Involvement of Medical Director The Medical Director met with the Interdisciplinary team on 12/29/23 and conducted an Ad HOC QAPI regarding physician notification and change in condition. The Medical Director, (Doctor's Name) was notified about the immediate Jeopardy on 12/29/23, the Plan of removal was reviewed and accepted by (Doctor's Name). Involvement of QA An Ad Hoc QAPI meeting was held with the Medical Director, facility administrator, director of nursing, and social services director to review plan of removal on 12/29/23. Who is responsible for the implementation of the process? The Director of Nursing will be responsible for the implementation of the new process. The New Process/system was started on 12/29/23. The Administrator will ensure DON implements the new process. Regional Nurse Consultant will audit the implementation of the new process. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy verbally issued on 12/29/23. Monitoring: In an interview on 01/02/24 at 12:01 PM, Social Worker stated she had received some in-services since 12/29/23. She stated she received an in-service on change of condition, protocols related to changes in residents, and how those changes should be reported. In an interview on 01/02/24 at 12:22 PM, Med Aide B stated she received in-services since Friday, 12/29/23. She stated she received an in-service on resident blood pressures, what and when to check and when it needs to be reported to a nurse. Med Aide B stated the in-services covered documenting the blood pressure and any changes and documenting that nurse was notified. She stated she also received an in-service on change of condition. In an interview on 01/02/24 at 12:35 PM, Charge Nurse stated she received in-services last Thursday that covered medication administration, documentation of meds administered and when vitals are rechecked, change of condition, taking blood pressure, physician's orders, what nurses should do if med aides report any changes of conditions, how to document change of condition in residents, blood pressure medications, care plans, vital signs, what to do when there is irregular vitals, and PRN blood pressure medications, if it's ordered to go ahead and give the medication according to the doctor's orders. In an interview on 01/02/24 at 1:05 PM, Med Aide D stated she was in-serviced yesterday, 01/01/24, that covered medications and residents changes of condition. She stated during the in-service she was told to notify the nurse with any changes of any resident. Med Aide D stated the in-service also covered how to take blood pressures and when to know there were issues with a resident's blood pressure. In an interview on 01/02/24 at 1:14 PM, ADON stated she received in-services last Thursday (12/28/23), and it covered medication administration, elevated blood pressures, change of condition in residents, notifying the resident's physician and family, following the care plan, and proper documentation. She stated she was in-serviced by DON. In an interview on 01/02/24 at 1:20 PM, DON stated she in-serviced all of the staff in the facility that reported to her, and Corporate Nurse in-serviced her. She stated she was in-serviced on change of condition, medication administration, when and how to notify the doctor and family, how to review the 24-hour reports to monitor for a change in condition, and how to ensure nurses are documenting and reporting changes in blood pressure. She stated the housekeeping and laundry department was in-serviced as well. In a telephone interview on 01/02/24 at 1:30 PM, Med Aide E stated he was in-serviced on change of condition, PRN medications, notifying the nurse when there are concerns, and blood pressures. In an interview on 01/02/24 at 1:36 PM, Nurse C stated she was in-serviced since last Thursday on PRN medications, vitals, change of conditions, and notifying the physician of any changes. In a telephone interview, on 01/02/24 at 1:52 PM, Nurse F stated he received additional training last week, around 12/28/23, that covered notification on changes, how the med aide should notify a nurse of any issues, how a nurse should contact the physician, or the DON/ADON if there are concerns of if the nurses are not able to reach the doctor. He stated the in-service also covered PRN medications, and checking vitals, including blood pressure. In an interview on 01/02/24 at 1:58 PM, Administrator stated he was in-serviced by Corporate Nurse. He stated he was in-serviced on change of condition, medication errors, physician notification, blood pressure, who needs to notify who of a change in condition with a resident, what the nurses should do once they are notified of a change in condition, and what the med aides are required to do in the process. A record review of the following was completed on 01/02/24: Blood Pressure medication audit of all residents, including all revisions since 12/28/23. There were no concerns. An in-service for Medication Administration, Documentation of rechecked Vitals, Documentation when all medications are given, Documentation of notifications to nurse and doctor, Change of Condition, and Following Physician's Orders, dated 12/29/23, instructor noted as DON, and instructor for DON was Corporate Nurse All post tests for all in-services completed Sign-off Verification that all vitals were checked on all residents and audits were completed on calendar for 12/28/23, 12/29/23, 12/30/23, 12/31/23, 01/01/24, and 01/02/24, and signed-off by Administrator, DON, and Corporate Nurse. An untitled, undated, facility document with review of all vitals for residents on 12/28/23, 12/29/23, 12/30/23, 12/31/23, 01/01/24, and 01/02/24, which included weight, respiration, blood pressure, temperature, pulse, blood sugar, height, O2 saturation, and pain levels for each resident. Document of verification of all active orders reviewed and updated if needed. Administrator was notified on 01/02/24, the Immediate Jeopardy was removed. While the immediacy was removed on 01/02/24, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not Immediate Jeopardy due to the facility continuing in-servicing and monitoring of the Plan of Removal.

Based on interview and record review, the facility failed to immediately consult with the physician of a significant change in the resident's health status; or a need to alter treatment significantly for 1 (Resident #1) of 3 residents reviewed for parameters to notify Physician of critical blood pressure levels. 1. The facility failed to notify Resident #'1's physician and administer PRN Clonidine, when Resident #1's systolic blood pressure was over 170, as ordered, on at least four days; on 10/17/23 when the systolic blood pressure was 200, 10/27/23 when the systolic blood pressure was 196, 11/08/23 when the systolic blood pressure was 185, and 11/09/23 when the systolic blood pressure was 181, all when Resident#1's systolic blood pressure was over 170. Resident #1 was sent to the hospital on 11/16/23 after a change of condition, Resident #1's initial blood pressure was documented as 214/117, Resident #1 did not eat breakfast, could not swallow, and jaws shifted to the left. Resident #1's hospital admission diagnoses was a hemorrhagic stroke. Resident #1 passed away at the hospital on 11/18/23. An immediate Jeopardy was identified on 12/29/23. While the Immediate Jeopardy was removed on 01/02/24, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not Immediate Jeopardy, due to the facility continuation of in-servicing and monitoring the Plan of Removal. This deficient practice placed residents at high risk of, or the likelihood of, serious injury, harm, impairment, or death by not receiving treatment, developing complications, and a negative outcome to a resident's physical, mental, or psychosocial health or well-being. Findings included: Record review of Resident #1' face sheet, dated 01/02/24, revealed a [AGE] year-old female, who admitted to the facility on [DATE], with a readmitted [DATE]. Her diagnoses included Seizures, Cerebral Infarction (stroke), Vitamin D deficiency, Long-term use of anticoagulants (blood thinners), Dysphagia (difficulty swallowing), Difficulty in walking, Cognitive Communication Deficit (difficulty thinking and how someone uses language), Conversion Disorder with Seizures or convulsions (physical and sensory problems), Hyperlipidemia (high cholesterol), and Essential Hypertension (high blood pressure). Record review of the active physician's order dated 10/30/22, revealed the following: Clonidine HCI tablet 0.1 MG. Give 1 tablet by mouth every 12 hours as needed for elevated B/P related to essential (primary) hypertension. Give clonidine 0.1 MG if the systolic blood pressure is > 170. Record review of Resident #1's Care Plan, dated 11/09/23, revealed the following, [Resident Name] will remain free from s/sx of hypertension through the next review date. Give anti-hypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension (blood pressure issues when standing up or sitting down) and increased heart rate and effectiveness. Monitor for and document any edema. Notify MD. Monitor/Document/Report to MD PRN any s/sx of malignant hypertension: Headache, visual problems, confusion, disorientation, lethargy, nausea and vomiting, irritability, seizure activity, difficulty breathing. Obtain blood pressure readings per order. Take blood pressure readings under same condition each time. Record review of Resident #1's Medication Administration Record dated, October 2023, revealed a blood pressure reading on 10/17/23 of 200/108 and another blood pressure reading on 10/27/23 of 196/113. There was no documentation of the blood pressure rechecked after these readings. There was no evidence documented that the PRN clonidine was administered to Resident #1 on either of these dates. Record review of Resident #1's Medication Administration Record, dated, November 2023, revealed a blood pressure reading on 11/08/23 of 185/30 and another blood pressure reading on 11/09/23 of 181/111. There was no documentation of the blood pressure rechecked after these readings. There was no evidence documented that the PRN clonidine was administered to Resident #1 on either of these dates. Record review of Resident #1's Progress Notes/Nurses Notes on the electronic record, revealed no documentation on 10/17/23, 10/27/23, 11/08/23, or 11/09/23. There was no documentation on Resident #1' electronic record regarding, rechecked blood pressure, administration of clonidine, or a consultation with the physician. There was no documentation that Resident #1's physician was contacted on either of these days. Record review of the progress note on 11/16/23, revealed the resident's physician was contacted regarding the change in condition. Record review of Resident #1's Progress Notes/Nurse Notes on the electronic record, revealed on 11/16/23, resident was checked on at 6:02 AM by Nurse G, she appeared stable, then 8:30 AM, Nurse G noticed she was not eating her breakfast, did not respond when her name was called, but just looked at the nurse. It was noted Nurse G noticed resident could not swallow, vitals were taken, and Resident #1's blood pressure was 214/117. The PRN Clonidine was noted as given, Nurse G rechecked vital signs at 10:03 AM and Resident #1's blood pressure was 161/89. It was noted that Nurse G noticed resident's jaws shifting to one side. Per the progress/nurse notes, the doctor and family were notified, and Resident #1 was sent to the hospital via ambulance at 10:25 AM. Record review of Resident #1's hospital record dated 12/28/23, revealed an admitted [DATE] with an admission diagnosis of hemorrhagic stroke. Resident #1's blood pressure was documented as 240/158 at admission, after intubation. The hospital record noted, She was hypertensive to the 240s systolic upon arrival and was minimally responsive. The death pronounced at 12:31 PM on 11/18/23. The preliminary cause of death was intraventricular hemorrhage. In an interview on 12/28/23 at 4:59 PM, Corporate Nurse stated Med Aide A was the person that noted the high systolic blood pressures. She stated Med Aide A informed a nurse about the high blood pressure. Corporate Nurse stated typically, a med aide would tell a nurse about a resident with high blood pressure. The staff would give a resident their scheduled blood pressure medication to see if that would help lower the resident's blood pressure. She stated in Resident #1's situation, if the scheduled high blood pressure medication was given and her blood pressure was checked later and the blood pressure was still elevated, then a nurse would give the PRN Clonidine medication. Corporate Nurse stated it should have been documented on the resident's electronic record if the blood pressure was elevated and needed to be rechecked. She stated sometimes the nurses did not document when the blood pressure had to be rechecked, but that should have been noted as well as if the PRN blood pressure medication had to be given. In an interview on 12/29/23 at 10:12 AM, Med Aide B stated she was the med aide who gave Resident #1 her medication on 10/17/23 and 10/27/23. Med Aide B stated she verbally notified Nurse C of Resident #1's high blood pressure. She stated Nurse C said okay, and she would handle it. Med Aide B stated most med aides don't document in the progress notes in the electronic record. She stated that most nurses would complete the documentation. Med Aide B stated she was told last night by DON, Administrator, and Corporate Nurse that she should have documented the high blood pressure and her verbal notification to Nurse C. She stated she was trained to document the blood pressures when she took them and to notify the nurse if there were any concerns. In an interview on 12/29/23 at 10:37 AM, Nurse Practitioner stated he was not informed of Resident #1's high blood pressure on 10/17/23, 10/27/23, 11/08/23, or 11/09/23. He stated he also was not notified that she did not receive the PRN Clonidine on those dates for the elevated systolic blood pressure. In an interview on 12/29/23 at 10:54 AM, Med Aide A stated she was one of the med aides that gave medications to Resident #1. She stated when Resident #1's blood pressure was high she gave Resident #1 her scheduled medications and let Nurse C know about the blood pressure. Med Aide A stated the nurses handled PRN medications and documentation regarding PRN medications given. Med Aide A stated the med aides would tell the nurses about the high blood pressure and the nurses would document in PCC and contact the doctor if needed. In an interview on 12/29/23 at 11:00 AM, Resident #1's physician stated the facility should have given the scheduled blood pressure medications to Resident #1, rechecked the blood pressure if it was high, then should have given the PRN blood pressure mediation if needed. On 12/29/23 at 11:15 AM, an attempt was made to contact Nurse G via telephone, but there was no answer or returned call. In an interview on 12/29/23 at 11:28 AM, Nurse C stated she was not told by any med aide that Resident #1 had high blood pressure on 10/17/23, 10/27/23, or 11/09/23. Nurse C stated Med Aide D told her Resident #1 had high blood pressure on 11/08/23. Nurse C stated she called Resident #1's physician on 11/08/23 and did not get an answer. Nurse C stated she also called and texted Resident #1's nurse practitioner but did not receive an answer regarding the high blood pressure. Nurse C stated she failed to document the blood pressure after she rechecked it, and did not remember what the last blood pressure reading was specifically. She stated she remembered the blood pressure went down, so she did not administer the PRN Clonidine. She stated she failed to note the PRN medication was not given due to Resident #1's blood pressure decreasing. Nurse C stated the risk of not notifying the doctor of any changes would be the doctor not having the option to make changes to the resident's care. In an interview on 12/29/23 at 2:47 PM, DON stated the med aides were supposed to verbally tell the nurses or write down on any piece of paper any issues or concerns with a resident. She stated there was no specific way, but the med aides knew to notify a nurse of any concerns. DON stated the nurse should recheck the blood pressure levels after the med aide voiced any concern. She stated if there were no concerns after rechecking, then the nurses do not have to document anything regarding rechecking and if any PRN medications were given. DON stated if the nurse rechecked and the blood pressure was abnormal, the nurse would either contact the doctor, or if there were orders for PRN medication, then the nurse would just follow those orders. DON stated the nurses should document if there were further issues or concerns after rechecking the blood pressure. DON stated she considered it a problem if a nurse rechecked a resident's blood pressure and it was still high. She stated if a med aide stated she told a nurse about an issue with a resident and did not document it, or if a nurse stated a med aide did not inform them, then it was no way to really know if a med aide told a nurse about an issue with a resident. DON stated the nurses are responsible for contacting the doctor if there are any concerns with the resident. DON stated Nurse C should have contacted her or an ADON if she was not able to get in contact with the doctor. DON stated since Nurse C did not document on the days in questions, she could only take the word of Nurse C when she told her Resident #1's blood pressure was rechecked and went down on the day she was informed by the med aides of any concerns. DON stated Resident #1's blood pressure would have generally been taken around 8 AM and 5 PM, give or take an hour from the scheduled medication time. DON stated Nurse G was the one that cared for Resident #1 on 11/16/23, but Nurse G's last day working at the facility was on 12/26/23. She stated Nurse G resigned. Record review of the facility's policy titled, Preventing and Detecting Adverse Consequences and Medication Errors, dated 08/2020, revealed the following: Policy The facility employs a system to ensure that medication usage is evaluated on an ongoing basis. When a resident has a change in condition, medication-related problems are considered. Significant medication-related problems are assessed, documented and reported as appropriate to the resident's attending physician, the Quality Assessment and Assurance Committee, the pharmacy, the consultant pharmacist, and the Food and Drug Administration MedWatch or Medication Error Reporting Program when applicable. An Immediate Jeopardy was identified on 12/29/23. Corporate Nurse, Administrator, DON, Regional Director of Operations, and Director of Clinical Education were notified of the Immediate Jeopardy on 12/29/23 at 4:18 PM and were provided with the Immediate Jeopardy Template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Plan of Removal was accepted on 01/02/23 at 10:35 AM and reflected the following: PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it may concern, Summary of Details which lead to outcomes On 12/29/23, a complaint was initiated at (Facility Name and Address). A surveyor provided an IJ Template notification that the Survey Agency has determined that a condition at the center constitute immediate jeopardy to resident health. The notification of the alleged immediate jeopardy states as follows: F580 Notify Physician of Changes The facility failed to notify the resident's physician when there was significant change in the resident's physical status and a need to alter treatment significantly. . Identify residents who could be affected All residents have the potential to be affected. Identify responsible staff/ what action taken 1. Director of Nurses were re-educated by the Regional Nurse Consultant on the facility policy on physician notification on 12/29/23. Understanding was verified by a written post test. 2. Licensed Nurses received a re-education by the DON on the facility policy and procedure regarding documentation and following parameters for elevated blood pressures. Knowledge of education was verified by written signatures and verbalization of understanding. 3. Training for licensed nurses and Medication aides on notification changes of condition to physician and nurse management with proper documentation was initiated on 12/29/2023 by the Director of Nursing. Knowledge of education was verified by post test ad verbal signatures. 4. Medication aides and nurses were also re-educated to follow physician orders regarding interventions to maintain the resident's medication regime by the Director of Nursing on 12/29/23. Understanding of education was verified by written signatures and verbalization of understanding. 5. An audit of all blood pressure medications with parameters was initiated on 12/29/2023 by the DON and ADON. Resulting in parameters being adjusted by physician and orders updated. 6. Audit of all PRN blood pressure medication with parameters was initiated on 12/29/2023 by the DON and ADON. In-Services conducted: 1. Change in condition 2. Medication administration 3. Physician notification The in-services were attended by licensed caregivers which include Registered Nurse, Licensed Vocational Nurse, and Certified Medication Aide. Understanding of in-services will be verified with a written/and or verbal post test. This in-service was initiated on 12/29/23 and all staff must be in-service before they are allowed to work. New staff will be educated about resident change in condition, medication administration before their floor orientation and monitored will be continued ongoing by the DON/Designee. Implementation of changes: The changes which include monitoring of medications not given and change in condition of residents through 24 reports were started by the Director of Nursing. The changes were implemented effective on 12/29/23 and will be ongoing until all staff are re-educated. The Director of Nursing will ensure competency through verbalization of understanding by staff and in servicing. Monitoring The Administrator/Director of Nursing/Assistant Director of Nursing will be responsible for monitoring the implementation and effectiveness of in-service on 12/29/23. Director of Nursing/Designee will monitor/review vital signs on the 24-hour report and SBAR for change in condition and physician notification x4 weeks, then weekly x2 weeks, then monthly and report any adverse finding during QAPI Director of Nursing/Designee will conduct a daily audit of scheduled and PRN blood pressure medications with parameters daily x4 weeks, then weekly x 2 weeks, then monthly and report any adverse findings during QAPI. The Regional Nurse Consultant will audit the implementation process 3x per week x4weeks, then weekly x4weeks, then monthly ongoing and report any adverse findings during QAPI Involvement of Medical Director The Medical Director met with the Interdisciplinary team on 12/29/23 and conducted an Ad HOC QAPI regarding physician notification and change in condition. The Medical Director, (Doctor's Name) was notified about the immediate Jeopardy on 12/29/23, the Plan of removal was reviewed and accepted by (Doctor's Name). Involvement of QA An Ad Hoc QAPI meeting was held with the Medical Director, facility administrator, director of nursing, and social services director to review plan of removal on 12/29/23. Who is responsible for implementation of process? The Director of Nursing will be responsible for the implementation of the new process. The New Process/system was started on 12/29/23. The Administrator will ensure DON implements the new process. Regional Nurse Consultant will audit the implementation of the new process. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy verbally issued on 12/29/23. Monitoring: In an interview on 01/02/24 at 12:01 PM, Social Worker stated she had received some in-services since 12/29/23. She stated she received an in-service on change of condition, protocols related to changes in residents, and how those changes should be reported. In an interview on 01/02/24 at 12:22 PM, Med Aide B stated she received in-services since Friday, 12/29/23. She stated she received an in-service on resident blood pressures, what and when to check and when it needs to be reported to a nurse. Med Aide B stated the in-services covered documenting the blood pressure and any changes and documenting that nurse was notified. She stated she also received an in-service on change of condition. In an interview on 01/02/24 at 12:35 PM, Charge Nurse stated she received in-services last Thursday that covered medication administration, documentation of meds administered and when vitals are rechecked, change of condition, taking blood pressure, physician's orders, what nurses should do if med aides report any changes of conditions, how to document change of condition in residents, blood pressure medications, care plans, vital signs, what to do when there is irregular vitals, and PRN blood pressure medications, if it's ordered to go ahead and give the medication according to the doctor's orders. In an interview on 01/02/24 at 1:05 PM, Med Aide D stated she was in-serviced yesterday, 01/01/24, that covered medications and residents changes of condition. She stated during the in-service she was told to notify the nurse with any changes of any resident. Med Aide D stated the in-service also covered how to take blood pressures and when to know there were issues with a resident's blood pressure. In an interview on 01/02/24 at 1:14 PM, ADON stated she received in-services last Thursday (12/28/23), and it covered medication administration, elevated blood pressures, change of condition in residents, notifying the resident's physician and family, following the care plan, and proper documentation. She stated she was in-serviced by DON. In an interview on 01/02/24 at 1:20 PM, DON stated she in-serviced all of the staff in the facility that reported to her, and Corporate Nurse in-serviced her. She stated she was in-serviced on change of condition, medication administration, when and how to notify the doctor and family, how to review the 24-hour reports to monitor for a change in condition, and how to ensure nurses are documenting and reporting changes in blood pressure. She stated the housekeeping and laundry department was in-serviced as well. In a telephone interview on 01/02/24 at 1:30 PM, Med Aide E stated he was in-serviced on change of condition, PRN medications, notifying the nurse when there are concerns, and blood pressures. In an interview on 01/02/24 at 1:36 PM, Nurse C stated she was in-serviced since last Thursday on PRN medications, vitals, change of conditions, and notifying the physician of any changes. In an interview on 01/02/24 at 1:48 PM, Housekeeper stated she received an in-service on change of condition in residents. She stated she was trained to notify the nurse if they see something different about the resident, like breathing differently, looks differently, or if they appear to not be their normal self. Housekeeper stated she was told to contact the DON or ADON if the nurse did not do anything about her concerns. In a telephone interview, on 01/02/24 at 1:52 PM, Nurse F stated he received additional training last week, around 12/28/23, that covered notification on changes, how the med aide should notify a nurse of any issues, how a nurse should contact the physician, or the DON/ADON if there are concerns of if the nurses are not able to reach the doctor. He stated the in-service also covered PRN medications, and checking vitals, including blood pressure. In an interview on 01/02/24 at 1:58 PM, Administrator stated he was in-serviced by Corporate Nurse. He stated he was in-serviced on change of condition, medication errors, physician notification, blood pressure, who needs to notify who of a change in condition with a resident, what the nurses should do once they are notified of a change in condition, and what the med aides are required to do in the process. A record review of the following was completed on 01/02/24: Blood Pressure medication audit of all residents, including all revisions since 12/28/23. There were no concerns. An in-service for Medication Administration, Documentation of rechecked Vitals, Documentation when all medications are given, Documentation of notifications to nurse and doctor, Change of Condition, and Following Physician's Orders, dated 12/29/23, instructor noted as DON, and instructor for DON was Corporate Nurse All post tests for all in-services completed Sign-off Verification that all vitals were checked on all residents and audits were completed on calendar for 12/28/23, 12/29/23, 12/30/23, 12/31/23, 01/01/24, and 01/02/24, and signed-off by Administrator, DON, and Corporate Nurse. An untitled, undated, facility document with review of all vitals for residents on 12/28/23, 12/29/23, 12/30/23, 12/31/23, 01/01/24, and 01/02/24, which included weight, respiration, blood pressure, temperature, pulse, blood sugar, height, O2 saturation, and pain levels for each resident. Document of verification of all active orders reviewed and updated if needed. Administrator was notified on 01/02/24, the Immediate Jeopardy was removed. While the immediacy was removed on 01/02/24, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not Immediate Jeopardy due to the facility continuing in-servicing and monitoring of the Plan of Removal.

Based on observations, interviews and record reviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (Residents #1) of six residents reviewed for elopements. 1. The facility failed to ensure Resident #1 was not adequately supervised to prevent him from leaving the facility unsupervised. Resident #1 had severe cognitive impairment, wandering behavior and lacked safety awareness. Resident #1 eloped from the facility on 11/27/20 and was found by facility staff, that was coming into work, in the back-parking lot without his wander guard bracelet on. Resident #1 sustained bruising to his left eye, a laceration to his left eyebrow, and left subacute subdural hematoma, resulting in a hospital visit. 2. The facility failed to ensure staff were trained and able to demonstrate competency on elopement and supervision. An Immediate Jeopardy was identified on 07/13/21 at 10:31 a.m. While the Immediate Jeopardy was removed on 07/14/21, the facility remained out of compliance at the severity level of potential for more than minimal harm that is not immediate jeopardy and at a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure could place residents at risk for injury and/or death from elopement-related harm, including vehicular accidents, falls, missing medications, and extreme weather exposure. Findings included: 1. Review of Resident #1's discharge MDS assessment, dated 12/16/20, revealed he was a [AGE] year old male admitted to the facility on [DATE] and discharged on [DATE]. His diagnoses included [CONDITION(S)], restlessness, and agitation, and alcohol dependency. The cognitive section of the MDS indicated Resident #1 had severe cognitive impairment. He had symptoms of [CONDITION(S)], which included continuous inattention that did not fluctuate, no [CONDITION(S)] and no wandering behavior. He had an unsteady gait and used a cane. Resident #1 had impaired vision and with right eye [CONDITION(S)] and he wore glasses. Review of Resident #1's care plan reflected identified a problem as Behavioral Symptoms initiated on 10/27/2020 which reflected, Resident #1 experiences wandering without purpose, seeming oblivious to needs or safety. Initial interventions on 10/27/20 included: to assure the resident had an identification band in place, equip resident with a device that alarmed when resident wandered check proper functioning every shift and provide visual cues. Revised care plan dated 12/02/20 reflected Place wander guard to left ankle with every shift monitoring placement. Restorative to check placement daily. Flowsheet: Behavior monitoring every 12 hours. Review of Resident #1's Elopement Risk Assessment, dated 10/30/2020, completed by an [Agency nurse Z] reflected Resident #1 was not aware of his surrounding, did not have safe decision making capabilities, had a history of wandering, and had attempted to leave the building, and had a diagnosis that required supervision. Review of Resident #1's Elopement Risk Assessment, dated 11/02/2020, completed by an [Agency nurse AA] reflected Resident #1 was aware of his surrounding , had safe decision making capabilities, did not have a history of wandering, had not attempted to leave the building, and had no diagnosis that required supervision . Review of Resident #1's Resident Progress notes, dated 10/27/20 reflected, .Resident wandering the hall, appears very agitated and asking if this is the VA hospital resident is redirected several times, but cont [continues] to get more agitated Further review reflected, 10/30/20, resident was found by the PT at the back door near the laundry room. She [NAME] him back to [unit 2], when ask where he was going resident stated am going to go to Fort [NAME] Team is continuing to keep an eye on him Review of Resident #1's TAR record, dated 10/30/20 through 12/01/20, reflected, for the wander guard placement .11/11/2020 11/11/2020 14:51 [2:51 p.m.] Not Administered: Refused Comment: res states I told them I was not letting them put one on me 11/25/2020 07:37 Not Administered: Refused Comment: res refuses to allow staff to place wander guard on him 11/27/2020 First 11/27/2020 11:44 Not Administered: Resident unavailable Review of Resident #1's elopement self-report incident, dated 11/27/21 at 1:31 p.m., revealed he was found on 11/27/20 by CNA C at 4:30 a.m. as she was coming to work. He was outside sitting upright on the concrete with his back leaned on the wall; he was noted to have wet pants and bleeding from his forehead. LVN D and RN E assessed Resident #1 revealing a laceration to his forehead and bruising to his left eye. Resident #1 was transferred to the hospital. Review of Resident #1's hospital records, dated 11/27/20, reflected Resident #1 was treated for a 1.5 cm left eyebrow laceration and left subacute subdural hematoma. Review of the Provider Investigation Report , dated 12/02/20 provided by the ADM on 07/12/21, revealed included was a written statement from agency CNA C that indicated on 11/27/20 around 4:30 a.m., she was scheduled to work the 6:00 a.m. to 2:00 p.m. shift. CNA C came to work a little early. CNA C said when she pulled up to park her car her headlights shined on a man sitting upright with his back against the wall, his pants wet and face bloody. CNA C drove around to the front of the building and called RN E and she got the other nurse, LVN D, and came to the back and said he was Resident #1. They had called an ambulance by the time CNA C had parked her car . Further review of the Provider Investigation Report 12/02/20 reflected, based on interview conducted, staff account of events, and resident's poor cognitive status the facility could not determine how Resident #1 came down the elevator and exited the facility though the back door . Resident #1 had an order for a wander guard to be placed on his ankle, when found outside he did not have the wander guard bracelet on him . the nursing staff in-serviced to ensure wander guard placement is verified and documented Q shift Attempts were made to contact CNA C, RN E, and LVN D on 07/13/21 at 11:00 a.m. , thought the Staffing Agency and they were no longer employed by the Staff Agency. Review of the in-service training, dated 11/27/20, at the time of Resident #1's elopement reflected training for: abuse, neglect, resident rights, documentation, reporting, and to ensure nursing checking wander-guard every shift. There was no elopement drill training. Further review of the trainings reflected no monitoring tool to assess the knowledge of the staff following the in-service given on 11/27/20 concerning placement and functionality of the wander guard, or the monthly elopement drills that did not begin until January 2021. An Observation on 07/13/21 at 10:15 a.m. with five residents identified as wanderers, were assisted by RNA to the elevator and the code was put in and the residents were brought down to the activity. RNA conducted activity with all residents including the residents identified as wanderers. Later the code was placed in the elevator and all the residents were taken back upstairs. The residents all had on visible wander guard bracelets on their ankle or wrist, were ambulating as a group, and the residents were not showing any exit seeking behaviors. An interview with LVN A on 07/12/21 at 10:30 a.m. revealed she had so much training she thought one training was for wandering residents, but could not recall, since she had been working at the facility for only 4 days. She said she knew there were some wandering residents on the floor and there was a place on the MAR to check off the wander guard. LVN A stated she was am not really sure how to check the wander guard and did not know how many residents wore wander guards. She stated she was still trying to figure everyone out. LVN A was asked about the elopement policy and she said she was not sure what the policy was, but she knew if a resident was missing she would look for the resident and after that she said she would just call somebody, meaning the DON or the ADON. The LVN was ask if she had been involved in an elopement drill in the four days she had worked, she said no. An interview with Agency LVN F on 07/12/21 at 10:45 a.m. revealed she had no training concerning elopement policy and procedure and this was her first day working at the facility. In a further interview with LVN F at 3:45 p.m. she was asked had she received 1:1 training with the DON prior to starting her shift today, she said no. The LVN was asked if she could identify the wandering residents, she said no that she would just have to watch their behaviors. She said she had worked in the LTC setting since she was young, and she knew how to observe residents. She stated as a nurse she would be able to figure out something if someone was missing but she did not know what the policy was or what they would expect of her. She was asked about the checking of the wander guard and she said there was a place they had to put it in on the MAR and someone else had done that already. The LVN was asked how would she know how to check the device and she said she did not have a clue, and she would just roll them up to the elevator or the door she guessed, to see if the alarm went off. An interview with CNA G on 07/12/21 at 11:30 a.m. revealed she was not sure which residents wandered and which residents wore wander guards and she was not sure of what to do if someone was missing. When asked about training, concerning elopement and who wore wander guards, she said she guessed so, but she did not recall. An interview with CNA H on 07/12/21 at 12:25 p.m. revealed she had worked at the facility for 2 weeks and was not sure what to do if a resident was missing and had no training offered concerning elopement or what residents wore wander guards. Further interview with CNA H at 6:26 pm revealed she had not been trained on wandering, eloping or a missing resident. CNA H said she had been trained at other facilities so thought she knew what to do but didn't want to say since she wasn't sure what this facility would want her to do. She said she was not sure if residents had wander-guards or not in this facility. An interview with Housekeeper X on 07/12/21 at 1:00 p.m. revealed she had not had any training related to elopement, but she would just call 911, if she heard that a resident was missing. An interview with the Administrator on 07/12/21 at 1:45 p.m. revealed the staff was trained with monthly elopement drills and wander guard placement and how they functioned. When asked about the training of the agency staff, the Administrator said they were trained 1:1 by the DON prior to starting of their shift . The Administrator was ask to provide the training for the agency staff and at the time of exit no trainings had been provided. An interview with CNA W on 07/12/2021 at 6:18 p.m. revealed she did know what to do when a resident was missing, wandering or eloped. Said there were a few residents in the facility who were at risk of wandering and wore a wander guard, but she didn't remember their names. Said she had training on elopement and wandering a few months ago she thought . An interview with Agency LVN I on 07/12/21 at 6:20 p.m. revealed she had just arrived for her shift, she was agency staff, and it was her first day. She stated she had no idea who the wanders were and said why should that be something I should be worried about here? No one told me that we had wanderers here. When the LVN was asked about wander guard and elopement training she said she did not have any training she just hit the floor moving. An interview with Agency LVN V on 07/12/21 at 6:23 p.m. revealed this was her first night to work at the facility, she had not received elopement policy and procedure training. She denied the knowledge of the facility's steps of procedure to take in event of an active elopement during her shift. She did not know who the residents were that were identified as an elopement risk and wore a wander guard, nor did she know how to assess the functionality of the wander guard or what was required to monitor the wander guard device . An interview with the Administrator on 07/13/21 at 10:44 a.m. revealed the Administrator brought all the elopement drills dated January 2021 through June 2021. The Administrator said he monitored all the in-services. He was asked how he monitored, and he said, I go up to the second floor and check the wander guards, myself . When asked what he checked, the Administrator replied he checked the residents to make sure they were safe. The Administrator gave an example of, about one month ago he went to the facility to check the wander guards on the residents and one of the resident's ankle was swollen and the bracelet was too tight, so he reported to the nurse so she could obtain a larger bracelet for the resident. When the Administrator was asked about Resident #1's elopement, he said he had no idea how long he was out or how he got out. The Administrator said maybe he took his wander guard off and was able to go down the elevator . Interview with the Department Director of Maintenance on 07/13/21 at 12:57 PM revealed he did not know why the Administrator wanted him to do elopement drills each month. He said before January 2021, they did not do them that often. He stated when he did the drills the staff participated, but they asked no questions and he did not ask them any questions, he would just time them. When he was asked if there was any follow-up to monitor the staffs understanding of the importance of the drill, he said not that he know of. He was asked if he recalled when Resident #1eloped the facility, he said he did and he checked the wander guard system after it happened. He was ask if he confirmed after the elopement that the system worked, he said yes, but he did not conduct an elopement drill until the first of January (2021 ). The Department Director of Maintenance said he check the wander guard weekly for function and he has had no problems with functionality. During this interview it was observed with Department of Director of Maintenance the wander guard system was functioning appropriately. An interview with the DON, on 07/14/21 at 1:13 p.m. revealed she said she expected her nursing staff to know what residents wore wander guards, be trained on wander guard checks, placement and elopement policy and that they do Q shift checks for placement and functionality of the wander guards and document on the MAR. The DON stated if a resident had exacerbation of behavior then initiate Q15 minute checks and use behavior monitoring. The DON stated she did not expect the staff to do 1:1 on all five wandering residents , unless they had a change in their behaviors and required 1:1 monitoring. Then the staff was to call her, the physician and let her know if the resident could not be redirected. She stated if there were not problems/changes with the residents behavior they would document in the nurse's notes. The DON said that she was not the DON at the time of Resident #1's elopement, and when she came to work the facility was having monthly elopement drills. An observation on 07/14/21 at 2:00 p.m. with five residents identified as wanderers getting on the elevator with the RNA to go to an activity. She placed the code in the elevator to get it to operate. The RNA monitored the residents during the activity. The residents had on their wander guards and had no exit seeking behaviors during the activity, the RNA brought the residents back to the elevator and took them back upstairs when the activity was completed. An observation on 07/15/21 at 12:00 p.m. 4 of the 5 wander guard residents were brought down to the patio area and to the main dining area for their meal, the RNA monitored the residents. All of the residents sat at the tables and one resident had exit seeking behaviors, was redirected during his meal. Review of the facility's Leadership Policies and Procedures, dated November 2017, reflected, Elopement: to safely and timely redirect patients/residents to a safe environment. A prompt investigation and search will be conducted if a patient/resident is considered missing. Once it is established a patient/resident is missing all employees are notified .the DON is notified when the /patient/resident are not located within 30 mins .DON completes a missing resident profile .The DON of designee institutes and immediate thorough search of the center and surrounding areas . the entire search of the grounds from the time the patient/resident is missing will be completed within 30mins .if search fails the Administrator or designee contact the appropriate community or agency Review of the facility's Leadership Policies and Procedures, dated November 2017, reflected, Elopement Risk Assessment: All residents are assessed upon admission by licensed nurse for elopement risk .evaluated the resident for exit seeking risk on admission/quarterly/with significant change in condition. If a resident is at risk for elopement:-the physician is notified of the patient/resident's risk for elopement and the interventions that are recommended/implemented for prevention of elopement and patient/resident safety-/should the patient/resident or his/her legal representative reuse/decline the recommended interventions, they are deciding to go against medical advice and, in that case, the legal department should be consulted-the care plan is immediately updated-the licensed nurse documents int the nurses' notes and behavior monitoring flow record and exit seeking behavior on an on-going basis and interventions are adjusted as needed An Immediate Jeopardy was identified on 7/13/21 10:31 a.m. and the Administrator was informed of IJ in the area of accidents/supervision and the IJ template was provided to him via email at 10:40 a.m. The plan of removal was accepted on 07/14/21 at 6:06 p.m. and included: Plan of Removal 7/13/21 1 . Identified resident no longer resides in facility. 2. Residents listed (see attached) are at risk for elopement and have the potential to be affected by the alleged deficient practice. At this time none of the five residents are currently exit seeking however as of 7/14/21 Behavior monitoring forms will be initiated. Director of Nursing, RN/ Designee: Verified Wander guard orders to include: Placement and Functionality have been reviewed and clarified 7/13/21. Care plans have been completed on resident deemed at risk for elopement by 7/13/21. 3. Director of Nursing RN/Designee will re-educate Facility Staff starting 7/13/21 and completing by 7/14/21 on the following: Licensed Nurses will verify and document that Wander guards are properly placed on identified residents' arm or leg and properly functioning, every shift. Elopement Policy and procedures of a prompt search and investigation that will be conducted if a resident is considered missing. (see attached policy) Licensed Nurses will be reeducated on use of Behavior Monitoring Forms on residents who are at risk for elopement or have exit seeking behaviors. If a resident develops new onset of exit seeking behaviors, a Behavior Monitoring Form will be initiated. Care plans will be updated to reflect behaviors. If a resident is deemed appropriate for Wander guard but refuses to wear the wander guard, DON will be notified, and this resident will be placed on 1:1 monitoring pending possible discharge Facility Staff will complete a post test on the above education to validate the transfer of learning. An employee roster and schedule will be used to validate education compliance by Director of Nurses and/or Designee The Clinical consultant will complete a competency using validation tool as a Train the Trainer with the Director of Nursing, and the Administrator to validate understanding of the process for validating placement and functionality of a wander Gard. This will be completed on July 14, 2021. Once the Director of Nursing, has successfully completed the competency, she will then complete a competency using validation tool on each licensed nurse to validate that checking placement and checking functionality using the Accutech is being performed properly. This will begin on 7/14/21 and will continue with each nurse prior to their next scheduled shift. Staff Scheduler/designee will inform Director of Nursing of daily staffing, Director of Nursing, will validate that staff on schedule for the day have received training. If not, DON will provide training prior to start of shift. This education will be presented in the new hire orientation to include agency and prn staff. Starting 7/14/21 Licensed Nurses will check wander guard placement and functionality by using Accutech device every shift and document. 4. The Director of nursing/facility Administrator, will observe a minimum of 5 nurses weekly for 4 weeks using validation tool to validate the understanding and proper checking of placement and functionality is occurring. This will include observation on all shifts and weekends by the Director of Nursing. Clinical Service Director, and/or, Administrator will review Director of Nursing validation for completion and accuracy starting 7/14/21 and will continue daily until 7/17/21. Then 3 times per week for 1 month to include all shifts and weekends starting 7/18/21. Ad Hoc QAPI was held on 7/13/21 to review contents of this plan. The Medical Director was notified on 7/13/21 of the Immediate Jeopardy Monitoring interviews for the Immediate Jeopardy were started on 07/15/21 at 12:49 p.m. and continued through 6:15 p.m. with 39 staff across all three shifts, including weekdays and weekends, all departments, including agency staff. The staff were interviewed about the elopement policy and procedure, wander guard placement and functionality, and behaviors monitor documentation, how to recognize residents with elopement seeking behaviors, training. Observations were made of the nursing staff using Accutech device. The following staff's in-service logs and competency tests were reviewed and staff was interviewed during the monitoring time frame and were able to articulate what they had been taught, new protocols and procedures related to elopements and the facility policy for wander guard placement, functionality and elopement seeking behaviors: LVN A, CNA B, DON, LVN M, ADM, Cook K, CNA N, CNA L, DOR, CNA G, Housekeeping Aide J, CNA H, CNA O, Laundry Aide P, COTA Q, LVN Q, Front Desk Receptionist, SW S, LVN T, Medical Record, BOM, and RN U. An Immediate Jeopardy was identified on 07/13/21 at 10:31 a.m. While the Immediate Jeopardy was removed on 07/14/21, the facility remained out of compliance at the severity level of potential for more than minimal harm that is not immediate jeopardy and at a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.

Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards or practice for one (Resident #1) of six residents reviewed for quality of care. The facility failed to ensure Resident #1 received treatment and care when she went 22 hours isolated in her room without any staff contact. Facility staff did not accompany the transport driver when he took Resident #1 to a room upon her readmission to the facility. Resident #1 was placed in a room on an unoccupied hall and staff were not informed of her presence. Resident #1 was found 22 hours later covered in urine and feces and it was determine staff were unaware of her presence and she had not received any care during this time. An Immediate Jeopardy (IJ) was determined to have exited from 01/11/21 through 01/12/21. The IJ was removed on 01/15/21 because the facility implemented actions that corrected the non-compliance prior to the beginning of the survey. The facility Administrator was provided the IJ template on 02/04/21 at 5:41 PM. This failure placed residents at risk of not receiving care and services to meet their needs which could result in serious injury, illness, or death. Findings include: Review of Resident #1's face sheet, dated 02/03/21, revealed the resident was a [AGE] year-old female, who was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's MDS Assessment, dated 01/20/21, revealed the resident had a BIMS score of 3, which indicated severe cognitive impairment. The resident required extensive assistance of one person in bed mobility, transfers, eating, and toileting. The resident was totally dependent on staff in dressing and required limited assistance in personal hygiene. Review of Resident #1's Care Plan, revised 10/26/20, revealed the following, not limited to: - Exposure to COVID-19 with a problem start date of 12/14/20, goal date of 12/24/20 ensuring Resident #1 was monitored for changes in condition with resolution of exposure, and included approaches such as monitoring vital signs, observing for signs and symptoms of COVID-19, perform lab or diagnostic testing as indicated, and isolation droplet precautions. - Stage II pressure ulcer to the sacrum with a problem start date of 09/30/20, goal date of 01/26/21 ensuring intact skin without evidence of redness, irritation, maceration, or open areas, and included approaches such as using heel protectors, position with pillows, and turn and reposition every two hours and PRN. - Weight loss with a problem start date of 09/09/20, goal date of 01/26/21 ensuring Resident #1 will eat at least 50% of meals through review period, and included approaches such as health shakes, encourage intake of foods and fluids, and allowing the resident to partake in meal planning if able. - [MEDICAL CONDITION] with a problem start date of 11/27/19, goal date of 01/26/21 ensuring Resident #1's [MEDICAL CONDITION] activities will be controlled, and included approaches such as administering anti-[MEDICAL CONDITION] medications as ordered. - Dementia with a problem start date of 07/20/17, goal date of 01/26/21 ensuring Resident #1 will not sustain serious injury due to memory recall/deficit, and included approaches such as administering medications as ordered, providing appropriate footwear, and redirecting resident from unsafe areas. Review of the facility's Provider Investigation Report, dated 01/15/21, involving Resident #1 revealed Resident #1 was brought back to the facility from a sister facility by an EMT van driver and placed in a room on an unoccupied hall. The nurse on duty was not notified. The facility did not find her until the following day. The facility first learned of the incident on 01/12/21 at 12:10 PM. The facility's investigation confirmed neglect did occur. An interview on 02/03/21 at 12:45 PM with Receptionist F revealed she had observed the EMT van driver bring Resident #1 to the facility on [DATE] around 2:30 PM. The receptionist stated she asked the Admissions Coordinator which room the resident was to go to, and then directed the EMT van driver to take the first-floor elevator with directions to the second floor's nurse's station. The receptionist stated neither she nor the Admissions Coordinator accompanied the EMT van driver to the second floor. Receptionist F was not aware the DON or nursing staff were not notified of Resident #1's arrival. An interview on 02/03/21 at 1:30 PM with the Admissions Coordinator and Medical Records Staff revealed Resident #1 had contracted COVID-19 and had been transported to a sister facility. The Admissions Coordinator stated she had been in communication with the Social Worker from the sister facility and was provided an ETA for Resident #1's return to the facility. According to the Admissions Coordinator this was communicated to all department heads in a group text which included the Administrator, the DON, Medical Records, the BOM, Activity Director, Dietary Manager, ADON, MDS Coordinator, and HR. The Admissions Coordinator stated while she did not see the resident directly, she did see the EMT van driver wheel in a resident around 2:15 PM on 01/11/21. During the morning meeting on 1/12/21 at around 9:30 AM, the BOM read off the census, which did not reflect an accurate count. The census did not include Resident #1. The Admissions Coordinator stated she, along with other departments heads, had stated they saw Resident #1 on 01/11/21, with the Admissions Coordinator recalling the receptionist asking her which room the resident was supposed to be in (room [ROOM NUMBER]). Medical Records Staff stated after the morning meeting she went to the second floor to room [ROOM NUMBER] but did not find the resident there before heading back downstairs to check with the nursing staff. Medical Records Staff stated she then went into the EMR system and saw the resident was in the system with medications past due. The Admissions Coordinator stated after the morning meeting she spoke with the Social Worker from the sister facility and was informed Resident #1 had been discharged from the sister facility and the ambulance dropped the resident off at the current facility around 2:15 PM. The Admissions Coordinator and Medical Records Staff stated they did a full sweep of the building and found Resident #1 on C Hall, which was previously a COVID-19 unit and was unoccupied by residents, in the last room to the right with the door closed. Upon opening the door, the resident was found in a fetal position and soiled in urine and feces. The Admissions Coordinator stated the resident said she was fine and appeared pleasantly confused. The Admissions Coordinator and Medical Records Staff stated they informed the DON immediately and the DON assessed the resident and found no skin breakdown or other concerns. The Admissions Coordinator stated the EMT never provided any confirmation or documentation that the resident had been transported to the facility. An interview on 02/05/21 at 1:59 PM with the EMT van driver revealed when she pulled up the van to the facility, she observed an employee smoking at the front. After parking, the EMT van driver took Resident #1 out of the van as policy stated. The front door of the facility was locked so she had to be let into the facility. The EMT van driver stated a male staff opened the door and gave entry to the EMT van driver and Resident #1. The EMT van driver stated she spoke to the receptionist in front and was informed the resident was to be taken to room [ROOM NUMBER]. The receptionist directed the EMT van driver towards the elevator which led to the second floor. The EMT van driver stated when she brought the resident out of the elevator, the monitor on the resident's ankle triggered an alarm. The EMT stated she observed the employee who was outside smoking at the nurses' station and asked where the nurse was. The EMT did not know who the staff member was. She stated then the staff member took her and Resident #1 to room [ROOM NUMBER], which was the last door on the right. The EMT van driver stated the doors were closed in the hallway and it appeared Resident #1 was the only resident staying in that wing. The employee took the EMT van driver and the resident to the room and transferred Resident #1 from the wheelchair to the bed as well as changed the resident's soiled brief. The EMT van driver stated she placed the information packet for the resident, on the dresser in front of the bed and the staff member acknowledged the packet. The EMT van driver stated she then took the wheelchair and went downstairs to leave the facility. An interview on 02/04/21 at 4:55 PM with LVN D revealed she worked from 6 AM to 6 PM on the second floor on 01/11/21. She stated on that day it was her first day working the second floor. LVN D stated she did not see the EMT van driver nor Resident #1 but did see a bag of medications at the nurse's station that was labeled for Resident #1. LVN D stated she inquired with multiple staff, including staff on the following shift, whose medication it was, but was told the resident was not in the building. LVN D stated she did not know what to do with the medication so she put it back at the nurse's station. LVN D stated she did not inform the DON or ADON and by the time she returned to the nurse's station again, the medication bag was no longer there. LVN D stated she knew the regular admission process where she would be informed of residents she was to be expecting for admission and signing off with the EMT that would bring the resident to the facility to confirm the transport of the resident. LVN D stated she was in-serviced on the process on admission/readmission after the incident. In an interview on 02/04/21 at 8:44 AM with LVN E revealed she worked from 6 PM to 6 AM on 01/11/21 on the second floor. She stated she was not made aware Resident #1 returned to the facility, nor did the nurse whom she relieved, LVN D, know. An interview on 02/04/21 at 9:10 AM with CNA C revealed she worked from 2 PM to 10 PM on the second floor and stated while she did not see the EMT van driver bring Resident #1 in, she did see the EMT van and the EMT van driver parked in front of the facility around 2 PM. She stated she let the DON know about the EMT transport but did not see what happened afterwards. CNA C was in-serviced and the admission/readmission protocol and the admission/readmission protocol and knew she could not receive residents, only nurses could. An interview on 02/04/21 at 9:49 AM with the DON revealed during the morning meeting of 01/12/21, there was back and forth between department heads on whether or not Resident #1 was already in the building. She stated Medical Records and the Admissions Coordinator both looked for the resident after the morning meeting. The DON stated Medical Records and the Admissions Coordinator did not let the team know when the sister facility confirmed Resident #1 was discharged from the facility. The DON stated had Medical Records Staff and the Admission Coordinator let them know Resident #1 should be in the building, the facility would have done a whole sweep of the building. Medical Records Staff and the Admission Coordinator ended up finding Resident #1 on a closed hall in the last room to the right and informed the DON around 12:00 PM. The DON stated she saw the resident was soiled and immediately cleaned her up and assessed her. The resident was given a health shake, food, drink, and a shower. The resident was taken to the nurse's station for one-on-one in order to continue to assess the resident. Resident #1 was pleasantly confused and stated she was fine. The DON stated the hall the resident was on had been closed since before Christmas (2020) due to a COVID-19 outbreak. The DON stated the facility failed to have proper readmission protocol in place for residents who returned from the sister facility due to COVID-19. An interview on 02/03/21 at 1:54 PM with the Administrator revealed the break in communication occurred when the EMT van driver failed to provide paperwork or contact a nurse when Resident #1 arrived at the facility. He stated EMT van drivers normally had nurses sign documents to confirm the resident was received by the facility. The Administrator stated the EMT van driver's description of a CNA that assisted her with Resident #1 did not match any of the facility staff. The Administrator also stated the sister facility failed to call to provide nurse-to-nurse communication regarding Resident #1. The EMT van driver, along with an unidentified CNA had taken the resident to the wrong room. room [ROOM NUMBER] was located on the hall with the rest of the residents, but the resident was taken to 214 instead, which was on an entirely different hall and had been empty. The charge nurse, LVN D, at the time was an agency nurse, whose first day working was the day Resident #1 returned to the facility. She did not see the resident enter the floor because she was on a lunch break. Upon her return, she found medication at the nurse's station that belonged to Resident #1. Per the Administrator, the agency nurse inquired with other staff about the medication at the nurse's station, but she was told the resident was not in the building. The Administrator stated the normal process for new admissions or readmissions involved the Admissions Coordinator, who was the first contact, and nurse management, which included the DON and the ADON. The Admissions Coordinator would communicate with the discharge entity, receive clinical information regarding the resident, receive transport information and estimated time of arrival. The Admissions Coordinator would email the clinicals to nurse management and communicate the resident's time of arrival including room number with all department heads via mass text. The discharge entity would normally call for a nurse-to-nurse report regarding the resident to let the facility nurse know they were discharging a resident and provide clinical information such as diagnoses. The accepting nurse would then be on a lookout for the admission of the resident. Once the resident arrived, the accepting nurse would admit the resident, place the resident's information into the EMR, see what equipment and medical supplies were needed, and etc . An interview on 02/04/21 at 10:44 AM with the Activity Director revealed on 01/11/21, as he was walking out to do grocery shopping for a resident, he remembered seeing the EMT van driver wheeling Resident #1 into the facility. Prior to seeing Resident #1, the Activity Director stated he received a group text from the Admissions Coordinator that Resident #1 was supposed to arrive at the facility on 01/11/21 some time. During the morning meeting of 01/12/21, the Activity Director informed the team that he had seen her. There was some back and forth about it. When the meeting ended, the department heads all went to their respective departments and figured it was a matter between the admission and nursing department. The Activity Director was in-serviced on admission/readmissions. Review of the facility's Accepting and Transferring Patients/Residents policy, undated, revealed, .Patients/Residents with No Clinical Concerns for COVID-19 All hospitalized patients/residents should be assessed for COVID-19 prior to transfer to a long-term care facility .The patient/resident should be placed on a 14-day quarantine on admission .the resident screening tool should be completed daily for non-respiratory illness facilities, and twice a day for facilities with respiratory illness-on all patients/residents . This policy was implemented prior to the incident and was part of the COVID-19 Response Plan. The facility implemented the following interventions to address the non-compliance: Review of the facility's Admission/Readmission Protocol in-service, dated 01/12/21, included procedure for communication between the Admission Coordinator with the accepting charge nurse, ensure the room is prepared, accepting nurse receiving paperwork from EMT and ensuring the resident was in the system based on admission paperwork, and educating CNAs on not accepting admission/readmission paperwork from EMT but to refer to the nurse or supervisor at all times. Review of the facility's Lunch Break in-service, dated 01/15/21, included instruction to charge nurses to notify the DON or ADON before going on break in order for the hall to be covered. In an interview on 02/03/21 at 1:30 PM the Admissions Coordinator stated she and all the staff were in-serviced on the new admissions process which included creating an admission alert on a brightly colored piece of paper which would be given straight to the charge nurse. The charge nurse would receive the form and check off that it had been received. The charge nurse would also be in charge of filling out an admissions checklist, which was printed on a different colored paper for the incoming resident. The DON would receive confirmation regarding the incoming resident and would follow up with the charge nurse to ensure completion of the admission alert and the admission checklist. In an interview on 02/04/21 at 4:30 PM with Receptionist F revealed she had participated in the in-service regarding admissions/readmissions. In an interview on 02/04/21 at 9:10 AM with CNA C revealed she was in-serviced and the admission/readmission protocol and the admission/readmission protocol and knew she could not receive residents, only nurses could. An interview on 02/04/21 at 10:44 AM with the Activity Director revealed the Activity Director was in-serviced on admission/readmissions. An interview on 02/04/21 at 4:55 PM with LVN D revealed she was in-serviced on the process on admission/readmission after the incident, including the 'lunch break' training. Review of the facility's Admit/Discharge Report: 01/01/21 - 01/31/21 revealed the only other resident readmitted to the facility after 01/12/21 was Resident #2. The resident was readmitted on [DATE]. An interview on 02/03/21 at 9:41 AM with Resident #2 revealed he had been discharged to the hospital due to some complications and was readmitted with no issues. In an interview on 02/04/21 at 9:49 AM the DON stated since the incident, the facility implemented a direct line of contact from admissions to the nurse assigned to the resident. The new sheet presented to the nurse from the Admissions Coordinator would be on a brightly colored sheet which had to be checked off. The DON would contact the charge nurse to ensure the charge nurse received the admission alert sheet. The nurse would also have to ensure an admission checklist provided by the facility was filled out. The DON and ADON would be in charge of coming behind the charge nurse to ensure the sheet was filled out and by the time of the morning meeting the next day, the DON would review the admission protocol to ensure the resident was properly admitted . In an interview on 02/03/21 at 1:54 PM The Administrator stated since the incident, the facility had implemented a new process for admissions/readmissions which included a new admissions alert. In addition to the normal process, the Admissions Coordinator would receive the admission information and provide direct communication to the nurse assigned to the resident. The admission alert would be printed on a brightly colored paper to make it hard to miss and have it handed directly to the assigned nurse which would include the name of the resident, the room number, and where the resident was being discharged from, that way there would be a direct line of communication. Review of the facility's MatrixCare Licensed Nurse Competency, undated, revealed a training checklist for agency staff which included topics such as admitting/discharging residents. The competency list required the trainer's initials, staff initials, a 30-day review, and comments section. This was updated on 01/12/21, per the DON. Review of the facility's New Admission/Readmit admission alert sheet, undated, revealed it was a bright pink sheet that included the required information: Name of resident, room number, payor, discharged from, diagnoses, equipment needed, diet, transport information, and signed by the Admissions Coordinator. This was included in their provider investigation report which was submitted on 01/12/21. Review of the facility's Admission/Re-admission Checklist, undated, revealed the required information to be checked off: Resident name, date, time of admission, nurse's initials, resident face sheet in chart with code status, allergies [REDACTED].This was created on 01/12/21, per the DON. Review of the facility's Admission Process Update policy, undated, which was the facility's plan on training any new agency nurse hired, revealed, During Admission/Discharge - Charge Nurse will receive admission form (pink in color along with a checklist) from Admission director signaling he/she will be getting a new admission/readmit. Admission form is handed straight to accepting nurse. This sheet will indicate ETA, room number, (diagnoses), diet, and transport info. Charge Nurse/Receiving Nurse should then verify the correct room and ensure assigned room is ready for patient. Once patient arrives report is taken and patient is signed off. Only charge nurse will be responsible for this duty. If charge nurse is not available, allow EMTs to wait or notify supervisor for further instructions. Once patient is comfortable in bed, clinical assessments starts and the admission check-off sheet is utilized. Once completed it is placed in the DON/ADON box for her to pick up the next morning. Clinical part begins check and balance. The admission/check-off sheet is sent to medical records for uploading into the clinical record. This was updated on 01/12/21, per the DON.

Based on interview and record review, the facility failed to permit the resident to remain in the facility, and not transfer or discharge the resident from the facility unless the transfer or discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility and failed to ensure the physician was notified regarding a decision for transfer or discharge for one (Resident #1) of four residents reviewed for transfer and discharge rights. The facility failed to ensure Resident #1 was discharged to a safe and appropriate environment when they decided they were no longer able to address her increased wandering behaviors and need for supervision. The facility discharged Resident #1 to her apartment in the community alone without family or any type of supervision or assistance despite her severe cognitive impairment, wandering behavior, and attempted elopements. Resident #1 was found wandering by the police on the same day she was discharged from the facility and left at her apartment. On 08/20/20 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 08/21/20, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy with a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. The facility was provided with the IJ template on 08/20/20 at 10:15 AM. This failure placed residents at risk of not the care and services necessary to ensure their needs are met which could result in illness, serious injury, or death. Findings include: Record review of Resident #1's face sheet, undated, revealed the resident was an [AGE] year-old female originally admitted to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. It did not list a responsible party or identify the resident as the responsible party. Record review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 06/12/20, revealed the resident had a BIMS (Brief Interview for Mental Status) score of four indicating she was severely and cognitively impaired. Further review of the assessment indicated the resident had behaviors of wandering . Further review revealed that she needed one person to assist her with bed mobility, walking, dressing, toilet use, and personal hygiene. Record review of Resident #1's care plan, dated 06/11/20, reflected that the resident was at risk for elopement and needed a wander guard to keep her safe until an alternate placement could be made. Further review reflected the resident had difficulty making herself-understood due to her cognitive impairment and would learn the skills necessary to make her needs known. Resident #1's care plan reflected she had impaired decision making due to dementia with the approach being to determine if decisions made by the resident endanger the resident or others and for staff to intervene if necessary. Further review of her care plan revealed the resident had disorganized thinking or was incoherent with the approach to orient her to person, place, and time. Further review reflected the resident was recently hospitalized for [REDACTED]. Record review of Resident #1's physician orders, dated 03/17/20, reflected that the resident wore a wander guard to left ankle to be checked for placement each shift. Record review of Resident #1's Discharge Summary, dated 08/20/20, reflected Resident #1 was discharged to her apartment. It was not signed by the physician and indicated that she was not responsible for herself. Record review of Resident #1's Social Services Progress Note, dated 05/26/20, revealed, Due to resident elopement risk, staff feels that a secure unit would be better. (Social Worker) referred resident to (alternate facility name). Face sheet and clinicals (have) been sent. Record review of Resident #1's Licensed Nurse's Progress Note, dated 05/26/2020, revealed, .once nurse placed wander guard, patient became upset and began hitting this nurse stating (staff) were fired and she owned (the facility) . Record review of Resident #1's Nursing Progress Notes, dated 05/31/20, revealed, (Resident #1) was cutting wander guard strap . Record review of Resident #1's Social Services Progress Note, dated 06/01/20, revealed, Talked with (Hospital SW) about (Resident #1) being (an) elopement risk, causing danger to herself. Let (Hospital SW) know that resident need(ed) to be in a secure unit . and the facility's SW said the facility did not want to accept the resident back due to her being a danger to herself, elopement, and (Resident #1) being violent. Record review of Resident #1's Licensed Nurse's Progress Notes, dated 06/05/20, revealed, Resident readmitted to facility .(was) alert, oriented to name. Confusion noted to place and time. Record review of Resident #1's Social Services Progress Note, dated 06/11/20, revealed, Resident somehow dislodged her wander guard .SW has contacted most of the secure units in the metroplex and surrounding cities, in an effort for a more appropriate placement (secure unit). SW will continue the search for a secure unit. Record review of Resident #1's Licensed Nurse's Progress Notes, dated 06/21/20, revealed, (Resident #1) cut or tore wander guard from ankle and (was) refusing to put it back on .15-minute watches in order. Record review of Resident #1's Nursing Progress Note, dated 06/24/20, 06/26/20, 06/27/20, 06/28/20, and 06/29/20 reflected Resident #1 was on one-to-one supervision due to increased elopement risk and behavior. Record review of Resident #1's Social Services Progress Note, dated 07/01/20, revealed, She was discharged with home health, Meal on Wheels, Adapt Behavioral and to APS (Adult Protective Services). APS report was done because of concerns around (patient) abilities. In an interview on 08/19/20 at 9:45 AM LVN C stated she had been working at the facility for about three months. She stated she recalled Resident #1 would constantly wander around the facility and would make attempts to elope although Resident #1 wore a wander guard. She stated Resident #1 was confused most of the time, and should not have been discharged home. She said that Resident #1 was frequently on one-to-one supervision due to her wandering behaviors and would not have been able to take care of herself due to her confusion and behaviors . In an interview on 08/19/20 at 2:00 PM the SW stated he had been working at the facility for a while . He stated he was the one who initiated services for discharges to the community for residents who qualified. He stated that he assisted in setting up community resources for the resident such as home health services. He said that the nursing department was in charge of contacting the physician for the discharge order. The SW stated he remembered Resident #1 and did not feel she should have been discharged . He stated that he was uncomfortable going through the process to discharge Resident #1 but did it anyway because he feared for his job. The SW stated he set up home health services, meals on wheels, and sent in a report to APS. He said that he reported the situation to APS because he did not agree with the previous Administrator's decisions. He stated Resident #1 was constantly attempting to elope, wore a wander guard, and was always confused. He stated Resident #1 had guardianship services paperwork in the works so she could remain in the facility. He stated Resident #1 could not take care of herself, but the previous Administrator wanted her out of the facility due to her being an elopement risk. He said that he talked to the previous Administrator about his feelings regarding the discharge, but she did not agree and told him to take care of discharging Resident #1. He stated it was not safe for Resident #1 to discharge back to her private apartment because she lived alone, was confused often, and did not have family involved or anyone to check on her. In an interview on 08/19/20 at 2:20 PM ADON A stated she felt Resident #1 was safely discharged . She stated Resident #1 had attempted to elope multiple times, wore a wander guard, was put on one-to-one supervision, but could care for herself if she lived alone. She stated that she felt the resident could take care of herself because she was able to ambulate well in the facility and make her needs known verbally. She stated she heard the police picked up Resident #1 a few hours after she had discharged from the facility and was found confused. She stated the same incident happened a few months ago as well, where she was found by police and sent to the hospital due to an altered mental state. After her hospital stay, she was admitted to the facility. In an interview on 08/19/20 at 2:30 PM the DON stated she felt the facility safely discharged Resident #1. She stated Resident #1 was an elopement risk, had a wander guard, was put on one-to-one supervision, but could take care of herself. She stated she was told the police found Resident #1 confused a few hours after she was discharged from the facility. The DON stated she knew from Resident #1's chart that the same incident happened a few months prior to her admittance to the facility. She stated she did not see anything wrong with Resident #1's discharge. She stated that the SW would arrange for community resources like home health and the nursing department would call the physician for discharge orders. She did not specify who in the nursing department would call the physician, but she said that the previous Administrator and SW were in charge of the discharge at the time since she was new. In an interview on 08/19/20 at 3:10 PM the Admissions Director stated Resident #1 was at the hospital after being found by police on 07/01/20 (date of discharge). The Admissions Director stated Resident #1 discharged from the facility that same day and was taken to her private apartment. She stated Resident #1 was often confused and was unable to care for herself alone . She stated Resident #1 was also known as an elopement risk and did not have anyone to take care of her at her apartment. The Admissions Director stated she had spoken to the previous Administrator about her concerns regarding Resident #1's discharge and felt it was not right to discharge the resident. The Admissions Director stated that she went on vacation, came back to the facility, and was told by the previous Administrator that Resident #1 was discharged . In an interview on 08/19/20 at 3:25 PM the Medical Director (Resident #1's physician) stated he did not think Resident #1 was competent enough to make her own decisions and had just completed paperwork for guardianship services for Resident #1. He stated he was never told Resident #1 was discharged or that she had an apartment. He stated he did not have Resident #1's medical record in front of him and would defer to his nurse practitioner who was more knowledgeable about the resident to continue answering questions. He stated that he would not have given the order to discharge her and was always involved in discharging residents. In an interview on 08/19/20 at 3:38 PM the Nurse Practitioner stated Resident #1 had severe dementia, was severely cognitively impaired, and was only oriented to herself. He stated Resident #1 could ask for things that she needed but could not make informed decisions for herself. The Nurse Practitioner stated he was not aware Resident #1 had her own apartment and he was not informed Resident #1 had been discharged . The Nurse Practitioner stated Resident #1 could not take care of herself and needed to be in a long-term care facility. He stated the last time he saw Resident #1 was in June (2020). An interview with the DON and a record review of Resident #1's physician orders [REDACTED].#1's discharge. She stated she did not know why there was not a discharge order for Resident #1. In an interview on 08/20/20 at 8:20 AM the Interim Administrator stated while he was not at the facility at the time of Resident #1's discharge, he did review the self-report investigation related to Resident #1's discharge. He stated that it was completed by the previous Administrator, but he began his own investigation yesterday evening (08/19/20). He stated that he was still in the process of speaking with staff and reviewing the records. Record review of facility's policy, titled Discharge/Transfer, dated 11/01/17, revealed The patient/resident will be discharged transferred (home/another entity) by order of his/her attending physician. Facility will include the patient/resident and family in developing a safe discharge plan to address the patient's/resident's individual needs. An IJ was identified on 08/20/20 at 10:15 AM, and the Administrator and DON were notified of the IJ. A plan of removal to remove the immediacy was requested on 08/20/20 at 10:15 AM. The following plan of removal was accepted on 08/20/20 at 6:30 PM: Plan of Removal (Facility Name) 8/20/2020 The facility will implement the following measures to ensure all discharges are safe and appropriate. (Medical Director) was notified of Immediate jeopardy on 8/20/20. No further instructions and/or recommendations received from (Medical Director). Training to be provided to Director of Nursing and Interdisciplinary Care Plan Team by (Regional Social Services Consultant). Training will be started 8/20/2020 and completed by 8/21/2020. Interdisciplinary Team: (Administrator) (IDT Team Leader), (Social Worker), (Dietary Manager), (ADON A), (Activity Director), (ADON B), (DON), (Therapy Director), (BOM), (MDS Coordinator). Training will include what is a safe appropriate discharge. Additional information will include calling Regional Compliance line if a team member feels a discharge/transfer to be unsafe. Training will be started 8/20/2020 and completed by 8/21/2020. Training will be validated with Post Test. New staff or others needing training will be provided training from Director of Nursing or designee. Director of HR will monitor training is provided for new hires and any additional personnel who are in a role involved in discharge planning. Starting 8/2020 all discharges will be reviewed for appropriateness by Director of Nursing and Interdisciplinary plan of care team during morning meeting. All discharges will require final approval of facility administrator or designee prior to discharge. To ensure ongoing compliance Regional Social Services Consultant or designee will review all discharges at (facility name) monthly for next three months. Interdisciplinary Team will discuss discharges during they Weekly Quality of Care Meeting. Findings to reported to Quality Assurance Performance Improvement Committee monthly times (three) months and/or until substantial compliance has been achieved. Monitoring of the plan of removal included the following: Interviews were conducted from 08/20/20 to 08/21/20 with the following staff: the Administrator, the DON, ADON A, ADON B, the Social Worker, the Therapy Director, the Admissions Director, the Business Office Manager, the MDS Coordinator, the Director of Human Resources, LVN C, LVN D, LVN E, RN F, RN G, LVN H, LVN I. These interviews with staff confirmed they had been in-serviced on how to ensure a safe and appropriate discharge to the community occurs for residents. The staff revealed all community discharges must first be approved by the Administrator and ordered by the doctor. The staff also revealed that if they felt a community discharge was not safe or appropriate that they would call the Regional Compliance Line. On 08/20/20 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 08/21/20 , the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy with a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.

Based on observation, interview, and record review the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (Resident #2) of four residents reviewed for pressure ulcers. The facility failed to assess and document a detailed description of Resident #2's pressure ulcer on admission and failed to accurately and completely assess and document the condition of Resident #2's pressure ulcer during weekly skin assessments. This failure placed residents at risk for unidentified deterioration in existing pressure ulcers/injuries, new pressure ulcers, and infections. Findings included: Review of Resident #2's MDS assessment, dated 06/12/20, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. The MDS assessment reflected Resident #2's cognition was severely impaired, and her [DIAGNOSES REDACTED]. Resident #2 required the extensive assistance of two staff for activities of daily living and was totally dependent for eating ([DEVICE]). Review of Section M of the MDS assessment related to skin conditions, reflected the resident was at risk of developing a pressure ulcer and had no pressure ulcers present on admission. Review of Resident #2's comprehensive care plan, dated 06/20/20, did not have any goals or approaches reflected for skin /wound development. Further review reflected on 07/23/20 goals and approaches for the development of a stage four wound on sacrum/coccyx area were added. The goal was to prevent further skin breakdown and interventions included inspecting the resident's skin head to toe weekly and documenting results, weekly treatments and dressing as ordered and weekly treatment documentation to include measurement of each area of skin breakdown's, width, length, depth, type of tissue and exudate. Review of the Nurse's Skin Focused Observation note, dated 06/05/20, reflected LVN E documented Resident #2 was admitted to the facility with a dime-sized stage two pressure area to the coccyx. There was no evidence of an assessment of the pressure area to include a measurements or other characteristics. Review of Resident #2's consolidated physician's orders [REDACTED]. A telephone interview on 08/20/20 at 6:20 p.m. with LVN E revealed she had worked at the facility for about three months on the 6:00 p.m-6:00 a.m. shift. During the interview LVN E was inquired about the 06/05/20 observation note regarding the Stage 2 pressure area to the coccyx. LVN E stated she did not recall the condition of Resident #2's skin when she admitted to the facility but did recall assessing Resident #2 and calling the physician for orders (in July 2020). LVN E stated she was supposed to assess residents when notified by the electronic medical record (EMR) system. She stated she document the assessment in the resident's record, called the doctor if there was a problem and notified the physician and let the family know. LVN E was unable to provide any information that indicated Resident #2 had a pressure ulcer present upon admission but confirmed there was a Pressure Sore on 07/16/20. Review of Resident #2's clinical record reflected there was no documentation of weekly skin assessments between 06/05/20 and 07/16/20. There were no Nurses' Skin Focused Observations that addressed the two pressure ulcers identified on Resident #2's initial assessment or any other skin assessments or observations conducted on Resident #2 after 06/05/20 and when the pressure ulcer was identified on 07/16/20. Review of Resident #2's nursing progress notes dated from 06/05/20 through 07/15/20 reflected the only documentation related to pressure ulcers was documented on 07/16/20 by LVN E. The note revealed: Resident has a wound to the sacrum that measures 3 X 3. Also wound to the left buttocks measuring 2.5 X 3. A physician's consolidated orders dated 06/05/20-08/20/20 reflected no treatment orders were obtained for treatment of [REDACTED]. Review of the order dated 07/16/20 revealed cleanse wound to sacrum with wound cleaner, pat dry, apply silver alginate and dry dressing every QD and cleanse wound to left buttock with wound cleanser, pat dry, apply silver alginate and dressing QD. Review of Resident #2's electronic TAR s, dated 06/01/20 through 07/16/20 revealed no documentation of any assessments addressing the condition of Resident #2's skin or the presence of pressure ulcers, including a description, stage, measurements or other characteristics of the wounds. The TAR revealed there were no treatment orders or treatments performed for pressure ulcers or skin issues until 07/16/20 when the wound to the sacrum and left buttocks were identified. An observation and interview on 08/19/20 at 10:28 a.m. with LVN H and CNA J revealed Resident #2 lying supine in bed on a low air loss pressure mattress. Resident #2's skin revealed a Stage four pressure ulcer to the coccyx. Measuring 9 X 8 X 3 cm, and the wound had undermining 6 cm at 9 o'clock. There was moderate serous drainage noted, with approximately 15 % necrotic tissue. LVN H stated that the wound did not have as much drainage today (08/19/20) and the wound care physician saw the resident yesterday (08/18/20). LVN H stated she had worked at the facility for about one month and Resident #2 had the pressure area since she had been working there. CNA J stated she had worked at the facility about the same length of time as LVN H and stated Resident #2 had the area pressure area for that length of time. An interview on 08/20/20 at 1:00 p.m. with the DON stated she had looked at all the resident's skin that were dependent and on low air loss mattresses , when she first started working at the facility (the end of June) The DON stated she thought she had documented her assessment of Resident #2 in the resident's nurses' notes. The DON stated she remember assessing the resident because the resident had issues with her arm. The DON stated she did not observe any pressure ulcers on the resident when she conducted her assessment. The DON stated, I know I saw her skin and she did not have anything on her body and that she got the Treatment Nurse to monitor, document and assess. She stated the Treatment Nurse was in orientation and performing skin assessments on the resident at that time, and the nurses were aware they were responsible for assessing wounds and performing care. The DON stated she informed each nurse individually of their responsibility due to having a high number of agency nurses. The DON stated her expectations were for nurses to document a full detailed assessment of all wounds weekly. She stated the documentation should include a description of the wound, if there was any odor, amount/color of drainage and measurements. The DON stated the Treatment Nurse was not currently working and she did not know if she would be returning to the facility. The DON stated she had no documentation concerning her skin audits. An interview on 08/20/20 at 12:10 p.m. with LVN C stated she had worked at the facility for about three months on the 6:00 a.m. until to 6:00 p.m. shift. LVN C stated residents were supposed to have skin assessments completed weekly. She stated the residents to be assessed came up on the computer and documentation was put in the electronic nurse's notes or the skin observation notes. LVN C stated that if a resident had a skin problem then physician must be notified and call the resident's responsible party would be notified. LVN C could did not recall if Resident #2 had any skin problems prior to the current wound to her coccyx. An interview on 08/20/20 at 12:30 p.m. with LVN H, charge nurse for Resident #2, revealed she worked the 6:00 a.m. until 6:00 p.m. shift and the skin assessments were conducted weekly. LVN H stated the resident that needed to be assessed would come up the computer. The nurse in charge was supposed to assess the skin. She stated the assessments were documented in the nurse's notes or on the electronic skin documentation sheets. LVN H stated staff were supposed to contact the physician if there was a need for treatment and the residents responsible party would be notified as well by the nurse performing the assessment. An interview on 08/20/20 at 12:40 p.m. ADON B stated the nursing staff should know to assess by what resident comes up in the computer. ADON B stated the charge nurse was supposed to document their assessment weekly, and call notify the physician about any changes, and then also inform the resident's responsible party. ADON B stated the wound care nurse was supposed to monitor the skin care process. ADON B stated her office was on the floor that Resident #2 lived on and she was unaware of any skin problems prior to the development of the current pressure ulcer on the resident's coccyx. ADON B stated she had observed Resident #2's skin with the DON back in June and the resident did not have any pressure ulcers at that time. She could not recall the exact date of her observation. ADON B stated she had not documented her observations. An interview on 08/20/20 at 2:45 p.m. with ADON A stated the nursing staff was supposed to assess the residents' skin that come came up on the computer and then document their assessment on the nurse's notes or the skin observation notes. ADON A did not know who was supposed to monitor weekly skin assessments to ensure they were completed. An interview on 08/20/20 at 4:00 p.m. with the Wound Care Physician stated he had evaluated Resident #2 for the first time on 07/28/20. He said Resident #2 had a stage four pressure wound to her coccyx for at least 1 day. The wound had no indication of infection or discomfort. I debrided a large amount of necrotic (dead tissue) tissue. When The Wound Care Physician was asked when the last time was he had treated Resident #2's wound he stated on 08/18/20. The Wound Care Physician said there had been some decrease in the wound bed, indicating slight improvement, but Resident #2 was a very compromised resident. Review of the in-service dated 08/20/20 provided by the DON reflected completion of the electronic alerts for skin assessments on the computer, for the indicated residents. Where to document the skin assessments and what to document concerning skin developments and who to notify. Review of the facility's Wound Care Policies and Procedures , dated 06/01/15, reflected, Evaluations of wounds will be performed on admission, weekly, and on discovery Review of the National Pressure Ulcer Advisory Panel web site (www.npuap.org) viewed on 04/05/19 revealed the following: Skin and tissue assessments were important in pressure ulcer prevention, classification, diagnosis, and treatment. Comprehensive assessment of the individual and his or her pressure ulcer informs development of the most appropriate management plan and ongoing monitoring of wound healing. Pressure ulcer assessment should be performed initially and re-assessed at least weekly and results documented. Assess and document the physical characteristics of the pressure ulcer to include location, stage, size, color, undermining, tunneling, exudate and, odor. A uniform and consistent method for measuring wound length, width, depth or wound area should be selected to facilitate meaningful comparisons of wound measurements across time.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest, practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for two (Resident # 3, and # 11) of 13 residents reviewed for pain management. The facility staff failed to re-order and ensure delivery of Resident #3's and #11's narcotic pain medication to ensure the availability of the pain medication. These failures could affect the residents who received pain medication and placed them at risk for unrelieved pain and discomfort resulting in decreased nutritional intake, unplanned weight loss, alteration in sleep patterns, decreased socialization, serious medical complications, and a delay for appropriate interventions. Findings included: According to a hospital discharge plan dated 10/26/15, Resident # 3 was readmitted to the facility from the hospital on [DATE], after a brief stay at the hospital for a urinary tract infection. The MDS dated [DATE], reflected Resident #3 was a [AGE] years-old female who was alert and oriented to person, place, time and event. Resident # 3 had a mood disorder, however there were no behaviors indicated. The MDS further reflected the following Diagnoses: [REDACTED]. The pain interview section of the MDS reflected Resident #3 received as needed pain medication and when interviewed, had no pain over the last five days. Resident #3's undated, consolidated physician orders [REDACTED]. Give 0.25-1 milliliter every two hours for shortness of breath or pain. Tylenol #3 was not on the consolidated orders, however, there was a telephone order dated 10/26/15 for Tylenol #3 (a narcotic) 2 tablets by mouth every six hours. On 10/29/15 at 12:25 PM during an interview with Resident #3, she revealed she had not had any pain medication since yesterday about 1:00 PM. The resident also revealed they (nurses) told her she was out of Tylenol #3 on the evening of 10/28/15. Resident # 3, stated she was having generalized pain at the present time, with a level of 8-9,on a scale of (0-10) and 10 being the severest pain experienced. Resident #3 stated she had been in pain since the previous night. Resident #3 also stated she was aware she could have [MEDICATION NAME], but taking [MEDICATION NAME] was like eating candy and did nothing for her pain. Review of Resident #3's Individual Control Drugs Record revealed the last dose of Tylenol #3 available, was given on 10/28/15 at 1:00 PM. Resident #3 had not been given anything for pain since 10/28/15 at 1 PM. Interview on 10/29/15 at 1:40 PM with LVN P, the nurse who ordered medications, revealed he had ordered the Tylenol #3 from the pharmacy on 10/28/15 but it had not been delivered yet. Review of the MAR for October 2015 revealed Resident #3 received Tylenol #3 on 10/28/15 at 1:00 PM and could have another pill on 10/28/15 at 6:00 PM, however, the facility ran out of this medication as documented by the administration of the last dose on 10/28/15 at 1:00 PM. The resident missed a total of three doses of Tylenol #3. The Tylenol #3 was discontinued at 4:50 PM on 10/29/15, and [MEDICATION NAME] mg twice daily was ordered. On 10/29/15 at 12:30 PM observation of LVN D of the narcotic lock box containing Resident #3's medication revealed there was not any Tylenol #3, however there was [MEDICATION NAME] and an unopened bottle of [MEDICATION NAME] ordered 10/28/15, available for pain management. Resident #3 had been placed on hospice services on 10/27/15, and these were new orders. LVN D was informed at 1:20 PM on 10/29/15, that Resident #3 was in pain and the [MEDICATION NAME] was available. Interview on 10/29/15 at 2:15 LVN D revealed she gave Resident #3 [MEDICATION NAME] 0.25 ml for pain at 1:55 PM. Interview on 10/29/15 at 2:20 PM with Resident #3 revealed her pain was only down to a 7 or 8 and the medication had not had time to work yet. Interview on 10/29/15 at 5:00 PM the DON revealed the [MEDICATION NAME] #3 was delivered at 3:45 PM but was sent back because it was discontinued. The DON was asked about the discontinuation of the Tylenol #3 and stated the hospice nurse visited and was informed by Resident #3 that she needed something stronger for pain. Resident #3 stated she was unaware of the [MEDICATION NAME] order when interviewed on 10/29/15 at 12:25 PM. 2. The MDS dated [DATE] reflected Resident #11 was admitted to the facility on [DATE], with the following Diagnoses: [REDACTED]. The assessment also reflected she was a [AGE] year-old female who was understood and understood others. The pain assessment section reflected she received routine and as needed pain medication; and in the last five days had occasional pain that interfered with her sleeping and limited her day-to-day activities. The assessment reflected Resident #11 stated her pain was an eight on a scale of one to ten, with ten being the worst pain imaginable. Review of the undated, consolidated Physician orders [REDACTED].#3 1 or 2 tablets every 4 hours as needed for mild pain, [MEDICATION NAME] 30 mg ([MEDICATION NAME] HCL) 2 tablets by mouth every morning, [MEDICATION NAME] 30 mg ([MEDICATION NAME] HCL) 1 tablets by mouth at noon, and [MEDICATION NAME] 30 mg ([MEDICATION NAME] HCL) 2 tablets by mouth every evening. Interview on 10/30/15 at 11:48 AM with Resident #11, revealed she had chronic back pain and had to get the narcotics from her primary doctor in the community as she was informed by the facility that her attending physician would not prescribe them for her because they were a class three narcotic. Resident #11 further revealed the facility ran out of the [MEDICATION NAME] October for about four to five days and she went through withdrawal and felt miserable. She identified her symptoms as chills, cold, headache and diarrhea. She added, the nurses didn't tell her in enough time to make an appointment with her community doctor so she could get the narcotics. The resident went on to state if the facility would have told me before the day I ran out of medications I could have made arrangements to go get the medication. Review of the as needed October 2015 MAR, Resident #11's pain ranged from from eight to ten on a scale of one to ten, with 10 being the worst pain imaginable. Observation on 10/30/15 at 11:50 AM Resident #11 asked LVN D for something for pain. LVN D brought Resident #11 [MEDICATION NAME] (Tylenol) #3 tablets at that time. Review of the Medication Administration Record [REDACTED]. This totaled to four days of missed medication to control the resident severe pain. Resident #11 missed doses of medication on 10/10/15 through 10/15/15. During the interview with Resident #11 on 10/30/15 at 11:48 AM, she mentioned the hospital had only sent a limited supply of the [MEDICATION NAME] that is why she ran out. Review of Resident #3's Individual Control Record for [MEDICATION NAME] the facility received 50 tablets on 09/29/15, and ran out on 10/10/15. The facility failed to obtain a refill on this medication and Resident #11 missed her scheduled doses. Interview on 10/30/15 at 12:50 PM DON revealed she was not aware of a problem with Resident #11's medication. The DON was again asked what was done about the resident not having the medications for 5 days and why the attending physician was not asked to address the problem. The DON did not have an answer. The DON provided a nursing note dated 10/12/15 which revealed the doctors office would not fax a triplicate to the facility or pharmacy. When asked what was done about Resident #11's not having MS Contin, the DON had no answer. 3. According to Form CMS- 672, Resident Characteristic and Condition of Residents, dated and signed by facility staff on 10/28/15, there were 58 residents on pain management.

Based on observation, interview, and record review, it was determined the Adminstrator (ADM), Director of Nursing (DON) and RN B (Charge Nurse) failed to administer the facility in a manner that enabled it to use its resources efectively and efficiently to attain or maintain the highest level of well-being for one (Resident #1) of eleven residents whose records were reviewed. 1. The ADM failed to implement the facility's abuse and neglect policies and procedures to prohibit abuse and neglect for residents. 2. The ADM failed to implement the facility's Elopement Policy to prevent residents from eloping. 3. The ADM failed to inform visitors and staff members to not let residents out of the facility's locked doors. 4. The DON failed to supervise and train nursing staff regarding Resident #1 and ensure adequate staff was present in the dining room to provide supervision to residents who were in the dining room. 5. RN B failed to supervise and inform her direct staff of their role with monitoring Resident #1, keeping her aware of the residents whereabouts. These failures resulted in Resident #1, who was an elopement risk, eloping and being gone from the facility for approximately two hours. Resident #1 eloped in a high traffic area near two freeways. An Immediate Jeopardy (IJ) was existed from 11/19/14 to 11/20/14. The facility remained out of compliance at a severity level of "potential for more than minimal harm that is not immediate jeopardy" and a scope of "pattern" due to the facility needing to monitor the effectiveness of their plan. This failure had the potential to affect the 11 residents, including Resident #1, who resided on or were being transitioned off the facility's secured unit and were considered an elopement risk. Findings included: An interview on 12/16/14 at 11:45 AM with the ADM revealed she attributed the incident to DADS ordering the secured unit be closed due to not meeting life safety code requirements. The ADM stated if the secured unit had been allowed to remain open, the incident would not have occurred. She said new ownership had taken over the facility on 10/18/14, and the facility's annual recertification survey began on 10/21/14. During this survey, facility management was informed the secured unit did not meet life safety code standards. Apparently the previous ownership company had opened the secured unit without state approval, and the new ownership group did not know this. In mid-November, the facility was informed by DADS the secured unit needed to be closed as modifications to meet life safety code standards were not feasible. The facility was given until 12/05/14 to close the secured unit. The ADM stated this was not enough time to safely transition everyone off the secured unit. The ADM said residents ' family members were consulted about this and asked where they wanted residents to go. She stated Resident #1 did not have any family members or guardianship in place, she was assessed as a low elopement risk, and the best option seemed to be to transition her to the facility ' s long term care unit. The ADM noted Resident #1 had been admitted from the hospital and had no family, so they had limited personal history on her, including any previous elopement attempts. The ADM said the only staff members trained on the transition were the ones assigned to work with her and provide care. She said if the facility had more time, she may have been able to train all staff members on the transition, and the incident may have been prevented. Other than that, she did not think the facility could have done anything differently to prevent the incident. Observation on 12/15/14 at 5:30PM of the area surrounding the facility, which is located in a Metropolitan area, revealed a heavily traffic area with two hospitals nearby. There was traffic traveling both directions in front of the facility. There are two major freeways also neare the facility and the location where the resident was found on 11/2014. There were several shops and businesses in the strip malls in the immediate area around the facility. An interview on 12/03/14 at 11:45 AM with Resident #1 revealed she could not offer many details of the incident (elopement) other than to say she liked to go for walks and had decided to go for a walk outside that morning. Review of a face sheet for Resident #1 dated 12/03/14 revealed she was an [AGE] year old female admitted to the facility on [DATE] for [DIAGNOSES REDACTED]. Review of Resident #1's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she had a Brief Interview for Mental Status (BIMS) score of two, indicating severe cognitive impairment. The MDS assessment reflected Resident #1 had wandering behaviors during one to three days during the previous week but wandering did not place her at significant risk. Review of Resident #1's Physician order [REDACTED]. Review of an Elopement Risk assessment for Resident #1 dated 10/14/14 revealed a score of 9 out of 24, indicating a "low risk" of elopement. Review of the facility's Provider Investigation Report, completed and signed by the ADM on 11/26/14 and reported to the Texas Department of Aging and Disability Services (DADS), identified the incident as occurring on 11/20/14 at 8:30 AM. The report identified Resident #1 as being ambulatory, having "minimal" functional ability, not having the capacity to make informed decisions, and requiring "within eyesight" level of supervision. The investigation summary reflected, "On 11/19/2014 Resident was assessed in an attempt to transition her from the secured unit to the long term care unit due to recent notification from the state that the facility's secured unit did not meet state criteria. The resident scored low on elopement risk and was moved from the secured unit, with physician notification from the secured unit to room (number). Resident was on (every) 15 minutes monitoring for transition/adjustment. Wander guard remained in place on the resident. Resident was tolerating the transition well on 11/19/2014. On 11/20/2014 resident was last seen by the charge nurse at (7:45 AM). Resident was seen at the doors of the secured unit attempting to get back in the unit. Restorative aide assisted the resident to the downstairs dining room. No alarms were noted to sound when exiting off the second floor. At (8:00 AM) charge nurse inquired the whereabouts of the resident which she was told that the resident had been assisted to the dining room by restorative aide. At approximately (8:10 AM) charge nurse entered the dining room and was unable to locate the resident. Staff began to search the inside of the facility. At approximately (8:30 AM) administrator was notified of missing resident. Resident was last seen in the dining room around 8:00 AM. Resident may have exited after a visitor through the front door. Outside grounds were checked. Facility began search by foot and car as well. At approximately (9:10 AM) police was notified of the missing resident. No family was contacted due to the resident has none. Search continued until resident was located at approximately 10:00 AM by police. Physician notified. Resident was returned to the secured unit and placed on close monitoring for 24 hours. Resident remains in pleasant mood. On 11/21/2014 resident returned on (every) 15 (minute) checks for continued monitoring." In response to the incident, the report indicated the facility's secured unit was scheduled to be closed on 12/05/14, Resident #1 will be transferred to another facility before the closure, in-services with all staff were completed, elopement drills were performed, the facility's wander guard system was checked by an outside provider, care plans were updated, and residents were reassessed for elopement risk. Review of Resident #1's care plans revealed an elopement care plan was written on 11/20/14 following the incident. An interview on 12/03/14 at 3:30 PM with the DON revealed she did not know if an elopement care plan was in place for Resident #1 prior to 11/20/14. The DON stated care plans were completed electronically, and once staff members completed or revised a care plan, any previous care plans for the same issue would be deleted and not able to be accessed. Review of a nursing note dated 11/19/14 at 12:32 PM by the ADON revealed Resident #1 was moved off the secured unit to the long term care hall and placed on visual checks every 15 minutes and documentation every four hours. (The facility wanted to monitor the resident closely due to the transition off of a secure unit to a unit that was not secured.) Review of a nursing note dated 11/20/14 at 2:00 AM by LVN C revealed the wander guard was in place. Review of a late entry nursing note dated 11/20/14 at 4:27 PM by RN B revealed, "Resident in bed asleep at beginning of shift ( at 6:00 AM). Resident was observed (every) 15 minutes by nurse thru (sic) (7:45 AM) and was in her room. At (8:00 AM) Resident was not in her room at check. Nurse asked CNA where the resident was. CNA stated that the resident had been taken to the dining room for breakfast. Nurse went to the dining room at (8:10 AM) and the resident was not there. Nurse sent two CNA to check throughout the building. Nurse checked all rooms on the firsr (sic) and second floor and was unable to locate resident. Nurse notified ADON that the resident could not be located and she notified the administrator." In an interview on 12/03/14 at 12:09 PM, RA A revealed she was doing morning rounds with residents on the second floor and was about to head downstairs at approximately 7:15 AM. RA A stated she observed Resident #1 knocking on the doors to the secured unit asking where the dining room was located. RA A offered to take Resident #1 to the dining room. RA A did not think there would be anything wrong with this and said she often escorted residents to the dining room. RA A said no wander guard alarm sounded when she escorted Resident #1 on the elevator and took her downstairs. RA A stated she got her seated in the dining room and left her there around 7:20 AM. RA A stated no staff members were present at the time in the dining room to supervise residents. RA A stated staff would typically not show up in the dining room until 7:30 AM, since that was when breakfast actually started. In a follow up interview on 12/15/14 at 1:25 PM, RA A again stated no wander guard alarm sounded when taking Resident #1 downstairs, and she did not have to punch in a code in a keypad to use the elevator. RA A stated she sat Resident #1 down in the middle row of tables and got four residents coffee, including Resident #1, before going back upstairs to bring down more residents for breakfast. She stated Resident #1 was sitting down drinking her coffee when she left to go back upstairs, and she did not know Resident #1 was transitioning off the secured unit. She revealed she did not think there would be any problems leaving her in the dining room. RA A noted that while there were no CNAs in the dining room supervising residents at the time. There were dietary staff members in the adjacent kitchen preparing breakfast so she was not concerned. During an interview on 12/15/14 at 1:40 PM, CNA D stated she worked the 6:00 AM to 2:00 PM shift on 11/20/14 on Hall D and was assigned to work with Resident #1. She said when starting her shift she saw Resident #1 in her room and recognized she was new to the hall and asked her charge nurse RN B about her. She said RN B told her Resident #1 was transitioning from the secured unit to long term care, and she was required to have visual checks every 15 minutes. CNA D stated RN B was responsible for the visual checks. CNA D revealed she was providing care to other residents that morning and somewhere between 7:30 AM and 8:00 AM she was told by CNA E that Resident #1 had been taken downstairs to the dining room for breakfast. CNA D said she did not think anything about it and was not aware of any plans concerning mealtimes for Resident #1. She helped search for Resident #1 after being told by RN B she was missing. An interview on 12/15/14 at 1:55 PM with CNA E revealed she was assigned to assist and supervise residents in the dining room on the morning of 11/20/14. She said RA A told her Resident #1 had been taken down to the dining room, and she informed CNA D about this. CNA E stated she arrived for dining room duty at 7:45 AM and did not recall seeing Resident #1 down there. She helped search for Resident #1 after being told by RN B she was missing. An interview on 12/03/14 at 10:58 AM with RN B revealed she was responsible for completing visual checks on Resident #1 every 15 minutes. RN B stated Resident #1 had been in her room all morning and was there at 7:45 AM. During the 8:00 AM check, she could not find her. RN B was told by CNA D that Resident #1 had been taken to the dining room, so she went to the dining room to look for her but did not see her. RN B stated she ordered CNA D and CNA E to go look for her and told the ADON Resident #1 was missing. A search of the building and surrounding area commenced, but Resident #1 was not found. The police were notified. RN B said Resident #1 did have a wander guard in place, but the wander guard alarms were not very loud and were difficult to hear. She did not hear any wander guard alarms go off that morning. Review of staff interview transcripts revealed CNA H reported she was on dining room duty on the morning of 11/20/14. She reported going to the dining room at 7:30 AM but did not recall ever seeing Resident #1 there. Review of staff interview transcripts revealed CNA D recalled seeing Resident #1 in her room at 6:15 AM. She asked RN B about her as she was new to the hall. She did not see her during the next couple hours and was informed by CNA E around 8:00 AM that Resident # 1 was missing. Review of 15 Minute Surveillance Checks for Resident #1 provided by the ADM on 12/15/14 revealed Resident #1 had been taken to the dining room for dinner on 11/19/14 from 6:45 PM to 7:15 PM and then returned to her room. On 11/20/14, RN B documented Resident #1 was in bed until 7:30 AM, and was in the dining room at 7:45 AM. Asked about the time discrepancies regarding when Resident # 1 was taken to the dining room at approximately 3:15 PM on 12/15/14, the ADM stated she tended to believe RN B because she was responsible for documenting visual checks on Resident #1 every 15 minutes and would have been checking the time. The ADM stated other staff members were less likely to have checked the time and had estimated when that morning's events occurred. The ADM also stated RN B had documented in a nursing note that she observed Resident #1 in her room at 7:45 AM. The ADM stated this explained why staff members in the dining room around 7:30 AM to 7:45 AM did report seeing Resident #1, as she was still in her room. (RN B stated she saw the resident in her room at 7:45A. RA A stated she took Resident # 1 to the dining room before 7:45AM, between7:15AM to 7:20AM) At 3:22 PM on 12/15/14, the DON brought a revised 15 minute surveillance note. For the 7:45 AM check on 11/20/14 for Resident #1, RN B had crossed out "dining room," initialed it, and wrote that Resident #1 was in her room at the time. In an interview on 12/15/14 at 2:45 PM, the ADM stated the other eight residents, including Resident #1, who had resided on the secured unit were transferred to other facilities with existing secured units. Asked at this time about how visitors were informed not to let potential residents out of the building, the ADM stated she thought a sign was posted next to the main entrance informing visitors not to let residents outside. Observation of the main entrance on 12/15/14 at 3:10 PM revealed no such sign was posted. An interview on 12/03/14 at 11:30 AM with the Maintenance Director revealed he was responsible for testing the facility's wander guard system weekly to ensure it was functioning. Asked to provide documentation of the weekly checks, the Maintenance Director stated he did not document them but started doing so following this incident. He said he checked Resident #1's wander guard within a couple hours after she had been returned the facility, and it was functioning properly. The Maintenance Director stated the wander guard alarm would sound near the secured unit door and near the two elevators on the second floor. The elevators would also not be able to function unless someone entered a code on a keypad near the elevator to turn off the alarm. The Maintenance Director stated the wander guard alarms were not set up to sound off if residents got near any of the exit doors on the first floor of the facility. The Maintenance Director demonstrated the facility's wander guard system on 12/03/14 at 11:30 AM. The facility used ankle bracelets. The wander guard alarm on the test ankle bracelet was observed sounding when near the secured unit entrance and near the two elevators on the second floor. However, the alarm was not very loud. The only nurses' station on the second floor was located approximately 15 to 20 feet from the nearest elevator, and with the substantial noise level in the facility at the time of this observation it would have been difficult to hear the alarm sounding from the nurses' station. An interview on 12/03/14 at 10:00 AM with the Administrator (ADM) revealed she investigated the incident regarding Resident #1 and reported it to the state survey and certification agency within the mandated timeframe. The ADM stated the facility's secured memory care unit was being closed due to not meeting life safety code requirements. Resident #1 resided on the secured unit, and they moved her off the secured unit to the long term care unit on 11/19/14 to determine if she was safe and could continue residing at the facility. Precautions were in place for the transition off the secured unit, including the use of a wander guard and visual checks every 15 minutes by nurses. The ADM stated on the morning of 11/20/14, Resident #1 asked RA A to go to breakfast. RA A then took Resident #1 downstairs to the facility's only dining room. The ADM said RA A was not responsible for caring for Resident #1 and should not have taken her down there. CNA D was assigned to care for Resident #1 that morning but was completing care with other residents during that time. Resident #1 was ordered to have visual checks every 15 minutes by RN B that morning, and Resident #1 was taken to the dining room between those checks. There should have been three or four staff members supervising residents in the dining room. The ADM stated Resident #1 was wearing an ankle bracelet with a wander guard alarm. Resident #1 resided on the facility's second floor, and the ADM stated the wander guard ' s alarm would sound when nearing both of the second floor elevators. Furthermore, the elevators were designed to not function when a wander guard alarm had been set off. Someone would have to punch a code in a keypad near the elevators to turn the alarms off and allow the elevators to be used again. The ADM stated a wander guard alarm system was not in place on the facility's first floor. The exit doors downstairs were locked. They were unlocked by entering a code on a keypad, and the code was not posted anywhere. Anyone could have let Resident #1 out one of the exit doors downstairs, and her wander guard alarm would not have sounded. Resident #1 was ambulatory and used no assistive devices and may not have looked like a typical nursing home resident. The ADM stated RN B went to complete a visual check on Resident #1 at 8:00 AM but did not find her. RN B was told by CNA D that Resident #1 was in the dining room downstairs. RN B went to the dining room to look for Resident #1 at 8:10 AM but could not find her there. Searches throughout the inside and outside of the building were conducted, and some staff members drove around the area in their personal vehicles but were not able to find Resident #1. The police were notified at 9:10 AM, and they found Resident #1 approximately one mile from the facility in a busy area and returned her unharmed at 10:08 AM. The ADM stated the breakdown occurred with RA A taking Resident #1 downstairs to the dining room when she should not have. The ADM stated the facility did have cameras in place. However, the cameras were not currently functioning due to a recent ownership change so could not be reviewed to see how Resident #1 was able to exit the building. Review of a nursing note dated 11/20/14 at 10:18 AM by RN B revealed Resident #1 was brought to her at 10:08 AM by the ADM. Resident #1 complained her legs were sore from walking a lot but was assessed to have no injuries. The wander guard was also noted to be in place. Review of an Elopement Risk assessment for Resident #1 dated 11/20/14, revealed she had been reassessed as having a score of 22 out of 24 following her elopement, indicating a high risk. Review of staff in-service training records revealed all staff members were trained on elopement and transitioning residents from the secured unit to long term care on 11/20/14, including that "these residents are not to leave the 2nd floor unless directed by (the) DON." In-service trainings with all staff on elopement drills were also conducted on 11/20/14. RN B received a one-on-one in-service training on 11/20/14 regarding residents transitioning from the secured unit to long term care. An invoice from an alarm company was included that indicated the facility's wander guard system was checked on 11/21/14 and found to be working properly. The facility's Elopement Policy dated September 2011 and provided by the ADM on 12/03/14 as the current policy, reflected once a resident was identified as missing a 30 minute search would be conducted in the facility and on the facility grounds. If the resident was not found after 30 minutes, the police would be contacted. Staff would then extend the search to within a two mile radius of the facility. On 12/15/14 at 3:19 PM, the ADM posted a sign at the main entrance that reflected, "Please do not assist any residents exiting the facility before asking staff for assistance. Thanks Management." The ADM also pointed out a couple pieces of tape on a window next to the main entrance door indicating a sign had been posted there at one point. An interview on 12/16/14 at 12:04 PM with the DON revealed she attributed the incident to RA A taking Resident #1 to the dining room for breakfast. The DON said she suspected someone had turned the wander guard alarm off to take Resident #1 downstairs, as the alarm was found to be functioning properly after Resident #1 returned from eloping. The DON stated additional training may have helped prevent this incident. The facility's put the following changes in to place after the incident with Resident #1: "Post Action: ? Total of 11 residents were in the secured unit on 11/20/2014- were all assessed and wander guard bracelets were checked ... ? ...Staff was reeducated on elopement policy and procedure & transitioning residents from the secured unit. Actual drills were performed on 6-2 and 2-10 shifts on 11/20/2014. ? One on one education performed with (RN B) on communication, transitioning residents from the secured unit, and communication to staff on 11/20/2014 ? Staff was reeducated on 11/21/2014 transitioning residents ? Nursing staff was reeducated on 11/26/2014 on q15 minutes and q4 documentation; sign and symptoms of wandering, etc. ? Staff was reeducated on 12/03/2014 on transitioning a resident, q15 minutes and q4 documentation ? Elopement drill performed on 2-10 and 10-6 on 12/04/2014 (resident was hidden in the stairway and dining room). Competency based drills were held with actual residents hidden to have staff to demonstrate competency. ? All staff was reeducated on 12/12/2014 on elopement policy and procedure. ? Weekly checks x 1 month performed by (Maintenance Director) on wander guard system effective 12/15/2014. Checks to be performed monthly thereafter. ? Elopement drills weekly x 1 month effective 12/15/2014. Drills to be performed monthly thereafter -Competency based drills were held with actual residents hidden to have staff demonstrate proficiency. ? Updated elopement risk assessment and care plan on remaining resident (Resident #2) on 12/15/2014 by (the DON). Resident was assessed on 11/13/2014 by (the DON). The resident was still at risk. ? Remaining resident (Resident #2) was discharged on [DATE] to secured unit. Resident was closely monitoring from 12/05/2014 until discharge. Resident has not exhibit any exit seeking behaviors during this time period. ? Administrator or designee will perform monitoring rounds randomly weekly x 5 weeks on the entire facility. Issues are corrected immediately upon discovery. Administrator will provide oversight for the entire plan. ? Signage placed at all doors informing visitors not to assist residents out of the building. Review of an in-service training record dated 11/21/14 and provided by the ADM on 12/15/14 revealed all staff were trained on Resident #2 transitioning from the secured unit to long term care and were instructed not to take her to the first floor unless instructed by the DON. Every 15 minute surveillance checks and documentation every four hours were also put in place. Review of an in-service training record dated 11/26/14 and provided by the ADM on 12/15/14 revealed all staff were trained on Resident #3 transitioning from the secured unit to long term care and were instructed not to take her to the first floor unless instructed by the DON. Every 15 minute surveillance checks and documentation every four hours were also put in place. Review of in-service training records provided by the ADM on 12/15/14 revealed elopement drills were conducted on 12/04/14 and 12/12/14. Additional in-service training records provided by the ADM on 12/16/14 revealed all staff members had now received training on elopement. Interviews on 12/16/14 at various times with LVN J, CNA K, CNA L, LVN M, CNA N, DA O, Housekeeper P, LVN Q, and CNA R, who represented staff from all days and shifts, revealed they had all received in-service training on elopement, including signs of exit seeking, the residents in the facility identified as an elopement risk, and what to do if a resident was identified as missing. The ADM was informed on 12/16/14 at 2:30 PM the facility remained out of compliance at a severity level of "potential for more than minimal harm that is not immediate jeopardy" and a scope of "pattern" due to the facility needing to monitor the effectiveness of their Post Action plan. A current census list provided by the DON on 12/03/14 revealed nine residents resided on the facility's secured unit, and two residents were being transitioned off the secured unit.

Based on observation, interview, and record review, it was determined the facility failed to ensure one (Resident #1) of 11 residents reviewed for elopement remained free of accident hazards and received adequate supervision and assistance to prevent accidents. The facility failed to: 1. Develop a complete transition plan, how Resident #1 would be supervised including how meals would be served, and train all staff members on this plan for Resident #1, who was transitioning from the secured unit to the long term care unit. 2. Ensure the wander guard system functioned properly. 3. Inform visitors and staff members to not let residents out of the facility's locked exit doors. These failures resulted in Resident #1, who was an elopement risk, eloping and being gone from the facility for approximately two hours. Resident #1 eloped in a high traffic area near two freeways. An Immediate Jeopardy (IJ) was existed from 11/19/14 to 11/20/14. The facility remained out of compliance at a severity level of "potential for more than minimal harm that is not immediate jeopardy" and a scope of "pattern" due to the facility needing to monitor the effectiveness of their plan. This failure had the potential to affect the 11 residents, including Resident #1, who resided on or were being transitioned off the facility's secured unit and were considered an elopement risk. Findings included: An interview on 12/16/14 at 11:45 AM with the ADM revealed she attributed the incident to DADS ordering the secured unit be closed due to not meeting life safety code requirements. The ADM stated if the secured unit had been allowed to remain open, the incident would not have occurred. She said new ownership had taken over the facility on 10/18/14, and the facility's annual recertification survey began on 10/21/14. During this survey, facility management was informed the secured unit did not meet life safety code standards. Apparently the previous ownership company had opened the secured unit without state approval, and the new ownership group did not know this. In mid-November, the facility was informed by DADS the secured unit needed to be closed as modifications to meet life safety code standards were not feasible. The facility was given until 12/05/14 to close the secured unit. The ADM stated this was not enough time to safely transition everyone off the secured unit. The ADM said residents ' family members were consulted about this and asked where they wanted residents to go. She stated Resident #1 did not have any family members or guardianship in place, she was assessed as a low elopement risk, and the best option seemed to be to transition her to the facility ' s long term care unit. The ADM noted Resident #1 had been admitted from the hospital and had no family, so they had limited personal history on her, including any previous elopement attempts. The ADM said the only staff members trained on the transition were the ones assigned to work with her and provide care. She said if the facility had more time, she may have been able to train all staff members on the transition, and the incident may have been prevented. Other than that, she did not think the facility could have done anything differently to prevent the incident. Observation on 12/15/14 at 5:30PM of the area surrounding the facility, which is located in a Metropolitan area, revealed a heavily traffic area with two hospitals nearby. There was traffic traveling both directions in front of the facility. There are two major freeways also neare the facility and the location where the resident was found on 11/2014. There were several shops and businesses in the strip malls in the immediate area around the facility. An interview on 12/03/14 at 11:45 AM with Resident #1 revealed she could not offer many details of the incident (elopement) other than to say she liked to go for walks and had decided to go for a walk outside that morning. Review of a face sheet for Resident #1 dated 12/03/14 revealed she was an [AGE] year old female admitted to the facility on [DATE] for [DIAGNOSES REDACTED]. Review of Resident #1's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she had a Brief Interview for Mental Status (BIMS) score of two, indicating severe cognitive impairment. The MDS assessment reflected Resident #1 had wandering behaviors during one to three days during the previous week but wandering did not place her at significant risk. Review of Resident #1's Physician order [REDACTED]. Review of an Elopement Risk assessment for Resident #1 dated 10/14/14 revealed a score of 9 out of 24, indicating a "low risk" of elopement. Review of the facility's Provider Investigation Report, completed and signed by the ADM on 11/26/14 and reported to the Texas Department of Aging and Disability Services (DADS), identified the incident as occurring on 11/20/14 at 8:30 AM. The report identified Resident #1 as being ambulatory, having "minimal" functional ability, not having the capacity to make informed decisions, and requiring "within eyesight" level of supervision. The investigation summary reflected, "On 11/19/2014 Resident was assessed in an attempt to transition her from the secured unit to the long term care unit due to recent notification from the state that the facility's secured unit did not meet state criteria. The resident scored low on elopement risk and was moved from the secured unit, with physician notification from the secured unit to room (number). Resident was on (every) 15 minutes monitoring for transition/adjustment. Wander guard remained in place on the resident. Resident was tolerating the transition well on 11/19/2014. On 11/20/2014 resident was last seen by the charge nurse at (7:45 AM). Resident was seen at the doors of the secured unit attempting to get back in the unit. Restorative aide assisted the resident to the downstairs dining room. No alarms were noted to sound when exiting off the second floor. At (8:00 AM) charge nurse inquired the whereabouts of the resident which she was told that the resident had been assisted to the dining room by restorative aide. At approximately (8:10 AM) charge nurse entered the dining room and was unable to locate the resident. Staff began to search the inside of the facility. At approximately (8:30 AM) administrator was notified of missing resident. Resident was last seen in the dining room around 8:00 AM. Resident may have exited after a visitor through the front door. Outside grounds were checked. Facility began search by foot and car as well. At approximately (9:10 AM) police was notified of the missing resident. No family was contacted due to the resident has none. Search continued until resident was located at approximately 10:00 AM by police. Physician notified. Resident was returned to the secured unit and placed on close monitoring for 24 hours. Resident remains in pleasant mood. On 11/21/2014 resident returned on (every) 15 (minute) checks for continued monitoring." In response to the incident, the report indicated the facility's secured unit was scheduled to be closed on 12/05/14, Resident #1 will be transferred to another facility before the closure, in-services with all staff were completed, elopement drills were performed, the facility's wander guard system was checked by an outside provider, care plans were updated, and residents were reassessed for elopement risk. Review of Resident #1's care plans revealed an elopement care plan was written on 11/20/14 following the incident. An interview on 12/03/14 at 3:30 PM with the DON revealed she did not know if an elopement care plan was in place for Resident #1 prior to 11/20/14. The DON stated care plans were completed electronically, and once staff members completed or revised a care plan, any previous care plans for the same issue would be deleted and not able to be accessed. Review of a nursing note dated 11/19/14 at 12:32 PM by the ADON revealed Resident #1 was moved off the secured unit to the long term care hall and placed on visual checks every 15 minutes and documentation every four hours. (The facility wanted to monitor the resident closely due to the transition off of a secure unit to a unit that was not secured.) Review of a nursing note dated 11/20/14 at 2:00 AM by LVN C revealed the wander guard was in place. Review of a late entry nursing note dated 11/20/14 at 4:27 PM by RN B revealed, "Resident in bed asleep at beginning of shift ( at 6:00 AM). Resident was observed (every) 15 minutes by nurse thru (sic) (7:45 AM) and was in her room. At (8:00 AM) Resident was not in her room at check. Nurse asked CNA where the resident was. CNA stated that the resident had been taken to the dining room for breakfast. Nurse went to the dining room at (8:10 AM) and the resident was not there. Nurse sent two CNA to check throughout the building. Nurse checked all rooms on the firsr (sic) and second floor and was unable to locate resident. Nurse notified ADON that the resident could not be located and she notified the administrator." In an interview on 12/03/14 at 12:09 PM, RA A revealed she was doing morning rounds with residents on the second floor and was about to head downstairs at approximately 7:15 AM. RA A stated she observed Resident #1 knocking on the doors to the secured unit asking where the dining room was located. RA A offered to take Resident #1 to the dining room. RA A did not think there would be anything wrong with this and said she often escorted residents to the dining room. RA A said no wander guard alarm sounded when she escorted Resident #1 on the elevator and took her downstairs. RA A stated she got her seated in the dining room and left her there around 7:20 AM. RA A stated no staff members were present at the time in the dining room to supervise residents. RA A stated staff would typically not show up in the dining room until 7:30 AM, since that was when breakfast actually started. In a follow up interview on 12/15/14 at 1:25 PM, RA A again stated no wander guard alarm sounded when taking Resident #1 downstairs, and she did not have to punch in a code in a keypad to use the elevator. RA A stated she sat Resident #1 down in the middle row of tables and got four residents coffee, including Resident #1, before going back upstairs to bring down more residents for breakfast. She stated Resident #1 was sitting down drinking her coffee when she left to go back upstairs, and she did not know Resident #1 was transitioning off the secured unit. She revealed she did not think there would be any problems leaving her in the dining room. RA A noted that while there were no CNAs in the dining room supervising residents at the time. There were dietary staff members in the adjacent kitchen preparing breakfast so she was not concerned. During an interview on 12/15/14 at 1:40 PM, CNA D stated she worked the 6:00 AM to 2:00 PM shift on 11/20/14 on Hall D and was assigned to work with Resident #1. She said when starting her shift she saw Resident #1 in her room and recognized she was new to the hall and asked her charge nurse RN B about her. She said RN B told her Resident #1 was transitioning from the secured unit to long term care, and she was required to have visual checks every 15 minutes. CNA D stated RN B was responsible for the visual checks. CNA D revealed she was providing care to other residents that morning and somewhere between 7:30 AM and 8:00 AM she was told by CNA E that Resident #1 had been taken downstairs to the dining room for breakfast. CNA D said she did not think anything about it and was not aware of any plans concerning mealtimes for Resident #1. She helped search for Resident #1 after being told by RN B she was missing. An interview on 12/15/14 at 1:55 PM with CNA E revealed she was assigned to assist and supervise residents in the dining room on the morning of 11/20/14. She said RA A told her Resident #1 had been taken down to the dining room, and she informed CNA D about this. CNA E stated she arrived for dining room duty at 7:45 AM and did not recall seeing Resident #1 down there. She helped search for Resident #1 after being told by RN B she was missing. An interview on 12/03/14 at 10:58 AM with RN B revealed she was responsible for completing visual checks on Resident #1 every 15 minutes. RN B stated Resident #1 had been in her room all morning and was there at 7:45 AM. During the 8:00 AM check, she could not find her. RN B was told by CNA D that Resident #1 had been taken to the dining room, so she went to the dining room to look for her but did not see her. RN B stated she ordered CNA D and CNA E to go look for her and told the ADON Resident #1 was missing. A search of the building and surrounding area commenced, but Resident #1 was not found. The police were notified. RN B said Resident #1 did have a wander guard in place, but the wander guard alarms were not very loud and were difficult to hear. She did not hear any wander guard alarms go off that morning. Review of staff interview transcripts revealed CNA H reported she was on dining room duty on the morning of 11/20/14. She reported going to the dining room at 7:30 AM but did not recall ever seeing Resident #1 there. Review of staff interview transcripts revealed CNA D recalled seeing Resident #1 in her room at 6:15 AM. She asked RN B about her as she was new to the hall. She did not see her during the next couple hours and was informed by CNA E around 8:00 AM that Resident # 1 was missing. Review of 15 Minute Surveillance Checks for Resident #1 provided by the ADM on 12/15/14 revealed Resident #1 had been taken to the dining room for dinner on 11/19/14 from 6:45 PM to 7:15 PM and then returned to her room. On 11/20/14, RN B documented Resident #1 was in bed until 7:30 AM, and was in the dining room at 7:45 AM. Asked about the time discrepancies regarding when Resident # 1 was taken to the dining room at approximately 3:15 PM on 12/15/14, the ADM stated she tended to believe RN B because she was responsible for documenting visual checks on Resident #1 every 15 minutes and would have been checking the time. The ADM stated other staff members were less likely to have checked the time and had estimated when that morning's events occurred. The ADM also stated RN B had documented in a nursing note that she observed Resident #1 in her room at 7:45 AM. The ADM stated this explained why staff members in the dining room around 7:30 AM to 7:45 AM did report seeing Resident #1, as she was still in her room. (RN B stated she saw the resident in her room at 7:45A. RA A stated she took Resident # 1 to the dining room before 7:45AM, between7:15AM to 7:20AM) At 3:22 PM on 12/15/14, the DON brought a revised 15 minute surveillance note. For the 7:45 AM check on 11/20/14 for Resident #1, RN B had crossed out "dining room," initialed it, and wrote that Resident #1 was in her room at the time. In an interview on 12/15/14 at 2:45 PM, the ADM stated the other eight residents, including Resident #1, who had resided on the secured unit were transferred to other facilities with existing secured units. Asked at this time about how visitors were informed not to let potential residents out of the building, the ADM stated she thought a sign was posted next to the main entrance informing visitors not to let residents outside. Observation of the main entrance on 12/15/14 at 3:10 PM revealed no such sign was posted. An interview on 12/03/14 at 11:30 AM with the Maintenance Director revealed he was responsible for testing the facility's wander guard system weekly to ensure it was functioning. Asked to provide documentation of the weekly checks, the Maintenance Director stated he did not document them but started doing so following this incident. He said he checked Resident #1's wander guard within a couple hours after she had been returned the facility, and it was functioning properly. The Maintenance Director stated the wander guard alarm would sound near the secured unit door and near the two elevators on the second floor. The elevators would also not be able to function unless someone entered a code on a keypad near the elevator to turn off the alarm. The Maintenance Director stated the wander guard alarms were not set up to sound off if residents got near any of the exit doors on the first floor of the facility. The Maintenance Director demonstrated the facility's wander guard system on 12/03/14 at 11:30 AM. The facility used ankle bracelets. The wander guard alarm on the test ankle bracelet was observed sounding when near the secured unit entrance and near the two elevators on the second floor. However, the alarm was not very loud. The only nurses' station on the second floor was located approximately 15 to 20 feet from the nearest elevator, and with the substantial noise level in the facility at the time of this observation it would have been difficult to hear the alarm sounding from the nurses' station. An interview on 12/03/14 at 10:00 AM with the Administrator (ADM) revealed she investigated the incident regarding Resident #1 and reported it to the state survey and certification agency within the mandated timeframe. The ADM stated the facility's secured memory care unit was being closed due to not meeting life safety code requirements. Resident #1 resided on the secured unit, and they moved her off the secured unit to the long term care unit on 11/19/14 to determine if she was safe and could continue residing at the facility. Precautions were in place for the transition off the secured unit, including the use of a wander guard and visual checks every 15 minutes by nurses. The ADM stated on the morning of 11/20/14, Resident #1 asked RA A to go to breakfast. RA A then took Resident #1 downstairs to the facility's only dining room. The ADM said RA A was not responsible for caring for Resident #1 and should not have taken her down there. CNA D was assigned to care for Resident #1 that morning but was completing care with other residents during that time. Resident #1 was ordered to have visual checks every 15 minutes by RN B that morning, and Resident #1 was taken to the dining room between those checks. There should have been three or four staff members supervising residents in the dining room. The ADM stated Resident #1 was wearing an ankle bracelet with a wander guard alarm. Resident #1 resided on the facility's second floor, and the ADM stated the wander guard ' s alarm would sound when nearing both of the second floor elevators. Furthermore, the elevators were designed to not function when a wander guard alarm had been set off. Someone would have to punch a code in a keypad near the elevators to turn the alarms off and allow the elevators to be used again. The ADM stated a wander guard alarm system was not in place on the facility's first floor. The exit doors downstairs were locked. They were unlocked by entering a code on a keypad, and the code was not posted anywhere. Anyone could have let Resident #1 out one of the exit doors downstairs, and her wander guard alarm would not have sounded. Resident #1 was ambulatory and used no assistive devices and may not have looked like a typical nursing home resident. The ADM stated RN B went to complete a visual check on Resident #1 at 8:00 AM but did not find her. RN B was told by CNA D that Resident #1 was in the dining room downstairs. RN B went to the dining room to look for Resident #1 at 8:10 AM but could not find her there. Searches throughout the inside and outside of the building were conducted, and some staff members drove around the area in their personal vehicles but were not able to find Resident #1. The police were notified at 9:10 AM, and they found Resident #1 approximately one mile from the facility in a busy area and returned her unharmed at 10:08 AM. The ADM stated the breakdown occurred with RA A taking Resident #1 downstairs to the dining room when she should not have. The ADM stated the facility did have cameras in place. However, the cameras were not currently functioning due to a recent ownership change so could not be reviewed to see how Resident #1 was able to exit the building. Review of a nursing note dated 11/20/14 at 10:18 AM by RN B revealed Resident #1 was brought to her at 10:08 AM by the ADM. Resident #1 complained her legs were sore from walking a lot but was assessed to have no injuries. The wander guard was also noted to be in place. Review of an Elopement Risk assessment for Resident #1 dated 11/20/14, revealed she had been reassessed as having a score of 22 out of 24 following her elopement, indicating a high risk. Review of staff in-service training records revealed all staff members were trained on elopement and transitioning residents from the secured unit to long term care on 11/20/14, including that "these residents are not to leave the 2nd floor unless directed by (the) DON." In-service trainings with all staff on elopement drills were also conducted on 11/20/14. RN B received a one-on-one in-service training on 11/20/14 regarding residents transitioning from the secured unit to long term care. An invoice from an alarm company was included that indicated the facility's wander guard system was checked on 11/21/14 and found to be working properly. The facility's Elopement Policy dated September 2011 and provided by the ADM on 12/03/14 as the current policy, reflected once a resident was identified as missing a 30 minute search would be conducted in the facility and on the facility grounds. If the resident was not found after 30 minutes, the police would be contacted. Staff would then extend the search to within a two mile radius of the facility. On 12/15/14 at 3:19 PM, the ADM posted a sign at the main entrance that reflected, "Please do not assist any residents exiting the facility before asking staff for assistance. Thanks Management." The ADM also pointed out a couple pieces of tape on a window next to the main entrance door indicating a sign had been posted there at one point. An interview on 12/16/14 at 12:04 PM with the DON revealed she attributed the incident to RA A taking Resident #1 to the dining room for breakfast. The DON said she suspected someone had turned the wander guard alarm off to take Resident #1 downstairs, as the alarm was found to be functioning properly after Resident #1 returned from eloping. The DON stated additional training may have helped prevent this incident. The facility's put the following changes in to place after the incident with Resident #1: "Post Action: ? Total of 11 residents were in the secured unit on 11/20/2014- were all assessed and wander guard bracelets were checked ... ? ...Staff was reeducated on elopement policy and procedure & transitioning residents from the secured unit. Actual drills were performed on 6-2 and 2-10 shifts on 11/20/2014. ? One on one education performed with (RN B) on communication, transitioning residents from the secured unit, and communication to staff on 11/20/2014 ? Staff was reeducated on 11/21/2014 transitioning residents ? Nursing staff was reeducated on 11/26/2014 on q15 minutes and q4 documentation; sign and symptoms of wandering, etc. ? Staff was reeducated on 12/03/2014 on transitioning a resident, q15 minutes and q4 documentation ? Elopement drill performed on 2-10 and 10-6 on 12/04/2014 (resident was hidden in the stairway and dining room). Competency based drills were held with actual residents hidden to have staff to demonstrate competency. ? All staff was reeducated on 12/12/2014 on elopement policy and procedure. ? Weekly checks x 1 month performed by (Maintenance Director) on wander guard system effective 12/15/2014. Checks to be performed monthly thereafter. ? Elopement drills weekly x 1 month effective 12/15/2014. Drills to be performed monthly thereafter -Competency based drills were held with actual residents hidden to have staff demonstrate proficiency. ? Updated elopement risk assessment and care plan on remaining resident (Resident #2) on 12/15/2014 by (the DON). Resident was assessed on 11/13/2014 by (the DON). The resident was still at risk. ? Remaining resident (Resident #2) was discharged on [DATE] to secured unit. Resident was closely monitoring from 12/05/2014 until discharge. Resident has not exhibit any exit seeking behaviors during this time period. ? Administrator or designee will perform monitoring rounds randomly weekly x 5 weeks on the entire facility. Issues are corrected immediately upon discovery. Administrator will provide oversight for the entire plan. ? Signage placed at all doors informing visitors not to assist residents out of the building. Review of an in-service training record dated 11/21/14 and provided by the ADM on 12/15/14 revealed all staff were trained on Resident #2 transitioning from the secured unit to long term care and were instructed not to take her to the first floor unless instructed by the DON. Every 15 minute surveillance checks and documentation every four hours were also put in place. Review of an in-service training record dated 11/26/14 and provided by the ADM on 12/15/14 revealed all staff were trained on Resident #3 transitioning from the secured unit to long term care and were instructed not to take her to the first floor unless instructed by the DON. Every 15 minute surveillance checks and documentation every four hours were also put in place. Review of in-service training records provided by the ADM on 12/15/14 revealed elopement drills were conducted on 12/04/14 and 12/12/14. Additional in-service training records provided by the ADM on 12/16/14 revealed all staff members had now received training on elopement. Interviews on 12/16/14 at various times with LVN J, CNA K, CNA L, LVN M, CNA N, DA O, Housekeeper P, LVN Q, and CNA R, who represented staff from all days and shifts, revealed they had all received in-service training on elopement, including signs of exit seeking, the residents in the facility identified as an elopement risk, and what to do if a resident was identified as missing. The ADM was informed on 12/16/14 at 2:30 PM the facility remained out of compliance at a severity level of "potential for more than minimal harm that is not immediate jeopardy" and a scope of "pattern" due to the facility needing to monitor the effectiveness of their Post Action plan. A current census list provided by the DON on 12/03/14 revealed nine residents resided on the facility's secured unit, and two residents were being transitioned off the secured unit.

Based on observation, interview, and record review, it was determined the facility failed to implement policies and procedures that prohibit neglect for one (Resident #1) of 11 residents whose clinical records were reviewed. The facility failed to: 1. Develop a complete transition plan, how Resident #1 would be supervised including how meals would be served, and train all staff members on this plan for Resident #1, who was transitioning from the secured unit to the long term care unit. 2. Ensure the wander guard system functioned properly. 3. Inform visitors and staff members to not let residents out of the facility's locked exit doors. These failures resulted in Resident #1, who was an elopement risk, eloping and being gone from the facility for approximately two hours. Resident #1 eloped in a high traffic area near two freeways. An Immediate Jeopardy (IJ) was existed from 11/19/14 to 11/20/14. The facility remained out of compliance at a severity level of "potential for more than minimal harm that is not immediate jeopardy" and a scope of "pattern" due to the facility needing to monitor the effectiveness of their plan. This failure had the potential to affect the 11 residents, including Resident #1, who resided on or were being transitioned off the facility's secured unit and were considered an elopement risk. Findings included: Review of the facility's abuse and neglect policies, dated 2012 and provided by the DON on 12/03/14 as the current policies, revealed, "The facility's Leadership prohibits neglect...Ongoing assessment, care planning, and monitoring of those patients/residens with special needs that may lead to neglect...Neglect: Failure to provide goods and services or treatment and care necessary to avoid physical harm, mental anguish, or mental illness." An interview on 12/16/14 at 11:45 AM with the ADM revealed she attributed the incident to DADS ordering the secured unit be closed due to not meeting life safety code requirements. The ADM stated if the secured unit had been allowed to remain open, the incident would not have occurred. She said new ownership had taken over the facility on 10/18/14, and the facility's annual recertification survey began on 10/21/14. During this survey, facility management was informed the secured unit did not meet life safety code standards. Apparently the previous ownership company had opened the secured unit without state approval, and the new ownership group did not know this. In mid-November, the facility was informed by DADS the secured unit needed to be closed as modifications to meet life safety code standards were not feasible. The facility was given until 12/05/14 to close the secured unit. The ADM stated this was not enough time to safely transition everyone off the secured unit. The ADM said residents ' family members were consulted about this and asked where they wanted residents to go. She stated Resident #1 did not have any family members or guardianship in place, she was assessed as a low elopement risk, and the best option seemed to be to transition her to the facility ' s long term care unit. The ADM noted Resident #1 had been admitted from the hospital and had no family, so they had limited personal history on her, including any previous elopement attempts. The ADM said the only staff members trained on the transition were the ones assigned to work with her and provide care. She said if the facility had more time, she may have been able to train all staff members on the transition, and the incident may have been prevented. Other than that, she did not think the facility could have done anything differently to prevent the incident. Observation on 12/15/14 at 5:30PM of the area surrounding the facility, which is located in a Metropolitan area, revealed a heavily traffic area with two hospitals nearby. There was traffic traveling both directions in front of the facility. There are two major freeways also neare the facility and the location where the resident was found on 11/2014. There were several shops and businesses in the strip malls in the immediate area around the facility. An interview on 12/03/14 at 11:45 AM with Resident #1 revealed she could not offer many details of the incident (elopement) other than to say she liked to go for walks and had decided to go for a walk outside that morning. Review of a face sheet for Resident #1 dated 12/03/14 revealed she was an [AGE] year old female admitted to the facility on [DATE] for [DIAGNOSES REDACTED]. Review of Resident #1's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she had a Brief Interview for Mental Status (BIMS) score of two, indicating severe cognitive impairment. The MDS assessment reflected Resident #1 had wandering behaviors during one to three days during the previous week but wandering did not place her at significant risk. Review of Resident #1's Physician order [REDACTED]. Review of an Elopement Risk assessment for Resident #1 dated 10/14/14 revealed a score of 9 out of 24, indicating a "low risk" of elopement. Review of the facility's Provider Investigation Report, completed and signed by the ADM on 11/26/14 and reported to the Texas Department of Aging and Disability Services (DADS), identified the incident as occurring on 11/20/14 at 8:30 AM. The report identified Resident #1 as being ambulatory, having "minimal" functional ability, not having the capacity to make informed decisions, and requiring "within eyesight" level of supervision. The investigation summary reflected, "On 11/19/2014 Resident was assessed in an attempt to transition her from the secured unit to the long term care unit due to recent notification from the state that the facility's secured unit did not meet state criteria. The resident scored low on elopement risk and was moved from the secured unit, with physician notification from the secured unit to room (number). Resident was on (every) 15 minutes monitoring for transition/adjustment. Wander guard remained in place on the resident. Resident was tolerating the transition well on 11/19/2014. On 11/20/2014 resident was last seen by the charge nurse at (7:45 AM). Resident was seen at the doors of the secured unit attempting to get back in the unit. Restorative aide assisted the resident to the downstairs dining room. No alarms were noted to sound when exiting off the second floor. At (8:00 AM) charge nurse inquired the whereabouts of the resident which she was told that the resident had been assisted to the dining room by restorative aide. At approximately (8:10 AM) charge nurse entered the dining room and was unable to locate the resident. Staff began to search the inside of the facility. At approximately (8:30 AM) administrator was notified of missing resident. Resident was last seen in the dining room around 8:00 AM. Resident may have exited after a visitor through the front door. Outside grounds were checked. Facility began search by foot and car as well. At approximately (9:10 AM) police was notified of the missing resident. No family was contacted due to the resident has none. Search continued until resident was located at approximately 10:00 AM by police. Physician notified. Resident was returned to the secured unit and placed on close monitoring for 24 hours. Resident remains in pleasant mood. On 11/21/2014 resident returned on (every) 15 (minute) checks for continued monitoring." In response to the incident, the report indicated the facility's secured unit was scheduled to be closed on 12/05/14, Resident #1 will be transferred to another facility before the closure, in-services with all staff were completed, elopement drills were performed, the facility's wander guard system was checked by an outside provider, care plans were updated, and residents were reassessed for elopement risk. Review of Resident #1's care plans revealed an elopement care plan was written on 11/20/14 following the incident. An interview on 12/03/14 at 3:30 PM with the DON revealed she did not know if an elopement care plan was in place for Resident #1 prior to 11/20/14. The DON stated care plans were completed electronically, and once staff members completed or revised a care plan, any previous care plans for the same issue would be deleted and not able to be accessed. Review of a nursing note dated 11/19/14 at 12:32 PM by the ADON revealed Resident #1 was moved off the secured unit to the long term care hall and placed on visual checks every 15 minutes and documentation every four hours. (The facility wanted to monitor the resident closely due to the transition off of a secure unit to a unit that was not secured.) Review of a nursing note dated 11/20/14 at 2:00 AM by LVN C revealed the wander guard was in place. Review of a late entry nursing note dated 11/20/14 at 4:27 PM by RN B revealed, "Resident in bed asleep at beginning of shift ( at 6:00 AM). Resident was observed (every) 15 minutes by nurse thru (sic) (7:45 AM) and was in her room. At (8:00 AM) Resident was not in her room at check. Nurse asked CNA where the resident was. CNA stated that the resident had been taken to the dining room for breakfast. Nurse went to the dining room at (8:10 AM) and the resident was not there. Nurse sent two CNA to check throughout the building. Nurse checked all rooms on the firsr (sic) and second floor and was unable to locate resident. Nurse notified ADON that the resident could not be located and she notified the administrator." In an interview on 12/03/14 at 12:09 PM, RA A revealed she was doing morning rounds with residents on the second floor and was about to head downstairs at approximately 7:15 AM. RA A stated she observed Resident #1 knocking on the doors to the secured unit asking where the dining room was located. RA A offered to take Resident #1 to the dining room. RA A did not think there would be anything wrong with this and said she often escorted residents to the dining room. RA A said no wander guard alarm sounded when she escorted Resident #1 on the elevator and took her downstairs. RA A stated she got her seated in the dining room and left her there around 7:20 AM. RA A stated no staff members were present at the time in the dining room to supervise residents. RA A stated staff would typically not show up in the dining room until 7:30 AM, since that was when breakfast actually started. In a follow up interview on 12/15/14 at 1:25 PM, RA A again stated no wander guard alarm sounded when taking Resident #1 downstairs, and she did not have to punch in a code in a keypad to use the elevator. RA A stated she sat Resident #1 down in the middle row of tables and got four residents coffee, including Resident #1, before going back upstairs to bring down more residents for breakfast. She stated Resident #1 was sitting down drinking her coffee when she left to go back upstairs, and she did not know Resident #1 was transitioning off the secured unit. She revealed she did not think there would be any problems leaving her in the dining room. RA A noted that while there were no CNAs in the dining room supervising residents at the time. There were dietary staff members in the adjacent kitchen preparing breakfast so she was not concerned. During an interview on 12/15/14 at 1:40 PM, CNA D stated she worked the 6:00 AM to 2:00 PM shift on 11/20/14 on Hall D and was assigned to work with Resident #1. She said when starting her shift she saw Resident #1 in her room and recognized she was new to the hall and asked her charge nurse RN B about her. She said RN B told her Resident #1 was transitioning from the secured unit to long term care, and she was required to have visual checks every 15 minutes. CNA D stated RN B was responsible for the visual checks. CNA D revealed she was providing care to other residents that morning and somewhere between 7:30 AM and 8:00 AM she was told by CNA E that Resident #1 had been taken downstairs to the dining room for breakfast. CNA D said she did not think anything about it and was not aware of any plans concerning mealtimes for Resident #1. She helped search for Resident #1 after being told by RN B she was missing. An interview on 12/15/14 at 1:55 PM with CNA E revealed she was assigned to assist and supervise residents in the dining room on the morning of 11/20/14. She said RA A told her Resident #1 had been taken down to the dining room, and she informed CNA D about this. CNA E stated she arrived for dining room duty at 7:45 AM and did not recall seeing Resident #1 down there. She helped search for Resident #1 after being told by RN B she was missing. An interview on 12/03/14 at 10:58 AM with RN B revealed she was responsible for completing visual checks on Resident #1 every 15 minutes. RN B stated Resident #1 had been in her room all morning and was there at 7:45 AM. During the 8:00 AM check, she could not find her. RN B was told by CNA D that Resident #1 had been taken to the dining room, so she went to the dining room to look for her but did not see her. RN B stated she ordered CNA D and CNA E to go look for her and told the ADON Resident #1 was missing. A search of the building and surrounding area commenced, but Resident #1 was not found. The police were notified. RN B said Resident #1 did have a wander guard in place, but the wander guard alarms were not very loud and were difficult to hear. She did not hear any wander guard alarms go off that morning. Review of staff interview transcripts revealed CNA H reported she was on dining room duty on the morning of 11/20/14. She reported going to the dining room at 7:30 AM but did not recall ever seeing Resident #1 there. Review of staff interview transcripts revealed CNA D recalled seeing Resident #1 in her room at 6:15 AM. She asked RN B about her as she was new to the hall. She did not see her during the next couple hours and was informed by CNA E around 8:00 AM that Resident # 1 was missing. Review of 15 Minute Surveillance Checks for Resident #1 provided by the ADM on 12/15/14 revealed Resident #1 had been taken to the dining room for dinner on 11/19/14 from 6:45 PM to 7:15 PM and then returned to her room. On 11/20/14, RN B documented Resident #1 was in bed until 7:30 AM, and was in the dining room at 7:45 AM. Asked about the time discrepancies regarding when Resident # 1 was taken to the dining room at approximately 3:15 PM on 12/15/14, the ADM stated she tended to believe RN B because she was responsible for documenting visual checks on Resident #1 every 15 minutes and would have been checking the time. The ADM stated other staff members were less likely to have checked the time and had estimated when that morning's events occurred. The ADM also stated RN B had documented in a nursing note that she observed Resident #1 in her room at 7:45 AM. The ADM stated this explained why staff members in the dining room around 7:30 AM to 7:45 AM did report seeing Resident #1, as she was still in her room. (RN B stated she saw the resident in her room at 7:45A. RA A stated she took Resident # 1 to the dining room before 7:45AM, between7:15AM to 7:20AM) At 3:22 PM on 12/15/14, the DON brought a revised 15 minute surveillance note. For the 7:45 AM check on 11/20/14 for Resident #1, RN B had crossed out "dining room," initialed it, and wrote that Resident #1 was in her room at the time. In an interview on 12/15/14 at 2:45 PM, the ADM stated the other eight residents, including Resident #1, who had resided on the secured unit were transferred to other facilities with existing secured units. Asked at this time about how visitors were informed not to let potential residents out of the building, the ADM stated she thought a sign was posted next to the main entrance informing visitors not to let residents outside. Observation of the main entrance on 12/15/14 at 3:10 PM revealed no such sign was posted. An interview on 12/03/14 at 11:30 AM with the Maintenance Director revealed he was responsible for testing the facility's wander guard system weekly to ensure it was functioning. Asked to provide documentation of the weekly checks, the Maintenance Director stated he did not document them but started doing so following this incident. He said he checked Resident #1's wander guard within a couple hours after she had been returned the facility, and it was functioning properly. The Maintenance Director stated the wander guard alarm would sound near the secured unit door and near the two elevators on the second floor. The elevators would also not be able to function unless someone entered a code on a keypad near the elevator to turn off the alarm. The Maintenance Director stated the wander guard alarms were not set up to sound off if residents got near any of the exit doors on the first floor of the facility. The Maintenance Director demonstrated the facility's wander guard system on 12/03/14 at 11:30 AM. The facility used ankle bracelets. The wander guard alarm on the test ankle bracelet was observed sounding when near the secured unit entrance and near the two elevators on the second floor. However, the alarm was not very loud. The only nurses' station on the second floor was located approximately 15 to 20 feet from the nearest elevator, and with the substantial noise level in the facility at the time of this observation it would have been difficult to hear the alarm sounding from the nurses' station. An interview on 12/03/14 at 10:00 AM with the Administrator (ADM) revealed she investigated the incident regarding Resident #1 and reported it to the state survey and certification agency within the mandated timeframe. The ADM stated the facility's secured memory care unit was being closed due to not meeting life safety code requirements. Resident #1 resided on the secured unit, and they moved her off the secured unit to the long term care unit on 11/19/14 to determine if she was safe and could continue residing at the facility. Precautions were in place for the transition off the secured unit, including the use of a wander guard and visual checks every 15 minutes by nurses. The ADM stated on the morning of 11/20/14, Resident #1 asked RA A to go to breakfast. RA A then took Resident #1 downstairs to the facility's only dining room. The ADM said RA A was not responsible for caring for Resident #1 and should not have taken her down there. CNA D was assigned to care for Resident #1 that morning but was completing care with other residents during that time. Resident #1 was ordered to have visual checks every 15 minutes by RN B that morning, and Resident #1 was taken to the dining room between those checks. There should have been three or four staff members supervising residents in the dining room. The ADM stated Resident #1 was wearing an ankle bracelet with a wander guard alarm. Resident #1 resided on the facility's second floor, and the ADM stated the wander guard ' s alarm would sound when nearing both of the second floor elevators. Furthermore, the elevators were designed to not function when a wander guard alarm had been set off. Someone would have to punch a code in a keypad near the elevators to turn the alarms off and allow the elevators to be used again. The ADM stated a wander guard alarm system was not in place on the facility's first floor. The exit doors downstairs were locked. They were unlocked by entering a code on a keypad, and the code was not posted anywhere. Anyone could have let Resident #1 out one of the exit doors downstairs, and her wander guard alarm would not have sounded. Resident #1 was ambulatory and used no assistive devices and may not have looked like a typical nursing home resident. The ADM stated RN B went to complete a visual check on Resident #1 at 8:00 AM but did not find her. RN B was told by CNA D that Resident #1 was in the dining room downstairs. RN B went to the dining room to look for Resident #1 at 8:10 AM but could not find her there. Searches throughout the inside and outside of the building were conducted, and some staff members drove around the area in their personal vehicles but were not able to find Resident #1. The police were notified at 9:10 AM, and they found Resident #1 approximately one mile from the facility in a busy area and returned her unharmed at 10:08 AM. The ADM stated the breakdown occurred with RA A taking Resident #1 downstairs to the dining room when she should not have. The ADM stated the facility did have cameras in place. However, the cameras were not currently functioning due to a recent ownership change so could not be reviewed to see how Resident #1 was able to exit the building. Review of a nursing note dated 11/20/14 at 10:18 AM by RN B revealed Resident #1 was brought to her at 10:08 AM by the ADM. Resident #1 complained her legs were sore from walking a lot but was assessed to have no injuries. The wander guard was also noted to be in place. Review of an Elopement Risk assessment for Resident #1 dated 11/20/14, revealed she had been reassessed as having a score of 22 out of 24 following her elopement, indicating a high risk. Review of staff in-service training records revealed all staff members were trained on elopement and transitioning residents from the secured unit to long term care on 11/20/14, including that "these residents are not to leave the 2nd floor unless directed by (the) DON." In-service trainings with all staff on elopement drills were also conducted on 11/20/14. RN B received a one-on-one in-service training on 11/20/14 regarding residents transitioning from the secured unit to long term care. An invoice from an alarm company was included that indicated the facility's wander guard system was checked on 11/21/14 and found to be working properly. The facility's Elopement Policy dated September 2011 and provided by the ADM on 12/03/14 as the current policy, reflected once a resident was identified as missing a 30 minute search would be conducted in the facility and on the facility grounds. If the resident was not found after 30 minutes, the police would be contacted. Staff would then extend the search to within a two mile radius of the facility. On 12/15/14 at 3:19 PM, the ADM posted a sign at the main entrance that reflected, "Please do not assist any residents exiting the facility before asking staff for assistance. Thanks Management." The ADM also pointed out a couple pieces of tape on a window next to the main entrance door indicating a sign had been posted there at one point. An interview on 12/16/14 at 12:04 PM with the DON revealed she attributed the incident to RA A taking Resident #1 to the dining room for breakfast. The DON said she suspected someone had turned the wander guard alarm off to take Resident #1 downstairs, as the alarm was found to be functioning properly after Resident #1 returned from eloping. The DON stated additional training may have helped prevent this incident. The facility's put the following changes in to place after the incident with Resident #1: "Post Action: ? Total of 11 residents were in the secured unit on 11/20/2014- were all assessed and wander guard bracelets were checked ... ? ...Staff was reeducated on elopement policy and procedure & transitioning residents from the secured unit. Actual drills were performed on 6-2 and 2-10 shifts on 11/20/2014. ? One on one education performed with (RN B) on communication, transitioning residents from the secured unit, and communication to staff on 11/20/2014 ? Staff was reeducated on 11/21/2014 transitioning residents ? Nursing staff was reeducated on 11/26/2014 on q15 minutes and q4 documentation; sign and symptoms of wandering, etc. ? Staff was reeducated on 12/03/2014 on transitioning a resident, q15 minutes and q4 documentation ? Elopement drill performed on 2-10 and 10-6 on 12/04/2014 (resident was hidden in the stairway and dining room). Competency based drills were held with actual residents hidden to have staff to demonstrate competency. ? All staff was reeducated on 12/12/2014 on elopement policy and procedure. ? Weekly checks x 1 month performed by (Maintenance Director) on wander guard system effective 12/15/2014. Checks to be performed monthly thereafter. ? Elopement drills weekly x 1 month effective 12/15/2014. Drills to be performed monthly thereafter -Competency based drills were held with actual residents hidden to have staff demonstrate proficiency. ? Updated elopement risk assessment and care plan on remaining resident (Resident #2) on 12/15/2014 by (the DON). Resident was assessed on 11/13/2014 by (the DON). The resident was still at risk. ? Remaining resident (Resident #2) was discharged on [DATE] to secured unit. Resident was closely monitoring from 12/05/2014 until discharge. Resident has not exhibit any exit seeking behaviors during this time period. ? Administrator or designee will perform monitoring rounds randomly weekly x 5 weeks on the entire facility. Issues are corrected immediately upon discovery. Administrator will provide oversight for the entire plan. ? Signage placed at all doors informing visitors not to assist residents out of the building. Review of an in-service training record dated 11/21/14 and provided by the ADM on 12/15/14 revealed all staff were trained on Resident #2 transitioning from the secured unit to long term care and were instructed not to take her to the first floor unless instructed by the DON. Every 15 minute surveillance checks and documentation every four hours were also put in place. Review of an in-service training record dated 11/26/14 and provided by the ADM on 12/15/14 revealed all staff were trained on Resident #3 transitioning from the secured unit to long term care and were instructed not to take her to the first floor unless instructed by the DON. Every 15 minute surveillance checks and documentation every four hours were also put in place. Review of in-service training records provided by the ADM on 12/15/14 revealed elopement drills were conducted on 12/04/14 and 12/12/14. Additional in-service training records provided by the ADM on 12/16/14 revealed all staff members had now received training on elopement. Interviews on 12/16/14 at various times with LVN J, CNA K, CNA L, LVN M, CNA N, DA O, Housekeeper P, LVN Q, and CNA R, who represented staff from all days and shifts, revealed they had all received in-service training on elopement, including signs of exit seeking, the residents in the facility identified as an elopement risk, and what to do if a resident was identified as missing. The ADM was informed on 12/16/14 at 2:30 PM the facility remained out of compliance at a severity level of "potential for more than minimal harm that is not immediate jeopardy" and a scope of "pattern" due to the facility needing to monitor the effectiveness of their Post Action plan. A current census list provided by the DON on 12/03/14 revealed nine residents resided on the facility's secured unit, and two residents were being transitioned off the secured unit.

Based on observation, interview, and record review, it was determined the facility failed to implement policies and procedures that prohibit neglect for one (Resident #1) of 11 residents whose clinical records were reviewed. The facility failed to: 1. Develop a complete transition plan, how Resident #1 would be supervised including how meals would be served, and train all staff members on this plan for Resident #1, who was transitioning from the secured unit to the long term care unit. 2. Ensure the wander guard system functioned properly. 3. Inform visitors and staff members to not let residents out of the facility's locked exit doors. These failures resulted in Resident #1, who was an elopement risk, eloping and being gone from the facility for approximately two hours. Resident #1 eloped in a high traffic area near two freeways. An Immediate Jeopardy (IJ) was existed from 11/19/14 to 11/20/14. The facility remained out of compliance at a severity level of "potential for more than minimal harm that is not immediate jeopardy" and a scope of "pattern" due to the facility needing to monitor the effectiveness of their plan. This failure had the potential to affect the 11 residents, including Resident #1, who resided on or were being transitioned off the facility's secured unit and were considered an elopement risk. Findings included: An interview on 12/16/14 at 11:45 AM with the ADM revealed she attributed the incident to DADS ordering the secured unit be closed due to not meeting life safety code requirements. The ADM stated if the secured unit had been allowed to remain open, the incident would not have occurred. She said new ownership had taken over the facility on 10/18/14, and the facility's annual recertification survey began on 10/21/14. During this survey, facility management was informed the secured unit did not meet life safety code standards. Apparently the previous ownership company had opened the secured unit without state approval, and the new ownership group did not know this. In mid-November, the facility was informed by DADS the secured unit needed to be closed as modifications to meet life safety code standards were not feasible. The facility was given until 12/05/14 to close the secured unit. The ADM stated this was not enough time to safely transition everyone off the secured unit. The ADM said residents ' family members were consulted about this and asked where they wanted residents to go. She stated Resident #1 did not have any family members or guardianship in place, she was assessed as a low elopement risk, and the best option seemed to be to transition her to the facility ' s long term care unit. The ADM noted Resident #1 had been admitted from the hospital and had no family, so they had limited personal history on her, including any previous elopement attempts. The ADM said the only staff members trained on the transition were the ones assigned to work with her and provide care. She said if the facility had more time, she may have been able to train all staff members on the transition, and the incident may have been prevented. Other than that, she did not think the facility could have done anything differently to prevent the incident. Observation on 12/15/14 at 5:30PM of the area surrounding the facility, which is located in a Metropolitan area, revealed a heavily traffic area with two hospitals nearby. There was traffic traveling both directions in front of the facility. There are two major freeways also neare the facility and the location where the resident was found on 11/2014. There were several shops and businesses in the strip malls in the immediate area around the facility. An interview on 12/03/14 at 11:45 AM with Resident #1 revealed she could not offer many details of the incident (elopement) other than to say she liked to go for walks and had decided to go for a walk outside that morning. Review of a face sheet for Resident #1 dated 12/03/14 revealed she was an [AGE] year old female admitted to the facility on [DATE] for [DIAGNOSES REDACTED]. Review of Resident #1's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she had a Brief Interview for Mental Status (BIMS) score of two, indicating severe cognitive impairment. The MDS assessment reflected Resident #1 had wandering behaviors during one to three days during the previous week but wandering did not place her at significant risk. Review of Resident #1's Physician order [REDACTED]. Review of an Elopement Risk assessment for Resident #1 dated 10/14/14 revealed a score of 9 out of 24, indicating a "low risk" of elopement. Review of the facility's Provider Investigation Report, completed and signed by the ADM on 11/26/14 and reported to the Texas Department of Aging and Disability Services (DADS), identified the incident as occurring on 11/20/14 at 8:30 AM. The report identified Resident #1 as being ambulatory, having "minimal" functional ability, not having the capacity to make informed decisions, and requiring "within eyesight" level of supervision. The investigation summary reflected, "On 11/19/2014 Resident was assessed in an attempt to transition her from the secured unit to the long term care unit due to recent notification from the state that the facility's secured unit did not meet state criteria. The resident scored low on elopement risk and was moved from the secured unit, with physician notification from the secured unit to room (number). Resident was on (every) 15 minutes monitoring for transition/adjustment. Wander guard remained in place on the resident. Resident was tolerating the transition well on 11/19/2014. On 11/20/2014 resident was last seen by the charge nurse at (7:45 AM). Resident was seen at the doors of the secured unit attempting to get back in the unit. Restorative aide assisted the resident to the downstairs dining room. No alarms were noted to sound when exiting off the second floor. At (8:00 AM) charge nurse inquired the whereabouts of the resident which she was told that the resident had been assisted to the dining room by restorative aide. At approximately (8:10 AM) charge nurse entered the dining room and was unable to locate the resident. Staff began to search the inside of the facility. At approximately (8:30 AM) administrator was notified of missing resident. Resident was last seen in the dining room around 8:00 AM. Resident may have exited after a visitor through the front door. Outside grounds were checked. Facility began search by foot and car as well. At approximately (9:10 AM) police was notified of the missing resident. No family was contacted due to the resident has none. Search continued until resident was located at approximately 10:00 AM by police. Physician notified. Resident was returned to the secured unit and placed on close monitoring for 24 hours. Resident remains in pleasant mood. On 11/21/2014 resident returned on (every) 15 (minute) checks for continued monitoring." In response to the incident, the report indicated the facility's secured unit was scheduled to be closed on 12/05/14, Resident #1 will be transferred to another facility before the closure, in-services with all staff were completed, elopement drills were performed, the facility's wander guard system was checked by an outside provider, care plans were updated, and residents were reassessed for elopement risk. Review of Resident #1's care plans revealed an elopement care plan was written on 11/20/14 following the incident. An interview on 12/03/14 at 3:30 PM with the DON revealed she did not know if an elopement care plan was in place for Resident #1 prior to 11/20/14. The DON stated care plans were completed electronically, and once staff members completed or revised a care plan, any previous care plans for the same issue would be deleted and not able to be accessed. Review of a nursing note dated 11/19/14 at 12:32 PM by the ADON revealed Resident #1 was moved off the secured unit to the long term care hall and placed on visual checks every 15 minutes and documentation every four hours. (The facility wanted to monitor the resident closely due to the transition off of a secure unit to a unit that was not secured.) Review of a nursing note dated 11/20/14 at 2:00 AM by LVN C revealed the wander guard was in place. Review of a late entry nursing note dated 11/20/14 at 4:27 PM by RN B revealed, "Resident in bed asleep at beginning of shift ( at 6:00 AM). Resident was observed (every) 15 minutes by nurse thru (sic) (7:45 AM) and was in her room. At (8:00 AM) Resident was not in her room at check. Nurse asked CNA where the resident was. CNA stated that the resident had been taken to the dining room for breakfast. Nurse went to the dining room at (8:10 AM) and the resident was not there. Nurse sent two CNA to check throughout the building. Nurse checked all rooms on the firsr (sic) and second floor and was unable to locate resident. Nurse notified ADON that the resident could not be located and she notified the administrator." In an interview on 12/03/14 at 12:09 PM, RA A revealed she was doing morning rounds with residents on the second floor and was about to head downstairs at approximately 7:15 AM. RA A stated she observed Resident #1 knocking on the doors to the secured unit asking where the dining room was located. RA A offered to take Resident #1 to the dining room. RA A did not think there would be anything wrong with this and said she often escorted residents to the dining room. RA A said no wander guard alarm sounded when she escorted Resident #1 on the elevator and took her downstairs. RA A stated she got her seated in the dining room and left her there around 7:20 AM. RA A stated no staff members were present at the time in the dining room to supervise residents. RA A stated staff would typically not show up in the dining room until 7:30 AM, since that was when breakfast actually started. In a follow up interview on 12/15/14 at 1:25 PM, RA A again stated no wander guard alarm sounded when taking Resident #1 downstairs, and she did not have to punch in a code in a keypad to use the elevator. RA A stated she sat Resident #1 down in the middle row of tables and got four residents coffee, including Resident #1, before going back upstairs to bring down more residents for breakfast. She stated Resident #1 was sitting down drinking her coffee when she left to go back upstairs, and she did not know Resident #1 was transitioning off the secured unit. She revealed she did not think there would be any problems leaving her in the dining room. RA A noted that while there were no CNAs in the dining room supervising residents at the time. There were dietary staff members in the adjacent kitchen preparing breakfast so she was not concerned. During an interview on 12/15/14 at 1:40 PM, CNA D stated she worked the 6:00 AM to 2:00 PM shift on 11/20/14 on Hall D and was assigned to work with Resident #1. She said when starting her shift she saw Resident #1 in her room and recognized she was new to the hall and asked her charge nurse RN B about her. She said RN B told her Resident #1 was transitioning from the secured unit to long term care, and she was required to have visual checks every 15 minutes. CNA D stated RN B was responsible for the visual checks. CNA D revealed she was providing care to other residents that morning and somewhere between 7:30 AM and 8:00 AM she was told by CNA E that Resident #1 had been taken downstairs to the dining room for breakfast. CNA D said she did not think anything about it and was not aware of any plans concerning mealtimes for Resident #1. She helped search for Resident #1 after being told by RN B she was missing. An interview on 12/15/14 at 1:55 PM with CNA E revealed she was assigned to assist and supervise residents in the dining room on the morning of 11/20/14. She said RA A told her Resident #1 had been taken down to the dining room, and she informed CNA D about this. CNA E stated she arrived for dining room duty at 7:45 AM and did not recall seeing Resident #1 down there. She helped search for Resident #1 after being told by RN B she was missing. An interview on 12/03/14 at 10:58 AM with RN B revealed she was responsible for completing visual checks on Resident #1 every 15 minutes. RN B stated Resident #1 had been in her room all morning and was there at 7:45 AM. During the 8:00 AM check, she could not find her. RN B was told by CNA D that Resident #1 had been taken to the dining room, so she went to the dining room to look for her but did not see her. RN B stated she ordered CNA D and CNA E to go look for her and told the ADON Resident #1 was missing. A search of the building and surrounding area commenced, but Resident #1 was not found. The police were notified. RN B said Resident #1 did have a wander guard in place, but the wander guard alarms were not very loud and were difficult to hear. She did not hear any wander guard alarms go off that morning. Review of staff interview transcripts revealed CNA H reported she was on dining room duty on the morning of 11/20/14. She reported going to the dining room at 7:30 AM but did not recall ever seeing Resident #1 there. Review of staff interview transcripts revealed CNA D recalled seeing Resident #1 in her room at 6:15 AM. She asked RN B about her as she was new to the hall. She did not see her during the next couple hours and was informed by CNA E around 8:00 AM that Resident # 1 was missing. Review of 15 Minute Surveillance Checks for Resident #1 provided by the ADM on 12/15/14 revealed Resident #1 had been taken to the dining room for dinner on 11/19/14 from 6:45 PM to 7:15 PM and then returned to her room. On 11/20/14, RN B documented Resident #1 was in bed until 7:30 AM, and was in the dining room at 7:45 AM. Asked about the time discrepancies regarding when Resident # 1 was taken to the dining room at approximately 3:15 PM on 12/15/14, the ADM stated she tended to believe RN B because she was responsible for documenting visual checks on Resident #1 every 15 minutes and would have been checking the time. The ADM stated other staff members were less likely to have checked the time and had estimated when that morning's events occurred. The ADM also stated RN B had documented in a nursing note that she observed Resident #1 in her room at 7:45 AM. The ADM stated this explained why staff members in the dining room around 7:30 AM to 7:45 AM did report seeing Resident #1, as she was still in her room. (RN B stated she saw the resident in her room at 7:45A. RA A stated she took Resident # 1 to the dining room before 7:45AM, between7:15AM to 7:20AM) At 3:22 PM on 12/15/14, the DON brought a revised 15 minute surveillance note. For the 7:45 AM check on 11/20/14 for Resident #1, RN B had crossed out "dining room," initialed it, and wrote that Resident #1 was in her room at the time. In an interview on 12/15/14 at 2:45 PM, the ADM stated the other eight residents, including Resident #1, who had resided on the secured unit were transferred to other facilities with existing secured units. Asked at this time about how visitors were informed not to let potential residents out of the building, the ADM stated she thought a sign was posted next to the main entrance informing visitors not to let residents outside. Observation of the main entrance on 12/15/14 at 3:10 PM revealed no such sign was posted. An interview on 12/03/14 at 11:30 AM with the Maintenance Director revealed he was responsible for testing the facility's wander guard system weekly to ensure it was functioning. Asked to provide documentation of the weekly checks, the Maintenance Director stated he did not document them but started doing so following this incident. He said he checked Resident #1's wander guard within a couple hours after she had been returned the facility, and it was functioning properly. The Maintenance Director stated the wander guard alarm would sound near the secured unit door and near the two elevators on the second floor. The elevators would also not be able to function unless someone entered a code on a keypad near the elevator to turn off the alarm. The Maintenance Director stated the wander guard alarms were not set up to sound off if residents got near any of the exit doors on the first floor of the facility. The Maintenance Director demonstrated the facility's wander guard system on 12/03/14 at 11:30 AM. The facility used ankle bracelets. The wander guard alarm on the test ankle bracelet was observed sounding when near the secured unit entrance and near the two elevators on the second floor. However, the alarm was not very loud. The only nurses' station on the second floor was located approximately 15 to 20 feet from the nearest elevator, and with the substantial noise level in the facility at the time of this observation it would have been difficult to hear the alarm sounding from the nurses' station. An interview on 12/03/14 at 10:00 AM with the Administrator (ADM) revealed she investigated the incident regarding Resident #1 and reported it to the state survey and certification agency within the mandated timeframe. The ADM stated the facility's secured memory care unit was being closed due to not meeting life safety code requirements. Resident #1 resided on the secured unit, and they moved her off the secured unit to the long term care unit on 11/19/14 to determine if she was safe and could continue residing at the facility. Precautions were in place for the transition off the secured unit, including the use of a wander guard and visual checks every 15 minutes by nurses. The ADM stated on the morning of 11/20/14, Resident #1 asked RA A to go to breakfast. RA A then took Resident #1 downstairs to the facility's only dining room. The ADM said RA A was not responsible for caring for Resident #1 and should not have taken her down there. CNA D was assigned to care for Resident #1 that morning but was completing care with other residents during that time. Resident #1 was ordered to have visual checks every 15 minutes by RN B that morning, and Resident #1 was taken to the dining room between those checks. There should have been three or four staff members supervising residents in the dining room. The ADM stated Resident #1 was wearing an ankle bracelet with a wander guard alarm. Resident #1 resided on the facility's second floor, and the ADM stated the wander guard ' s alarm would sound when nearing both of the second floor elevators. Furthermore, the elevators were designed to not function when a wander guard alarm had been set off. Someone would have to punch a code in a keypad near the elevators to turn the alarms off and allow the elevators to be used again. The ADM stated a wander guard alarm system was not in place on the facility's first floor. The exit doors downstairs were locked. They were unlocked by entering a code on a keypad, and the code was not posted anywhere. Anyone could have let Resident #1 out one of the exit doors downstairs, and her wander guard alarm would not have sounded. Resident #1 was ambulatory and used no assistive devices and may not have looked like a typical nursing home resident. The ADM stated RN B went to complete a visual check on Resident #1 at 8:00 AM but did not find her. RN B was told by CNA D that Resident #1 was in the dining room downstairs. RN B went to the dining room to look for Resident #1 at 8:10 AM but could not find her there. Searches throughout the inside and outside of the building were conducted, and some staff members drove around the area in their personal vehicles but were not able to find Resident #1. The police were notified at 9:10 AM, and they found Resident #1 approximately one mile from the facility in a busy area and returned her unharmed at 10:08 AM. The ADM stated the breakdown occurred with RA A taking Resident #1 downstairs to the dining room when she should not have. The ADM stated the facility did have cameras in place. However, the cameras were not currently functioning due to a recent ownership change so could not be reviewed to see how Resident #1 was able to exit the building. Review of a nursing note dated 11/20/14 at 10:18 AM by RN B revealed Resident #1 was brought to her at 10:08 AM by the ADM. Resident #1 complained her legs were sore from walking a lot but was assessed to have no injuries. The wander guard was also noted to be in place. Review of an Elopement Risk assessment for Resident #1 dated 11/20/14, revealed she had been reassessed as having a score of 22 out of 24 following her elopement, indicating a high risk. Review of staff in-service training records revealed all staff members were trained on elopement and transitioning residents from the secured unit to long term care on 11/20/14, including that "these residents are not to leave the 2nd floor unless directed by (the) DON." In-service trainings with all staff on elopement drills were also conducted on 11/20/14. RN B received a one-on-one in-service training on 11/20/14 regarding residents transitioning from the secured unit to long term care. An invoice from an alarm company was included that indicated the facility's wander guard system was checked on 11/21/14 and found to be working properly. The facility's Elopement Policy dated September 2011 and provided by the ADM on 12/03/14 as the current policy, reflected once a resident was identified as missing a 30 minute search would be conducted in the facility and on the facility grounds. If the resident was not found after 30 minutes, the police would be contacted. Staff would then extend the search to within a two mile radius of the facility. On 12/15/14 at 3:19 PM, the ADM posted a sign at the main entrance that reflected, "Please do not assist any residents exiting the facility before asking staff for assistance. Thanks Management." The ADM also pointed out a couple pieces of tape on a window next to the main entrance door indicating a sign had been posted there at one point. An interview on 12/16/14 at 12:04 PM with the DON revealed she attributed the incident to RA A taking Resident #1 to the dining room for breakfast. The DON said she suspected someone had turned the wander guard alarm off to take Resident #1 downstairs, as the alarm was found to be functioning properly after Resident #1 returned from eloping. The DON stated additional training may have helped prevent this incident. The facility's put the following changes in to place after the incident with Resident #1: "Post Action: ? Total of 11 residents were in the secured unit on 11/20/2014- were all assessed and wander guard bracelets were checked ... ? ...Staff was reeducated on elopement policy and procedure & transitioning residents from the secured unit. Actual drills were performed on 6-2 and 2-10 shifts on 11/20/2014. ? One on one education performed with (RN B) on communication, transitioning residents from the secured unit, and communication to staff on 11/20/2014 ? Staff was reeducated on 11/21/2014 transitioning residents ? Nursing staff was reeducated on 11/26/2014 on q15 minutes and q4 documentation; sign and symptoms of wandering, etc. ? Staff was reeducated on 12/03/2014 on transitioning a resident, q15 minutes and q4 documentation ? Elopement drill performed on 2-10 and 10-6 on 12/04/2014 (resident was hidden in the stairway and dining room). Competency based drills were held with actual residents hidden to have staff to demonstrate competency. ? All staff was reeducated on 12/12/2014 on elopement policy and procedure. ? Weekly checks x 1 month performed by (Maintenance Director) on wander guard system effective 12/15/2014. Checks to be performed monthly thereafter. ? Elopement drills weekly x 1 month effective 12/15/2014. Drills to be performed monthly thereafter -Competency based drills were held with actual residents hidden to have staff demonstrate proficiency. ? Updated elopement risk assessment and care plan on remaining resident (Resident #2) on 12/15/2014 by (the DON). Resident was assessed on 11/13/2014 by (the DON). The resident was still at risk. ? Remaining resident (Resident #2) was discharged on [DATE] to secured unit. Resident was closely monitoring from 12/05/2014 until discharge. Resident has not exhibit any exit seeking behaviors during this time period. ? Administrator or designee will perform monitoring rounds randomly weekly x 5 weeks on the entire facility. Issues are corrected immediately upon discovery. Administrator will provide oversight for the entire plan. ? Signage placed at all doors informing visitors not to assist residents out of the building. Review of an in-service training record dated 11/21/14 and provided by the ADM on 12/15/14 revealed all staff were trained on Resident #2 transitioning from the secured unit to long term care and were instructed not to take her to the first floor unless instructed by the DON. Every 15 minute surveillance checks and documentation every four hours were also put in place. Review of an in-service training record dated 11/26/14 and provided by the ADM on 12/15/14 revealed all staff were trained on Resident #3 transitioning from the secured unit to long term care and were instructed not to take her to the first floor unless instructed by the DON. Every 15 minute surveillance checks and documentation every four hours were also put in place. Review of in-service training records provided by the ADM on 12/15/14 revealed elopement drills were conducted on 12/04/14 and 12/12/14. Additional in-service training records provided by the ADM on 12/16/14 revealed all staff members had now received training on elopement. Interviews on 12/16/14 at various times with LVN J, CNA K, CNA L, LVN M, CNA N, DA O, Housekeeper P, LVN Q, and CNA R, who represented staff from all days and shifts, revealed they had all received in-service training on elopement, including signs of exit seeking, the residents in the facility identified as an elopement risk, and what to do if a resident was identified as missing. The ADM was informed on 12/16/14 at 2:30 PM the facility remained out of compliance at a severity level of "potential for more than minimal harm that is not immediate jeopardy" and a scope of "pattern" due to the facility needing to monitor the effectiveness of their Post Action plan. A current census list provided by the DON on 12/03/14 revealed nine residents resided on the facility's secured unit, and two residents were being transitioned off the secured unit.

Based on interview and record review, the facility failed to ensure the necessary care and services were provided to maintain the highest practicable physical, mental and psychological well-being, in accordance with the comprehensive assessment and plan of care was received by one (Resident #1) of seven residents reviewed for change of condition. RN A failed to notify the physician when Resident #1's condition continued to deteriorate. RN A failed to document evidence of continued assessments on Resident #1. RN A failed to carry out the physician's orders [REDACTED]. RN A failed to perform cardiopulmonary resuscitation (CPR) on Resident #1, who was a full code, when the resident was unresponsive and without a BP or heart rate. These failures contributed to the death of Resident #1. These failures could affect the facility's 65 residents, and placed them at risk for not being assessed, having their physicians informed of a continuing and deteriorating change of condition, implementing physician orders [REDACTED]. life. Findings included: Review of the facility's Investigation Report dated [DATE] and written by the DON revealed Resident #1 had "passed and was not given CPR." Per the investigation, an allegation of neglect was identified due to RN A not providing CPR to Resident #1. Resident #1's MDS assessment dated [DATE] reflected the resident, an [AGE] year-old female, was admitted on [DATE]. The resident had no hearing difficulties, spoke distinctly with the ability to express ideas and wants, which were understood, and had clear comprehension of what was said to her. The MDS assessment reflected she was cognitively intact. Resident #1 required the limited assistance of one person for bed mobility, transfers, walking in her room, mobility off her unit, dressing, eating, toilet use and personal hygiene. She was independent, required supervision for mobility off her unit and used a wheelchair. Her balance during transitional movements and walking was not steady and needed staff assistance to stabilize. Resident #1 required the total assistance of one person for bathing. The resident was incontinent of both bladder and bowel. The MDS assessment reflected Resident #1 had [DIAGNOSES REDACTED]. The MDS assessment further reflected Resident #1 had no pain, no shortness of breath and no condition or chronic disease, which could result in a life expectancy of less than six months. Review of Resident #1's Comprehensive Plan of Care originally dated [DATE] and a review date of [DATE], revealed the resident had a history of [REDACTED]. The goal was for the resident to not experience signs/symptoms of an elevated or below normal BP. Approaches included to monitor the resident's BP, increased swelling... and report abnormals to the resident's physician and/or responsible party. Resident #1's progress notes dated [DATE] at 1:19 AM reflected there were Cardiovascular concerns regarding [MEDICAL CONDITION] in her left arm. The resident had clear lung sounds, had an Oxygen saturation level of 98% and had a BP of ,[DATE], pulse of 80 and respirations of 20. Resident #1's progress notes dated [DATE] at 2:21 AM reflected the resident was restless, weak, and had fatigue with labored breathing. The note also reflected Resident #1's vital signs were: BP ,[DATE] (normal is 110-,[DATE] -80), pulse 107 (normal is approximately 72 beats per minute), respirations 20 (normal is 16 - 20), and oxygen saturation level of 93% (normal is 95 - 100%). Resident #1's s skin was warm and dry to touch, and the head of the bed was lowered to a comfortable position. Interview on [DATE] at 10:58 AM with RN A revealed he was the charge nurse for the facility's C, D, and E halls on [DATE]. RN A stated the facility was short of staff on the night of [DATE], and CNA B was scheduled to work on C, D and E halls. RN A stated he had CNA B work on D hall, which was the heaviest hall, and he worked on C and E halls as "a CNA" and nurse. RN A stated the census on those halls was 45 to 80 residents. During the same interview, RN A stated Resident #1 was on C hall. RN A stated Resident #1 was making noises, and he went into her room. RN A told the surveyor Resident #1 asked him, "Can you turn me?" RN A stated he turned Resident #1 toward the window and elevated her head. RN A stated Resident #1 was then quiet. RN A stated Resident #1 was making noise, again, and he went back to her room. The RN stated Resident #1 did not look good, but he could not remember what the time was. RN A stated Resident #1 appeared weak, and he took her vital signs. RN A stated the top number of Resident #1's BP was 59, and he could not remember the bottom reading. Her heart rate was 115, and her blood sugar was 114. RN A stated he called the doctor, and the NP answered the call at 2:00 AM. RN A stated he told the nurse practitioner Resident #1 had a change of condition. RN A stated the nurse practitioner ordered Normal Saline at 180 mL per hour via the intravenous route at 2:30 AM. RN A stated he went around looking for IV poles to transfuse the Normal Saline in the facility. RN A stated he found the IV pole in the soiled linen room at 3:00 AM. RN A stated he wiped down the pole and brought it into Resident #1's room. RN A stated he inserted the peripheral IV site on Resident #1's right arm and started the IV solution. RN A stated Resident #1 was moaning and stated, "Help me." RN A stated he lowered Resident #1's head for blood to flow into her brain since her blood pressure was low. RN A stated he checked on Resident #1 at 3:50 AM and she was sleeping. RN A stated he went back to Resident #1's room and noticed her IV was not running, the pump was beeping. RN A stated he attempted to arouse Resident #1 and the resident was not responding. RN A stated he turned on the call light for assistance and no one came. RN A stated CNA B was the only staff on the hall, who could have helped him. CNA B was on a different hall. RN A was queried why he did not do CPR and he replied he was not sure if Resident #1 was a full code or a Do Not Resuscitate. RN A was asked why he did not check if Resident #1 was a full code. RN A replied he did not know where to check on the computer for a resident's code. RN A stated he was not trained on the way to find the resident's code on the computer. RN A was queried why he did not call for help. RN A stated he did not want to leave the resident by herself. RN A stated, " Now you are asking me. I feel bad. What will happen to me?" RN A was queried why he did not reassess the resident and check vital signs after the infusion. RN A stated he was giving the IV infusion time to run in for a while before he reassessed the resident. RN A stated he rechecked the resident's blood pressure, but he could not remember the time, and the top number was 70 and could not remember the bottom reading. RN A stated the BP was still low. RN A was queried why he did not call the physician again. RN A stated, "It did not cross my mind, she was going to die." RN A stated at 6:00 AM, when he was still stimulating Resident #1, the two morning nurses came in and they were LVN D and LVN E. RN A stated he and LVN E and D wheeled Resident #1 to an empty room because they did not want Resident #1's roommate to know what was going on. RN A stated LVN D and LVN E did their own assessment and found the resident was dead. RN A stated at 6:05 AM, he called the physician and the nurse practitioner answered, and he told her Resident #1 died . RN A stated the nurse practitioner stated she would notify the physician. Review of Resident #1's physician's orders [REDACTED]. Resident #1's physician telephone order dated [DATE] at 6:00 AM reflected RN A was to pronounce Resident #1 dead and release the body to a mortuary of the family's choice. Included with the Investigation Report (dated [DATE]) was an interview with RN A, which was conducted by Nurse Consultant G. RN A stated he heard Resident #1 yelling and went into her room to see what was wrong. RN A said the resident told him she was uncomfortable. RN A said Resident #1 was very anxious and restless and requested the RN to turn her, which he did. When asked if it was normal for Resident #1 to yell, be anxious and restless, why was there no assessment, RN A stated, "It is unusual for her to be yelling and be restless, but I thought at the time that she was just uncomfortable and needed to be turned." When Nurse Consultant G asked if the resident remained quiet, RN A stated Resident #1 started yelling out again at around 2:00 AM. When asked what he did, he stated he took her vital signs, and her BP was low and heart rate was high. RN A stated he figured the resident was dehydrated, called the physician and the PA called back and gave orders for IV fluids and labs to be drawn. When RN A was asked where the [DIAGNOSES REDACTED]. When asked if he was aware he could not make diagnoses, he stated he knew that. Nurse Consultant G asked when the IV was started on Resident #1, and RN A stated it was around 2:00 AM. When asked if the IV was patent (not clogged), RN A said he saw the IV infusing and the pump would have alarmed to let him know if it was not infusing. When asked if he rechecked the resident's vital signs, RN A stated he did, but they were the same so he did not chart them. RN Consultant spoke to RN A, "So you had a resident whose blood pressure was abnormal causing you to have to start fluids, and you did not think it was important to document the vital signs follow(ing) the intervention (of starting IV fluid) to reassess the effectiveness of the treatment," RN A responded, "No, I didn't think it was important. The vital signs were the same." When RN A was asked if he had any trouble starting the IV, the RN admitted he had "some." When questioned about his documentation regarding starting the IV without difficulty, RN stated, "Well I had a hard time finding a vein and I spent a while looking for a spot to stick her. I had to go downstairs to get the pump and supplies for the IV." He was questioned again about the start time of the IV and RN A admitted it may have been 3:20 AM or later. When asked about the entry documented at 5:45 AM, he said it was the time he "found the resident dead." RN A stated he shook the resident, but she did not respond. When he checked for a pulse and respirations, there were none. RN A said that was when he called the PA. He said he did not check Resident #1's chart for her code status. RN A said he did not realize the resident's code status until after he received orders to pronounce the resident (dead). A written statement dated [DATE] from RN A reflected Resident #1 was doing fine until after 1:00 Am. He repositioned the resident and wrote Resident # became "restless... carried on, and showed, elevated heart rate, and low blood pressure." RN A wrote he got an order from the NP to start and IV, which he "started immediately." At 4:00 AM, he checked the resident and found the IV patent. At 5:45 AM, he found Resident #1 with no pulse, (no) chest rise and fall... Try to stimulated the patient with no success." The DON documented on the Investigation Report CNA F had reported when she went back to Resident #1's room at 4:45 AM, RN A was still trying to start Resident #1's IV. CNA F stated she asked RN A if he was going to send Resident #1 to the hospital, and he said, "No. I think she is dehydrated." Interview on [DATE] at 1:28 PM with the DON revealed RN A was having problems starting IV infusions. The DON stated RN A had gone through the IV classes, and the DON had performed the check-off skill for starting IVs on RN A. The DON was queried why RN A did not start Resident #1's IV fluid in a timely manner. The DON replied, "You are talking about IV infusion. Why did he not perform CPR on ____ (Resident #1)?" Interview on [DATE] at 1:00 PM with the Administrator revealed when he interviewed RN A concerning why he did not perform CPR on Resident #1, RN A gave conflicting stories. The Administrator stated, "How can ___ (LVN A) leave me and the DON with a deficiency on quality of care?" Interview on [DATE] at 9:55 AM with CNA B revealed CNA F was working upstairs by herself. CNA B stated she went upstairs to help CNA F. CNA B stated Resident #1 turned her call light on. CNA B stated she and CNA F heard a resident moaning. CNA B stated she and CNA F went from room to room to find out which resident was moaning. CNA B stated when they went into Resident #1's room, they noticed she was the one moaning and Resident #1 said, "Help." Both CNAs repositioned the resident, and it did not help. CNA B stated Resident #1's eyes were rolling around, and the resident appeared to be in distress. CNA B stated CNA F called the charge nurse, RN A. CNA B stated RN A brought the blood pressure machine and checked Resident #1's BP. CNA B stated Resident #1's body was cold like ice, but the resident was still talking. CNA B stated the last time she saw Resident #1 alive was between 3:00 AM to 4:00 AM. CNA B stated she turned Resident #1's light off when she finished repositioning her. CNA B stated she left Resident #1's room to answer other resident's call lights. CNA B said RN A was gathering supplies to start an IV infusion. CNA B stated RN A said Resident #1 was dehydrated. Review of an undated witness statement written by LVN C revealed when she reported to work at 6:08 AM, RN A informed her Resident #1 was dead. The note reflected RN A stated CNA B saw Resident #1 alive at 4:00 AM, so the resident died after 4:00 AM. LVN C's witness statement when she went into Resident #1's room, the bag of Normal Saline, which was to be given IV, was full. RN A was asked by LVN C why the bag of Normal Saline was full. RN A replied, "I got an order at midnight for IV fluids because her BP was low." When LVN C stated the bag of IV fluids looked full, RN A stated, "I was pushing the fluids as fast as I could, it was just too late...." LVN C stated when they moved Resident #1 to a private room, her body was cool, and her arms were stiff and contracted to her chest. LVN C further wrote two CNAs started CPR on Resident #1 at 6:08 AM when they came in and saw Resident #1 was dead, but it was too late. On [DATE], the facility provided an in-service to staff on Advance Directives (decisions made by the resident and/or family/ guardian whether or not to conduct CPR or life-saving measures). The facility had a total of 16 residents with a code status of DNR and the remaining 49 Residents were full code. The facility's current policy on Cardiopulmonary Resuscitation (CPR) and Basic Life Support (BLS) reflected, "If an individual (Resident, visitor, or staff) is found unresponsive and not breathing normally, a licensed staff person who is certified in CPR/BLS shall initiate CPR unless it is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and all external defibrillation for the individual." The facility's current policy and procedure on acute condition changes: Monitoring and follow-up reflected the following, "The staff will monitor and document the Resident's progress and responses to treatment and the physician will adjust treatment accordingly." The facility's Resident List Report dated [DATE] reflected a total census of 65 residents.

Based on interview and record review, it was determined the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident#1) of nine residents reviewed for transfers with a Hoyer lift. CNA A transferred Resident #1 via the Hoyer lift by herself instead of with assistance. As a result, Resident #1 sustained a fractured hip. This failure could affect the facility's 58 residents, who required staff assistance with transfers, and placed them at risk for being transferred incorrectly resulting in the potential for resident falls, injuries, lacerations, bruises, fractures, discomfort, pain, and/or mental anguish at the thought of having to be transferred. Findings included: The face sheet dated 04/09/12 reflected Resident #1, a [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #18's quarterly MDS assessment dated [DATE] revealed the resident was unable to walk and was totally dependent on two plus staff for transfers. Review of the facility's Investigation Report dated 04/04/12 reflected "On 04/03/12 resident was up in the chair before breakfast. Hospice aid and our CNA went in to pull resident up in wheelchair, resident verbalized to aids that her left leg was hurting. Charge nurse and nurse manager were notified promptly. Resident was placed back in the bed immediately. Doctor and family notified. New orders for x-ray received. Pain was well controlled. On 04/04/12 at 08:00 (8:00 AM) received reports of x-rays with results of acute fracture doctor notified, resident was transferred to ___ (Hospital) at 8:45 (AM)." Resident #1's x-ray report dated 04/03/12 reflected "Left femur: Acute appearing impacted supracondylar fracture." Review of the facility's amended Provider Investigation Report dated 04/19/12 revealed a Witness Statement from LVN B, dated 04/18/12. LVN B stated Resident #1 complained of leg pain, but "she always said her legs hurt. I asked my CNA (CNA A) how did she (Resident #1) get up, and she said I used a Hoyer (lift). She (CNA A) said I know how to use the Hoyer (lift). I told the CNA you have to use two people to use a Hoyer (lift). That is corporate policy. The CNA said I have more people to get up. That was the first time the CNA had worked the hall. She did not know the residents but was just trying to get as many patients up as she could to help day shift out." Interview with CNA A on 04/19/12 at 10:22 AM revealed the CNA had been employed at the facility for only a week at the time of the accident with Resident #1. CNA A stated she did not receive any training on the use of the Hoyer lift at the facility. CNA A stated the morning of the incident (04/03/12) "someone" told her to get Resident #1 up. CNA A stated, "I cannot remember who. I got the Hoyer (lift) and transferred her with someone. I don't know who helped me. It was the first time I saw her, and I never saw her again." Review of the facility's staffing sheet dated 04/02/12 - 04/03/12 revealed there was only one CNA working the hall where Resident #1 resided on the 6 PM - 6 AM shift, and it was CNA A. Interview with Resident #1's family member on 04/18/12 at 10:10 AM revealed Resident #1 had been bed-bound for about four weeks. Resident #1's family member stated he/she had been told in a telephone conversation with the facility's former DON on 04/03/12, Resident #1 was transferred from the bed to her wheelchair by one CNA (CNA A) using a hoyer lift. Resident #1's family member stated, "According to ___ (the former DON), the CNA heard a 'snap' when Resident #1 was placed in the wheelchair." In an interview on 04/18/12 at 12:35 PM, the facility's Nurse Consultant stated, "On April 4th (2012) in morning meeting ____ (Resident #1's) fracture came up. The previous DON did not think we needed to report it. I told her we needed to turn in a report to state. It likes like an aide moved her (Resident #1) by herself instead of doing a two-person assist." In an interview on 04/19/12 at 10:45 AM, the facility's Adm stated, "We have talked to several CNAs and nurses and ____ (Resident #1) was moved with a Hoyer (lift) by one CNA (CNA A). We have interviewed the CNA, and she said there were two CNAs but we interviewed the nurse who worked that night, and she told us the CNA told her she moved ____ (Resident #1) by herself with a Hoyer (lift). I trust the nurse's statement. We have suspended the CNA pending our re-investigation. I don't think the facility had done a lot of training or inservicing prior to my arrival but I have never worked in a facility where one person could use a Hoyer (lift) alone." In an interview on 04/18/12 at 12:45 PM, NP C stated Resident #1 had severe Osteoporosis. He stated transferring the resident incorrectly could easily cause a fracture. In an interview on 04/19/12 at 10:00 AM, CNA D stated she had never received an in-service on how to operate the Hoyer lift but she knew there should always be two people operating the Hoyer lift. In an interview on 04/19/12 at 10:30 AM, CNA E stated she received training on how to use the Hoyer lift at hire, in September 2011. She stated there should always be two people operating the Hoyer lift. In an interview on 04/19/12 at 10:40 AM, CNA F stated she had received no training on the Hoyer lift at this facility but she knew there should always be two people operating the Hoyer lift. In an interview on 04/19/12 at 11:00 AM, CNA G stated she had inservicing on transfers the previous week. She stated prior to that inservice she had received no training on transfers or using the Hoyer lift. She stated she knew there should always be two people operating the Hoyer lift. Review of the Ultralift Electric Lifter User Manual (undated) provided by the facility on 04/19/12 reflected the following Operating Skills and Training Instructions: * Operators need a working knowledge of resident-handling procedures. * Follow the training program designed by your training officer. * Test each trainee's understanding of the lift. Safety Information: * Untrained operators can cause injury or be injured. Permit only trained personnel to operate the lift. The Resident Census and Conditions of Residents (CMS Form 672) dated 04/18/12 and signed by the DON reflected there were 58 residents who required assistance or were totally dependent on staff for transfers. On 04/18/12 at approximately 11:45 AM, the DON informed the surveyor there were nine residents in the facility who were transferred using a Hoyer lift.