Every finding on record at Lake Mariam Health and Rehabilitation Center

Based on record reviews and interviews, the facility failed to refund two (Residents #3 and #9) of three sampled residents within thirty days after discharge. Findings included: An interview was conducted with Resident #3's representative (RR) on 04/29/2026 at 9:22 a.m. RR stated not receiving Resident #3's refund from the facility. Review of Resident #3's medical record showed Resident #3 was discharged on 08/10/2025 at 5:55 p.m. to a hospital and passed away on 09/01/2025. Resident #3 was admitted to the facility on [DATE]. Review of Resident #3's financial files transaction report, dated May 1, 2025 to March 31, 2026 showed a total due from patient liability a credit of $620.29. Meaning the Resident #3 was due a refund from moneys paid. Review of Resident #9's medical record showed Resident #9 admitted to the facility on [DATE] and passed away on 08/20/2026 at 12:20 p.m. Review of Resident #9's financial file transaction report, dated July 1, 2025 to March 31, 2026 showed a total due from patient liability a credit of $804.81. Meaning the Resident #9 was due a refund from moneys paid. During an interview on 04/29/2026 at 12:11 p.m. with the Business Office Manager (BOM) and Nursing Home Administrator (NHA) the BOM stated that Resident #9 requested a refund. Resident #9's request was sent to the accounts payable office in their corporate office on 3/30/2026, for the amount of $804.80. The BOM confirmed the refund has not been sent to the resident. The BOM and NHA stated that Resident #3 refund has not been issued. The NHA stated that Resident #9 and Resident #3 have not been issued a refund and both residents have exceeded 30 days post discharge.A review of the facility's Refund of Overpayments Policy not dated revealed:-Purpose: To ensure refund of overpayments are made consistent with applicable legal requirements and standards of practice.-Policy: Personnel will promptly refund to any private payor any overpayment received. Any monies on deposit with the facility shall be refunded upon the appropriate request or the death of the resident.-Procedure: . 3. As soon as it is determined that the overpayment exists, a refund to the appropriate payor should be completed as soon as possible but not later than 60 days. 4. If an electronic adjustment can be completed, it should be completed as soon as possible but not later than 30 days. Refunds Due Residents . within thirty days of the death of a resident, the personal funds . will be made available to the resident's representative. 8. As soon as it is determined that the overpayment exists, a refund to the appropriate payor should be completed as soon as possible but not later than 60 days.

Based on interviews and record reviews, the facility failed 1) to report abnormal radiology results to the provider and complete an assessment and change in condition for a resident with respiratory distress for one resident (#7) out of six residents sampled, 2) to ensure laboratory orders were entered in the electronic laboratory (lab) portal and completed as ordered for two residents (#7, #1) out of six residents sampled and 3) to ensure timely administration of an antibiotic for one resident (#1) out of three residents sampled. Resident #7's laboratory orders were not completed as ordered, the abnormal radiology results were not reported to the doctor, and an assessment and change in condition were not completed and Resident #7 suffered a cardiac arrest. These failures created a situation that resulted in a worsened condition and the likelihood for serious injury and/or death to residents and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the scope and severity was reduced to a D after verification of removal of immediate jeopardy.Cross reference F773.Findings included: 1.An interview was conducted on [DATE] at 3:53 p.m. with Staff M, Certified Nursing Assistant (CNA). Staff M said she knew Resident #7 very well. She said on her shift from 11:00 p.m. on [DATE] through 7:00 a.m. on [DATE] Resident #7 was not herself. Staff M said she had helped the resident to bed after she was up walking around and she knew the resident was not right. Staff M said she kept a close eye on the resident. She said around 4:00 a.m. she saw Resident #7 sitting on the side of her bed gasping for air. Staff M said she told Staff I, Licensed Practical Nurse (LPN) something was wrong with the resident, and she was gasping for air. Staff M said Staff I told her the resident probably just had the hiccups. Staff M said the nurse then went to Resident #7's room and tried to take vital signs but was unable to get a pulse or oxygen saturation (O2 sats) reading due to the resident's hands being too cold. Staff M said she was told to warm up with resident's hands and they would try again. Staff M said she told the nurse she thought Resident #7 needed to be sent to the hospital, but nothing else was done for Resident #7. Staff M said when she left at the end of her shift that morning ([DATE]), she told a CNA who was working the day shift to keep an eye on Resident #7 because she was not doing good. Staff M said when she returned in the evening at approximately 10:45 p.m. on [DATE] for her next shift that CNA told her Resident #7 was not the resident they knew. Staff M said she went to Resident #7's room around 11:00 p.m. to check on her. She said Resident #7 was lying down and not responding. She said the resident was breathing and had a faint pulse but was unresponsive. Staff M said she yelled out for a nurse and Staff I, LPN was the only nurse on the unit, so she came down to help. Staff M said Staff I, LPN tried to get vital signs and could not get any readings. Staff M said Resident #7 did not have any oxygen in place at the time and the oxygen concentrator in her room was not even plugged in. Staff M said she alerted Staff I, LPN to the resident's tongue hanging out of her mouth. Staff M said she got oxygen turned on and placed on the resident and Staff I, LPN called a code. Staff M said the resident stopped breathing and lost a pulse and staff performed CPR until Emergency Medical Services (EMS) arrived. Review of admission Record showed Resident #7 was admitted on [DATE] with diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, gastro-esophageal reflux disease without esophagitis, essential (primary) hypertension, and generalized anxiety disorder. Review of Resident #7's Quarterly Minimum Data Set (MDS), dated [DATE], Section C, Cognitive Patterns, showed a Brief Interview for Mental Status (BIMS) could not be conducted due to the resident rarely/never being understood. Review of Resident #7's Care plan showed a focus area of risk for cardiovascular complications related to (r/t) hypertension, dated [DATE]. Interventions included monitor for shortness of breath (SOB), chest pain, bradycardia, hypotension, tachycardia, hypertension, increased edema, weight gain, etc. report any significant abnormalities to the medical doctor. Review of Resident #7's physician orders showed: -O2 (oxygen) via nasal cannula at 2 Liters (L) for SOB (shortness of breath). Dated [DATE]. -STAT (immediate) Complete blood count (CBC) (a common blood test that measures red/white blood cells, hemoglobin, hematocrit, and platelets to evaluate overall health, diagnose symptoms and detect infections) and comprehensive metabolic panel (CMP) (a blood test that measures key indicators of kidney and liver health, electrolytes, blood sugar, and protein levels). Dated [DATE] at 11:13 a.m.-STAT chest x-ray 2 view for SOB. Dated [DATE]. -Ipratropium-Albuterol Solution 0.5-2.5 (3) milligram (mg)/3 milliliter (ml). 3 ml inhale orally via nebulizer every 6 hours every 5 days for SOB. Dated [DATE]. -Full Code. Dated [DATE]. An interview was conducted on [DATE] at 12:43 p.m. with Staff I, LPN. Staff I said Staff M, CNA did speak to her on the overnight shift from 2/15-[DATE] about Resident #7 not breathing normal. She said she went to the resident's room looked at her and thought she was fine. Staff I said she thought the resident just had the hiccups or something. Staff I said she tried to take the resident's vital signs, but her hands were cold so she could not get a reading. She said she just kept an eye on the resident. Review of Resident #7's medical records did not show documentation of an assessment, change in condition or progress note related to the breathing concerns brought to Staff I, LPN's attention by Staff M, CNA. Review of Resident #7's progress notes showed: -[DATE] 12:00 p.m. Narrative Note (General) Late Entry: Created [DATE] 3:03 p.m. by Staff K, LPNResident is showing signs of shortness of breath, slightly labor [EH1.1][sic] breathing, oxygen reading at seventy three on room air. MD [Medical Doctor] notified ordered oxygen at two liters, stat chest x ray, stat cmp, neb [nebulizer] tx [treatment] and cbc and UA/CS [urinalysis/culture and sensitivity]. Guardian called voicemail left. Resident is in bed at this time with oxygen at 2L. The resident has to be redirected to keep nasal cannula in place. Bed is in the lowest position and call light is within reach.An interview was conducted on [DATE] at 2:36 p.m. with Staff K, LPN. Staff K said she took care of Resident #7 during the 7:00 a.m. to 3:00 p.m. shift on [DATE]. She said Resident #7 seemed okay other than her breathing being a little off if you really looked at her. She said the resident had light labored breathing and a runny nose. Staff K said she knew the flu or something had been going around the facility, so she checked her oxygen saturation, and it was low. Staff K said she texted Resident #7's primary care provider (PCP)/Medical Director letting him know the resident's oxygen saturation was 88% and asked for oxygen orders. Staff K said she did not get a response from the PCP, so she went ahead and placed oxygen on the resident. She said not long after that the PCP's Advanced Registered Nurse Practitioner (ARNP) came in and ordered STAT labs and x-ray. Staff K said STAT labs had to be put into a lab website and Staff P, Registered Nurse RN/Unit Manager (UM) put the labs in the site for her. Staff K said she administered the breathing treatments the ARNP ordered for Resident #7 and had to stand and watch her because she would not keep the mask on and would not keep her nasal cannula on either. Staff K said she honestly thought Resident #7 had a cold or whatever else was going around the facility.Review of Resident #7's medical records did not show any lab results from [DATE]. An interview was conducted on [DATE] at 1:00 p.m. with the laboratory company for the facility. The lab looked up Resident #7's record and said they did not show a phone call or requisition ticket entered for STAT labs on [DATE]. They said no labs were drawn for Resident #7 on [DATE]. The lab representative said if STAT labs are ordered the nurse had to go to their website and create a ticket with the lab requisition and mark that they were ordered STAT. They said the ticket being created triggered the STAT lab process. The lab said STAT labs are drawn between 75-90 minutes after the ticket is created and resulted within four hours. Review of Resident #7's chest x-ray reported to the facility on [DATE] at 2:37 p.m. showed: FINDINGS:The heart is enlarged.Mild indistinct pulmonary vascularity with peribranchial cuffing.There are no focal infiltrates. Slightly elevated right dome of diaphragm again noted.No evidence of pleural effusions.No evidence of the pneumothorax.No acute osseous findings.IMPRESSION:Cardiomegaly and suggestion of mild pulmonary venous hypertension. No focal infiltrates. Slightly elevated right dome of diaphragm redemonstrated. No active pulmonary tuberculosis.There is interval worsening of pulmonary congestion noted.Review of Resident #7's medical records did not show any documentation a provider was notified of the chest x-ray results on [DATE] that were completed at 2:37 p.m. Review of Resident #7's progress notes showed: [DATE] 12:41 a.m. Narrative Note (General) by Staff I, LPN This writer was just on coming for night shift and performing walking round. oncoming CNA called for a nurse to [Resident #7's room]. Upon arrival to the room, the resident was observed laying on her bed. she was very pale and had gasping breaths. This writer obtained vitals BP [blood pressure] 96/60, p [pulse] 58, RR [respiratory rate] 4-6 bpm, O2 sat 73% on O2@2l. The resident's eyes then closed and respirations ceased. This writer performed sternal rub with no response from resident. lost pulse and O2 sat. Sent a CNA to check code status. Was advised resident is full code. This writer called code blue at [11:09 p.m.]. this writer initiated chest compressions and CPR at [11:10 p.m.]. this writer delegated code notes to CNA. Other staff arrived. Another nurse called 911 at [11:11 p.m.]. other staff arrived to assist this writer and cna [sic] with break from CPR. [11:18 p.m.] CPR paused to check for vitals resident had no pulse and no respirations. CPR resumed and continued with the dispatcher on the phone guiding until EMS arrived at [11:20 p.m.]. 2 nurses and 3 CNA performed CPR in Rotations until EMS came and took over the code. Resident transferred to stretcher and taken to [Hospital] on stretcher and with EMS via ambulance at [11:33 p.m.]. Call placed to resident guardian and message left of resident transfer to hospital at [11:46 p.m.]. MD notified of code blue and transfer to [Hospital] at [11:51 p.m.].An interview was conducted on [DATE] at 1:14 p.m. with Staff I, LPN. Staff I said she came on shift on [DATE] and counted medications with the off-going nurse. She said she got there around 10:45 p.m. and she saw Staff L, LPN, the off-going nurse for Resident #7. She said she started her room rounds and was about halfway through when she heard Staff M, CNA yelling nurse. Staff I said she was the only nurse on the unit at the time because Staff L had left and her replacement wasn't there yet and when she got to Resident #7's room and the resident did not look good. She said the resident did not have oxygen on, so staff quickly put the resident's nasal cannula on and checked her O2 sats. She said Resident #7's oxygen saturation was 73%. Staff I said the resident kept trying to pull the nasal cannula off. She said then the residents heart rate and oxygen dropped to 0 and the resident went limp and her eyes closed. Staff I said she started CPR. She said CPR continued until EMS arrived. Staff I said she did not hear there was any issue with the resident prior to the CNA yelling for the nurse and her going down to check on the resident and do CPR. An interview was conducted on [DATE] 1:27 p.m. with the PCP/Medical Director. He said he was not notified of Resident #7's chest x-ray result on [DATE]. After review of results he said he would have given treatment orders immediately if he had been notified. He was unaware the STAT labs were not completed for Resident #7 and said they should have been. The PCP/Medical Director said to confirm with his partner physician to ensure she had not been notified of the results as one of the two of them should have been.An interview was conducted on [DATE] at 1:45 p.m. with the PCP/Medical Director's partner physician. She said she was not notified of the chest x-ray results for Resident #7 on [DATE]. After reading the results she said a provider should have been notified and treatment put in place.An interview was conducted on [DATE] at 3:10 p.m. with the PCP/Medical Director's ARNP. The ARNP said she ordered the STAT labs and chest x-ray for Resident #7 on [DATE], but she was not notified of the results, and she was not aware the resident's STAT labs were not completed as ordered. The ARNP said her expectation is for orders to be completed and the nurse to call with results when they come in. The ARNP reviewed Resident #7's chest x-ray results and said if she had seen those, she would have given new treatment orders for the resident. An interview was conducted on [DATE] at 2:07 p.m. with the Director of Nursing. (DON). She said if a CNA tells a nurse a resident is not breathing well and is not herself, she expected the nurse to do a full assessment including listening to lungs, visual assessment, check vitals, check oxygen level, and put oxygen on the resident. She said having cold hands wouldn't matter if the nurse needed to find a way to get vitals or call 911. She then said they should document the assessment and notification to the provider and family. The DON said for the lab process the nurse should put orders in the computer, then go to the lab portal and enter the orders in the chat box for STAT orders. She said it is a new process to the nurses, and they don't seem to be doing it right. She said as soon as the labs or imaging results are back the nurse should notify the provider and document the notification in the medical record. The DON reviewed Resident #7's record and confirmed there was no documentation of notification of the STAT chest x-ray results and no lab results on [DATE]. 2.An interview was conducted on [DATE] at 3:27 p.m. with the Resident Representative (RR) for Resident #1. The RR said the week before the resident went to the hospital, he had a chest cold and on Monday [DATE] she was told by a nurse Resident #1 had run a fever on Saturday [DATE] and Sunday [DATE]. The RR said she was not notified the resident had a change in condition over the weekend. She said when she came to the facility on Monday morning, [DATE], Resident #1 was lethargic, nonresponsive, very clammy, gasping for air, and had mottling (patchy, discoloration of the skin caused by uneven blood circulation or constricted vessels) from the feet up to his mid shin. The RR said she told staff she wanted the resident sent out to the hospital immediately. An interview was conducted on [DATE] at 2:35 p.m. with Staff E, Certified Nursing Assistant (CNA). Staff E said Resident #1 came down with a cold on Thursday [DATE]. Then on Saturday [DATE] and Sunday [DATE] was worse; he was sick. She said the resident was on oxygen all weekend and was running a fever. Staff E said she was close with the resident and was able to get him to eat and drink. She said he was not drinking as much as usual, but she got him to drink a full cup of water on Sunday. Staff E said she came in Monday [DATE] at 7:00 a.m. and Resident #1 was even worse. She said the nurse that had the resident from [EH2.1]11:00 p.m. to 7:00 a.m. told her Resident #1 was probably going out to the hospital. Staff E said when the RR arrived at approximately 8:00 a.m. she said she wanted the resident sent out immediately. Staff E said Resident #1 was clammy and was working harder to breathe, but he was not gasping for air. Staff E said after the nurse administered medication, Resident #1's temperature was 101.7 and he felt warm but was not burning up hot. She said the resident was lethargic and more peaceful but was still responding to her. Review of admission Records showed Resident #1 was admitted on [DATE] with diagnoses including aphasia, apraxia, hemiplegia/hemiparesis affecting right side from cerebrovascular disease, and dementia. Review of Resident #1's Quarterly MDS dated [DATE], Section C, Cognitive Patterns, showed a BIMS couldn't be conducted due to the resident being rarely/never understood. Review of Resident #1's medical records revealed a Determination of Incapacity signed by a physician, dated [DATE]. Review of Resident #1's orders showed: -O2 at 3 L Start date [DATE]-Ipratropium-Albuterol 0.5-2.5 mg/2 ml solution. 1 vial inhale orally every 4 hours as needed for shortness of breath. Start date [DATE]-Ceftriaxone Sodium Solution Reconstituted 1 gram (g). Inject 1 gram intramuscularly (IM) one time a day for infection for 3 days. Start date [DATE]. -CBC and CMP Every night shift for labs for 1 day. Start date [DATE]. -STAT Chest X-ray 2 view r/t congestion portable due to (d/t) generalized weakness. Start date [DATE]. -Flu swab, covid swab, RSV swab, CBC, CMP one time only for SOB, respiratory. Start dated [DATE]. Review of Resident #1's February 2026 Medication Administration Record (MAR) showed Ceftriaxone was not administered on [DATE] and the order was put in the computer to start on [DATE]. On [DATE] Ceftriaxone was documented as refused. There was no additional documentation a provider or RR was called about the medication refusal. Review of Resident #1's chest x-ray on [DATE] showed:Findings: Comparison with prior study February 2, 2026Linear atelectasis seen bilaterally. Mild elevation right hemidiaphragm. No focal infiltrate or evolving mass. Mild CHF [congestive heart failure] is noted.The costophrenic angles are sharp, without evidence of effusion.Heart size is mildly enlarged, and mediastinal contours are within normal limits. There is no osseous abnormality identified.IMPRESSION:There is mild CHF again seen. Follow-up chest x-ray is needed.There is no documentation the provider was notified of the STAT chest x-ray results on [DATE]. Review of Resident #1's progress notes showed: -[DATE] 10:03 p.m. CXR [chest x-ray] results sent to MD, gave new orders for BNP [B-type natriuretic peptide, a test to detect or monitor heart failure], order placed in [electronic charting system].-[DATE] 1:57 a.m. Resident presented with fever of 101.2 and SOB with labored breathing MD notified new orders received to obtain labs, flu, covid [sic], rsv [sic] [respiratory syncytial virus-a virus that affects the lungs] testing, start levsin, repeat chest x-ray and duo neb [Ipratropium bromide/albuterol sulfate nebulizer] prn [as needed] Tylenol prn HOB [head of bed] elevated at 90 digress [sic]. POA [power of attorney] made aware of situation.-[DATE] 4:38 a.m. Change In Condition: Fever, shortness of breath. BP 113/64, pulse 109, respirations 24, temperature 101.2, O2 sats 89%, blood glucose 367. Respiratory status evaluation: shortness of breath, labored or rapid breathing. Cardiovascular status evaluation: new irregular pulse. Review of Resident #1's Medication Administration Record (MAR) and administration notes showed: -Acetaminophen 650 mg was administered for fever on [DATE] at 5:33 p.m. documented as effective with a temperature of 99 at 6:36 p.m. It was administered again on [DATE] at 1:47 a.m. for a temperature of 101.2 and was documented as ineffective. -Albuterol Sulfate nebulizer 0.63 mg/3ml was documented as given on [DATE] at 12:12 a.m. and again on [DATE] at 1:46 a.m. -Ipratropium-Albuterol solution 0.5-2.5 mg/3 ml was documented as given [DATE] at 12:11 a.m., 4:14 a.m., and 5:32 p.m. Review of Resident #1's lab results showed a CBC, CMP, flu and COVID test was collected on [DATE] at 5:52 a.m. Results showed: -Hemoglobin (Hg) high at 18.6 with a reference (ref) range of 13.8-17.2-Hematocrit (Hct) high at 58.6 with a ref range of 41.0-50.0-Platelet count low at 91 with a ref range of 130-400-Glucose Serum high at 304 with a ref range of 70-105-BUN (blood urea nitrogen) high at 49 with a ref range of 7-25-Creatinine Serum high at 2.33 with a ref range of 0.70-1.30-Sodium Serum CRITICALLY HIGH at 164 with a ref range of 135-145-Flu A positiveAn interview was conducted on [DATE] at 2:30 p.m. with Staff D, LPN. She said she cared for Resident #1 on Saturday [DATE] during the day shift. She said the resident did not look like himself, was not vocal like normal, and had a temperature over 102. Staff D said she contacted Resident #1's PCP/Medical Director on [DATE] at 11:28 a.m. when the resident's fever was 102, his O2 saturation was 89%, and he had crackles in lung sounds. Staff D said the PCP gave orders for oxygen, nebulizer treatments, Ceftriaxone antibiotic injections for 3 days, flu and COVID swabs, stat chest x-ray, stat CMP, and stat CBC. Staff D was observed reading the text messages from her phone. Staff D said at first when Staff H, LPN/Weekend supervisor looked at the texted orders she thought maybe the PCP meant only the chest x-ray was STAT, but Staff D said she told her they were all STAT and Staff H, LPN/Weekend Supervisor put the orders in the computer to help out. Staff D said she did not have access to the electronic medication dispensing machine to access Ceftriaxone to give an immediate dose, but she believed the Staff H, LPN/Weekend supervisor got a dose out of the machine to administer. Staff D said she was new in the facility and did not know who did the flu and COVID swabs or if the lab did those. Staff D said she thought maybe she should have sent Resident #1 out to the hospital on Saturday [DATE] but his oxygen saturation showed improvement when he was put on oxygen. Review of Resident #1's physician orders did not show any orders for flu and COVID swabs on [DATE]. The resident's medical records did not show any progress notes or documentation of Resident #1's change in condition on [DATE]. An interview was conducted on [DATE] at 12:01 p.m. with Staff H, LPN/Weekend Supervisor. Staff H confirmed she worked on Saturday [DATE] day shift. She said she entered STAT orders for chest x-ray, labs, Ceftriaxone, nebulizer treatment, and oxygen at 2 p.m. for Resident #1. She said she knew the chest x-ray was completed but did not recall if the labs were done. Staff H said she did not pull a dose of Ceftriaxone out of the electronic medication dispensing machine and administer to Resident #1, but she thought Staff D, LPN did. An interview was conducted on [DATE] at 9:54 a.m. with the facility's pharmacy. The pharmacy representative said Resident #1 had Ceftriaxone 1 g x 3 doses delivered to the facility on [DATE] at 6:35 a.m. During a follow-up call on [DATE] at 1:23 p.m. they stated Ceftriaxone was not pulled from the facility's electronic medication dispensing machine on [DATE] or [DATE]. Review of Resident #1's physician orders showed a CBC and CMP order was placed on [DATE] at 12:32 p.m. by Staff H, LPN/Weekend Supervisor. The order was placed for routine labs to be completed on [DATE]. The orders did not show a flu or COVID test was ordered until Monday [DATE]. An interview was conducted on [DATE] at 3:01 p.m. with Staff G, LPN. Staff G said she worked from Sunday [DATE] 11:00 p.m. until Monday [DATE] at 7:00 a.m. She said around 11:30 p.m. Resident #1 had more congestion and was warm to touch. She said he was already on oxygen, so she texted the resident's PCP. She said the doctor explained what he had already done and ordered a repeat STAT chest x-ray. Staff G said she noticed Resident #2 had not yet been administered the ordered Ceftriaxone Sodium injection that had been ordered so she administered a dose around 1:00-2:00 a.m. on [DATE]. Staff G said she did not document she had given the medication. Staff G said the resident had a temperature of 101.2 but it went down after getting Acetaminophen. She said Monday morning Resident #1 was moaning and breathing harder. She said she had given report to the oncoming nurse and then she stayed to help get the resident sent out to the hospital. Review of Resident #1's Fire Rescue Division Run Report showed: Unit dispatched [DATE] 9:23 a.m. Arrived at patient 9:33 a.m. Depart [DATE] 9:50 a.m. At hospital [DATE] 9:54 a.m. Chief Complaint: altered mental status barely responsive to painful stimuli found by facility staff coming onto shift no last seen normal. Arrived on scene to find patient lying in bed of nursing home residents reported to have been found during morning checks and have been unresponsive hot to touch patient placed on cardiac monitor noted to have slight response to painful stimuli patient IV access established patient fluid bolus given and patient placed on non-rebreather passive oxygenation began and preparations began for airway management facility provides paperwork including DNR patient determined to be appropriate for non-rebreather per [organization] guidelines. Patient reported to have been given 1g of rocephin prior to EMS activation.Vital Signs9:34 a.m. BP 90/palpHR 72SpO2 86% Resp rate 40Effort RapidGlucose 4089:41 a.m. BP 90/palpHR 143SpO2 88%Resp rate 42Effort Rapid9:34 a.m. 15 liters/minute [LPM] nonrebreather mask. Response: unchanged9:36 a.m. 600 ml normal saline. Response: unchanged9:40 a.m. 20 LPM nonrebreather mask. Response: unchangedReview of Resident #1's hospital record dated, [DATE] showed: Chief Complaint BIBA [brought in by ambulance] from [facility name] for AMS [altered mental status]. Pt [patient]was found unresponsive by staff, and EMS [emergency medical services] was called. Sats [oxygen saturation] in the 70s per EMS PTA [patient transport assistant]. Pt arrives responding to painful stimuli, tachy [tachycardia-rapid heart rate], and febrile. Extensive hx [history]History of Present Illness [AGE] year-old male with significant past medical history including epilepsy, prior CVA [cerebrovascular accident], diabetes, hypertension, obesity, prostate carcinoma, atrial fibrillation, HIT [heparin induced thrombocytopenia], and IVC [inferior vena cava filter] filter placement was found unresponsive at [facility name] with oxygen saturations in the 70s. Patient was transported to the emergency department where he was noted to be febrile with a temperature of 107.4, hypoxic, septic, and in respiratory distress, placed on oxy [oxygen] mask at 15 L. Laboratory values revealed influenza A positive, severe hyponatremia, lactic acidosis, trending troponin, and elevated Pro-Cal [procalcitonin, which indicate a systemic inflammatory response to severe bacterial infection or sepsis]. He was transferred to the critical care unit for management for septic shock and multisystem metabolic derangements. Intensive Care Unit (ICU) notedInfectious:-Sepsis bundle initiated in the emergency department patient was given 1 L LR [lactated ringer's] bolus/50 mL NS [normal saline]-After arriving at the critical care unit patient was given 2 L LR bolus- [Infectious Disease Dr] consulted for infectious disease-Cefepime and vancomycin ordered per infectious disease recommendations-Tamiflu-Monitor for temperature curve, temperature 107.4 on arrival to the unit-Cooling blanket system placedThis patient is critically ill with septic shock requiring multiple vasopressors and acute hypoxic respiratory failure requiring mechanical ventilation requiring ongoing evaluation and management in the intensive care unit.Assessment:Septic shock requiring vasopressor supportAcute hypoxic respiratory failure requiring mechanical ventilationInfluenza A infectionCommunity-acquired pneumoniaSevere hypernatremiaStress hyperglycemia versus uncontrolled diabetesLactic acidosisHistory of atrial fibrillation not on anticoagulationHistory of epilepsyHistory of prostate cancerIVC filter[DATE]: Overnight patient is steadily declining. Patient is in multiorgan failure. [DATE] 2:50 p.m. Time of death. An interview was conducted on [DATE] at 12:54 p.m. with Resident #1's PCP/Medical Director. He said he talked to staff a few times over the weekend about Resident #1. He said on Saturday [DATE] around 12:00 p.m. the nurse called and he gave orders for STAT labs, STAT chest x-ray and breathing treatments. He said he also ordered Ceftriaxone to be administered for three days. The PCP said he did not become aware until later Resident #1's labs did not get entered as STAT labs and were not completed that day. He was also unaware Resident #1 did not receive Ceftriaxone on Saturday [DATE] when it was ordered or on Sunday [DATE] when it was documented as refused. The PCP said he would have expected the antibiotic to have been administered on Saturday [DATE] when it was ordered. He said he did not know if the delay in Resident #1 getting Ceftriaxone would have fixed the issues because the resident probably already had flu and pneumonia, but it could have made it worse. The PCP said as far as the labs not being ordered STAT; the labs did not show the resident was septic, however, with the critically high sodium level he would have definitely given fluids if I had seen those [lab results] on Saturday. The PCP said, any delay in care is not our policy and not acceptable. The PCP said he reviewed the hospital record and saw they diagnosed the resident with pneumonia and sepsis but the labs and imaging in the facility did not show that. He said the labs drawn on [DATE] had a critically high sodium level but, the white blood cells were normal. He said the chest x-ray done on [DATE] showed atelectasis. He said that is like where the small parts of the lungs collapse. He said it can look kind of like bubbles on the x-ray and can hide pneumonia or be mistaken as pneumonia. An interview was conducted on [DATE] at 10:05 a.m. with the Nursing Home Administrator (NHA) and the Director of Nursing (DON). The DON said Resident #1 started coughing and running a fever on Sunday night shift (11:00 p.m. [DATE] through 7:00 a.m. on [DATE]). She said the nurse notified the doctor and he ordered labs and Flu/COVID/RSV panels. The DON said Flu/COVID/RSV panels are ordered when a resident's temperature is over 99.0 Fahrenheit (F). She said she saw Resident #1 when she came in to work the morning on [DATE] and he did not look that bad and his oxygen saturation was fine. She said one CNA was giving him water and another was going to try to feed him. The DON said she got a message from Resident #1's RR that said they wanted him sent to the hospital. The DON said on Saturday [DATE] Resident #1 should have been given Ceftriaxone when it was ordered. She said the nurse tried to give a dose on Sunday [DATE], but the resident refused. The DON said the doctor and RR should have been called when the resident refused the Ceftriaxone on [DATE]. The DON reviewed Resident #1's medical records and confirmed there was no documentation there was notification of the medication refusal to the provider or family. The DON said upon review she found the labs ordered on Saturday for Resident #1; were entered as routine labs, not STAT labs. She said routine labs are not drawn on Sunday morning which would have put them scheduled for Monday morning, [DATE]. The DON confirmed STAT labs can be drawn any day and time. She said the lab usually comes within a couple of hours and has results back in about four hours. The DON read a statement from Staff H, LPN/Weekend Supervisor regarding Resident #1 on Saturday [DATE] that said Resident #1 had audible breathing and congestion; the doctor was called and ordered STAT chest x-ray, STAT labs, and nebulizer treatments. A follow-up interview was conducted on [DATE] at 1:27 p.m. with Resident #7 and Resident #1's PCP/Medical Director. The PCP said he expected labs to be completed as ordered and to be notified of results. When discussing lab concerns related to Residents #7 and Resident #1, the Medical Director said, sounds like a problem with the lab process. He added that the facility started doing education already due to the issues found. Review of a facility in-service education titled Change in Condition: Nu

Based on interviews and record reviews, the facility failed to ensure laboratory orders were entered properly in the electronic medical record and electronic laboratory (lab) portal, for four (#7, #1, #8, #9) out of six residents sampled.Resident #7's labs were not completed as ordered and Resident #7 suffered a cardiac arrest This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and/or death to residents and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the scope and severity was reduced to a D after verification of removal of immediate jeopardy. Cross Reference F684.Findings included: 1.Review of admission Record showed Resident #7 was admitted on [DATE] with diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, gastro-esophageal reflux disease without esophagitis, essential (primary) hypertension, and generalized anxiety disorder. Review of Resident #7's Quarterly Minimum Data Set (MDS), dated [DATE], Section C, Cognitive Patterns, showed a Brief Interview for Mental Status (BIMS) could not be conducted due to the resident rarely/never being understood. Review of Resident #7's Care plan showed a focus area of risk for cardiovascular complications related to (r/t) hypertension, dated [DATE]. Interventions included monitor for shortness of breath (SOB), chest pain, bradycardia, hypotension, tachycardia, hypertension, increased edema, weight gain, etc. report any significant abnormalities to the medical doctor. Review of Resident #7's physician orders showed: -STAT (immediate) Complete blood count (CBC) (a common blood test that measures red/white blood cells, hemoglobin, hematocrit, and platelets to evaluate overall health, diagnose symptoms and detect infections) and comprehensive metabolic panel (CMP) (a blood test that measures key indicators of kidney and liver health, electrolytes, blood sugar, and protein levels). Dated [DATE] at 11:13 a.m.Review of Resident #7's progress notes showed: -[DATE] 12:00 p.m. Narrative Note (General) Late Entry: Created [DATE] 3:03 p.m. by Staff K, LPNResident is showing signs of shortness of breath, slightly labor [sic] breathing, oxygen reading at seventy three on room air. MD [Medical Doctor] notified ordered oxygen at two liters, stat chest x ray, stat cmp, neb [nebulizer] tx [treatment] and cbc and UA/CS [urinalysis/culture and sensitivity]. Guardian called voicemail left. Resident is in bed at this time with oxygen at 2L. The resident has to be redirected to keep nasal cannula in place. Bed is in the lowest position and call light is within reach.An interview was conducted on [DATE] at 2:36 p.m. with Staff K, LPN. Staff K said she took care of Resident #7 during the 7:00 a.m. to 3:00 p.m. shift on [DATE]. Staff K said PCP's Advanced Registered Nurse Practitioner (ARNP) came in and ordered STAT labs and x-ray. Staff K said STAT labs had to be put into a lab website and Staff P, Registered Nurse RN/Unit Manager (UM) put the labs in the site for her. Review of Resident #7's medical records did not show any lab results from [DATE]. An interview was conducted on [DATE] at 1:00 p.m. with the laboratory company for the facility. The lab looked up Resident #7's record and said they did not show a phone call or requisition ticket entered for STAT labs on [DATE]. They said no labs were drawn for Resident #7 on [DATE]. The lab representative said if STAT labs are ordered the nurse had to go to their website and create a ticket with the lab requisition and mark that they were ordered STAT. They said the ticket being created triggered the STAT lab process. The lab said STAT labs are drawn between 75-90 minutes after the ticket is created and resulted within four hours. Review of Resident #7's progress notes showed: [DATE] 12:41 a.m. Narrative Note (General) by Staff I, LPN This writer was just on coming for night shift and performing walking round. oncoming CNA called for a nurse to [Resident #7's room]. Upon arrival to the room, the resident was observed laying on her bed. she was very pale and had gasping breaths. This writer obtained vitals BP [blood pressure] 96/60, p [pulse] 58, RR [respiratory rate] 4-6 bpm, O2 sat 73% on O2@2l. The resident's eyes then closed and respirations ceased. This writer performed sternal rub with no response from resident. lost pulse and O2 sat. Sent a CNA to check code status. Was advised resident is full code. This writer called code blue at [11:09 p.m.]. this writer initiated chest compressions and CPR at [11:10 p.m.]. this writer delegated code notes to CNA. Other staff arrived. Another nurse called 911 at [11:11 p.m.]. other staff arrived to assist this writer and cna [sic] with break from CPR. [11:18 p.m.] CPR paused to check for vitals resident had no pulse and no respirations. CPR resumed and continued with the dispatcher on the phone guiding until EMS arrived at [11:20 p.m.]. 2 nurses and 3 CNA performed CPR in Rotations until EMS came and took over the code. Resident transferred to stretcher and taken to [Hospital] on stretcher and with EMS via ambulance at [11:33 p.m.]. Call placed to resident guardian and message left of resident transfer to hospital at [11:46 p.m.]. MD notified of code blue and transfer to [Hospital] at [11:51 p.m.].An interview was conducted on [DATE] 1:27 p.m. with the PCP/Medical Director. He was unaware the STAT labs were not completed for Resident #7 and said they should have been.An interview was conducted on [DATE] at 3:10 p.m. with the PCP/Medical Director's ARNP. The ARNP said she ordered the STAT labs for Resident #7 on [DATE], but she was not aware the resident's STAT labs were not completed as ordered. The ARNP said her expectation is for orders to be completed and the nurse to call with results when they come in.An interview was conducted on [DATE] at 2:07 p.m. with the Director of Nursing. (DON). The DON said for the lab process the nurse should put orders in the computer, then go to the lab portal and enter the orders in the chat box for STAT orders. She said it is a new process to the nurses, and they don't seem to be doing it right. She said as soon as the labs are back the nurse should notify the provider and document the notification in the medical record. The DON reviewed Resident #7's record and confirmed there was no lab results on [DATE]. 2.Review of admission Records showed Resident #1 was admitted on [DATE] with diagnoses including aphasia, apraxia, hemiplegia/hemiparesis affecting right side from cerebrovascular disease, and dementia. Review of Resident #1's Quarterly MDS dated [DATE], Section C, Cognitive Patterns, showed a BIMS couldn't be conducted due to the resident being rarely/never understood. Review of Resident #1's medical records revealed a Determination of Incapacity signed by a physician, dated [DATE]. Review of Resident #1's orders showed: -CBC and CMP Every night shift for labs for 1 day. Start date [DATE]. -Flu swab, COVID swab, RSV swab, CBC, CMP one time only for SOB, respiratory. Start dated [DATE]. Review of Resident #1's progress notes showed: -[DATE] 1:57 a.m. Resident presented with fever of 101.2 and SOB with labored breathing MD notified new orders received to obtain labs, flu, covid [sic], rsv [sic] [respiratory syncytial virus-a virus that affects the lungs] testing, start levsin, repeat chest x-ray and duo neb [Ipratropium bromide/albuterol sulfate nebulizer] prn [as needed] Tylenol prn HOB [head of bed] elevated at 90 digress [sic]. POA [power of attorney] made aware of situation.-[DATE] 4:38 a.m. Change In Condition: Fever, shortness of breath. BP 113/64, pulse 109, respirations 24, temperature 101.2, O2 sats 89%, blood glucose 367. Respiratory status evaluation: shortness of breath, labored or rapid breathing. Cardiovascular status evaluation: new irregular pulse. Review of Resident #1's lab results showed a CBC, CMP, flu and COVID test was collected on [DATE] at 5:52 a.m. Results showed: -Hemoglobin (Hg) high at 18.6 with a reference (ref) range of 13.8-17.2-Hematocrit (Hct) high at 58.6 with a ref range of 41.0-50.0-Platelet count low at 91 with a ref range of 130-400-Glucose Serum high at 304 with a ref range of 70-105-BUN (blood urea nitrogen) high at 49 with a ref range of 7-25-Creatinine Serum high at 2.33 with a ref range of 0.70-1.30-Sodium Serum CRITICALLY HIGH at 164 with a ref range of 135-145-Flu A positiveAn interview was conducted on [DATE] at 2:30 p.m. with Staff D, LPN. She said she cared for Resident #1 on Saturday [DATE] during the day shift. She said the resident did not look like himself, was not vocal like normal, and had a temperature over 102. Staff D said she contacted Resident #1's PCP/Medical Director on [DATE] at 11:28 a.m. when the resident's fever was 102, his O2 saturation was 89%, and he had crackles in lung sounds. Staff D said the PCP gave orders for oxygen, nebulizer treatments, Ceftriaxone antibiotic injections for 3 days, flu and COVID swabs, STAT chest x-ray, STAT CMP, and STAT CBC. Staff D was observed reading the text messages from her phone. Staff D said at first when Staff H, LPN/Weekend supervisor looked at the texted orders she thought maybe the PCP meant only the chest x-ray was STAT, but Staff D said she told her they were all STAT and Staff H, LPN/Weekend Supervisor put the orders in the computer to help out. Staff D said she was new in the facility and did not know who did the flu and COVID swabs or if the lab did those. Staff D said she thought maybe she should have sent Resident #1 out to the hospital on Saturday [DATE] but his oxygen saturation showed improvement when he was put on oxygen. Review of Resident #1's physician orders did not show any orders for flu and COVID swabs on [DATE]. The resident's medical records did not show any progress notes or documentation of Resident #1's change in condition on [DATE]. An interview was conducted on [DATE] at 12:01 p.m. with Staff H, LPN/Weekend Supervisor. Staff H confirmed she worked on Saturday [DATE] day shift. She said she entered STAT orders for chest x-ray, labs, Ceftriaxone, nebulizer treatment, and oxygen at 2 p.m. for Resident #1. She said she did not recall if the labs were done.Review of Resident #1's physician orders showed a CBC and CMP order was placed on [DATE] at 12:32 p.m. by Staff H, LPN/Weekend Supervisor. The order was placed for routine labs to be completed on [DATE]. The orders did not show a flu or COVID test was ordered until Monday [DATE]. An interview was conducted on [DATE] at 3:01 p.m. with Staff G, LPN. Staff G said she worked from Sunday [DATE] 11:00 p.m. until Monday [DATE] at 7:00 a.m. She said around 11:30 p.m. Resident #1 had more congestion and was warm to touch. She said he was already on oxygen, so she texted the resident's PCP. She said the doctor explained what he had already done and ordered a repeat STAT chest x-ray. Staff G said the resident had a temperature of 101.2 but it went down after getting Acetaminophen. She said Monday morning Resident #1 was moaning and breathing harder. She said she had given report to the oncoming nurse and then she stayed to help get the resident sent out to the hospital. Review of Resident #1's hospital record dated, [DATE] showed: Chief Complaint BIBA [brought in by ambulance] from [facility name] for AMS [altered mental status]. Pt [patient]was found unresponsive by staff, and EMS [emergency medical services] was called. Sats [oxygen saturation] in the 70s per EMS PTA [patient transport assistant]. Pt arrives responding to painful stimuli, tachy [tachycardia-rapid heart rate], and febrile. Extensive hx [history]History of Present Illness [AGE] year-old male with significant past medical history including epilepsy, prior CVA [cerebrovascular accident], diabetes, hypertension, obesity, prostate carcinoma, atrial fibrillation, HIT [heparin induced thrombocytopenia], and IVC [inferior vena cava filter] filter placement was found unresponsive at [facility name] with oxygen saturations in the 70s. Patient was transported to the emergency department where he was noted to be febrile with a temperature of 107.4, hypoxic, septic, and in respiratory distress, placed on oxy [oxygen] mask at 15 L. Laboratory values revealed influenza A positive, severe hyponatremia, lactic acidosis, trending troponin, and elevated Pro-Cal [procalcitonin, which indicate a systemic inflammatory response to severe bacterial infection or sepsis]. He was transferred to the critical care unit for management for septic shock and multisystem metabolic derangements. [DATE]: Overnight patient is steadily declining. Patient is in multiorgan failure. [DATE] 2:50 p.m. Time of death. An interview was conducted on [DATE] at 12:54 p.m. with Resident #1's PCP/Medical Director. He said he talked to staff a few times over the weekend about Resident #1. He said on Saturday [DATE] around 12:00 p.m. the nurse called and he gave orders for STAT labs, STAT chest x-ray and breathing treatments. He said he also ordered Ceftriaxone to be administered for three days. The PCP said he did not become aware until later Resident #1's labs did not get entered as STAT labs and were not completed that day. The PCP said as far as the labs not being ordered STAT; the labs did not show the resident was septic, however, with the critically high sodium level he would have definitely given fluids if I had seen those [lab results] on Saturday. The PCP said, any delay in care is not our policy and not acceptable. The PCP said he reviewed the hospital record and saw they diagnosed the resident with pneumonia and sepsis but the labs and imaging in the facility did not show that. He said the labs drawn on [DATE] had a critically high sodium level but, the white blood cells were normal.An interview was conducted on [DATE] at 10:05 a.m. with the Nursing Home Administrator (NHA) and the Director of Nursing (DON). The DON said Resident #1 started coughing and running a fever on Sunday night shift (11:00 p.m. [DATE] through 7:00 a.m. on [DATE]). She said the nurse notified the doctor and he ordered labs and Flu/COVID/RSV panels. The DON said Flu/COVID/RSV panels are ordered when a resident's temperature is over 99.0 Fahrenheit (F). She said she saw Resident #1 when she came in to work the morning on [DATE] and he did not look that bad and his oxygen saturation was fine. She said one CNA was giving him water and another was going to try to feed him. The DON said she got a message from Resident #1's RR that said they wanted him sent to the hospital. The DON said upon review she found the labs ordered on Saturday for Resident #1; were entered as routine labs, not STAT labs. She said routine labs are not drawn on Sunday morning which would have put them scheduled for Monday morning, [DATE]. The DON confirmed STAT labs can be drawn any day and time. She said the lab usually comes within a couple of hours and has results back in about four hours. The DON read a statement from Staff H, LPN/Weekend Supervisor regarding Resident #1 on Saturday [DATE] that said Resident #1 had audible breathing and congestion; the doctor was called and ordered STAT chest x-ray, STAT labs, and nebulizer treatments. A follow-up interview was conducted on [DATE] at 1:27 p.m. with Resident #7 and Resident #1's PCP/Medical Director. The PCP said he expected labs to be completed as ordered and to be notified of results. When discussing lab concerns related to Residents #7 and Resident #1, the Medical Director said, sounds like a problem with the lab process. He added that the facility started doing education already due to the issues found. 3. Review of admission Records showed Resident #8 was admitted on [DATE] with diagnoses including Type II Diabetes Mellitus, obesity, hypotension, anxiety disorder, gastrostomy status, muscle weakness, cognitive communication deficit. Review of Resident #8's Quarterly MDS, dated [DATE], Section C, Cognitive Patterns, showed a BIMS score of 15, indicating she was cognitively intact. Review of Resident #8's progress notes showed: [DATE]- Got report from night shift that resident was a bit more confused than normal, notified provider that resident was vomiting and not eating meals, provider ordered STAT labs for CBC, CMP & ammonia level. prior UA [urinalysis] was already collected on night shift early Saturday Morning [DATE]. Shortly after heard resident on a call with 911 dispatch saying she was trying to get out of restaurant bathroom, and she needed someone to come help her leave the restaurant. Got on phone with dispatch to ensure them that resident wasn't at a restaurant she was at Nursing home facility. Dispatch verbalized understanding. Notified provider again. Provider ordered Rocephin 1gm IM [intramuscular] for five days daily. first dose given on [DATE]. Resident was assisted out of bed to wheelchair, fluid encouraged, vital signs taken 126/79, 110p [pulse], 97.7 T [temperature], 16 resp [respirations], 96o2 [oxygen saturation]. will continue to monitor resident. Will pass on to next nurseReview of Resident #8's physician orders showed:-STAT labs. CBC, CMP, ammonia level for nausea and vomiting and confusion. Start [DATE] at 8:56 a.m. Review of Resident #8's lab results showed the labs were collected on [DATE] at 10:00 a.m. There were results for the CBC and CMP, however, there were no ammonia level results. An interview was conducted on [DATE] at 4:51 p.m. with Staff Q, LPN. Staff Q said she cared for Resident #8 on [DATE] and received orders from the doctor for her labs, however, Staff R, LPN put the lab orders in for her. An interview was conducted on [DATE] at 5:16 p.m. with Staff R, LPN. Staff R reviewed Resident #8's medical record. She confirmed she put STAT lab orders in the facility's charting system for Resident #8 to help Staff Q, LPN. Staff R said she did not enter STAT orders into the lab system because she thought Staff Q did that. Staff R said the labs were drawn quickly because the lab technician was in the facility drawing labs on another resident, so she stopped them and asked them to draw labs for Resident #8. Staff R said she filled out the lab requisition paper for a CBC, CMP, and ammonia level. Staff R checked Resident #8's lab results and confirmed there were no results for an ammonia level. She said she would call and follow up with the lab to see what happened. An interview was conducted on [DATE] at 9:00 a.m. and at 3:46 p.m. with the lab used by the facility. The lab said there was an incident with Resident #8's ammonia level and the lab was not completed. They said they updated the facility portal for the resident on [DATE] at 8:12 p.m. with that information. The lab said Resident #8's CBC was reported to the facility portal on [DATE] at 2:04 p.m. and the CMP was reported on [DATE] at 5:20 p.m. The lab said Resident #8's orders for CBC, CMP and ammonia were not put in as STAT orders, only routine. The lab said if the orders had been STAT they would have reported the results sooner and would have called to notify the facility the ammonia lab was not completed. 4.Review of admission Records showed Resident #9 was admitted on [DATE] with diagnoses including atherosclerotic heart disease, neurocognitive disorder with Lewy bodies, essential hypertension, atrioventricular block, first degree, dementia, and cardiomegaly. Review of Resident #9's progress notes showed: [DATE] 7:52 p.m.- Resident observed with episode of vomiting and c/o [complaints of] chest pain. Vitals were taken, blood pressure was elevated. NP [nurse practitioner] notified us of the findings and orders were given. IM promethazine 25MG, clonidine 0.1MG, nitroglycerin 0.4, STAT c/xray 2 views, CBC, and CMP. Will continue to monitor for any further changes.Review of Resident #9's physician orders showed: [DATE] 4:40 p.m. STAT CBC, CMP, chest x-ray 2 views. Portable due to weakness. Review of Resident #9's lab and imaging results showed the chest x-ray was completed on [DATE] at 8:05 p.m. The CBC and CMP were not drawn until [DATE] at 8:15 a.m. and reported [DATE] at 3:26 p.m. An interview was conducted on [DATE] at 3:46 p.m. with the facility's lab. The lab reviewed records for Resident #9 and said a CBC and CMP were ordered routine on [DATE] and they were drawn on [DATE]. The lab said the orders were not put in as STAT orders and that is why they were not drawn until the next morning. The lab said Resident #9's CBC was reported on [DATE] at 2:51 p.m. and the CMP was reported on 2/2126 at 3:18 p.m. An interview was conducted on [DATE] at approximately 11:45 a.m. with the DON and PCP/Medical Director. The DON said she did not know what happened with Resident #9's labs and why they were not done timely. She said the time between ordering and being completed was not acceptable for STAT labs. The PCP said they had put a plan in place for following up on STAT labs because labs had been ordered for residents that had not been completed by nursing.Review of a facility in-service education titled Nursing In-Service: Read-Back Orders & STAT Lab Ordering, undated, showed PurposeTo ensure safe, accurate, and timely implementation of provider orders by reinforcing proper read-back order procedures and STAT lab ordering processes in the skilled nursing facility.Why This MattersFailure to properly read back and implement provider orders can lead to medication errors, delayed treatment, hospitalization, or resident harm. Proper documentation and timely action are required to meet professional standards and CMS expectations.Review of a facility policy titled Provision of Physician Ordered Services, revised [DATE], showed: Policy: The purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality.Definition:Professional Standards of Quality means that care and services are provided according to accepted standards of clinical practice. Standards may apply to care provided by a particular clinical discipline or in a specific clinical situation or setting.Policy Explanation and Compliance Guidelines:1. Facility will maintain a schedule of diagnostic tests (laboratory and radiology) in accordance with the physician's orders. No diagnostic tests or consultation requests will be performed without specific physician, physician assistant, nurse practitioner or clinical nurse specialist's orders in accordance with State law, including scope of practice laws.2. Qualified nursing personnel will submit timely requests for physician ordered services (laboratory, radiology, consultations) to the appropriate entity.3. Qualified nursing personnel will receive and review the diagnostic test reports or consults and communicate the results to the ordering Physician, physician assistant, nurse practitioner or clinical nurse specialist within 24 hours of receipt unless the reports fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders. Ordering Provider will be notified of results upon receipt if deemed critical and/or require immediate attention.4. Documentation of consultations, diagnostic tests, the results, and date/time of Physician notification will be maintained in the resident's clinical record.The facility's immediate actions to correct the deficient practice and remove the Immediate Jeopardy included: As of 2-17-2026 Resident #7 no longer resides in the facility. She was noted with absence of VS's; a code blue was called and CPR initiated per physician orders. 911 was notified, arrived at the facility and took over CPR. Resident #7 was transported to a local hospital where she expired. Resident #1 no longer resides at the facility. Resident #1 was transferred to the hospital on [DATE] due to respiratory distress and elevated temperature, he expired in the hospital. Resident # 9 no longer resides at the facility. Her labs ordered on [DATE] as STAT were completed on [DATE], STAT CXR was completed on 2-20-26 they were reviewed by the APRN in the electronic medical record on [DATE], no new orders were obtained. Resident #8's STAT labs ordered on [DATE] at 8:56 am were obtained on [DATE] at 10:00 am and resulted on [DATE] the NH3 [ammonia] level ordered did not result due to poor specimen. The provider was notified on [DATE] with no new orders and to discontinue the order for the NH3 level. On 3-10-25 the Director of Nursing was educated by the Regional Nurse Consultant on the process to review clinical records to validate diagnostic testing was completed per health care providers orders and they were notified of the results. On 3-10-26 The Director of Nurses reviewed clinical records of current residents with orders for diagnostic tests from the 30 days to validate labs and or diagnostic tests were completed as ordered. The provider was notified of any discrepancies. On 2-17-26 the Assistant Director of Nursing/Staff Development coordinator began educating licensed nurses on process to obtain STAT labs from current lab services. On 3-11-26 the ADON/SDC educated licensed nurses on process to obtain STAT labs from current lab services. On 3-11-26 the Staff Development Coordinator began lab process competency with license nurses on the process for obtaining routine and STAT labs. On 3-11-26 step by step instructions on how to obtain labs through the website to include STATs was placed in the front of each lab binder. -Total Licensed Nurses -Total licensed nurses received education; 32 of 34 nurses were educated.-On 3-11-26; 32 out of 34 nurses completed the education.-Ad Hoc QAPI on 3-10-26 completed with Medical Director, Administrator, Director of Nursing and additional IDT members on the adherence to policy and process for identifying change in condition, following provider orders, obtaining STAT labs, diagnostic results and notification of providers of lab and diagnostic results. Discussion also included provider access to the electronic medical record and ability to view lab and diagnostic results. Verification of the facility's removal plan was conducted by the survey team on [DATE]. All education and sign-in sheets were reviewed and validated 32 out of 34 licensed nurses educated on the lab process, provider notification and documentation. Interviews to verify education were conducted with 13 out of 34 nurses across all shifts and attempts were made to reach 4 additional nurses. In-Service sign-in sheets were reviewed as well as reports for voice/text education that went out to all licensed nurses. Based on verification of the facility's Immediate Jeopardy Removal Plan the Immediate Jeopardy was determined to be removed on [DATE], and the non-compliance was reduced to a scope and severity of E.

Based on observation and interview, the facility did not safeguard medical record information against unauthorized use and ensure residents' personal and medical records were communicated confidentially for one (Resident #1) out of four residents reviewed. Findings include:An observation and interview were conducted on 2/24/26 at 12:54 p.m. with the facility's Medical Director. The Medical Director said staff sent text messages to him about residents regularly. Text messages on his phone were observed with Resident #1's information, including a photo and video of Resident #1.An observation and interview were conducted on 2/24/26 at 2:30 p.m. with Staff D, Licensed Practical Nurse (LPN.) Staff D, LPN showed how she used her personal phone to contact the Medical Director through a Short Messaging Service (SMS) text application. Text messages to and from the Medical Director regarding Resident #1's health status and orders were observed on her phone. Staff D, LPN stated staff used their personal phones to take pictures of prescriptions and texted the pictures to the Medical Director to get an order.An interview with Staff A, LPN was conducted on 2/24/26 at 3:04 p.m. Staff A, LPN revealed she used her personal phone to call and send text messages to physicians. She said she had used her personal phone and regular text messaging system to text pictures of lab results and prescriptions. She stated she did not use a special, secure, system when communicating with providers.An interview with Staff B, Registered Nurse (RN) was conducted on 2/24/26 at 3:11 p.m. Staff B, RN revealed she used her personal phone to call and send text messages to physicians. She stated she had sent text messages containing patient information, pictures of lab results, and pictures of prescriptions. She stated her phone did not have any special or secure text messaging system.An interview with Staff C, LPN, was conducted on 2/24/26 at 3:16 p.m. Staff C revealed she was in training, but if she needed to communicate with the physicians, she would call them using the phone located in the nurses' station. She stated if she needed to send labs or prescriptions, she would have used the fax machine. She stated she would not use her personal phone to communicate with physicians since the message would contain private patient information.An interview with the Director of Nursing (DON) was conducted on 2/24/26 at 3:35 p.m. The DON stated staff should have used the phone in the nurses' station to communicate with physicians. She said personal phone devices should not have been used to communicate with medical staff regarding patient information. The DON said staff should not have texted physicians if they could not get in contact by phone. She stated staff should have reached out to her and she would have reached out to the physician personally.A review of the facility's policy titled Medical Records revealed.6. The facility will safe guard clinical record information against loss, destruction or unauthorized use.A review of the facility's policy titled Resident Right- Personal Privacy/ Confidentiality of Records revealed 1. The resident has a right to personal privacy and confidentiality of his or her personal and medical records.4. The resident has a right to secure and confidential personal and medical records.

Based on record review and interviews, the facility failed to ensure a safe an orderly discharge and appropriately document in the medical record the events and follow through of the discharge for one resident (#1) who was transferred to an inappropriate location following an emergent incident between Resident #1 and another resident of three residents reviewed for transfer and discharge rights. Findings included: Review of the Admission Record for Resident #1 showed the resident was initially admitted to the facility on [DATE] with admitting diagnoses to include: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety; major depressive disorder, recurrent, moderate; generalized anxiety disorder; other specified persistent mood disorders; nicotine dependence, cigarettes, uncomplicated. The Admission Record showed Resident #1 was discharged from the facility on 08/04/2024. Review of a Determination of Incapacity signed by the resident's attending physician on 02/24/2024, revealed the physician evaluated and determined Resident #1 lacked the capacity to give informed consent to make medical decisions and does not have reasonable medical probability of recovering mental and physical capacity to directly exercise rights. Review of an Administration Note, dated 8/5/24 at 00:42 (12:42 a.m.), showed Increase to one on one supervision due to behaviors, every shift. Resident out of facility taken by police. Review of an Administration Note, dated 8/5/24 at 3:52 (a.m.), showed Resident out of facility. resident escorted by police out of facility. A review of a social service note, dated 8/5/24, revealed SS (social services) assisted the assistant administrator with a resident to resident. SS called the [Local Police Department] and advised them we had a Res. To Res. In our memory unit and both residents were incapacitated. The assistant administrator notified SS that the resident had been arrested. SS immediately got in contact with [Local Police Department], and they notified the officer to writer back immediately. The officer that responded to the altercation did call back and at that moment I 3-way [Staff Name] in as we were previously on the phone together. The officer said when he arrived at our facility, he asked multiple times if the resident was incapacitated, and the nurses responded no multiple times. The officer mentioned he knows our facility and he knows our downstairs unit very well this is why he asked multiple times about the resident's capacity. He took the nurses words on no capacity in place. The Officer also stated he had on his body cam footage the resident admitting what she had done and said if she could have hit the other resident, she would have done that. She explained in detail to the officer what she had done. SS will assist where needed. A review of Resident #1's electronic medical revealed the resident was arrested on 08/04/2024, by the [Local] Police Department, after an altercation with another resident in the facility. Resident #1 was charged with Battery on Person [AGE] years of Age or Older. Review of an Order Granting Pretrial Release for Resident #1, dated 08/05/2024, revealed the Circuit/County Judge ordered Resident #1 may return to the residence listed on affidavit but must stay on a separate floor. Review of a psychiatry subsequent note, dated 8/5/24, revealed, Resident #1 was unstable and required a psychiatric assessment. As per collected information, DON (Director of Nursing) requested patient be seen due to having an altercation with another patient. Patient states another patient called her a [explicative] So she pushed them. Discussed not touching people and talking with staff. Patient verbalized understanding. No addictive substances cravings. No other psychiatric symptoms noted. No side effects to current psych meds (medications) were reported. Dementia is persisting, but no other behaviors noted. On 10/17/2024 at 11:25 a.m. an interview was conducted with the Social Services Director (SS). She stated Resident #1 was physically aggressive, but not all of the time. She said the behaviors happened more when Resident #1 was initially admitted to the facility because she wanted to smoke. She said the resident would say that she wanted to leave the facility. Resident #1 was deemed to be an elopement risk. The resident was sharing a room with her spouse, and the SS said the facility created a space outside for the resident, so she could smoke. The SS stated Resident #1 did not have behaviors anymore. She enjoyed hanging out in the courtyard with her spouse and drink coffee. The SS said normally when the police are called and the resident is in the memory unit, the resident is [emergency transfer] and not arrested. Resident #1 was housed in the memory care unit and had a dementia diagnosis. The SS said Resident #1's arrest was a result of the police officer deciding to arrest Resident #1 after she pushed the other resident down and admitted it. She said that corporate would not allow Resident #1 to return to the facility after the arrest. An interview was conducted on 10/17/2024 at 12:19 p.m. with the Director of Nursing (DON). The DON confirmed she could not find any progress notes related to discharge planning or finding alternative placement for Resident #1. The DON also confirmed Resident #1's discharge care plan had not changed during the resident's stay in the facility. At this time the Assistant Nursing Home Administrator (ANHA) stated the SS called the police and the police spoke to the nurse (Staff A, Registered Nurse). The nurse said he was passing meds in the solarium area and heard Resident #1 yelling out loud and was standing next to the other resident. She stated she pushed the other resident because he called her a [explicative]. The other resident was on the floor on his right side with his wheelchair turned over. The nurse called the DON and the residents were immediately separated. We placed a psych consult and the nurse stated at that point the police arrived. The police decided to do an arrest at this time. An attempt to contact Staff A, RN who was involved in the incident was made and no return call was received during or post survey. 43453 A telephone interview was conducted on 10/17/2024 at 12:49 p.m. with Resident #1's Power of Attorney (POA). The POA said her [Resident #1] and her [Resident #1's spouse] were both admitted to the facility at the same time, and everything was going well. She said her [Resident #1] had dementia with psychosis and was placed in the dementia unit along with her [Resident #1's spouse]. The POA said Resident #1 was involved in an altercation with another resident on 08/04/2024 and it was her first physical altercation with another resident. Resident #1 told the POA the altercation started out as something simple and ended up becoming more physical when the other resident pushed her and she pushed the other resident back. The POA said the facility called the [Local] Police Department and had Resident #1 arrested. The facility did not call the POA until after the resident was already out of the facility and headed to jail. She said not even a week after the arrest the facility told her Resident #1 could not return to the facility and the facility forced the POA to sign discharge papers. The POA stated they said they could help find another place for Resident #1. The POA said the Social Services Director (SS) was present at the court hearing held on 08/05/2024. She said Resident #1 was in jail until 09/20/2024 because the facility would not take her back. She was in jail for over a month and I had to accept the ALF (assisted living facility) referral they sent even though I did not think it was the right place for her. I did not want her to sit in jail. She was at the new facility for 24 hours and she left. It was not a safe discharge plan. My big issue was she was in a secured unit because she had behavior issues, and there was nobody supervising them. The POA stated the resident is currently at [Local Hospital] and Resident #1 left the ALF multiple times and had an [Emergency Transfer] initiated. Now she is living in a hospital, has a battery charge on her record and no one can take her. This whole incident and the way it was handled has caused her a lot of pain and anxiety not to mention being separated from her spouse. Review of Resident #1's most recent MDS, dated [DATE], showed in Section C - Cognitive Patterns the resident was moderately impaired; meaning poor decision making and needed cues and supervision. Additional review revealed Resident #1 had no evidence of an acute change in mental status from the resident's baseline. Review of the active physician orders as of 8/6/24 revealed: - Behavior Monitoring - observe for (specify resident's behavior). Document Y if the resident is exhibiting behaviors. N if resident is not exhibiting behaviors. If Y document in the PN's (progress notes), every shift; start date of 7/15/24. - Mood Stabilizing Medication - observe for agitation, and/or fluctuation in mood. Document y if resident is having behaviors and N if the resident does not have behaviors. If Y document in the PNs, every shift; start date 7/16/24. Review of Resident #1's care plan dated, 02/26/2024, showed the following Focus Areas: - [Resident #1's discharge plan was long term care in the facility. Interventions included discussing changes in discharge plan with Resident #1 and resident's representative. - The resident has a behavior problem aggression towards other residents r/t (related to) does not like others to enter her or [spouse's] personal space. Controlling/Verbally & Physically tries to break things. Behaviors throwing things exit seeking more. Refuses Showers (initiated 6/14/24, cancelled 8/7/24). Goal was the resident will have fewer episodes by review date. Interventions included administer medications as ordered, increase to one on one supervision due to behaviors, initiated on 8/4/24; intervene as necessary to protect the rights and safety of others, approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed, initiated 6/14/24; monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. - [Resident #1] is at risk for elopement/exit seeking actively exit seeking. Actively verbalizing desire to leave & has the means to do so. Agitation, aimless wandering due to cognition, has the potential to approach exit doors. History of elopement. Sent to hospital/ER (emergency room ) r/t - aggressive behaviors trying to break window with w/c (wheelchair), disruptive behaviors, cursing, yelling, threaten remarks unable to re-direct; police here and took [Resident #1] out of facility: due to her pushed down another resident. She was redirected and spoken to and 15 min checks for observation and behaviors was in place; initiated 3/1/24. Goal was for Resident #1 to not leave the facility unattended through the review date. Interventions included: 15 minute checks on night shift & 1:1 supervision on day and evening shifts for safety, initiated 7/8/24 - Focus Area - [Resident #1] has the following behavior problem(s) restlessness/pacing. [Resident #1] has hx (history) of placing self on floor, refusing care and medication, initated on 2/28/24 and resolved on 5/29/24. An interview was conducted on 10/17/2024 at 1:14 p.m. with the SS and Assistant Nursing Home Administrator (ANHA). and she stated the facility could not accept Resident #1 back to the facility because she would have required 1:1 supervision. The ANHA stated Resident #1 was physically and verbally aggressive, however, she could not confirm another specific incident other than the incident when Resident #1 was arrested. Review of a progress note, dated 06/13/2024, for Resident #1 revealed the resident was taking smoke breaks, and she stated upon entering her room, her bed was occupied by a resident from another room. Resident #1 woke up the resident in her bed and he attempted to kick her, she called for help, the hall monitor entered the room and redirected the intruding resident to his room. Review of a Social Service progress note, dated 07/09/2024, showed a care plan meeting was held with the team and Resident #1's daughter. No new concerns noted at the time. Review of a progress note, dated 07/17/2024, for Resident #1 revealed the resident continues on 1:1 monitoring with Certified Nursing Assistant (CNA) at bedside. The resident was calm and resting peacefully at that time. Review of a progress note, dated 07/21/2024, for Resident #1 showed the resident remained safe with no behavioral issues throughout the shift with 1:1 at bedside. Review of a progress note, dated 07/26/2024, for Resident #1 showed the resident was observed down the hall with 1:1. The resident was alert with no obvious distress noted, due to meds given as prescribed. No agitation noticed throughout the shift. Review of a progress note, dated 07/30/2024, for Resident #1 showed the resident was on checks every 15 minutes, resident was observed in her room resting, smoke break was provided as needed, no obvious distress noted at that time. A follow-up interview was conducted on 10/17/2024 at 3:58 p.m. with the ANHA and she said it was not her decision to not allow Resident #1 to be admitted back to the facility. She said it was a corporate decision. She agreed the facility did not document the reasons why Resident #1 could not be readmitted to the facility. The ANHA confirmed if a resident's plan of care changed it should be documented in the resident's chart. No documentation was done by the facility indicating the discharge care plan changed for Resident #1. The ANHA stated if Resident #1 had increased behaviors which impacted her residency in the facility these behaviors should have been documented in the resident's chart. The ANHA confirmed she was aware Resident #1 was granted court approval to return to the facility. She re-stated it was not her decision to deny readmission to Resident #1. Review of the facility's Discharge Planning Process Policy, dated 11/3/2020 and revised 9/19/2023, revealed: Policy: It is the policy of this facility to develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. Definitions: Discharge planning is a process that generally begins on admission and involves identifying each resident's discharge goals and needs, developing and implementing interventions to address them, and continuously evaluating them throughout the resident's stay to ensure a successful discharge. Procedure: 1. The facility will support each resident in the exercise of his or her right to participate in his or her care and treatment, including planning for discharge. 2. The facility will determine the resident's expected goals and outcomes regarding discharge upon admission, routinely in accordance with the MDS assessment cycle, and as needed. (a) Initial information and discharge goals will be included in the resident's baseline care plan. (b) Subsequent assessment information and discharge goals will be included in the resident's comprehensive plan of care. 3. If Discharge to community is determined to not be feasible, the facility will document in the clinical record who made the determination and why. 4. In cases where the resident wishes to be discharged to a setting that does not appear to meet his or her post-discharge needs, or appears unsafe, the interdisciplinary team will treat this situation similarly to refusal of care: (a) Discuss with the resident, (and/or his or her representative, if applicable) and document the implications and/or risks of being discharged to a location that is not equipped to meet his/her needs and attempt to ascertain why the resident is choosing that location. (b) Offer other, more suitable, options of locations that are equipped to meet the needs of the resident. Document any discussions related to the options presented. (c) Document refusals of other options that could meet the resident's needs. (d) At time of discharge, follow policies regarding discharges Against Medical Advice, and refer to Adult Protective Services (or other state entity charged with investigating abuse and neglect), as necessary. 5. If discharge to community is a goal, an active discharge plan will be implemented and will involve the interdisciplinary team, including the resident and/or resident representative. 6. An active individualized discharge care plan will address, at a minimum: (a) Discharge destination, with assurances the destination meets the resident's health/safety needs and preferences. (b) Identified needs, such as medical, nursing, equipment, educational or psychosocial needs. (c) Caregiver/support person availability and the resident's caregiver's/support person's capacity and capability to perform required care. (d) Resident's goals of care and treatment preferences. 7. The ongoing process of developing the discharge plan will include a regular re-evaluation of the resident to identify changes that require modification of the discharge plan, and updating of the discharge plan, as needed, to reflect the modifications. 8. The facility will document any referrals to local contact agencies or other appropriate entities made for the purpose of the resident's interest in returning to the community. 9. The facility will update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities. 10. The facility will assist residents and their resident representatives in choosing an appropriate post-acute care provider (i.e., another SNF, HHA, IRF, or LTCH) that will meet the resident's needs, goals and preferences. (a) The Social Services Director, or designee, shall compile available data on other post-acute care options to present to the resident, including, but not limited to: (i) Data on providers within the resident's desired geographic area, where available. (ii) Quality measure data, based on standardized patient assessment data, publicly available on the CMS Care Compare website. (iii) Data on resource use to the extent the data is available, such as number of residents/patients are discharged to the community, and rates of potentially preventable hospital readmissions. (b) The facility will ensure that the data used is relevant and applicable to the resident's goals of care and treatment preferences. (c) The facility will comply with the Federal Anti-Kickback statute when making referrals to other provider types. (d) The facility will present provider information to the resident and resident representative, if applicable, in an accessible and understandable format, and will answer any questions to assist in the resident's/representative's understanding. 11. The evaluation of the resident's discharge needs and discharge plan will be completely documented on a timely basis in the clinical record. 12. The results of the evaluation and the final discharge plan will be discussed with the resident or resident's representative. All relevant information will be provided in a discharge summary to avoid unnecessary delays in the resident's discharge or transfer, and to assist the resident in adjustment to his or her new living environment. 13. Education needs, as identified in the discharge plan, will be provided to the resident and/or family member prior to discharge.

Based on observations, interviews and record review, the facility failed to ensure resident spaces, and resident equipment were clean/sanitary and maintained to include Soiled Air Conditioner unit filters; Soiled walls; Soiled ceiling tiles; Soiled bathroom equipment, Soiled walls and doorways on two of two floors and within two of four halls (100 and 200). Findings included: On 10/7/2024 at 9:08 a.m., 11:00 a.m. and 1:45 p.m., The facility was toured with the following findings. The first floor dementia unit to include resident rooms 101 - 134 revealed: 1. Resident room [ROOM NUMBER] was observed with a window wall mounted Packaged Terminal Air Conditioner PTAC unit with heavy caked-on dust debris on both filters. 2. Resident room [ROOM NUMBER] was observed with a window wall mounted Packaged Terminal Air Conditioner PTAC unit with heavy caked-on dust debris on both filters. The baseboard on the right side of the PTAC unit was observed waterlogged and peeled off the wall, leaving a gap between the plastic baseboard and the wall. The shared bathroom was observed with floor material peeled up and leaving a trip hazard, and also was not a cleanable surface. 3. Resident room [ROOM NUMBER] was observed with a window wall mounted Packaged Terminal Air Conditioner PTAC unit with heavy caked-on dust debris on both filters. The baseboard in the shared bathroom right side observed peeled and leaving hole and gap between the baseboard and wall. 4. Resident room [ROOM NUMBER] was observed with a window wall mounted Packaged Terminal Air Conditioner PTAC unit with heavy caked-on dust debris on both filters. A spotted black colored biogrowth was observed behind the main room door on the door frame. The shared bathroom was observed with cracked and missing floor tiles at the base of the toilet leaving a non cleanable surface. 5. Resident room [ROOM NUMBER] was observed with a window wall mounted Packaged Terminal Air Conditioner PTAC unit with heavy caked-on dust debris on both filters. The shared bathroom was observed with a grey metal over the commode seat. All four legs and the metal cross connectors were observed with heavy paint peeling with heavy rusting. 6. Resident room [ROOM NUMBER] was observed with a window wall mounted Packaged Terminal Air Conditioner PTAC unit with heavy caked-on dust debris on both filters. 7. Resident room [ROOM NUMBER] was observed with a window wall mounted Packaged Terminal Air Conditioner PTAC unit with heavy caked-on dust debris on both filters. Also, one ceiling tile was observed heavily waterlogged, posing recent water damage. 8. Resident room [ROOM NUMBER] was observed with a window wall mounted Packaged Terminal Air Conditioner PTAC unit with heavy caked-on dust debris on both filters. Also, observed black biogrowth on the wall on the right side of the a/c PTAC unit. 9. Resident room [ROOM NUMBER] was observed with a hole in the wall on the baseboard on right side of the PTAC unit. 10. The 100 unit Dining room/Activity Solarium room, which was frequented by over 8 residents each time of observation, was observed with heavy wet appearing black biogrowth on four ceiling tiles near the television and at the back of the room. 11. Resident room [ROOM NUMBER] was observed with a window wall mounted Packaged Terminal Air Conditioner PTAC unit with heavy caked-on dust debris on both filters. The floor baseboard on the right side of the PTAC unit was peeled up and with water damage. 12. Resident room [ROOM NUMBER] was observed with a window wall mounted Packaged Terminal Air Conditioner PTAC unit with heavy caked-on dust debris on both filters. 13. Resident room [ROOM NUMBER] was observed with a window wall mounted Packaged Terminal Air Conditioner PTAC unit with heavy caked-on dust debris on both filters. There was also black biogrowth on the wall at and near the PTAC power plug-in plate/area. 14. Resident room [ROOM NUMBER] was observed with a window wall mounted Packaged Terminal Air Conditioner PTAC unit with heavy caked-on dust debris on both filters. 15. room [ROOM NUMBER] was observed with a window wall mounted Packaged Terminal Air Conditioner PTAC unit with heavy caked-on dust debris on both filters. There was also Ceiling water damage on ceiling above window bed. The second main floor was observed with the following: 16. The main hallway ceiling near the 200 unit nurse station, which is frequented by residents, was observed with a metal ceiling vent with black biogrowth spotting as well as heavy rusted areas. The rusted areas were not cleanable. 17. The ceiling above the 200 unit station was observed with a metal ceiling vent with black biogrowth spotting as well as heavy rusted areas. The rusted areas were not cleanable. 18. The main hallway outside resident room [ROOM NUMBER] was observed with a metal ceiling vent with black biogrowth spotting as well as heavy rusted areas. The rusted areas were not cleanable. 19. The main hallway outside resident room [ROOM NUMBER] was observed with a metal ceiling vent with heavy black biogrowth spotting as well as heavy rusted areas. The rusted areas were not cleanable. 20. The main dining room was observed with a tray ceiling. The metal ceiling vent and extended ceiling area above the door leading to the education room, was observed with black and grey colored dirt/debris. The air vent blows directly into the dining room and was above two tables where residents dine and sit. 21. The Education room, which was located on the other side of the door from the main dining room, revealed two sets of doors that led to the outside porch. The outside porch was utilized for residents to sit at and there were four residents and a staff member seated out in this porch. Two of the doors on the inside of the building were noted with heavy blotches of black biogrowth. 22. The 200 unit smaller dining room/activity room was observed with three recently water logged and still wet ceiling and air duct tiles. Many residents were observed in this room during the times of the observations. Also, a metal ceiling vent with black biogrowth spotting as well as heavy rusted areas. 23. The therapy department gym was observed with four recently water logged ceiling tiles and two metal air conditioner ceiling vents with black biogrwoth and heavy rusted areas. Photographic evidence obtained. On 10/17/2024 at 10:02 a.m., Staff I, who was the interim Housekeeping Director was interviewed with relation to Housekeeping cleaning and maintenance services. Staff I revealed she has just taken over as interim Housekeeping Director yesterday on 10/16/2024, as the previous Housekeeping Director was terminated. Staff I did confirm she has been employed at the facility as a Houskeeper for almost two years. She revealed she knows the layout of the facility and proceeded to talk about what a Housekeeper staff's responsibilities were. She proceeded to say on a daily basis staff are to go into residents spaces to include resident rooms and bathrooms and they clean high touch surfaces to include light switches, call light buttons, hand rails on beds, door knobs, A/C PTAC plastic covers, television remotes, etc. She also revealed staff are to change out the trash cans, wipe down tables and furniture, clean the entire bathroom to include floor, walls, toilet and sink. Staff I revealed housekeeping staff use a long stick sweeper to clean ceiling vents in the rooms as well. She also indicated staff sweep and mop the floors and clean the windows that look outside. She revealed housekeeping staff are not responsible for changing the air filters in the PTAC units. Staff I revealed since she had just taken over as interim Housekeeping Director, she did not know where the paper schedules and procedures were located. mmmmmm Interviews with Housekeeping staff at 1:00 p.m. to include Staff I, J, K and L all confirmed their duties as indicated above from interview with Staff I. Staff J, K and L all revealed they feel they are provided with sufficient supplies to do their job however, they felt they could receive more education and inserivces in order to perform their duties with regards to cleaning black biogrowth. Staff I, J, K, and L all revealed that they have seen areas in residents spaces that looked like mold-like substances and did not know how to appropriately clean those areas. Staff I, J, K, and L all revealed once they see areas that appear to be mold-like they report it to maintenance department by way of electronic reporting work order system or by way of word of mouth. Staff I, J, K, and L all revealed that once those areas are reported, it was found that the Maintenance Director would clean off those mold-like areas. They did not know how he cleaned the areas not did they know what type of cleaning agent he used. They all felt the reported areas would be taken care of quickly. Housekeeping staff I, J, K and L could not remember if they had ever received any complaints from residents or visitors with regards to mold-like debris. Staff I, J, K, and L all revealed they felt safe in the building and they have not observed or smelled areas with must or mold-like odors. On 10/27/2024 at 10:35 a.m. an interview was conducted with the Maintenance Director. He revealed he was at the time the only person who handles maintenance issues in the building. He revealed that management was in the process of hiring another employee to add to his department. The Maintenance Director revealed he had been employed at the facility as the Maintenance Director for over a year. He was asked how he handles electronic and word of mouth maintenance work orders. He revealed he reviews the electronic work orders on a daily basis and will do correction based on priority. He revealed the work orders that are put in word of mouth, he will put in electronically so they are documented. He revealed he will try and correct each issue timely, but there are times when he has to order parts or get additional help to correct the issue. The Maintenance Director was asked who was responsible for cleaning and maintaining the resident room wall mounted air conditioner PTAC units. He explained that Housekeeping staff will clean the outside cover and buttons and maintenance department is responsible for cleaning and replacing the air filters. He revealed he will try to clean the PTAC unit air filters at least once a month. He was not able to show paperwork/documentation of this expectation. He was also not able to provide evidence that he had cleaned or replaced PTAC unit air filters the past three months as requested. The Maintenance Director revealed since he was the only maintenance staff in the building, some tasks have not been completed in a timely manner. He was shown photographic evidence of soiled PTAC unit air filters and he confirmed he had not gotten to them yet and that they should not be caked with dust/debris. The Maintenance Director denied any mold in the building. He revealed that if he, or any of the facility staff observe and report black biogrowth suspected as mold, he will immediately go to those areas and assess it. He revealed if he does not think the areas are mold, he will clean with a detergent the area and then housekeeping will continue to clean the areas after that. He revealed if he had suspected mold, he would report to the Nursing Home Administrator and Regional Maintenance Director of that suspicion and the facility has a contacted service to come out and assess and remediate the suspected mold areas. The Maintenance Director revealed since his employ, he has not observed or had any staff report to him of mold, but he has been reported of mold-like biogrowth. He revealed he had cleaned those areas and then brushed on surface of mold killing paint product called, KILZ. He revealed he spreads out this product for preventative maintenance and to keep mold like substances away. The Maintenance Director was unable to confirm how he would identify mold-like substances that would need to be reported as to opposed to just black biogrowth areas that he cleans himself. The Maintenance Director did not have any paper documentation or electronic documentation to support cleaning of black biogrwoth or mold-like substances within the last three months as per request. Further, the Maintenance Director had no current work orders to support evidence that any of the above mentioned areas were in the process of correction. On 10/17/2024 at 3:00 p.m. an interview with the Nursing Home Administrator was not aware of any mold-like substances in the building and that no staff had reported to her of this suspicion. She further confirmed the Maintenance Director would handle suspicion of mold and they have an outside sourced company that would come out and assess and remediate if need. She was not able to provide any documentation to support what the process would be if suspected mold like substances in the building. On 10/17/2024 at 3:00 p.m. the Nursing Home Administrator provided the Safe and Homelike Environment Policy and Procedure with a revision date of 4/11/2023, for review. The policy showed; In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Definitions included but was not limited to: Environment refers to any environment int the facility that is frequently that is frequented by residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patio, therapy areas and activity areas. Sanitary includes, but not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. Resident care equipment includes, but is not limited to: equipment used in the completion of the activities of daily living. On 10/17/2024 at 3:00 p.m. Staff I and the Nursing Home Administrator could not provide a Housekeeping and Maintenance department policy and procedure for review.

Based on interview and record review, the facility failed to provide a copy of the transfer and discharge notice to the Office of the State Long-Term Care (LTC) Ombudsman for one (#1) of three residents reviewed for transfer and discharge rights. Findings included: Review of the Admission Record revealed Resident #1 was originally admitted to the facility in February of 2024 with diagnoses to include unspecified dementia without behavioral disturbance, major depressive disorder, and generalized anxiety disorder. Review of Resident #1's Nursing Home Transfer and Discharge Notice revealed the notice was given on 8/4/24. The location to which Resident #1 was transferred to was the county jail. The address and phone number were not listed. Under reason for discharge or transfer, none of the boxes were checked. Under brief explanation, the form showed, Resident incarcerated. The area to show that the notice was given to the Local Long Term Care Ombudsman Council was incomplete/blank. Review of a document titled [Name of Facility], and the facility's social services phone number, showed a list of resident names for the Ombudsman discharge notifications dated 08/02/24 to 08/31/24. This list did not include Resident #1's name and there was no entry on 8/4/24 the day Resident #1 was discharged . On 10/17/24 at 2:14 p.m., an interview was conducted with the Social Services Director (SSD). The SSD stated the discharge process included a documented discharge note, a discharge summary and the notification to the Ombudsman. She stated she normally notified the Ombudsman of discharges through an electronic fax on the first of each month. She stated she had emails to confirm the notifications. The SSD stated she did not notify the Ombudsman of Resident #1's discharge, because she only notified the Ombudsman of hospital transfer discharges and any planned discharges. She stated she did not notify the Ombudsman if a resident's transfer was unplanned. She stated she did not have transcripts confirming the receipt of the faxes the last three months. She stated the facility's IT (Information Technology) department deleted their emails after every 30 days. The SSD stated she did not have confirmation of the paperwork being faxed. Review of a facility policy titled, Discharge Planning Process, implemented 11/3/20, did not show expectations regarding Ombudsman notifications of the facility's transfers and discharges.

Based on observations, interviews and record reviews, the facility failed to protect residents' right to be free from sexual abuse by a resident. Three residents (#2, #4, #8) of five with physician-signed lack of capacity to consent documents experienced sexual abuse in the facility. Resident #1 had a documented history of inappropriately touching and attempting to kiss staff beginning August 25, 2023. The facility did not respond with interventions that prevented sexual abuse from occurring to vulnerable residents. On 9/5/23 Resident #4 was discovered naked in their room with another resident (Resident #1). On 3/29/24 staff observed a resident (Resident #7) removing his hand from Resident #8's pants. On 4/15/24 during the 3:00 p.m. to 11:00 p.m., shift staff observed Resident #1 masturbating while Resident #2 watched standing in his room's doorway. Facility staff did not respond to this observation. On 4/16/2024 Resident #2 was observed in bed with another resident (Resident #1) standing next to the bed, his penis in her mouth. Applying the reasonable person concept to Residents #2, #4, and #8 due to their severe cognitive impairments, they would be expected to be distressed and/or afraid after non-consensual or coerced sexual contact. These failures created situations that resulted in a worsened condition for Residents #2, #4, and #8 and the likelihood for continued sexual abuse to these and other residents and resulted in the determination of Immediate Jeopardy that began on 1/26/2024. The findings of Immediate Jeopardy were determined to be removed on 5/17/2024 and the severity and scope was reduced to E after verification of removal of immediacy of harm. Findings Included: An interview was conducted with Staff E, CNA, on 5/15/24 at 1:38 p.m. Staff E, CNA, stated she knew Resident #1 prior to the incident on 4/16/24 with Resident #2. Staff E said while completing shift change rounds with Staff T, CNA, Resident #1 was observed going across the hallway into Resident #2's room. Staff E, CNA, said when she entered Resident #2's room, Resident #2 was sucking his [Resident #1's] thing, and he was so into it he didn't know I was there, I yelled at him to stop. Resident #2 was observed in the B-bed laying on her side, the bed was raised to [Resident #1's] waist . He [Resident #1] had his hand behind his head. I [had] never seen it before that and haven't seen that since. Staff E, CNA, said It was like she [Resident #2] never had a reaction; she went back to sleep, she did not react. Resident #1 didn't say anything to Staff E, CNA, and Staff T, CNA. The Unit Manager, Staff U, Licensed Practical Nurse (LPN), said to Resident #1 I thought you stopped doing that, and he [Resident #1] stated No, I've never stopped that. Staff T, CNA, told Staff E, CNA, she observed the night before [April 15, 2024] Resident #1 was ejaculating and Resident #2 was watching. Attempts were made to telephone Staff T, CNA, messages left, and no response received. An interview was conducted with Staff R, CNA, on 5/15/24 at 1:57 p.m. Staff R, CNA, said she typically works on the first floor [Memory Unit] and is familiar with Resident #1 and Resident #2. He [Resident #1] has a habit of being sexual. Yesterday [Resident #1] was playing with self in room in his bed. [I] have seen him standing naked. On 4/16/24 Staff R, CNA, was assigned to care for Resident #1 and Resident #2 on the 7:00 a.m. to 3:00 p.m. shift. Staff R, CNA, said at approximately 2:00 p.m. after providing care to Resident #2, she observed Resident #1 sitting on the side of his bed and left both room doors open. Staff R, CNA, heard Staff T, CNA, ask Resident #1 What are you doing? Staff R, CNA said she went to Resident #2's room and was told Resident #1's penis was in the mouth of Resident #2. She observed Resident #2 covered with a cloth bed pad. Staff R, CNA, said Staff T, CNA, told her on 4/14/24 during the 3:00 p.m. to 11:00 p.m. shift Resident #2 was peeking in the door and Resident #1 who was sitting on his bed with pants down and he was playing with himself. Staff R, CNA said Staff T, CNA, said she told the nurse of her observation of Resident #1 and Resident #2. Staff R, CNA, heard Resident #1 tell Staff U, LPN, I can't stop, I don't want to. Staff R, CNA, said when assigned to 1:1 observation (staff supervision requiring constant visualization of the resident) for Resident #1 would be sexual and would come and stand over me. Staff R, CNA, said when assigned to hall monitoring, she received safety check logs from the hall monitor on the previous shift. Each resident on every 15 minutes, every 30 minute or every 1 hour checks will have separate logs. An interview was conducted on 5/15/24 at 2:34 p.m. with Staff C, Social Services Director (SSD), who said she was familiar with the 4/16/24 incident involving Resident #1 and Resident #2. Staff C, SSD, said she spoke with Resident #2 and asked, If she was ok, remembered anything happen. Resident #2 said She was in pain but did not report area. We sent her to the hospital on the same day and they sent her back. Staff C, SSD, said she spoke with Resident #1 to find out what he was thinking before going deep into investigation. When Resident #1 was asked why he did it, he said because he wanted to. After the incident, she completed a psychosocial evaluation on Resident #1 and Resident #2 and contacted family members for each resident. Resident #2's family member did not want to press charges. Staff C, SSD, said she assumed a full-time employee position at the facility in late February 2024. She did not know Resident #1's history and he was not discussed during the transition by the previous Social Services staff. Staff C, SSD, said Resident #1 had been discussed in Quality Assurance Performance Improvement meetings (QAPI) and the following interventions had been implemented: 1:1 monitoring, room changes and hallway changes. I know right now he's 1:1, prior to this [4/16/24] incident he was referred for transfer to other facilities. During the interview with Staff C, SSD, Staff D, LPN, Staff Development Coordinator (SDC) said, no one wants him [Resident #1], family wants to keep him on 1:1 forever. Staff D, LPN, SDC, said according to Resident #1's family, elopement risk was the reason for his admission to the facility. Resident #1's family member doesn't want anything to do with him and hasn't been forthright with any information. Staff C, SSD, said I did the psychosocial evaluation with Resident #8. I notified Resident #8's family member of the incident on 3/29/24. Resident #8's family did not want the [resident] in the solarium without facility staff. Staff C, SSD, said when Resident #8 was asked about the incident, there was no response. During the interview on 5/15/24 at 2:34 p.m. a situation between Residents #7 and #4 was discussed, Staff C, Social Services Director (SSD) said when Resident #7 was asked about the incident, the resident did not admit the incident occurred. Staff C, SSD, said 1:1 monitoring of Resident #7 was started immediately. Staff C, SSD, said Resident #4 does not remember anything from September. Resident #4 hangs out with others from the same culture and communicates in her [native language]. Resident #2 Review of Resident #2's admission record revealed initial admission to the facility was on 6/4/2023 with diagnoses of Parkinson's disease, major depressive disorder, heart failure, chronic kidney disease, dementia, hyperlipidemia, high blood pressure, encephalopathy, and dysphagia. Review of Resident #2's Minimum Data Set (MDS), quarterly dated 12/4/23, revealed a Brief Interview for Mental Status (BIMS) score of 4 out of 15, meaning severe cognitive impairment. Section GG for Functional abilities and goals revealed Resident #2 uses a wheelchair for mobility. Review of section E, Wandering - Presence and Frequency revealed Resident #2 wanders daily. Review of section J, Prognosis revealed Resident #2 has a medical condition or chronic disease that may result in a life expectancy of less than 6 months. Review of a care plan, created on 6/6/23, revealed Resident #2 has impaired cognitive function/dementia or impaired thought processes related to dementia, impaired decision-making, long-term memory loss, short term memory loss. The care plan's goal is Resident #2 will maintain current level of cognitive functioning. Review a of care plan, created on 2/26/24, revealed Resident #2 is receiving hospice services due to terminal diagnosis of Parkinson's disease. The care plan's goal is to keep Resident #2 comfortable throughout the end-of-life journey. Review of a care plan created on 3/4/24, revealed Resident #2 has a terminal condition related to Parkinson's disease. The care plan's goal is Resident #2's comfort to be maintained. Review of care plan, Resident #2 is at risk for cardiovascular complications related to congestive heart failure and high blood pressure. The care plan's goal is Resident #2 will have minimized complications related to cardiac (heart) condition. Review of the care plan created on 6/23/23, revealed Resident #2 at times wanders but is usually easily redirected to the nurses' station or day activities. The care plan's goal is Resident #2's safety will be maintained through next review date. Review of a care plan created on 9/17/23 revealed Resident #2 is impulsive and pulls wheelchair behind her difficult to redirect. The care plan's goal is Resident #2 will cooperate with care through the next review date. Review of order summary report revealed physician orders active as on 5/13/24 included 1) actively exit seeking, record number of occurrences every shift; 2) Hospice services for Parkinson's disease; 3) Trazodone for depression; 4) Metoprolol for Hypertension; 5) Morphine Sulfate 20 mg/ml (milligrams per milliliter) by mouth every 6 hours when needed for pain ; 6) Ativan 1 mg for anxiety every 4 hours as needed. Review of Resident #2's Determination of Incapacity, dated 4/5/24, and signed by two providers, revealed .resident lacks capacity to give informed consent to make medical decisions and does not have reasonable probability of recovering mental and physical capacity to directly exercise rights. Review of a psychiatric note, authored by the psychiatric-mental health nurse practitioner (PMHNP), dated 4/2/24. The history of present illness section revealed no reports of anxiety symptoms .no behaviors reported at this time. Resident #2's mental status examination section revealed the following: Appearance/ behaviors: confused. Mood: Patient mood is fine Affect: constricted Insight judgement: Impaired The plan of action section revealed continue medications, lorazepam for agitation intramuscularly (IM) three times daily as needed (PRN) for the next two weeks. Review of a subsequent psychiatric note, authored by the PMHNP, dated 4/17/24, section history of present illness revealed Prior to last visit, patient was doing well. Patient was not depressed or anxious. Patient had no behaviors reported. During the last visit, patient had no distress noted unit manager and director of nursing (DON) requested resident to be [evaluated] via tele psych due to patient having increase agitation and combativeness. Patient appeared irritable. Resident #2's mental status examination section revealed the following: Appearance/ behaviors: Well groomed, poor eye contact Mood: Patient mood is irritable Affect: Tensed Insight judgement: Impaired The sectioned titled assessment and plan revealed patient is unstable requiring medication changes .symptoms are occurring due to exacerbation of underlying .mood disorder. the symptoms occurring almost daily causing severe distress. The start medication section revealed Trazadone 25mg three times daily. On 5/13/24 at 9:48 a.m. during observation and interview, Resident #2 was found lying on her left side, linen up to her shoulders. Resident #2 opened her eyes when greeted, and nodded when asked if she was feeling okay. She did not respond verbally during the interaction. On 5/14/24 at 2:45 p.m. Resident #2 was observed in bed with her eyes closed. She appeared calm without any indication of pain or discomfort. On 5/17/2024 at approximately 3:40 p.m. Resident #2 was observed waking and was accompanied back to her wheelchair by staff. Review of a progress note, dated 4/17/24 at 10:42 p.m. authored by Staff CC, RN, revealed . Lorazepam was administered due to agitation. Review of Resident #2's facility progress note, dated 4/18/24 at 12:26 p.m. authored by Staff U, LPN, revealed resident noted very agitated refusing care combative Ativan 0.5 mg IM resident placed in crisis care by hospice with 24 hours at bedside. Review of Resident #2's facility progress note, dated 4/19/24 at 9:21 p.m. authored by Staff CC, RN, revealed . resident had increased agitation during the shift. Lorazepam 1 mg administered .to decrease agitation. Review of Resident #2's facility progress note, dated 4/23/23 authored by Staff EE, LPN revealed new order was given by the hospice nurse Lorazepam (Ativan) 1mg every four hours and d/c (discontinue Lorazepam 0.5 mg). Review of Resident #2's eINTERACT SBAR Summary for Providers note dated, 4/16/24 at 6:25 p.m., authored by Staff U, LPN, Unit Manager, revealed the change in condition (CIC) being reported is: other change in condition, and lists vital signs from 4/16/24 at 6:31 p.m. The section titled Outcomes of Physical Assessment revealed: Mental Status evaluation: No changes observed. Functional status evaluation: No changes observed. Behavioral status evaluation: No documentation Nursing observations, evaluation, and recommendation resident to resident altercation MD order resident out evaluation. Review of Resident # 2's progress notes, dated 4/16/24 at 5:00 p.m., authored by Staff C, SSD, revealed, resident was interviewed by writer and does not have memory of a male being in her room or a memory of anything happening to her .verbalized she was not feeling well and was in pain. Review of Resident # 2's progress notes, dated 4/16/24 at 4:02 p.m., authored by Staff DD, RN, revealed tele health done, no new orders. A review of Resident #2's Emergency Department Discharge instructions, dated 4/15/24, section titled, Tests Performed, revealed blood tests for hepatitis and HIV screen were performed. Section titled: Education Material revealed Treating sexual assault. Resident #4 Review of Resident #4's admission record revealed the initial admitted was on 8/11/23 with diagnoses including gastroesophageal reflux disease, hyperlipidemia (high fat content in the blood), dementia, mood disturbance, Alzheimer's disease, cerebral atherosclerosis (buildup of plaque in the artery) major depressive disorder, generalized anxiety disorder, other persistent mood disorders and brief psychotic disorder. Review of Resident #4's Minimum Data Set (MDS), quarterly dated 4/21/24, revealed a Brief Interview for Mental Status (BIMS) score 1 out of 15 meaning severe cognitive impairment. Section GG for Functional abilities and goals revealed Resident #4 walks independently and is dependent with personal hygiene. Review of Resident #4's Determination of Incapacity, dated 2/2/24, and signed by two providers revealed .resident lacks capacity to give informed consent to make medical decisions and does not have reasonable probability of recovering mental and physical capacity to directly exercise rights. On 5/13/24 at 11:30 a.m. Resident #4 was observed sitting on the side of her bed. English is a second language for Resident #4 and an interpreter was used for communication. Resident #4 said she was doing well and did not have any concerns. On 5/114 at 2:15 p.m., Resident #4's family member was contacted by telephone and said they would return the phone call with another family member due to language barrier. A return call was not received. Review of Order Summary Report active orders as of 5/15/24 reveal Resident #4: 1) actively exit seek, record interventions. admitted to hospice on 10/23/23 related to diagnosis of cerebral atherosclerosis. 2) Attest that rounding with visualization of resident has been completed every two hours during the shift, ordered on 8/22/23. Resident #4's Depakote for mood disorder, Trazadone for depression, Paxil for depression, Zonisamide for seizures, and Olanzapine for psychosis. A review of the care plan focus created on 8/14/23 revealed Resident #4 had potential for pain related to muscle weakness and terminal prognosis, and the care plan's goal was Resident #4 will not experience a decline in overall function. A care plan created on 8/20/23 revealed Resident #4 was at risk for complications due to being incontinent of urine and bowel. At risk for developing areas of impaired skin integrity and UTIs (Urinary Tract Infections). The goal was to minimize Resident #4's risk for skin breakdown and infection. A care plan created on 8/14/23 revealed Resident #4 was an elopement risk/wanderer related to impaired safety awareness, resident wanders aimlessly. The care plan's goal was Resident #4's safety will be maintained through the next review date. A review of the care plan created on 8/13/23 revealed Resident #4 had potential to be physically aggressive related to dementia, history of harm to others, poor impulse control, and inappropriate behaviors. The care plan goal was Resident #4 will not harm self or others through the next review date. A review of the care plan created on 8/14/23 revealed Resident #4 had impaired cognitive function/dementia or impaired thought processes related to dementia, impaired decision making, and short-term memory loss. The care plan goal was Resident #4 will maintain level of cognitive function through the review date. A review of Resident #4's care plan focusing on impaired thought process related to dementia, impaired decision making and short-term memory loss, initiated on 8/14/23, stated the care plan goal was resident will maintain the current level of cognitive function through review date. The care plan interventions include cue, reorient and supervise as needed. A review of Resident #4's progress note dated 9/5/23 at 11:25 p.m. revealed .Resident was observed by staff in room with [Resident #1], at this time resident was without clothing, resident was redirected .family member and physician notified. Resident #8 Review of Resident #8's admission record revealed initial admission to the facility was on 6/29/20 with diagnoses of cerebral atherosclerosis, depression, dementia, psychotic disturbance, anxiety, pseudobulbar affect (condition that affects how the brain controls emotion), high blood pressure, type 2 diabetes, pressure ulcer (sore) right hip. Review of Resident #8's active orders as of 5/14/24 revealed: 1) hospice services effective 7/6/23 for cerebral atherosclerosis. 2) attest that rounding with visualization of resident every 2 hours. 3) Hydrocodone with acetaminophen every 12 hours as needed for pain. 4) Levothyroxine for hypothyroidism. 5) Trazodone for depression. Review of Resident #8's Minimum Data Set (MDS) quarterly, dated 4/5/24, revealed a Brief Interview for Mental Status (BIMS) score of 99, meaning severe cognitive Impairment. Section F, Preferences for Customary routine Activities, revealed Resident #8 is rarely/never understood and family/significant is not available. Section GG, Functional Abilities and Goals, reveals Resident #8 uses a wheelchair and is dependent on staff for mobility and self-care. On 5/14 at 3:17 p.m. Resident #8 was observed sitting in a Geri chair by the nurses' station. Her eyes were open; she did not react to greetings or respond to questions. Review of Resident #8's Determination of Incapacity, dated 6/8/20, and signed by two providers, revealed .resident lacks capacity to give informed consent to make medical decisions and does not have reasonable probability of recovering mental and physical capacity to directly exercise rights. Review of care plan focus revealed Resident #8 was at risk for skin breakdown. The care plan's goal was Resident #8's Risk for skin breakdown will be minimized through next review. Review of care plan focus revealed Resident #8 had a pressure wound to right hip. The care plan goal was Resident #8 wound will heal without complications. Review of care plan revealed Resident #8 had diabetes and was at risk for high and low blood sugars. The care plan's goal was Resident #8 will remain free from complications related to high and low blood sugars. Review of care plan focus revealed Resident #8 was at risk for decreased ability to perform activities of daily living in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting. The care plan goal revealed Resident #8 will continue to participate in activities of daily living as tolerated. Review of care plan revealed Resident #8 had the potential for pain related to wound, diabetes and depression. The care plan's goal was Resident #8 will not experience a decline in overall function. Review of care plan focus revealed Resident #8 was at risk for complications due to being incontinent of urine and bowel related to impaired cognition and impaired mobility. The care plan goal was Resident #8 will minimize the resident's risk of skin breakdown through the next review date. Review of care plan focus revealed Resident #8 was receiving Hospice services as of 7/6/23 for diagnosis of cerebral atherosclerosis. The care plan goal was Resident #8 will be kept comfortable throughout the end-of-life journey. Review of care plan focus revealed Resident #8 had a terminal condition related to cerebral atherosclerosis. The care plan's goal was Resident #8's comfort will be maintained through next review date. Review of care plan focus revealed Resident #8 had impaired cognitive function/dementia or impaired thought processes related to dementia. The care plan goal was Resident #8 will maintain current cognitive function through review date. Review of Resident #8's Psychiatry Subsequent Note, authored by the psychiatric-mental health nurse practitioner (PMHNP), date of service (DOS) 3/29/24, the History of Present illness section, revealed . as per collected information, DON requested patient to be seen as patient was touched by a male patient. Patient did not respond to providers questions but appears to be lying comfortably with eyes open. No noted signs or symptoms of distress. No other psychiatric symptoms observed. Dementia is persistent, but no behaviors noted. The Mental status examination section revealed; Appearance/ Behaviors: calm, Mood: stable, Affect: appropriate, Insight and Judgement: Impaired. The Plan of action section revealed no medication changes. Resident #1 Review of Resident #1's admission record revealed initial admission to the facility was on 6/22/2023 with diagnoses of Syncope and collapse, Hyperlipidemia, Dementia, Anxiety Disorder, Depressive Disorder, Persistent Mood Disorders, Insomnia, Essential hypertension, Muscle weakness and bradycardia. Review of Resident #1's Determination of Incapacity, dated 3/7/24, and signed by a provider revealed .resident lacks capacity to give informed consent to make medical decisions and does not have reasonable probability of recovering mental and physical capacity to directly exercise rights. Review of Resident #1's Minimum Data Set (MDS) quarterly, dated 3/22/24, revealed a Brief Interview for Mental Status (BIMS) score of 7 out of 15, meaning moderate cognitive Impairment. Functional Abilities revealed he was independent in walking and transferring from bed to chair. Behaviors showed he had verbal behaviors directed towards others and other behavioral symptoms. He exhibited wandering in the past one to three days. Review of the Facility's progress notes, order summary report and interviews for Resident #1 revealed the following: 7/19/23 transferred to the facility's memory unit due to behaviors. Resident #1 was reported to inappropriately touch and attempt to kiss staff. On 9/5/23 Resident #1 and Resident #4 were observed naked in Resident #1's bedroom. On 9/6/23 he was moved to a room on the opposite hallway away from Resident #4. On 9/8/24 Depakote 250 mgs was prescribed for mood disorder. On 11/6/23 and 12/16/23 Resident #1 had physical and verbal altercations with other residents. On 12/17/23 Resident #1's room was changed due to the 12/16/23 altercation with his roommate. On 2/6/24 resident was redirected because of inappropriate conversation with a female resident. On 2/7/24 Resident #1 was observed exhibiting inappropriate sexual behaviors. On 3/5/24 Resident #1 was observed following a female resident, when redirected he became agitated and said, he can if he wants to. On 4/15/24 Resident #1 was masturbating while Resident #2 was watching. On 4/16/24 Resident #1 was observed in Resident #2's room engaged in oral sex. Review of Resident #1's care plans revealed the following focus Resident #1 is at risk for hypersexual behaviors. Resident is inappropriate at times with others, initiated on 10/13/2023. The care plan goal was Resident #1 will be free from inappropriate sexual behaviors through next review, initiated on 10/13/2023. The interventions included medication adjustments, initiated on 12/21/23. Monitor each shift for inappropriate sexual behaviors, initiated on 10/13/23. Resident 1:1 supervision, initiated on 4/17/24. Review of Resident #1's care plans revealed the following focus Resident can be sexually inappropriate with others, initiated on 7/5/23 and revised on 4/30/24. The goal was Resident #1 will cooperate with care through next review date, initiated on 7/5/23. The interventions included psych consult with medication adjustments, initiated on 9/8/23. Review of Resident #1's care plans revealed the following focus: Resident #1 has poor impulse control, initiated on 11/6/23. The goal is Resident will not harm self or others through review date, initiated on 11/6/23. The interventions included psychiatric/psychogeriatric consult as indicated, initiated on 11/6/23. Redirect others as needed from his room, initiated 11/14/23. Review of Resident #1's care plans revealed the following focus: Resident #1 has impaired cognition impaired decision making, initiated on 6/26/23. The goal was Resident will maintain current level of cognitive function through the review date, initiated on 6/26/23. The interventions included cue, reorient and supervise as needed, initiated on 6/26/23. Review of the facility's care plan meeting minutes quarterly, dated 4/9/24, revealed 4 signatures for the team members in attendance. The Discussion section listed the following: Discharge Plans: Long Term Care (LTC) Advanced Directive: Full Code incapacity Acute Medical Conditions: No documentation Chronic Medical Conditions: hypertension (HTN) and hyperlipidemia Skin/ Wound Conditions: Within Normal Limits (WNL) Nutrition/ Hydration: Regular thin liquid Bowel/ Bladder: Continent Rehabilitation Service: No documentation Physical Function: requires assist to complete ADL's. Behavioral Health/ Activities: No documentation Resident/ Family Concerns: No Documentation Review of Resident #1's Order Summary Report, Active orders as of 5/13/24 revealed the following: 1:1 supervision every shift, start date 4/30/24 Observe sexual behaviors. Document 'Y' if resident has behaviors and 'N' if the resident does not have behaviors. If 'Y' document in the progress notes (PNs) and notify provider, start date 4/30/24. Depakote 250 mg three times daily for mood disorder. Estradiol 2 mg twice daily for hypersexual behaviors Lithium 150 mg twice daily for mood disorder, the start date is 5/11/24. Paroxetine 20 mg daily for Major Depressive Disorder (MDD) Trazodone 50 mg for depression. Review of Resident #1's facility progress note, dated 8/24/23 at 2:29 p.m. authored by Social Services, revealed notified by staff resident has been inappropriate at times, attempts to hit them on butt and has attempted to kiss them. Review of Resident #1's facility progress note, dated 9/5/23 at 9:32 p.m. authored by Staff FF, LPN, revealed Resident is alert, resident was observed with a female resident in his bed. Resident was not dressed he was redirected to get dressed . [family member] was informed of incident and that there will also be a room change . MD was notified. Review of Resident #1's facility progress note, dated 9/5/23 at 10:17 p.m. authored by Staff GG, LPN, revealed Resident is alert oriented able to make needs known, Resident was observed by staff in a female resident room with missing clothing, resident was redirected, call was placed to [family member] to inform her of current situation, .MD notified .room was changed and staff to constantly monitor resident and redirect as needed. Review of Resident #1's facility progress note, dated 11/6/2023, Nursing, revealed, Resident pushed another resident from his room to the floor on the hallway floor. Resident's family member and MD aware, psych consult, increase Trazadone 25 mg po bid and 50 mg po [milligrams by mouth twice a day] at night, resident stated he is not sleeping at night. Review of Resident 1's facility progress note, dated 12/16/2023, Nursing, revealed, Resident became aggressive towards roommate, started yelling and cursing because roommate stated he was wearing his clothes. Review of Resident1's facility progress note, dated 12/17/2023, Nursing, revealed, Resident had a room change. Review of Resident #1's progress note, dated 2/7/2024 at 9:02 a.m., Social Service Note, Resident was noted to exhibit inappropriate sexual behaviors. Resident was redirected and was currently on every hour checks. Psych was notified for consult. MD was notified regarding behaviors. Resident will be placed on 1:1 observation with staff. Review of Resident #1's progress note dated 3/5/2024 at 8:58 a.m., Nursing, revealed Resident observed following a female resident, when redirected he became agitated and said, he can if he wants to. Review of Resident #1's facility progress note, dated 4/16/24 at 4:08 p.m. authored by Staff FF, LPN, revealed Resident is alert, resident was observed in another resident room inappropriate sexually with another resident. Resident told staff he had no regrets, Resident was removed from the situation and placed on 1:1 supervision. [family member] and MD notified. Review of Resident #1's Medication Administration Record/Treatment Administration Record, dated April 2024, revealed sexual behaviors were observed 4/15/24, on the night shift and 4/22/24 on the day and night shifts. Review of resident #1's progress notes dated 4/15/24 and 4/22/24 did not describe the behaviors or if the medical team was notified as ordered. Review of a Psychiatry Subsequent Note, authored by the psychiatric-mental health nurse practitioner (PMHNP), date of stay (DOS) 4/5/24 revealed the following: The Reason for Today's encounter: .medication management, Mental Status Exam: Appearance Behaviors: Disheveled Mood: Patient mood is okay Affect: Appropriate Insight and Judgement: Impaired The summaries section revealed the following: On 7/7/23 the patient is at base line, no medication changes. On 7/21/23 the patient was referred to neurology On 8/25/23 discontinued Zoloft, started Trazadone 25 mg three times daily and Estradiol 1 mg daily. On 9/8/23 started Depakote 250 mg twice daily On 11/6/23 Increased Trazadone to 25 mg in the morning and at noon and 50mg at bedtime. Discontinued 1:1 sitter. On 2/9/24 Patient has sexually inappropriate behaviors. On 4/5/24 Patient is at baseline, no medication changes. Plan of action .Depakote is needed for mood disorder, Estradiol to control symptoms of sexual disinhibition and Trazadone for manag [TRUNCATED]

Based on observations and interviews, the facility failed to dispose of and maintain garbage and refuse in a sanitary manner. The findings included: In an observation conducted on 01/22/24 at 7:04 AM of the outside dumpster area, the following were noted: 2 large dumpster bins, with one open bin and garbage overflowing outside. Closer observation showed debris that consisted of dirty gloves, linens, plastic utensils, and plastic bottles. Three large garbage bags were sealed and placed near the first closed dumpster. The two dumpster bins were located right outside the entrance to the central kitchen. Photographic Evidence Obtained. In an interview conducted on 01/22/24 at 8:00 AM, Staff K, Certified Nursing Assistant (CNA), stated that the dumpster bins get picked up daily. When asked if they are also picked up on the weekend, she said: Not always. Staff K reported that she usually gets to the facility around 6:15 AM and that by 6:30 AM, they come to empty the dumpsters. Another observation conducted on 01/22/24 at 7:41 AM, accompanied by the Certified Dietary Manager (CDM) revealed two large dumpster bins, one closed and the other opened, with garbage overflowing at the top. Closer observation showed dirty gloves, plastic medicine cups, and other debris behind the two large dumpsters. In this observation, the CDM said the garbage dumpsters get picked up three times a week, on Mondays, Wednesdays, and Fridays. Photographic Evidence Obtained. In an observation conducted on 01/22/24 at 4:28 PM, one dumpster was opened with debris and carton boxes overflowing on the top. Other debris and carton boxes were noted all around the dumpster. Continued observation showed three large round bins with garbage inside and no lids. Photographic Evidence Obtained. A further observation on 01/23/24 at 8:12 AM revealed debris of dirty used gloves, plastics, and wood. Further observation showed two large round garbage bins with garbage inside and no lids. In an interview with the facility's Administrator on 01/25/24 at 5:00 PM, he was told of the findings.

Based on observations, interviews, and record reviews the facility failed to maintain the medical records for 7 of 32 sampled residents, Resident #80, 88, 93, 153, 94, 57, and 34 in a manner that was complete, accurate, and systematically organized. The findings included: Review of the facility's policy titled Documentation in Medical Record, dated ,d+[DATE] revealed the following- each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred. 1) Resident #80 was admitted to the facility on [DATE]. She had a medical history significant for Depression and Schizophrenia. During the initial tour of the facility conducted on [DATE] at 7:35 AM, the surveyor noted a paper taped inside the nurse's station, titled Unit Update for 1st Floor Supervision that documented Resident #80 was ordered to have every 30-minute checks. This paper did not specify the reason for the increased supervision. A Quarterly Minimum Data Set (MDS) done on [DATE] documented Resident #80 had a Brief Interview of Mental Status (BIMS) score of 1, which indicates she was severely cognitively impaired. Review of Resident #80's Care Plans revealed Resident #80 had a history of aggressive behaviors toward other residents and that she was identified as an elopement risk. Review of Resident #80's physician orders revealed an order was written from [DATE] to [DATE] for continue Q15 [every 15] minute behavior monitoring every shift and a new order was written on [DATE] for continue Q30 minute behavior monitoring every shift. An interview was conducted on [DATE] at 8:34 AM with Staff F, Certified Nursing Assistant (CNA). She explained that the CNAs perform the ordered checks and that they document them on a clipboard that is kept behind the nurse's station. She said every day the forms are collected by the nurse manager and are taken somewhere, but she did not know where. She said she did not know why Resident #80 was on safety checks. She said she was not performing the safety checks that day and was unable to tell the surveyor which staff member was. An interview was conducted on [DATE] at 10:08 AM with Staff G, CNA. Staff G was observed holding a purple clipboard and she confirmed she was tasked with performing the safety checks for the day. She said Resident #80 required safety checks because she falls. She stated she did not know where the safety check sheets were kept after they were removed from the clipboard. An interview was conducted on [DATE] at 10:35 AM with Staff B, Licensed Practical Nurse (LPN). She confirmed she was assigned to Resident #80 and that the safety checks were ordered because she gets up on her own a lot. She said the safety check sheets were uploaded into the Documents tab on the electronic health record. Review of the behavior monitoring sheets revealed there was not consistent documentation of these physician ordered behavior monitoring checks. Of the 50 days (from [DATE] to [DATE]) Resident #80 had behavior monitoring checks ordered, there were 28 forms documented. This indicates the documentation of the ordered behavioral checks was not accurate for Resident #80. 2) Resident #88 was admitted to the facility on [DATE]. He had a medical history significant for Encephalopathy, Dementia, Anxiety, and Depression. During the initial tour of the facility conducted on [DATE] at 7:35 AM, the surveyor noted a paper taped inside the nurse's station, titled Unit Update for 1st Floor Supervision that documented Resident #88 was ordered to have every 1-hour checks, document if there is any inappropriate sexual behavior. A Quarterly MDS done on [DATE] documented Resident #88 had a BIMS score of 7, which indicates he was severely cognitively impaired. Review of Resident #88's Care Plans revealed Resident #88 had a history of hypersexual and physically aggressive behaviors toward other residents. Review of Resident #88's physician orders revealed an order was written from [DATE] to [DATE] for behavior monitoring Q30 minutes every shift, then from [DATE] to [DATE] for increased supervision every 1 hour checks for safety every shift, then from [DATE] to [DATE] for 1 on 1 close observation every shift for behavior monitoring, then from [DATE] to [DATE] for 15 minute check with supervision every shift for behavior monitoring, then from [DATE] to [DATE] for 30 minute check with supervision every shift for behavior monitoring, and finally [DATE] for Q1 hour checks for increased supervision every shift for behavior monitoring. An interview was conducted on [DATE] at 8:34 AM with Staff F, CNA. She explained that the CNAs perform the ordered checks and that they document them on a clipboard that is kept behind the nurse's station. She said every day the forms are collected by the nurse manager and are taken somewhere, but she did not know where. She said she did not know why Resident #88 was on safety checks. She said she was not performing the safety checks that day and was unable to tell the surveyor who was. An interview was conducted on [DATE] at 10:08 AM with Staff G, CNA. Staff G was observed holding a purple clipboard and she confirmed she was tasked with performing the safety checks for the day. She said Resident #88 required safety checks because he walks a lot. She then clarified Resident #88 was an elopement risk. She stated she did not know where the safety check sheets were kept after they were removed from the clipboard. She said she was unaware of his hypersexual behaviors. An interview was conducted on [DATE] at 10:39 AM with Staff C, LPN. She confirmed she was assigned to Resident #88 and that the safety checks were ordered because he was at risk of wandering and elopement. She said she was unaware of his hypersexual behaviors. Review of the behavior monitoring sheets revealed there was not consistent documentation of these physician ordered behavior monitoring checks. Of the 50 days (from [DATE] to [DATE]) Resident #88 had behavior monitoring checks ordered, there were 28 forms documented. This indicates the documentation of the ordered behavioral checks was not accurate for Resident #88. 3) Resident #93 was admitted to the facility on [DATE]. He had a medical history significant for Encephalopathy, Dementia, Alzheimer's Disease, and Bipolar Disorder. During the initial tour of the facility conducted on [DATE] at 7:35 AM, the surveyor noted a paper taped inside the nurse's station, titled Unit Update for 1st Floor Supervision that documented Resident #88 was ordered to have every 15-minute checks. This paper did not specify the reason for the increased supervision. A Quarterly MDS done on [DATE] documented Resident #93 had a BIMS score of 3, which indicates he was severely cognitively impaired. Review of Resident #93's Care Plans revealed Resident #93 had a history of attempted facility elopement. Review of Resident #93's physician orders revealed an order was written from [DATE] to [DATE] for 1:1 check with supervision every shift and then on [DATE] for Q15 minute checks for increased supervision every shift for monitoring. An interview was conducted on [DATE] at 8:34 AM with Staff F, CNA. She explained that the CNAs perform the ordered checks and that they document them on a clipboard that is kept behind the nurse's station. She said every day the forms are collected by the nurse manager and are taken somewhere, but she did not know where. She said she did not know why Resident #93 was on safety checks. She said she was not performing the safety checks that day and was unable to tell the surveyor who was. An interview was conducted on [DATE] at 10:08 AM with Staff G, CNA. Staff G was observed holding a purple clipboard and she confirmed she was tasked with performing the safety checks for the day. She said Resident #93 required safety checks because he sometimes fights with other residents. She stated she did not know where the safety check sheets were kept after they were removed from the clipboard. She said she was unaware that Resident #93 was an elopement risk but that there was an additional CNA used daily as a hall monitor to ensure residents did not elope. An interview was conducted on [DATE] at 10:39 AM with Staff C, LPN. She confirmed she was assigned to Resident #93 and that the safety checks were ordered because he was at risk of wandering and elopement. Review of the behavior monitoring sheets revealed there was not consistent documentation of these physician ordered behavior monitoring checks. Of the 14 days (from [DATE] to [DATE]) Resident #93 had behavior monitoring checks ordered, there were 11 forms documented. This indicates the documentation of the ordered behavioral checks was not accurate for Resident #93. 41837 4) Record review for Resident #57 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Alzheimer's Disease, Bipolar Disorder, Dementia, Post-Traumatic Stress Disorder, and Anxiety. Review of the Minimum Data Set (MDS) for Resident #57 dated [DATE] revealed in Section C a Brief Interview of Mental Status (BIMS) score of 5, indicating severe cognitive impact. Review of the Physician's Orders for Resident #57 dated [DATE] for Do Not Resuscitate (DNR). Review of the Care Plan for Resident #57 dated [DATE] with a focus on the resident has an established CPR (Cardiopulmonary Resuscitation) (Full Code) order in place. The goal is to make the resident wishes for code status to be followed through the next review date. The Interventions included: Activate the resident's advanced directives as indicated. Notify the physician of resident's wishes regarding life prolonging procedures. This indicates the advance directive care plan regarding code status for Resident #57 was never updated to reflect the DNR status. Review of the DNR form in the resident's Electronic Medical Record (EMR) was unsigned by the physician. Review of the Do Not Resuscitate (DNR) form had no physician signature on the DNR form in the yellow DNR binder located in the medication room. The SSD stated there has been a back log of uploading documents into the EMR from the old system prior to switching to the current EMR system they are using. An interview was conducted on [DATE] at 9:16 AM with the Social Service Director (SSD) who stated she has worked at the facility for 4 years. She stated upon the admission of a resident, the code status is addressed, and it is verified with the resident/resident representative. The SSD stated the quarterly care plans will readdress unresolved advance directive concerns/issues. For a resident who want a code status of DNR (Do Not Resuscitate) the resident or the family will sign the yellow DNR form, she then gets the physician to sign it and the nurse will get the order for the DNR and will put that into the resident's EMR (Electronic Medical Record). In the state of Florida to legally be a DNR they have to have the physician order and the yellow form with Florida insignia on it signed by the responsible party and the physician. There was a physician who signed the DNR form dated [DATE] (before the resident was admitted to the memory care unit at the facility). On [DATE] there was a Certification of Incapacity to Make Informed Healthcare Decision signed by physician (prior to admission to the memory care unit at the facility) and based on this form the facility reached out to the daughter of Resident #57 about the code status for the resident. When the SSD spoke to the daughter, the daughter was adamant the resident was a DNR status. The facility obtained verbal consent from the daughter for the DNR status, and the form needed to be signed by the physician. The SSD verified the DNR form in the resident's EMR was unsigned by the physician. The SSD stated all DNRs are in the yellow binder in the med room. The SSD stated she is the person responsible to make sure the DNR binder is updated at all times. The SSD verified there was no physician signature on the DNR form in the yellow DNR binder located in the medication room. During an interview conducted on [DATE] at 10:30 AM with Staff A Licensed Practical Nurse/Unit Manager (LPN/UM) who stated he has been working at the facility since [DATE]. When asked where he would look to know the code status of a resident, he stated it is at the top of the computer for each resident. During an interview conducted on [DATE] at 10:35 AM with Staff C Licensed Practical Nurse (LPN) who stated she has worked at the facility for 2 months. When asked where she would look to know the code status, she said she would look the resident up in the computer and it is at the top of the computer under the resident's name. 5) Record review for Resident #94 revealed the resident was admitted to the facility on [DATE] with diagnosis that included: Vascular Dementia Mild With Agitation. Review of the MDS for Resident #94 dated [DATE] revealed in Section C a Brief Interview of Mental Status score of 0, indicating severe cognitive impairment. Review of the Physician's orders for Resident #94 revealed an order dated [DATE] for Resident is on 1:1 for ,d+[DATE] and ,d+[DATE] and 15 mins at night. The order was discontinued on [DATE]. Review of the Physician's orders for Resident #94 revealed an order dated [DATE] for Resident is on 1:1 for ,d+[DATE] and ,d+[DATE] and 30 mins at night shift. The order was discontinued on [DATE]. Review of the Physician's orders for Resident #94 revealed an order dated [DATE] for Resident is on 1:1 for ,d+[DATE] and ,d+[DATE] and every 1 hr. (hours) at night shift. The order was discontinued on [DATE] Review of the Physician's orders for Resident #94 revealed an order dated [DATE] for Resident is on 1:1 for ,d+[DATE] and ,d+[DATE] until Resident Goes to Bed. The order was discontinued on [DATE]. Review of the Physician's orders for Resident #94 revealed an order dated [DATE] for Resident is on 1:1 for ,d+[DATE] and ,d+[DATE] until Resident Goes to Bed Once resident in bed change to 15min checks. The order was discontinued on [DATE]. Review of the Physician's orders for Resident #94 revealed an order dated [DATE] for Resident is on 1:1 for ,d+[DATE] and ,d+[DATE] until Resident Goes to Bed. The order was discontinued on [DATE]. Review of the Physician's orders for Resident #94 revealed an order dated [DATE] for ,d+[DATE] Q 15-minute checks, 1:1 supervision for ,d+[DATE] until he goes to bed. Review of the Care Plan for Resident #94 dated [DATE] with a focus on the resident is resistive to care, shower, getting changed, and dressed, disrobes throwing BM (Bowel Movement), combative with staff swinging his arms resident has h/o of aggressive behaviors, prior to admission was on hospice for behavior management. Resident attempts to push other residents. Aggressive with his roommate. The goal is for the resident to cooperate with care through the next review date. The interventions included: 15 minute check ,d+[DATE], 1:1 ,d+[DATE] until resident goes to bed. Allow the resident to make decisions about treatment regime, to provide sense of control. If the resident resists with ADLs, reassure the resident, leave, and return ,d+[DATE] minutes later and try again. Psych consult with medication adjustments. Redirect resident from pushing others, resident enjoys music and dancing. Review of the Safety Check Logs for Resident #94 from [DATE] to [DATE] revealed no Safety Check Logs for the following dated: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and 1 Safety Check Log had no date. This indicated, not all of the Safety Check Logs are in the EMR for Resident #94. During an interview conducted on [DATE] at 11:00 AM With Staff C, Licensed Practical Nurse (LPN), who stated she has worked at the facility for 2 months. When asked about residents who are on 1:1 observations or observations every 15 minutes, where is this documented, the LPN stated for resident who are on 1:1 or every 15-minute observations, they are monitored by the Certified Nursing Assistants (CNAs) and document on an observation sheet. The CNA will notify the nurse of any issues. During an interview conducted on [DATE] at 11:30 AM with Staff B, Licensed Practical Nurse (LPN), who stated she has worked at the facility for 1 year. When asked about the documentation for residents who are on 1:1 or every 15-minute observations, she stated the residents who are on 1:1 or every 15 minute checks are done by the CNA or a nurse and it is documented on the observation sheet and if any issue the CNA will report to the nurse. During an interview conducted on [DATE] at 11:50 AM with Staff A, Licensed Practical Nurse Unit Manager (LPN/UM), who stated he has been with the facility since August/September. When asked where the Safety Check Logs are located, he stated they should be in the resident's chart under documents. 39026 6) Resident #153 was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes, Heart Failure, and Hypertension. He was admitted with a suprapubic catheter. During record review on [DATE] at 10:00 AM for Resident #153, there were no physician orders for catheter care. There also was no care plan for catheter care. A review of the order summary report revealed the orders for catheter care were initiated on [DATE]. Discussed with the Director of Nurses on [DATE] at 4:00 PM. 40153 7) A record review revealed that Resident #34 was readmitted to the facility on [DATE] with diagnoses of Gastrostomy, Psychotic disturbances, and Dementia. The Physician's orders showed the following: clarification order for Resident #34 to begin one meal a day- lunch: puree solids and thin liquids, dated [DATE]. An order for tube feeding is to be administered with Jevity 1.2 (tube feeding formulary) continuously at 60 milliliters (ml) an hour for 24 hours/day, dated [DATE]. Start tube feeding at 2:00 PM for 20 hours dated [DATE]. Another order was noted for Nothing by Mouth, with the exception of the Speech Therapist to introduce food/fluids consistency for enteral feeding, which was started on [DATE] and discontinued on [DATE]. An observation conducted on [DATE] at 12:28 PM showed Resident #34 with a lunch tray and the tube feeding on hold. Closer observation showed Staff X, Speech Language Pathologist, at the bedside assisting Resident #34 with her lunch tray. The lunch meal was noted with pureed roast turkey, pureed collard greens, pureed mashed potatoes, and a slice of soft cake. The meal ticket revealed the following: regular pureed with Nothing by Mouth (NPO), do not send tray, on the top and bottom of the meal ticket. In this observation, Staff X stated that Resident #34 was not eating by mouth until last Thursday and that she upgraded Resident #34 ' s diet. The diet was upgraded to a one-a-day, pureed diet with trials of mechanical soft. According to Staff X, they are trying to wean Resident #34 from tube feeding, so they started with one meal a day. When asked by the Surveyor if she was the only one who could assist Resident #34 with her lunch meals, she said no and that any staff members could help her during mealtimes. The Surveyor asked Staff X if she knew why it said NPO/do not send a tray on the meal ticket; she did not know. In an observation conducted on [DATE] at 12:30 PM, Resident #34 was noted in the main dining room on the 2nd floor. A closer observation showed Staff X sitting near Resident #34 and assisting her with the lunch meal. The Surveyor asked Staff X if she found out why the meal ticket still says NPO/do not send a tray. She said, You need to ask the main kitchen. They are the ones who print out the meal tickets. A review of the Medication Administration Record for the month of [DATE] showed that the orders to start the tube feeding at 2:00 PM for 20 hours were documented as done daily, and the tube feeding Jevity 1.2 to run for 24 hours at 60 ml an hour was documented as done on a daily basis. In an interview conducted on [DATE] at 1:42 PM with Staff L, Licensed Practical Nurse, she stated that when she was asked earlier if any staff member could assist Resident #34 during the lunch meal, and she said yes, it was incorrect. When asked by Surveyor as to why she marked both tube feeding orders as above as completed, she stated that it was an oversight on her part and that both tube feeding orders contradict each other.

Based on observations, interviews, and record reviews, the facility failed to have an effective pest control program. The findings included: A review of the policy titled, Pest Control Program, revised on 01/06/23, revealed the following: It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. The facility will maintain a written agreement with a qualified outside pest service to provide comprehensive pest control services regularly and regularly. The facility will maintain a reporting system of issues arising between scheduled visits with the external pest service and treat them as indicated. An observation conducted on 01/22/24 at 7:34 AM, in the main kitchen showed pests in all stages of life near the food production area. Continued observation showed pests in all stages of life in the dishwasher room on the floor. In this observation, the Certified Dietary Manager said that the pest control company comes into the kitchen twice a month to treat pests. An observation conducted on 01/22/24 at 3:05 PM, in the 2nd-floor Nourishment room revealed pests in all stages of life. An observation conducted on 01/22/24 at 3:12 PM, in the 1st-floor hallway, near the elevator showed a live pest. In an interview conducted on 01/22/24 at 3:20 PM with Staff A, the Unit Manager stated that he had not seen any sightings of pests on the 1st floor. He further said that if there are any sightings of pests, they will write them in the pest control book that is located on the unit. This is later reviewed by the pest control company when they come into the facility to spray. An observation conducted on 01/23/24 at 10:54 AM, in the 1st-floor unit, near room [ROOM NUMBER] revealed pests in all stages of life. In an observation conducted on 01/23/24 at 11:00 AM, in the elevator with Staff A present, a roach-like insect was seen moving on the elevator floor. Staff A then stomped on the insect and stated, I will have to put this in the pest control sighting book. A record review conducted on 01/24/24 of the insect log sighting book on the first floor revealed that the insect sighting in the elector was not documented by Staff A. An observation conducted on 01/23/24 at 11:01 AM, in the 1st-floor unit, near the fish tank revealed pests in all stages of life. In this observation, an additional sighting of pests in all stages of life was noted near the nurse ' s station. An observation conducted on 01/24/24 at 11:00 AM, on the 1st-floor unit, behind the fish tanks revealed pests in all stages of life. A record review of the Service Log located on the 1st floor revealed that Nursing reported a pest sighting on the 1st floor near room [ROOM NUMBER] on 01/22/24, which did not show that the service was completed. A record review of the Pest Control Sighting Log revealed that eight pest sightings were documented on the type of pests, locations, and the person who reported the sighting. Further review did not show that it was addressed or treated by pest control. In an interview conducted on 01/25/24 at 8:06 AM, the Maintenance Director stated that he started working in this facility about six weeks ago. He noticed they had pest issues, which were mostly on the 1st floor. The Administrator gave him a contact number for a pest control company. He reached out and was told that because of pending invoices, they would not come anymore. The Maintenance Director expressed concern to the Administrator regarding the pending invoices that were not paid and that the pest company would not come to treat the affected areas. According to the Maintenance Director, a new pest control company treated the building this week and last. No current invoices were provided, the last invoice provided was dated 12/22/23. In an interview conducted on 01/25/24 at 5:15 PM, the Administrator stated that he was aware of pests sighting around the facility. When the pest control company comes in for their routine visits, they will first look in the pest control sighting log to spot-treat the specific areas as needed. After the areas are treated, the book is signed and dated as treated.

Based on interviews and record review, the facility failed to provide documentation of offering/acceptance/declination of the pneumococcal vaccine for 4 out of 5 sampled residents reviewed for vaccines (Residents #9, #53, #69, and #94). The findings included: Review of the facility's policy titled, Pneumococcal Vaccine (Series) Policy with a reviewed/revised date of 01/31/22 included: It is our policy to offer our residents, staff, and volunteer workers immunization against pneumococcal disease in accordance with current CDC (Center for Disease Control) guidelines and recommendations. Each resident will be assessed for pneumococcal immunization upon admission. Self-report of immunization shall be accepted. Any additional efforts to obtain information shall be documented, including efforts to determine date of immunization or type of vaccine received. The type of pneumococcal vaccine (PCV15, PCV20, or PPSV23/PPSV) offered will depend upon the recipient's age and susceptibility to pneumonia, in accordance with current CDC guidelines and recommendations. A pneumococcal vaccination is recommended for all adults [AGE] years and older and based on the following recommendations: a. For adults [AGE] years' or older who have not previously received any pneumococcal vaccine: Give 1 dose of PCV15 or PCV20. b. For adults [AGE] years or older who have only received a PPSV23: Give 1 dose PCV15 or PCV20. i. The PCV15 or PCV20 dose should be administered at least one year after the most recent PPSV23 vaccination. The resident's medical record shall include documentation that indicates at a minimum, the following: a. The resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization b. The resident received the pneumococcal immunization or did not receive due to medical contraindication or refusal. 1) Record review for Resident #9 revealed the resident was admitted to the facility on [DATE]. The resident is [AGE] years or older. Record review for Resident #9 revealed the resident had historically received the Pneumococcal Vaccine (PPSV23) on 12/17/18 and was eligible to receive a pneumococcal vaccine. There was no documentation of the pneumococcal vaccine being offered, accepted, or declined. 2) Record review for Resident #53 revealed the resident was admitted to the facility on [DATE]. The resident is [AGE] years or older. Record review for Resident #53 revealed the resident had historically received the Pneumococcal Vaccine (PPSV23) on 09/22/20 and was eligible to receive a pneumococcal vaccine. There was no documentation of the pneumococcal vaccine being offered, accepted, or declined. 3) Record review for Resident #69 revealed the resident was admitted to the facility on [DATE]. The resident is [AGE] years or older. Record review for Resident #69 revealed the resident had not received the pneumococcal vaccine historically and was eligible to receive the pneumococcal vaccine. There was no documentation of the pneumococcal vaccine being offered, accepted, or declined. 4) Record review for Resident #94 revealed the resident was admitted to the facility on [DATE]. The resident is [AGE] years or older. Record review for Resident #94 revealed the resident had not received the pneumococcal vaccine historically and was eligible to receive the pneumococcal vaccine. There was no documentation of the pneumococcal vaccine being offered, accepted, or declined. During an interview conducted on 01/24/24 at 3:45 PM with the Licensed Practical Nurse/Infection Preventionist (LPN/IP), who stated she has worked at the facility for 4 years and has been the Infection Preventionist since 08/01/23. The interview was also conducted with the Director of Nursing (DON) who stated she has worked at the facility for 3 years. When asked about pneumococcal vaccines for residents, they stated the pneumococcal vaccine is offered annually at the same time as the influenza and it is offered on admission. To determine eligibility, they refer to the CDC guidelines and if it is unknown what previous vaccine the resident may have had, they would discuss with the physician to determine if the resident should have the vaccine. When asked if a resident or residents representative refused a pneumococcal vaccine while in the facility, how was this documented. The LPN/IP and the DON stated, if the resident or residents representative refuses a pneumococcal vaccine while in the facility, they would simply not check that the pneumococcal vaccine was accepted/administrated on the Vaccine Consent and Administration form the facility utilized. The refusal of a vaccine would be documented in the EMR (Electronic Medical Record) under immunization tab that the resident declined the vaccine. The DON stated the facility went back to using a consent/declination form for vaccines that had a separate section for influenza and pneumococcal, for the resident or resident representative to accept or decline each individual vaccine being offered.

Based on observations, interviews and record review the facility failed to maintain an infection prevention and control program to provide a safe and sanitary environment for the laundry area, for 2 of 2 shower rooms located on the 1st floor; failed to ensure urinary catheter drainage bag was maintained off the floor for 1 sampled resident for catheter care (Resident #153); failed to utilize appropriate PPE (Personal Protective Equipment) during administration of an injectable for Resident #155; and failed to provide snacks in a sanitary manner for 1 of 36 sampled residents (Resident #86). The findings included: Review of the facility's policy titled, Infection Prevention and Control Program with a reviewed/revised date of 08/15/22 included: This facility has established and maintains 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 as per accepted national standard and guidelines. 4. Standard Precautions: a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. c. All staff shall use personal protective equipment (PPE) according to the established facility policy governing the use of PPE. d. Licensed staff shall adhere to safe injection and medication administration practices, as described in relevant facility policies. e. Environmental cleaning and disinfection shall be performed according to facility policy. All staff have responsibilities related to the cleanliness of the facility and are to report problems outside of their scope to the appropriate department. 11. Linens: a. Laundry and direct care staff shall handle, store, process, and transport linens to prevent the spread of infection. b. Clean linen shall be separated from soiled linen at all times. c. Clean linen shall be delivered to resident care units on covered linen carts with covers down. d. Linen shall be stored on all resident care units on covered carts, shelves, in bins, drawers, or linen closets. Review of the facility's policy titled, Administration of Injections with a reviewed/revised date of September 2023 included: Injections are administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice. Dispose of sharps in puncture resistant containers near the point of use. Review of the facility's policy titled, Personal Protective Equipment with a reviewed/revised date of May 2022 included: This facility promotes appropriate use of personal protective equipment to prevent the transmission of pathogens to residents, visitors, and other staff. All staff who have contact with residents and/or their environments must wear personal protective equipment as appropriate during resident care activities and at other times in which exposure to blood, body fluids, or potentially infectious material is likely. 1) During an initial tour of the facility conducted on 01/22/24 from 7:30 AM to 11:40 AM the following observations were made in the 2 locked Bath (Shower) Rooms located on the 1st floor: In the Bath (Shower) Room located on the 1st floor across from room [ROOM NUMBER] there were 2 locked treatment carts, uncovered clean hanging resident clothing items, 2 1-gallon jugs of skin/hair cleaner on the shower stall floor, clean linens on a cart with no cover. There were 2 disposable sharps containers, both filled so full several razors were extended out of the sharps container, 1 of the 2 disposable sharps containers was not locked/secured in place, just set inside a bracket that was affixed to the wall and easily removed from the wall as instructed by Staff A Licensed Practical Nurse/Unit Manager who attempted to remove the unsecured sharps container and in doing so spilled several of the razors out onto the floor of the room. Photographic Evidence Obtained. In the Bath (Shower) Room located on the 1st floor across from room [ROOM NUMBER] there were 2 sharps containers, both resting on top of the locked base that was affixed to the wall. There were no paper towels or paper towel holder at the sink area. On the counter next to the sink were 2 unlabeled and uncovered hairbrushes with hair. Also, on the counter next to the sink in a small plastic 3 drawer bin which had an uncovered and unlabeled used toothbrush as well as 3 additional unlabeled used toothbrushes (2 of which were in the same drawer of the bin). There were 2 1-gallon jugs of skin/hair cleaner on the shower stall floor, clean linens on a cart with no cover, clean resident clothing hanging with no cover. Photographic Evidence Obtained. During an interview conducted on 01/22/24 at 9:05 AM with Staff A, Licensed Practical Nurse/Unit Manager, he acknowledged the 2 disposable sharps containers, both filled so full several razors were extended out of the sharp's container, 1 of the 2 disposable sharps containers was not locked/secured in place. He stated the disposable sharps containers should have been replaced. 2) During the laundry tour conducted on 01/22/24 from 12:00 PM to 2:50 PM with the Director of Plant Operations, Director of Maintenance, and the Director of Housekeeping present the following observations were made: In the laundry sorting room, there were 2 white bins with soiled linens uncovered and 2 yellow bins with clean mop heads uncovered. In the washer room there were uncovered resident shoes sitting on the windowsill to dry, there was a missing ceiling tile above the washers. In the dryer room [ROOM NUMBER] out of 3 dryers had drums that were rusty and had melted debris inside. In the folding room, none of the linens were covered. There was a small refrigerator with beverages, containers of food and an orange. During an interview conducted on 01/24/24 at 2:50 PM with the Director of Housekeeping who stated the girls who work in the laundry area have a refrigerator so they can have cold beverages to drink because it gets hot, and they can keep their lunch in there as well because when they put their lunch in the employee lounge it gets stolen. During an interview conducted on 01/24/24 at 3:45 PM with LPN/Infection Preventionist (LPN/IP) who stated she has worked at the facility for 4 years and has been the IP since 08/01/23. The interview was also conducted with the Director of Nursing (DON) who stated she has worked at the facility for 3 years. They both have been in the laundry room several times and routinely go once a week. They said they had never noticed any issues and always thought it was clean. The only issues she had were just in general how things get cleaned. The LPN/IP said she knew they had a refrigerator but did not think it was an infection prevention issue and always thought they just had water in the refrigerator. 39026 3) On 01/22/24 at 7:30 AM, an initial tour was conducted of the residential rooms on the second floor. Resident #153 was observed in bed with the catheter bag on the floor (photographic evidence obtained). Resident #153 was admitted to the facility on [DATE] with a suprapubic catheter. 4) On 01/22/24 at 9:00 AM, Resident #155 was observed in bed being served breakfast. Staff L, a Licensed Practical Nurse, entered the room and gave Resident #155 an insulin injection into his left arm without wearing gloves. 45951 5) During a tour of the facility conducted on 01/22/24 at 10:51 AM, the surveyor observed numerous residents on the first floor of the facility mingling in the milieu. Staff A, Licensed Practical Nurse Unit Manager was assisting the staff by passing out snacks to the residents. Resident #86 asked Staff A for a snack. Staff A retrieved a snack package from the nutrition room and attempted to open it for Resident #86. After some difficulty, Staff A used his teeth to open the snack package. He began to hand the opened snack package to Resident #86 when the surveyor intervened, pointing out what he had done and asked if it was appropriate for Resident #86 to receive this snack package. Without responding, Staff A retrieved a new snack from the nutrition room and gave it to Resident #86, who proceeded to walk into the dining room for an activity.

Based on record and policy review, observations and interviews, the facility failed to ensure of a safe, clean, comfortable, and homelike environment for 13 of 31 rooms on the 1st floor, 2 of 2 Shower Rooms on the 1st floor, 1 laundry area, and a pillar located in the Memory Care Unit Nursing Station. The findings included: Review of the facility's policy, titled, Safe and Homelike Environment with a reviewed / revised date of 04/11/23, included: In accordance with residents' rights, the facility will provide a safe, clean, comfortable, and homelike environment allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment. The facility will provide and maintain bed and bath linens that are clean and in good condition. General considerations: Minimize odors by disposing of soiled linens promptly and reporting lingering odors and bathrooms needing cleaning to Housekeeping Department. Report any furniture in disrepair to Maintenance promptly. Report any unresolved environmental concerns to the Administrator. During an initial tour of the facility conducted on 01/22/24 from 7:30 AM to 11:40 AM, the following observations were made: In room [ROOM NUMBER], the door frame had a large area of missing/chipping paint. Photographic Evidence Obtained. In room [ROOM NUMBER], the ceiling paint by the window was bubbling / peeling; the ceiling paint by the entry door / privacy curtain track was discolored; the bathroom floor and toilet seat were discolored; both nightstands had broken drawers and chipped/missing/scratched veneer. Photographic Evidence Obtained. In room [ROOM NUMBER], the bed near the window had no overbed table for meals. Photographic Evidence Obtained. In room [ROOM NUMBER], the bathroom ceiling had large unpainted patches; and the floor near the bed by the door had cracked floor tiles. Photographic Evidence Obtained. In room [ROOM NUMBER], the wall by the sink had a large scuff mark and missing paint. Photographic Evidence Obtained. In room [ROOM NUMBER], the window screen had large holes. Photographic Evidence Obtained. In room [ROOM NUMBER], the light above the bed, closest to the entry door, had a large amount of rust. Photographic Evidence Obtained. In room [ROOM NUMBER], the wall by the air-conditioning (A/C) unit had a hole with a metal plate inside; the wall of the entry door was unpainted; the closet door was off-track; and blackish mold like substance was noted on the inside closet of the wall near the floor. Photographic Evidence Obtained. In room [ROOM NUMBER], there was no window covering except the valance, to block the light; and the closet door was missing. In room [ROOM NUMBER], the base of the bed closest to the entry door was rusty; the nightstand closest to the entry door had drawers misaligned; the closet door was bowed and had layers of the wood separated; blackish mold like substance was noted on the inside of the closet, on the wall near the floor; and the windowsill was cracked and uneven. Photographic Evidence Obtained. In room [ROOM NUMBER], the ceiling was dark / discolored. In room [ROOM NUMBER], the privacy curtain track above the bed by the door was pulling away from the ceiling; the bed by the door had 2 large gray stains at the foot of the bed; the A/C vents were dirty; there were no chairs in the room; the cold-water handle to the bathroom sink was broken and there was no hot water; and there was an overwhelming smell of urine in the bathroom. Photographic Evidence Obtained. Outside of room [ROOM NUMBER], there was no room number, and just 1 of the 2 residents' names taped to the wall. In room [ROOM NUMBER], the florescent light in the bathroom that extends over the toilet and sink, was uncovered (Photographic Evidence Obtained), and the nightstand near the room window had a broken handle. In the Bath / Shower Room across from room [ROOM NUMBER], there was no paper towel holder and no paper towels at the sink; and 2 open gallon jugs of skin/hair cleaner were on the floor in the shower stall. Photographic Evidence Obtained. In the Bath / Shower Room across from room [ROOM NUMBER], there were 2 treatment carts; and 2 open gallon jugs of skin/hair cleaner on the floor in the shower stall. Photographic Evidence Obtained. The Memory Care Unit Nursing Station had a pillar with no laminate, exposing glue and particle board. During the laundry tour conducted on 01/22/24 from 12:00 PM to 2:50, PM with the Director of Plant Operations, Director of Maintenance, and the Director of Housekeeping, the following observations were made: The washing tub located in the sorting room was dirty / stained. There were 7 (seven) 5-gallon containers of floor stripper, directly on the floor, in the sorting room. There was an empty wet / dry vacuum that was pulled apart, with dried debris on the filter exposed in the sorting area. There were 4 (four) open containers of chemicals attached to the washing machines, placed directly on the floor in the washing room. There were 5 (five) sealed containers of chemicals stored directly on the floor in the washing room. There was an open container of laundry detergent and an open container of fabric softener stored directly on the floor in the washing room. There was a missing ceiling tile above the washing machines in the washing room. There was a portable hot water heater stored behind the dryers in the drying room. There was a box fan covered with dust / debris and a curtain rod in plastic stored in the corner between the dryers and the wall with the window. The florescent ceiling light in the dryer room had no cover. During an environmental tour conducted on 01/24/24 at 1:30 PM with the Director of Plant Operations, the Director of Maintenance (DOM), and the Maintenance Assistant (MA), they acknowledged the identified concerns. During an interview conducted on 01/24/24 at 2:50 PM with the Director of Housekeeping, she stated the Administrator walks through the laundry area periodically and he makes suggestions on things for her to do in the laundry area. The Director of Housekeeping was unable to clarify what the Administrator had suggested for her to do in the laundry area. 45951

Based on observations, interviews, and record review, the facility failed to provide care and services in accordance with the plan of care for two (Resident #6 and Resident #9) of three residents sampled for bedrail use and two (Resident #3 and Resident #6) of three residents sampled for unnecessary medication use. Findings included: A review of Resident #6's medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses of vascular dementia, cerebral atherosclerosis, schizoaffective disorder, bipolar type, major depressive disorder, and anxiety disorder. A review of Resident #6's physician's orders revealed the following orders: - An order, dated 6/16/2023, for olanzapine 10 mg (milligrams) PO (orally) two times a day for schizoaffective disorder, bipolar type. - An order, dated 6/16/2023, for clonazepam 0.5 mg PO every 12 hours for anxiety disorder. - An order, dated 6/16/2023, for Eliquis 5 mg PO two times a day for cerebral atherosclerosis. - An order, dated 6/16/2023, for Side Effect Observation: 1-Dystonia, torticollis (stiffness of neck); 2-Anticholinergic symptoms: dry mouth/blurred vision, constipation/urinary retention; 3-Hypotension ; 4-Sedation/drowsiness; 5-Increased falls/dizziness ;6-Cardiac abnormalities; 7-Anxiety/agitation; 8-Blurred Vision; 9-Sweating/rashes; 10-Headache; 11-Urinary retention/hesitancy; 12-Weakness; 13-Hangover effect; 14-Pseudoparkinsonism; 15-Insomnia; 16-New Onset Confusion, every shift for medication side effect monitoring. - An order, dated 6/16/2023, Side Effect Observation: 17-Akathisia--restlessness/pacing/inability to sit still/anxiousness/sleep disturbances; 18-Tardive dyskinesia--lip smacking/chewing/abnormal tongue movement/spasmodic movement of arms/legs-rocking/swaying; 19-Sore throat; 20-Seizures; 21-Photosensitivity; 22-Suicidal ideations; 23-Hepatic or renal abnormalities; 24-Ataxia; 25-Nausea/Vomiting; 26-Diarrhea; 27-Abdominal Discomfort; 28-discolored urine; 29-black tarry stools; 30-bruising; 31-nose bleeds, every shift for medication side effect monitoring. - An order, dated 6/16/2023, for antianxiety medication monitoring. Observe for restlessness every shift. - An order, dated 6/16/2023, for antipsychotic medication monitoring. Observe for delusions, hallucinations, and/or paranoia every shift. - An order, dated 3/11/2024, for 1/4 side rail x (times) 1 for bed mobility. A review of Resident #6's Side Rail Evaluation dated 3/11/2024 revealed Resident #6 demonstrated poor bed mobility or difficulty moving to a sitting position on the side of the bed and required assistance with toileting and a quarter rail on the left side of the bed was implemented to assist with positioning, support, and/or bed mobility. A review of Resident #6's care plan revealed a Focus area, last revised on 3/21/2024, Resident #6 required assistance to perform, improve or maintain Activities of Daily Living (ADL) activities. Interventions included to assist the resident with ADL's as needed, observe for ADL decline, and 1/4 side rail x 1 for bed mobility. Resident #6's care plan also revealed a Focus, last revised on 2/13/2024, Resident #6 uses antipsychotic and anxiolytic medications. Interventions include to administer psychotropic medications as ordered and monitor for side effects and effectiveness every shift. Resident #6's care plan revealed a Focus area, last revised on 6/8/2023, Resident #6 is on anticoagulant therapy. Interventions include to administer anticoagulant medications as ordered and monitor for side effects and effectiveness every shift. A review of Resident #6's Behavior Monitoring Log for March 2024 revealed the following related to Resident #6's order for antianxiety medication monitoring: - No documentation of monitoring for the day shift on 3/21/2024. - No documentation of monitoring for the night shift on 3/6 and 3/17/2024. A review of Resident #6's Behavior Monitoring Log for March 2024 revealed the following related to Resident #6's order for antianxiety medication monitoring: - No documentation of monitoring for the day shift on 3/21/2024. - No documentation of monitoring for the night shift on 3/6 and 3/17/2024. A review of Resident #6's Behavior Monitoring Log for March 2024 revealed the following related to Resident #6's order for antipsychotic medication monitoring: - No documentation of monitoring for the day shift on 3/21/2024. - No documentation of monitoring for the night shift on 3/6 and 3/17/2024. A review of Resident #9's medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses of dementia, muscle weakness, and anxiety disorder. A review of Resident #9's physician's orders revealed an order, dated 3/11/2024 for 1/4 side rail x 1 for bed mobility. A review of Resident #9's Side Rail Evaluation dated 3/11/2024 revealed Resident #9 demonstrated poor bed mobility or difficulty moving to a sitting position on the side of the bed and required assistance with toileting and a quarter rail on the right side of the bed was implemented to assist with positioning, support, and/or bed mobility. A review of Resident #9's care plan revealed a Focus area, last revised on 6/9/2023, Resident #9 was at risk for decreased ability to perform ADL's in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting. Interventions included to use a wheelchair for locomotion and side rail x 1 for bed mobility. A review of Resident #3's medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses of dementia, cerebral infarction, cognitive communication deficit, and depression. A review of Resident #3's physician's orders revealed the following orders: - An order, dated 2/14/2024, for sertraline hydrochloride (HCl) 50 milligrams (mg) by gastric tube (GT) one time a day for depression. - An order, dated 3/28/2024 for escitalopram oxalate 10 milliliters (ml) GT one time a day for depression. - An order, dated 2/13/2024 for apixaban 5 mg GT two times a day for cerebral infarction. - An order, dated 2/13/2024 for Side Effect Observation: 1-Dystonia, torticollis (stiffness of neck); 2-Anticholinergic symptoms: dry mouth/blurred vision, constipation/urinary retention; 3-Hypotension ; 4-Sedation/drowsiness; 5-Increased falls/dizziness ;6-Cardiac abnormalities; 7-Anxiety/agitation; 8-Blurred Vision; 9-Sweating/rashes; 10-Headache; 11-Urinary retention/hesitancy; 12-Weakness; 13-Hangover effect; 14-Pseudoparkinsonism; 15-Insomnia; 16-New Onset Confusion, every shift for medication side effect monitoring. - An order, dated 2/13/2024 for Side Effect Observation: 17-Akathisia--restlessness/pacing/inability to sit still/anxiousness/sleep disturbances; 18-Tardive dyskinesia--lip smacking/chewing/abnormal tongue movement/spasmodic movement of arms/legs-rocking/swaying; 19-Sore throat; 20-Seizures; 21-Photosensitivity; 22-Suicidal ideations; 23-Hepatic or renal abnormalities; 24-Ataxia; 25-Nausea/Vomiting; 26-Diarrhea; 27-Abdominal Discomfort; 28-discolored urine; 29-black tarry stools; 30-bruising; 31-nose bleeds, every shift for medication side effect monitoring. - An order, dated 2/13/2024 for antidepressant medication monitoring. Observe for sadness, tearfulness, and/or self-isolation every shift. A review of Resident #3's Behavior Monitoring Log for March 2024 revealed the following related to Resident #3's order for side effect observation: - No documentation of monitoring for the day (7 AM to 3 PM) shift on 3/15, 3/16, and 3/25/2024. - No documentation of monitoring for the evening (3 PM to 11 PM) shift on 3/10, 3/12, 3/20, and 3/26/2024. A review of Resident #3's Behavior Monitoring Log for March 2024 revealed the following related to Resident #3's order for antidepressant medication monitoring: - No documentation of monitoring for the day (7 AM to 3 PM) shift on 3/15, 3/16, and 3/25/2024. - No documentation of monitoring for the evening (3 PM to 11 PM) shift on 3/10, 3/12, 3/20, and 3/26/2024. A review of Resident #3's care plan revealed a Focus, last revised 12/14/2023, Resident #3 used antidepressant medication. Interventions included to administer antidepressant medications as ordered and monitor/document side effects and effectiveness every shift. An observation was conducted on 4/2/2024 at 2:33 PM of Resident #6's bed. Resident #6's bed was observed to have built in side rails, which fold up and down, into the side of the resident's bed. Both side rails were observed zip tied in the down position to Resident #6's bed frame. An observation was conducted on 4/2/2024 at 2:36 PM of Resident #9's bed. No side rails were observed to Resident #9's bed. An interview was conducted on 4/2/2024 at 1:00 PM with Staff N, Licensed Practical Nurse (LPN). Staff N, LPN stated residents on psychotropic medications should have orders in place for behavioral and side effect monitoring, which is documented every shift. An interview was conducted on 4/3/2024 at 9:34 AM with Staff M, Licensed Practical Nurse (LPN) and Unit Manager (UM). Staff M, LPN UM stated the facility mainly had two types of beds. One of the beds had built in side rails and the other type of bed required the side rails to be attached by the maintenance staff. If a resident is assessed to not have a side rail, the beds with the built in side rails have the side rails zipped tied down by the maintenance staff. If a resident is ordered a side rail and they are in a bed with built in side rails, one side rail remains zip tied to the frame while the other one is released for the resident to use as indicated in the Side Rail Evaluation. If a resident is ordered a side rail and they are in a bed without built in side rails, a request to attach the appropriate side rail is put in and addressed by maintenance staff. Following the interview, observations of Resident #6 and Resident #9's bed were conducted with Staff M, LPN UM. Staff M, LPN UM address Resident #6 and Resident #9 did not have side rails in use. Staff M, LPN UM reviewed Resident #6's and Resident #9's Side Rails Evaluations and addressed the residents should have side rails to their beds. An interview was conducted on 4/3/2024 at 1:34 PM with the facility's Director of Nursing (DON). The DON stated she conducted a facility audit and performed side rail assessments for each resident in the facility. The DON also stated she put orders in each resident's medical record who required a side rail and provided the maintenance staff with a list of the resident's requiring side rails so they could be put into place. The DON was not able to state why the side rails were not put into place as ordered. An interview was conducted on 4/3/2024 at 2:20 PM with the facility's Maintenance Director (MD). The MD stated he is directed by the DON to either put side rails on the resident beds of to remove/secure the side rails not in use. The MD also stated Resident #6's bed was supposed to have a side rail in use and both of the side rails should not have been zip tied to the bed frame. An interview was conducted on 4/3/2024 at 2:58 PM with the facility's Regional Director of Operations (RDO), DON, and MD. The RDO stated the MD was informed of the residents who required side rails. The MD stated he assigned the bed rail project to his assistant with specific directions related to which resident's required side rails and which side of the resident's bed required a side rail. The MD also stated his assistant did not carry out the task as directed and they were not able to state why the task was not completed correctly. The DON stated she performed an audit to ensure the appropriate side rails were in place to resident beds, which was spot on, but now the side rails are not in place as they should be. The DON also stated medication monitoring should be conducted in accordance with the physician's order and addressed the missing documentation for Resident's #3, #6, and #7 in the monitoring logs. A review of the facility policy titled Proper Use of Bed Rails, last revised on 7/25/2022, revealed under the section titled Policy it is the policy of the facility to utilize a person-centered approach when determining the use of bed rails. If bed rails are used, the facility ensures correct installation, use, and maintenance of the rails. A review of the facility policy titled Comprehensive Care Plans, last revised on 7/27/2022, revealed under the section titled Policy it is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with 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 resident's comprehensive assessment. The policy also revealed under the section titled Policy Explanation and Compliance Guidelines the comprehensive care plan will describe resident specific interventions that reflect the resident's needs and preferences. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. Photographic evidence obtained.

Based on interview and record review, the facility failed to update an Advance Directive care plan for 1 of 32 sampled residents reviewed for Advance Directives (Resident #57). The findings included: Review of the facility's policy, titled, Comprehensive Care Plans with a reviewed / revised date of [DATE] that included: The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS (Minimum Data Set) assessment. Review of the facility's policy, titled, Residents' Rights Regarding Treatment and Advance Directives with a reviewed / revised date of [DATE] that included: During the care planning process, the facility will identify, clarify, and review with the resident or legal representative whether they desire to make any changes related to any advance directives. Record review revealed Resident #57 was admitted to the facility on [DATE] with diagnoses that included: Alzheimer's Disease, Bipolar Disorder, Dementia, Post-Traumatic Stress Disorder, and Anxiety. Review of the Minimum Data Set (MDS) assessment for Resident #57 dated [DATE] revealed in Section C a Brief Interview of Mental Status (BIMS) score of 5, indicating severe cognitive impairment. Review of the Physician's Orders for Resident #57, dated [DATE], revealed a Do Not Resuscitate (DNR) order. Review of the Care Plan for Resident #57 dated [DATE] with a focus on the resident has an established CPR (Cardiopulmonary Resuscitation) (Full Code) order in place. The goal is to make the resident's wishes for code status to be followed through the next review date. The Interventions included: Activate the resident's advanced directives as indicated. Notify the physician of resident's wishes regarding life prolonging procedures. This indicated the Advance Directive care plan regarding code status for Resident #57 was never updated to reflect the DNR status. An interview was conducted on [DATE] at 9:16 AM with the Social Service Director (SSD), who stated she has worked at the facility for 4 years. She further explained for a resident who wants a code status of DNR (Do Not Resuscitate), the resident or the family will sign the yellow DNR form. She then has the physician sign the form and the nurse will obtain the order for the DNR and put it in the resident's EMR (Electronic Medical Record). She stated once there is an order in the computer for the code status, then she would update the care plan with the code status. When asked about Resident #57, she verified the resident had a DNR order dated [DATE], and the resident has a care plan for Full Code.

Based on observation, interview and policy review, the facility failed to ensure call lights remained in reach for 2 of 100 sampled residents observed during the initial screening process (Resident #58 and Resident #155). The findings included: The policy of the facility, titled, Call Lights: Accessibility and Timely Response implemented 11/2020 and revised 07/19/22, revealed Staff will ensure the call light is within reach of resident and secured, as needed; and The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room. 1. Review of the resident's Medicare A 5-day scheduled assessment with a target date of 01/06/24 documented: Section C: the resident is rarely/never understood. Section GG: the ability to safely come to a standing position from sitting in a chair or on the side of the bed is not applicable and picking up object is dependent. On 01/22/24 at 7:55 AM, Resident #58 was observed in his wheelchair. The call light was observed on the floor next to the bed. Resident #58 was not able to pick up the call light off the floor to call staff, if needed. 2. Record review revealed Resident #155 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Type 2 Diabetes Mellitus with Diabetic Neuropathy, Hypothyroidism and Hypocalcemia. Review of the Medicare 5-day Minimum Data Set (MDS) assessment, with an assessment reference date of 11/07/23, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10, indicating the resident had moderate cognitive impairment. Resident #155 was observed in bed on 01/22/24 at 9:00 AM. His call light was observed on the floor next to his bed and not within reach of the resident. Photographic Evidence Obtained. At the time of observation, Resident #155 was asked if he could reach his call light, and stated that he could not.

Based on observation, interview, and record review, the facility failed to develop and implement baseline care plans within 48 hours of a resident's admission for 1 of 1 sampled resident, reviewed for catheter care (Resident #153). The findings included: During an observation on 01/22/24 at 7:30 AM, Resident #153 was observed in bed. On the floor, next to his bed, a catheter bag containing urine was observed on the floor. Record review revealed Resident #153 was admitted to the facility on [DATE], in the late afternoon, with diagnoses that included Type 2 Diabetes Mellitus, Heart Failure and Urinary Retention. The resident was admitted with a suprapubic catheter. (A suprapubic catheter is a device that's inserted directly into the bladder to drain urine). Review of the Electronic Health Record (EHR) revealed no evidence of a baseline care plan for the catheter or for catheter care. Review of the comprehensive care plans revealed no care plan for a catheter or catheter care. On 01/22/24 at 11:13 AM, an interview was conducted with the Director of Nurses (DON). She was asked who completes the baseline care plans. She stated the Minimum Data Set (MDS) Coordinator would initiate the baseline care plans on Monday, if a resident was admitted after hours on a Friday.

Based on observations, interviews, and record review, the facility failed to treat residents in a dignified manner during dining observations for 3 of 7 sampled residents reviewed for dignity, Residents #79, #40, and #25; and failed to provide timely grooming to preserve dignity, for 1 of 7 sampled residents, Resident #15, also reviewed for dignity. The findings included: Review of the facility's policy, titled Promoting/Maintaining Resident Dignity, revised on 08/02/22, revealed the following: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Staff members provide care to residents to promote and maintain resident dignity during interactions with residents. 1. Record review revealed Resident #79 was admitted to the facility on [DATE] with diagnoses that included Dementia, Anxiety, and Dysphagia. The care plan initiated on 06/28/23 revealed that Resident #79 had impaired cognitive function and impaired thought process due to his Dementia. In an observation conducted on 01/22/24 at 12:30 PM, Resident #79's roommate received his lunch tray. Resident #79 was noted in his bed with no lunch tray. Resident #79's lunch tray was noted sitting outside on the meal cart in the hallway. At 12:55 PM, Staff S, Certified Nursing Assistant (CNA), brought Resident #79's lunch meal into the room, about 25 minutes later. Continued observation showed that Resident #79's roommate had already finished his lunch meal. 2. Record review revealed Resident #40 was admitted to the facility on [DATE] with diagnoses that included Dementia and Behavioral Disturbances. Resident #40 was admitted to hospice services on 07/05/23. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #40 has a Brief Interview of Mental Status (BIMS) score of 99, indicating the score could not be due to cognitive impairment. In an observation conducted on 01/22/24 at 12:43 PM, Resident #40 was in her room with her lunch tray. Staff P, Hospice Registered Nurse, was observed in the room standing over Resident #40 while assisting her with the lunch meal. Closer observation did not show any sitting chairs in the room. An interview was conducted with Staff J, Registered Nurse / Unit Manager, on 01/25/24 at 9:51 AM, who stated that she expects all staff to sit at eye level while assisting residents during dining. An interview was conducted on 01/25/24 at 2:30 PM, with Staff I, Certified Nursing Assistant, who stated that when assisting a resident during dining, they need to sit at eye level and not stand over the resident. 41837 3. Record review revealed Resident #25 was admitted to the facility on [DATE] with diagnoses that included Age-Related Nuclear Cataract, Bilateral, Anxiety Disorder, and Mild Intellectual Disabilities. The Minimum Data Set (MDS) assessment for Resident #25 dated 12/16/23 revealed in Section C, a Brief Interview of Mental Status (BIMS) assessment was not attempted, due to the resident is rarely/never understood. Section GG revealed for eating the resident's usual performance is setup or clean-up assistance. Review of the Care Plan for Resident #25 dated 06/07/23 with a focus on the resident remains at risk for nutritional decline related to clinical condition of Depression, Dysphagia, Schizophrenia, and Heart Disease. The goal was for the resident to be free from signs/symptoms (S/S) of dehydration and/or fluid overload. The interventions included: Assist as needed with proper positioning, setup, feeding and encouragement. On 01/22/24 at 12:25 PM, an observation was made of Resident #25 sitting on the side of the bed, being fed lunch by Staff W, Certified Nursing Assistant (CNA). The CNA was standing while feeding the resident. There was a chair observed on the opposite side of the room. An interview was conducted on 01/22/24 at 12:27 PM with Staff W, who stated she has worked at the facility for 2 months. When asked if she always stands to feed the resident, she replied yeah, and sometimes the resident is sitting in his wheelchair. An interview was conducted on 01/25/24 at 10:30 AM with Staff D, CNA, who stated she has been working at the facility for 2 months. When asked if she stands to feed a resident, she said, No, because what you are supposed to do is sit in a chair beside the resident to assist with feeding. They always have a chair available. Not every room has a chair, sometimes you have to go across the hallway to get a chair. 39026 4. Record review revealed Resident #15 was admitted to the facility on [DATE] with diagnoses that included Hypertension, Chronic Obstructive Pulmonary Disease and Cognitive Communication Deficit. Her Brief Interview for Mental Status (BIMS) score from the annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/01/23 was 13, indicating the resident was cognitively intact. Review of the resident's care plan for risk for decreased ability to perform ADLS (activities of daily living) in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion and toileting, which was created on 06/12/23 revealed an intervention created on 08/06/23 of assist as indicated with transfers, ambulation, WC (wheelchair) mobility, bathing/grooming, and meals. The care plan does not address any refusals that the resident might have made for personal grooming. On 01/22/24 at 10:47 AM, Resident #15 was interviewed during the initial screening process. The resident was observed as having facial hair. The resident was asked if she wanted to keep or remove the facial hair. She stated that she would like it removed but no one has done it yet. An interview was conducted with Staff K, CNA/Transporter on 01/25/24 at 1:12 PM. Staff K was asked if an offer was made to Resident #15 to remove her facial hair. Staff K stated that the resident does allow the CNAs to do it. An interview was conducted with the Medical Director on 01/25/24 at 1:55 PM, who revealed he had an in-service with the CNAs around 6 months ago regarding personal care.

Based on observations, interviews and record review, the facility failed to provide written notice to the resident or the resident's representative of a room change for 1 of 32 sampled residents reviewed for room changes (Resident #69). The findings included: Review of the facility's policy, titled, Change of Room or Roommate with a reviewed / revised date of 03/08/23 included: It is the policy of this facility to conduct changes to room and/or roommate assignments when considered necessary and/or when requested by the resident or resident representative. Prior to making a room change or roommate assignment, all persons involved in the change/assignment, such as residents and their representatives, will be given advance notice of such a change as is possible. The notice of change in room or roommate will be provided in writing, in a language and manner the resident and representative understand. Record review for Resident #69 revealed the resident was admitted to the facility on [DATE] with a diagnosis that included Bipolar Disorder and Schizophrenia. The Minimum Data Set (MDS) assessment for Resident #69 dated 01/04/24 revealed in Section C, a Brief Interview of Mental Status (BIMS) score of 9, indicating a moderate cognitive impairment. During an interview conducted on 01/22/24 at 1:33 PM with Resident #69, she stated they (staff) moved her one day and didn't tell her why or where she was going. She said she liked her prior room better because of the staff and her roommate. Review of the Electronic Medical Record (EMR) for Resident #69 revealed no notice of her room change, as required. When a resident is being moved at the request of facility staff, the resident, family, and/or resident representative must receive an explanation in writing of why the move is required. An interview was conducted on 01/22/24 at 1:35 PM with the Activities Director, who stated she has been at the facility for just over a year. When asked about Resident #69, she stated the resident was previously in another room but thinks they moved her to make the previous room a male room. An interview was conducted on 01/23/24 at 9:50 AM with the Resident Representative (Guardian) for Resident #69, who was asked if the facility had discussed a room change for the resident on 01/04/24. She stated the facility contacted her about a room change regarding trying to get all females on one side of the hall and all males on the other side of the hall, and the resident would have a similar room and be near the window. When asked if the facility provided her with any paperwork or documentation about the room change, she said she did not recall. When the Representative was advised that the resident had informed the surveyor that she wanted to go back to her old room, the Resident Representative said the resident changes her mind all of the time and she lacks capacity to make her own decisions. An interview was conducted on 01/24/24 at 9:16 AM with the Social Service Director (SSD), who stated she has worked at the facility for 4 years. When asked if there is a room change for a resident and what she does, she said they notify the resident and the resident's representative. She would complete a room change form and provide it to the resident or the resident representative. When asked about Resident #69, she said they were trying to do room changes to make the memory care unit with a male side and a female side. When asked if she had notified the representative for Resident #69 about the room change, she said she did. The SSD was asked for a copy of the written notice, but none was produced. The SSD stated the notice may not have been uploaded into the resident's EMR.

Based on observations, interviews with the nursing staff, Nursing Home Administrator, the Director of Nursing, the facility's Staff Development Coordinator, the facility's Medical Director, the resident's family member and review of the resident's medical record and facility policies, the facility neglected to ensure one resident (#1), at risk for elopement, was provided with services related to the resident's known cognitive deficits and history of wandering out of 47 residents sampled. The facility nursing staff neglected to ensure the safety of Resident #1; between approximately 9:00 PM on 7/18/2023 and 4:00 AM on 7/19/2023, Resident #1 ambulated from his room on the second floor of the facility, passed the unit nurse's station, and walked approximately 40 feet to the facility elevator. Resident #1 pushed the elevator button to access the rear service hallway of the facility where no staff were present. Resident #1 walked approximately 45 feet unsupervised through the rear service hallway and pushed open a staff entrance door, equipped with an electromagnetic locking device (a magnetic lock that is unlocked when de-energized and requires power to remain locked), which was not locked. Resident #1 exited the facility without staff knowledge and walked appropriately 3.1 miles without shoes, through areas with no sidewalks, and along 4 lane roads, to a private residence. The facility neglected to take action to prevent the resident from accessing the rear service hallway by not providing supervision for the resident, not accounting for the resident for approximately 10 hours, and not ensuring facility doors were secured before the resident eloped. Resident #1 was discovered by police on 7/19/2023 at approximately 7:00 AM in the backyard of a community member, sitting on a trampoline. Resident #1 was returned to the facility by police at approximately 7:30 AM, disheveled with holes in his socks, and was discovered to have multiple insect bites and a blister to his left heel. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #1 and resulted in the determination of Immediate Jeopardy on 8/17/2023. The findings of Immediate Jeopardy were determined to be removed on 8/18/2023 and the severity and scope was reduced to a D. Findings included: A review of a law enforcement report dated 7/19/2023 at 5:41 AM revealed law enforcement responded to the facility at approximately 6:11 AM for a report of a missing endangered person, who went missing around 6:00 PM on 7/18/2023. A search of the facility was conducted by law enforcement but Resident #1 was not found on the facility grounds. The report revealed Staff H, CNA, who was the last caretaker to have contact with Resident #1, provided law enforcement with a description of the resident. Law enforcement received a service call at a residence approximately 3.1 miles from the facility involving a suspicious person matching Resident #1's description. Upon arrival at the residence, law enforcement observed Resident #1 in the backyard of the residence sitting on a trampoline. Resident #1 was returned to the facility and interviewed by law enforcement. Resident #1 told law enforcement he exited the facility around 4:30 PM on 7/18/2023 to go for a walk. A review of Resident #1's progress notes dated 7/19/2023 at 11:49 AM and authored by Staff A, Licensed Practical Nurse (LPN), revealed the following: Upon arrival to facility, [Resident #1] alert with some confusion. Head to toe assessment performed .[Resident #1] c/o [complained of ] pain to [the] left heel. Tylenol was given for mild pain .Skin assessment was complete and possible mosquito bites on back, [Resident #1] noted scratching areas [to] bilateral arm, abdomen, back of both legs as well as front of legs, left foot heel has a blister MD is aware and ordered scheduled Tylenol for pain r/t [related to] left heel as well as skin prep [a protective wipe which forms a barrier between the patient's skin and adhesives to help preserve skin integrity] to left heel blister and Hydrocortisone cream for itching . A telephone interview was conducted on 8/16/2023 at 2:24 PM with Resident #1's Responsible Party (RP). The RP stated prior to being admitted to the facility, Resident #1 went missing in December of 2022 after getting lost and was found by law enforcement. The RP stated Resident #1 had gone missing several times and had to be located by law enforcement prior to admission to the facility and was not able to make medical decisions due to his dementia. A review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of encephalopathy, unspecified; dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; cognitive communication deficit; unspecified abnormalities of gait and mobility; muscle weakness (generalized); depression, unspecified; and anxiety disorder. A review of Resident #1's physician's orders revealed the following: - An order dated 8/1/2023 to record active exit seeking behaviors and record the following intervention code(s) every shift: 1: N/A, 2. Engage in conversation, 3. Redirect to alternative location in facility, 4. Call family/friend, 5. Activity, 6. Give snacks/food, 7. Give fluids, 8. Toileting. - An order dated 8/1/2023 for behavioral monitoring related to exit-seeking behaviors and record the number of occurrences every shift. A review of Resident #1's baseline care plan, dated 6/23/2023, did not reveal problems or potential concerns related to elopement risk. A review of Resident #1's 5-Day Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 6/27/2023 revealed under Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of C - BIMS: 7 which indicated severely impaired cognition. Resident #1's MDS assessment revealed under Section E - Behavior, Resident #1 did not display behaviors of wandering but rejected care 1 to 3 days of the assessment period. Section G - Functional Status revealed Resident #1 required supervision and set up help only with locomotion on the unit and required one-person physical assistance with locomotion off the unit. Resident #1 was unsteady, but able to stabilize without staff assistance while walking and turning around. Resident #1 did not require an assistive device for mobility. Resident #1's MDS assessment revealed under Section I - Active Diagnoses Resident #1 had diagnoses of Non-Alzheimer's Dementia, Anxiety Disorder, Depression, and Encephalopathy, unspecified. According to the National Institutes of Health, wandering behavior is one of the most important and challenging management aspects in persons with dementia. Wandering behavior in people with dementia (PwD) is associated with an increased risk of falls, injuries, and fractures, as well as going missing or being lost from a facility. This causes increased distress in caregivers at home and in healthcare facilities. The approach to the comprehensive evaluation of the risk assessment, prevention, and treatment needs more strengthening and effective measures as the prevalence of wandering remains high in the community. Both the caregiver and clinicians need a clear understanding and responsibility of ethical and legal issues while managing and restraining the PwD. The consequences of the wandering can vary from minor injury on the body to severe injury and death. The persistent wandering behavior and weak gait and balance have been shown to increase the risk of falls, fractures, and accidents in PwD. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8543604/#:~:text=Outcome%20of%20Wandering%20in%20Dementia,to%20severe%20injury%20and%20death.&text=The%20persistent%20wandering%20behavior%20and,fractures%2C%20and%20accidents%20in%20PwD. An interview was conducted on 8/15/2023 at 12:30 PM with the facility's Social Services Director (SSD), the Staff Development Coordinator (SDC) and the Nursing Home Administrator (NHA). The SDC stated on 7/19/2023, Resident #1 was returned to the facility after Staff C, Certified Nursing Assistant (CNA) discovered Resident #1 was not in his room at approximately 4:00 AM. Staff C, CNA reported Resident #1 missing to Staff D, LPN, who reported the finding to Staff B, LPN Supervisor. A code pink was called through the facility, which alerted staff a resident was missing from the facility and a facility search was conducted. After verifying Resident #1 was not in the facility, Staff B, LPN Supervisor notified law enforcement and the NHA. The SDC stated the facility cameras did not capture Resident #1 leaving the facility due to a power surge. Law enforcement located Resident #1 in a community member's backyard on a trampoline. They said Resident #1 was returned to the facility on [DATE] at 7:15 AM but they did not provide an address where Resident #1 was located. The SSD stated law enforcement did not provide an incident report and stated, they said if they had one, they would send it to us. The SDC and NHA stated they conducted an interview with Resident #1 following the elopement. Resident #1 stated he left the facility by accessing the facility elevator, walking through the rear service hallway of the facility, and pushing open a door to exit the facility. Resident #1 explained he wanted to go for a walk. Upon Resident #1's return to the facility, a head-to-toe assessment was completed by Staff A, LPN and the facility's Medical Director was notified. Staff A, LPN discovered several bites on the resident's body during the assessment. The NHA stated following the incident, the facility's former maintenance director conducted an exterior door security audit to ensure all exterior doors were secure. Modifications were made to the facility elevator so the rear service hallway could not be accessed through the elevator. The NHA stated the door Resident #1 exited the facility through was equipped with a magnetic lock, but the lock did not engage. The SDC stated the last time staff confirmed seeing Resident #1 was around 11 PM on 7/18/2023 when Staff E, Agency LPN handed the resident a snack. An interview was conducted on 8/16/2023 at 9:48 AM with Staff A, LPN. Staff A, LPN stated she was called into the facility on [DATE] around 4:30 AM by Staff B, LPN Supervisor due to a resident elopement. Staff A, LPN stated she last saw Resident #1 on 7/18/2023 on the 7 AM to 3 PM shift and he did not express desires of leaving the facility. Staff A, LPN stated Resident #1 usually stayed in his room during the shift and was very pleasant. Staff A, LPN stated she arrived at the facility around 5:00 AM and joined the staff at the facility in searching for Resident #1. Staff A, LPN stated the last staff member to see Resident #1 was Staff F, LPN around 9:00 PM on 7/18/2023 when the LPN provided Resident #1 with a snack. Staff A, LPN stated Resident #1 was returned to the facility by law enforcement around 8:00 AM on 7/19/2023. Staff A, LPN spoke with Resident #1 upon his return and asked the resident what happened? Resident #1 responded to Staff A, LPN I don't know. Staff A, LPN stated Resident #1 was wearing a burgundy short sleeved shirt, blue basketball shorts, and non-skid socks with a tear in the left sock. Resident #1 was not observed wearing shoes. Once Resident #1 was back in the facility, Staff A, LPN performed an assessment. Staff A, LPN stated she documented several possible mosquito bites described as red dots throughout Resident #1's body and a blister on Resident #1's left foot. Staff A, LPN stated after the assessment, Resident #1 laid in the fetal position in his bed and appeared very tired. Staff A, LPN stated Resident #1 was provided fluids because he was very thirsty. Staff A, LPN stated the door Resident #1 exited out of was usually kept locked with a magnetic lock but Resident #1 was able to push the door open. Staff A, LPN stated she completed Resident #1's elopement assessment upon admission to the facility and did not assess the resident as an elopement risk. Staff A, LPN stated she would expect CNA staff to round every 30 minutes to an hour at the latest to check on the resident's needs and to take account of that resident. A review of Resident #1's admission assessment dated [DATE] revealed under the section titled EL. Elopement Risk a question Is resident ambulatory and/or able to self-propel wheelchair? and a documented response No. The section revealed If no, next question will be disabled. The disabled section of the EL. Elopement Risk portion of the admission assessment related to risk factors to indicate the resident was at risk for elopement and contained no information. An interview was conducted on 8/16/2023 at 10:16 AM with Staff F, LPN. Staff F, LPN stated she worked a double shift on 7/18/2023 during the 7 AM to 3 PM and the 3 PM to 11 PM shifts. Staff F, LPN stated Resident #1 would usually stay in his room and sometimes go to the nurse's station to ask for coffee. Staff F, LPN last saw Resident #1 on 7/18/2023 at 9:00 PM when the resident walked to the nurse's station and asked for a snack. Staff F, LPN left the facility around 11:15 PM and did not see Resident #1 between 9:00 PM and 11:15 PM. Staff F, LPN received a phone call around 6:00 AM on 7/19/2023 from facility staff telling her she needed to come to the facility. When Staff F, LPN arrived at the facility around 6:45 AM, facility staff were already searching for Resident #1 throughout the facility and the facility grounds. Staff F, LPN was not able to state what time Resident #1 was returned to the facility but stated the resident looked tired. Staff F, LPN stated she was not sure how Resident #1 exited the facility but thinks he might have gone out through the back door leading out to the facility staff parking lot. Staff F, LPN stated before Resident #1's elopement, staff would enter the facility through the rear entrance and the door was usually locked using the magnetic lock and could only be opened by entering a code. Staff F, LPN stated she would expect the CNA staff to check on residents at least every 2 hours to check on the resident's needs and to take account of that resident. An interview was conducted on 8/16/2023 at 10:40 AM with Staff G, CNA. Staff G, CNA stated she was familiar with Resident #1 and had transported him to several outside appointments. Staff G, CNA stated Resident #1 was normally quiet and laid back in demeanor but would observe a lot and was very sneaky. Staff G, CNA received a phone call on 7/19/2023 at approximately 4:30 AM from Staff B, LPN because Resident #1 was missing from the facility, and he was not sure what to do. Staff G, CNA told Staff B, LPN to contact the NHA and DON and to notify the police. Staff G, CNA called Staff A, LPN and Staff I, CNA and told them to come to the facility to assist in searching for Resident #1. Staff G, CNA arrived at the facility at approximately 4:45 AM and stated local law enforcement arrived after. After searching the facility grounds for Resident #1, Staff G, CNA stated she spoke with law enforcement around 6 or 7 AM, who told her they found Resident #1 in a lady's yard on a trampoline. Staff G, CNA stated she drove to Resident #1's location in the facility van around 7 AM and witnessed Resident #1 being escorted into a police car by law enforcement. Staff G, CNA drove back to the facility and saw Resident #1. Staff G, CNA observed Resident #1 with a lot of bites on his body and wearing socks with no shoes. Staff G, CNA stated Resident #1 told herself, Staff I, CNA, Staff A, LPN, and the SDC how he was able to exit the facility. Resident #1 told Staff G, CNA he walked through the elevator, accessed the rear service hallway, and exited out of the facility through the back door leading into the facility staff parking lot. A telephone interview was conducted on 8/16/2023 at 1:20 PM with the facility's Medical Director (MD), who was Resident #1's primary care provider. The MD stated Resident #1 was mildly confused but was able to follow commands and was easy to redirect during previous interactions with the resident. The MD was notified by the facility Resident #1 eloped from the facility by accessing the rear service hallway through the facility elevator and was found by law enforcement several hours later. The MD assessed Resident #1 around 10 or 11 AM after the resident was showered. The MD discovered a couple of abrasions here and there and a couple of bug bites presumed to be mosquito bites. The MD stated Resident #1's feet here mildly edematous but the resident did not sustain any injuries from the elopement. The MD stated Resident #1 was able to explain how he exited the facility and he was trying to go home. A review of a SOAP (Subjective, Objective, Assessment, Plan) note dated 7/19/2023 and authored by the MD revealed the following: .I was call[ed] to [Resident #1]'s bedside as it was brought to my attention that [Resident #1] had an elopement incident yesterday [7/18/2023]. [Resident #1] was found by the police and [br]ought back to the facility on examination. [Resident #1] appears to be stable and at baseline. [Resident #1] does have multiple mosquito bites. In various places .On questioning, [Resident #1] does not recall the incident. States that he was going for a walk . An interview was conducted on 8/16/2023 at 1:39 PM with Staff H, CNA, Resident #1's assigned CNA for the 7 AM to 3 PM shift on 7/18/2023. Staff H, CNA stated she frequently provided care for Resident #1 and Resident #1 was cooperative with care. Staff H, CNA stated on 7/13/2023, Resident #1 pressed his call light and asked Staff H, CNA how he could transfer out of here. Staff H, CNA stated Resident #1 did not express a desire to exit the facility other than that one incident. Staff H, CNA stated she arrived at the facility on 7/19/2023 around 6:45 AM and witnessed several law enforcement vehicles and personnel upon her arrival. Staff H, CNA provided a description of the clothing Resident #1 was wearing to law enforcement because other staff members gave the wrong description. Staff H, CNA stated about an hour after her arrival at the facility, Resident #1 was returned to the facility by law enforcement. Staff H, CNA stated Resident #1 appeared to be wearing wet clothing and had holes in his socks. Staff H, CNA provided Resident #1 with clean clothing and ice water because the resident stated he was thirsty. Staff H, CNA stated Resident #1 did not state how he exited the facility, but she found out by speaking with other facility staff. An interview was conducted on 8/16/2023 at 1:54 PM with Staff I, CNA. Staff I, CNA stated she received a phone call from Staff G, CNA on 7/19/2023 at approximately 4:30 AM who stated Resident #1 was missing from the facility. Staff I, CNA then drove to the facility and assisted staff in attempting to locate Resident #1 by searching inside and outside of the facility and near local businesses. Staff I, CNA stated law enforcement arrived during the search for Resident #1 and assisted in the search. Staff I, CNA stated Resident #1 was returned to the facility sometime before breakfast and appeared tired and walked out his socks, meaning Resident #1 had holes in the bottoms of his socks. Staff I, CNA spoke with Resident #1 following the incident, who stated he accessed the rear service hallway through the facility elevator, walked down the service hallway, pushed open the rear exit door and hit it, meaning he began walking down the street. Resident #1 stated to Staff I, CNA he was just going for a walk. Staff I, CNA stated Resident #1's memory comes and goes. An interview was conducted on 8/16/2023 at 2:40 PM with Resident #1 on the facility's dementia care unit. Resident #1 was observed lying in bed in his room. Resident #1 stated be remembered going for a walk and was gone from the facility for a few hours. Resident #1 was not able to recall details of the elopement and only stated he left through one of the exits and came back here. An interview was conducted on 8/16/2023 at 2:53 PM with the SSD and the facility's MDS Coordinator (MDS). The SSD stated when a resident is admitted to the facility, a welcome meeting or welcome conference is held with the resident and/or family to go over the resident's history. The MDS Coordinator stated the residents medications, baseline care plan, dietary preferences, allergies, and other care conditions are discussed during the meeting. The SSD stated if the resident is not alert and oriented, the resident's family is called to participate in the meeting. The SSD stated a welcome conference was conducted with Resident #1 upon admission and the RP was contact by phone to participate in the meeting. The SSD stated Resident #1 was his own responsible party upon admission. The RP told the SSD Resident #1 had an incident in December of 2022 where he went to the airport and got lost, but not much else. Telephone interviews were attempted on 8/16/2023 with Staff C, CNA, Resident #1's assigned CNA for the 11 PM to 7 AM shift on 7/18/2023, Staff B, LPN, the assigned facility supervisor for the 11 PM to 7 AM shift on 7/18/2023, Staff D, LPN, Resident #1's assigned nurse for the 11 PM to 7 AM shift on 7/18/2023, Staff J, CNA, Resident #1's assigned CNA for the 3 PM to 11 PM shift on 7/18/2023, and Staff E, Agency LPN, Resident #1's assigned nurse for the 3 PM to 11 PM shift on 7/18/2023. The staff members could not be reached. A review of Resident #1's preadmission Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form, with a Physician Certification date of 6/18/2023 revealed under Section C: Decision Making Capacity (Patient) Resident #1 required a surrogate for medical decision making. The transfer form revealed under Section E: Medical Condition, primary discharge diagnoses of altered mental status (AMS) and incompetence. A review of Resident #1's psychology evaluation notes dated 7/5/2023 revealed under the section titled Patient Consent This provider confirms that the written consent to treat was obtained from the patient Power of Attorney (POA) as patient is not capable of giving the consent. The note revealed under the section titled History of Present Illness Patient has history of depression, anxiety, and dementia. Patient stated, 'my memory is bad'. He reported he feels depressed, sad, and irritable since he was admitted to the facility . An interview and tour were conducted on 8/17/2023 at 11:15 AM with the facility's Maintenance Director and NHA near the facility elevator. The NHA stated modifications were made to the facility elevator to ensure residents of the facility could not access the rear service hallway through the elevator. The NHA stated a keypad would be installed for the elevator and anyone who used the elevator would be required to enter a code, which would not be provided to facility residents. The NHA stated the rear service hallway could be accessed through the 200 unit and required a code to access. An observation of the facility elevator revealed the buttons to access the rear service hallway were not able to be pressed due to being covered with a cap and black tape. The NHA stated the modifications were temporary until the elevator vendor could install the keypad. A tour was conducted of the rear service of the facility. The facility elevator cannot be accessed through the rear service hallway and was observed to be blocked with yellow caution tape. An observation of the rear exit door of the facility revealed signage posted on the door entrance temporarily closed use front entrance!! The rear exit door was locked and secured. A review of the facility policy titled Abuse Prohibition/Investigative Policy, revised in August 2023, revealed under the section titled Policy the facility will prohibit abuse, neglect, misappropriation of resident property, and exploitation. The policy revealed under the section titled Purpose the purpose of the policy is to ensure the facility is doing all that is within its control to prevent occurrences of abuse/neglect. The policy defines neglect as .the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Facility's immediate actions to remove the Immediate Jeopardy included: o Facility egress doors checked for alarming/functioning with no other issues identified. The door that resident exited from noted to not automatically close has been taken out of services. An outside vendor was contacted on 7/19/2023 by the NHA to replace the door. The rear elevator door was taken out of service on 7/19/2023 by blocking the buttons to open them. An outside vendor was contacted on 7/19/2023 by the NHA to service the elevator and put a code box on to prevent it from opening without putting in the code. o Elopement drills initiated on 7/19/2023 starting on 7:00 AM to 3:00 PM shift then conducted every shift for 3 days then weekly for 4 weeks then monthly. o Staff education was initiated 7/19/2023 on Abuse, Neglect and Exploitation Policy w/ emphasis on neglect to include reporting requirements, elopement standard and guidelines, shift to shift rounds and mid night census by the staff development coordinator, this education included actual visualization of each resident during these rounds this education was completed on 7/20/2023. Newly hired staff and agency staff will be educated during the orientation process. Staff will be educated on every 2-hour rounding on residents to include physical visualization of residents. Licensed nurses will validate that this rounding is being done and document attestation of rounding in the medication administration record. Education will be completed by the SDC, or designee. Residents that are evaluated to be at risk for elopement and not placed on the secured unit will have rounding with physical visualization every 1 hour or as indicated in their plan of care. The licensed nurse will validate that this rounding is being done and document attestation of rounding the medication administration record. o Residents currently residing in the facility were re-evaluated for elopement risk by the DON or Designee on 7/19/2023 to 7/25/2023. No new residents identified at risk for elopement. o An ad-hoc QAPI meeting was held on 7/19/2023 at 3:00 PM. o Elopement risk alert binders reviewed for accuracy and confirmed to have demographics present for all residents at risk for elopement based on Elopement Risk Evaluations on 7/19/2023. The binders were again reviewed on 7/25/2023, no new updates were needed. New admissions or residents with a change in behavior that increases risk for elopement will be reviewed during morning clinical meeting and placed in the elopement risk binders located at each nurses station and at the receptionist desk. o Care plans for residents at risk for elopement confirmed to be present on 7/20/2023. Updates were completed as needed. o Rounds are conducted throughout each shift, at shift change, during AM, PM care, during meal services and during care provision. Mid-night census sheet will be signed by the unit nurse and turned into the Director of Nurses each day. Verification of the facility's removal plan was conducted by the survey team on 8/18/2023. An attestation provided by the facility revealed on 7/19/2023, the former maintenance director ensured the rear service elevator door, and the rear exit door of the facility were taken out of service and outside vendors were contacted to service the elevator door and to replace the rear door of the facility. A sample of five residents at risk for elopement, including Resident #1, were reviewed for verification of new orders related to rounding, care plan including elopement risk, elopement risk evaluation, and presence in the facility elopement book. Review of the five residents revealed all residents had new orders related to rounding, care plan including elopement risk, updated elopement risk evaluation, and presence in the facility elopement book. A review of education conducted by the DON and the SDC revealed education related to resident rounding was conducted on 8/17/2023 for facility nursing staff. Education related to abuse/neglect and elopement procedures was conducted on 7/19/2023 and completed on 7/20/2023 with all staff educated. Post-test and competencies included as part of the facility training. A review of facility elopement drills revealed elopement drills were conducted from 7/19/2023 to 7/22/2023. Elopement drills completed on all shifts with documentation of participating staff. Interviews were conducted with 48 staff members, including 2 Registered Nurses, 7 LPNs, 13 CNAs, 7 dietary staff, 3 therapy staff, 6 housekeeping staff, and 10 other staff members. The staff members were able to state that they had been trained and were knowledgeable about the policies and procedures. Based on verification of the facility's Immediate Jeopardy removal plan the immediate jeopardy was determined to be removed on 8/18/2023 and the non-compliance was reduced to a scope and severity of D.

Based on observations, interviews with the nursing staff, Nursing Home Administrator, the Director of Nursing, the facility's Staff Development Coordinator, the facility's Medical Director, the resident's family member and review of the resident's medical record and facility policies, the facility failed to ensure one resident (#1) of 47 residents at risk for elopement, was provided with supervision and services related to the resident's known cognitive deficits and history of wandering before admission to the facility. The facility nursing staff failed to ensure the safety of Resident #1; between approximately 9:00 PM on 7/18/2023 and 4:00 AM on 7/19/2023, Resident #1 ambulated from his room on the second floor of the facility, passed the unit nurse's station, and walked approximately 40 feet to the facility elevator. Resident #1 pushed the elevator button to access the rear service hallway of the facility where no staff were present. Resident #1 walked approximately 45 feet unsupervised through the rear service hallway and pushed open a staff entrance door, equipped with an electromagnetic locking device (a magnetic lock that is unlocked when de-energized and requires power to remain locked), which was not locked. Resident #1 exited the facility unsupervised and without staff knowledge and walked appropriately 3.1 miles without shoes, through areas with no sidewalks, and along 4 lane roads, to a private residence. The facility failed to take action to prevent the resident from accessing the rear service hallway by not providing supervision for the resident, not accounting for the resident for approximately 10 hours, and not ensuring facility doors were secured before the resident eloped. Resident #1 was discovered by police on 7/19/2023 at approximately 7:00 AM in the backyard of a community member, sitting on a trampoline. Resident #1 was returned to the facility by police at approximately 7:30 AM disheveled and with holes in his socks and was discovered to have multiple insect bites and a blister to his left heel. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #1 and resulted in the determination of Immediate Jeopardy on 8/17/2023. The findings of Immediate Jeopardy were determined to be removed on 8/18/2023 and the severity and scope was reduced to a D. Findings included: A review of Resident #1's progress notes dated 7/19/2023 at 11:49 AM and authored by Staff A, Licensed Practical Nurse (LPN), revealed the following: Upon arrival to facility, [Resident #1] alert with some confusion. Head to toe assessment performed .[Resident #1] c/o [complained of ] pain to [the] left heel. Tylenol was given for mild pain .Skin assessment was complete and possible mosquito bites on back, [Resident #1] noted scratching areas [to] bilateral arm, abdomen, back of both legs as well as front of legs, left foot heel has a [has a] blister MD is aware and ordered scheduled Tylenol for pain r/t [related to] left heel as well as skin prep [a protective wipe which forms a barrier between the patient's skin and adhesives to help preserve skin integrity] to left heel blister and Hydrocortisone cream for itching . A review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of encephalopathy, unspecified; dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; cognitive communication deficit; unspecified abnormalities of gait and mobility; muscle weakness (generalized); depression, unspecified; and anxiety disorder. A review of Resident #1's physician's orders revealed the following: - An order dated 8/1/2023 to record active exit seeking behaviors and record the following intervention code(s) every shift: 1: N/A, 2. Engage in conversation, 3. Redirect to alternative location in facility, 4. Call family/friend, 5. Activity, 6. Give snacks/food, 7. Give fluids, 8. Toileting. - An order dated 8/1/2023 for behavioral monitoring related to exit-seeking behaviors and record the number of occurrences every shift. According to the National Institutes of Health, wandering behavior is one of the most important and challenging management aspects in persons with dementia. Wandering behavior in people with dementia (PwD) is associated with an increased risk of falls, injuries, and fractures, as well as going missing or being lost from a facility. This causes increased distress in caregivers at home and in healthcare facilities. The approach to the comprehensive evaluation of the risk assessment, prevention, and treatment needs more strengthening and effective measures as the prevalence of wandering remains high in the community. Both the caregiver and clinicians need a clear understanding and responsibility of ethical and legal issues while managing and restraining the PwD. The consequences of the wandering can vary from minor injury on the body to severe injury and death. The persistent wandering behavior and weak gait and balance have been shown to increase the risk of falls, fractures, and accidents in PwD. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8543604/#:~:text=Outcome%20of%20Wandering%20in%20Dementia,to%20severe%20injury%20and%20death.&text=The%20persistent%20wandering%20behavior%20and,fractures%2C%20and%20accidents%20in%20PwD. A review of Resident #1's baseline care plan, dated 6/23/2023, did not reveal problems or potential concerns related to elopement risk. A review of Resident #1's 5-Day Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 6/27/2023 revealed under Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of C - BIMS: 7 which indicated severely impaired cognition. Resident #1's MDS assessment revealed under Section E - Behavior, Resident #1 did not display behaviors of wandering but rejected care 1 to 3 days of the assessment period. Section G - Functional Status revealed Resident #1 required supervision and set up help only with locomotion on the unit and required one person physical assistance with locomotion off the unit. Resident #1 was unsteady, but able to stabilize without staff assistance while walking and turning around. Resident #1 did not require an assistive device for mobility. Resident #1's MDS assessment revealed under Section I - Active Diagnoses Resident #1 had diagnoses of Non-Alzheimer's Dementia, Anxiety Disorder, Depression, and Encephalopathy, unspecified. An interview was conducted on 8/15/2023 at 12:30 PM with the facility's Social Services Director (SSD), the Staff Development Coordinator (SDC) and the Nursing Home Administrator (NHA). The SDC stated on 7/19/2023, Resident #1 was returned to the facility after Staff C, Certified Nursing Assistant (CNA) discovered Resident #1 was not in his room at approximately 4:00 AM. Staff C, CNA reported Resident #1 missing to Staff D, LPN, who reported the finding to Staff B, LPN Supervisor. A code pink was called through the facility, which alerted staff a resident was missing from the facility and a facility search was conducted. After verifying Resident #1 was not in the facility, Staff B, LPN Supervisor notified law enforcement and the NHA. The SDC stated the facility cameras did not capture Resident #1 leaving the facility due to a power surge. Law enforcement located Resident #1 in a community member's backyard on a trampoline. They said Resident #1 was returned to the facility on [DATE] at 7:15 AM but they did not provide an address where Resident #1 was located. The SSD stated law enforcement did not provide an incident report and stated, they said if they had one they would send it to us. The SDC and NHA stated they conducted an interview with Resident #1 following the elopement. Resident #1 stated he left the facility by accessing the facility elevator, walking through the rear service hallway of the facility, and pushing open a door to exit the facility. Resident #1 explained he wanted to go for a walk. Upon Resident #1's return to the facility, a head to toe assessment was completed by Staff A, LPN and the facility's Medical Director was notified. Staff A, LPN discovered several bites on the resident's body during the assessment. The NHA stated following the incident, the facility's former maintenance director conducted an exterior door security audit to ensure all exterior doors were secure. Modifications were made to the facility elevator so the rear service hallway could not be accessed through the elevator. The NHA stated the door Resident #1 exited the facility through was equipped with a magnetic lock, but the lock did not engage. The SDC stated the last time staff confirmed seeing Resident #1 was around 11 PM on 7/18/2023 when Staff E, Agency LPN handed the resident a snack. A review of the facility policy titled Safety and Supervision of Residents, revised in July of 2017, revealed under the section titled Policy Statement the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The policy revealed under the section titled Individualized, Resident-Centered Approach to Safety the individualized, resident centered approach to safety addresses safety and accident hazards for individual residents. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. An interview was conducted on 8/16/2023 at 9:48 AM with Staff A, LPN. Staff A, LPN stated she was called into the facility on [DATE] around 4:30 AM by Staff B, LPN Supervisor due to a resident elopement. Staff A, LPN stated she last saw Resident #1 on 7/18/2023 on the 7 AM to 3 PM shift and he did not express desires of leaving the facility. Staff A, LPN stated Resident #1 usually stayed in his room during the shift and was very pleasant. Staff A, LPN stated she arrived at the facility around 5:00 AM and joined the staff at the facility in searching for Resident #1. Staff A, LPN stated the last staff member to see Resident #1 was Staff F, LPN around 9:00 PM on 7/18/2023 when the LPN provided Resident #1 with a snack. Staff A, LPN stated Resident #1 was returned to the facility by law enforcement around 8:00 AM on 7/19/2023. Staff A, LPN spoke with Resident #1 upon his return and asked the resident what happened? Resident #1 responded to Staff A, LPN I don't know. Staff A, LPN stated Resident #1 was wearing a burgundy short sleeved shirt, blue basketball shorts, and non-skid socks with a tear in the left sock. Resident #1 was not observed wearing shoes. Once Resident #1 was back in the facility, Staff A, LPN performed an assessment. Staff A, LPN stated she documented several possible mosquito bites described as red dots throughout Resident #1's body and a blister on Resident #1's left foot. Staff A, LPN stated after the assessment, Resident #1 laid in the fetal position in his bed and appeared very tired. Staff A, LPN stated Resident #1 was provided fluids because he was very thirsty. Staff A, LPN stated the door Resident #1 exited out of was usually kept locked with a magnetic lock but Resident #1 was able to push the door open. Staff A, LPN stated she completed Resident #1's elopement assessment upon admission to the facility and did not assess the resident as an elopement risk. Staff A, LPN stated she would expect CNA staff to round every 30 minutes to an hour at the latest to check on the resident's needs and to take account of that resident. A review of Resident #1's admission assessment dated [DATE] revealed under the section titled EL. Elopement Risk a question Is resident ambulatory and/or able to self-propel wheelchair? and a documented response No. The section revealed If no, next question will be disabled. The disabled section of the EL. Elopement Risk portion of the admission assessment related to risk factors to indicate the resident was at risk for elopement and contained no information. An interview was conducted on 8/16/2023 at 10:16 AM with Staff F, LPN. Staff F, LPN stated she worked a double shift on 7/18/2023 during the 7 AM to 3 PM and the 3 PM to 11 PM shifts. Staff F, LPN stated Resident #1 would usually stay in his room and sometimes go to the nurse's station to ask for coffee. Staff F, LPN last saw Resident #1 on 7/18/2023 at 9:00 PM when the resident walked to the nurse's station and asked for a snack. Staff F, LPN left the facility around 11:15 PM and did not see Resident #1 between 9:00 PM and 11:15 PM. Staff F, LPN received a phone call around 6:00 AM on 7/19/2023 from facility staff telling her she needed to come to the facility. When Staff F, LPN arrived at the facility around 6:45 AM, facility staff were already searching for Resident #1 throughout the facility and the facility grounds. Staff F, LPN was not able to state what time Resident #1 was returned to the facility but stated the resident looked tired. Staff F, LPN stated she was not sure how Resident #1 exited the facility but thinks he might have gone out through the back door leading out to the facility staff parking lot. Staff F, LPN stated before Resident #1's elopement, staff would enter the facility through the rear entrance and the door was usually locked using the magnetic lock and could only be opened by entering a code. Staff F, LPN stated she would expect the CNA staff to check on residents at least every 2 hours to check on the resident's needs and to take account of that resident. An interview was conducted on 8/16/2023 at 10:40 AM with Staff G, CNA. Staff G, CNA stated she was familiar with Resident #1 and had transported him to several outside appointments. Staff G, CNA stated Resident #1 was normally quiet and laid back in demeanor but would observe a lot and was very sneaky. Staff G, CNA received a phone call on 7/19/2023 at approximately 4:30 AM from Staff B, LPN because Resident #1 was missing from the facility, and he was not sure what to do. Staff G, CNA told Staff B, LPN to contact the NHA and DON and to notify the police. Staff G, CNA called Staff A, LPN and Staff I, CNA and told them to come to the facility to assist in searching for Resident #1. Staff G, CNA arrived at the facility at approximately 4:45 AM and stated local law enforcement arrived after. After searching the facility grounds for Resident #1, Staff G, CNA stated she spoke with law enforcement around 6 or 7 AM, who told her they found Resident #1 in a lady's yard on a trampoline. Staff G, CNA stated she drove to Resident #1's location in the facility van around 7 AM and witnessed Resident #1 being escorted into a police car by law enforcement. Staff G, CNA drove back to the facility and saw Resident #1. Staff G, CNA observed Resident #1 with a lot of bites on his body and wearing socks with no shoes. Staff G, CNA stated Resident #1 told herself, Staff I, CNA, Staff A, LPN, and the SDC how he was able to exit the facility. Resident #1 told Staff G, CNA he walked through the elevator, accessed the rear service hallway, and exited out of the facility through the back door leading into the facility staff parking lot. A telephone interview was conducted on 8/16/2023 at 1:20 PM with the facility's Medical Director (MD), who was Resident #1's primary care provider. The MD stated Resident #1 was mildly confused but was able to follow commands and was easy to redirect during previous interactions with the resident. The MD was notified by the facility Resident #1 eloped from the facility by accessing the rear service hallway through the facility elevator and was found by law enforcement several hours later. The MD assessed Resident #1 around 10 or 11 AM after the resident was showered. The MD discovered a couple of abrasions here and there and a couple of bug bites presumed to be mosquito bites. The MD stated Resident #1's feet here mildly edematous but the resident did not sustain any injuries from the elopement. The MD stated Resident #1 was able to explain how he exited the facility and he was trying to go home. A review of a SOAP (Subjective, Objective, Assessment, Plan) note dated 7/19/2023 and authored by the MD revealed the following: .I was call[ed] to [Resident #1]'s bedside as it was brought to my attention that [Resident #1] had an elopement incident yesterday [7/18/2023]. [Resident #1] was found by the police and [r]ought back to the facility on examination. [Resident #1] appears to be stable and at baseline. [Resident #1] does have multiple mosquito bites. In various places .On questioning, [Resident #1] does not recall the incident. States that he was going for a walk . An interview was conducted on 8/16/2023 at 1:39 PM with Staff H, CNA, Resident #1's assigned CNA for the 7 AM to 3 PM shift on 7/18/2023. Staff H, CNA stated she frequently provided care for Resident #1 and Resident #1 was cooperative with care. Staff H, CNA stated on 7/13/2023, Resident #1 pressed his call light and asked Staff H, CNA how he could transfer out of here. Staff H, CNA stated Resident #1 did not express a desire to exit the facility other than that one incident. Staff H, CNA stated she arrived at the facility on 7/19/2023 around 6:45 AM and witnessed several law enforcement vehicles and personnel upon her arrival. Staff H, CNA provided a description of the clothing Resident #1 was wearing to law enforcement because other staff members gave the wrong description. Staff H, CNA stated about an hour after her arrival at the facility, Resident #1 was returned to the facility by law enforcement. Staff H, CNA stated Resident #1 appeared to be wearing wet clothing and had holes in his socks. Staff H, CNA provided Resident #1 with clean clothing and ice water because the resident stated he was thirsty. Staff H, CNA stated Resident #1 did not state how he exited the facility, but she found out by speaking with other facility staff. An interview was conducted on 8/16/2023 at 1:54 PM with Staff I, CNA. Staff I, CNA stated she received a phone call from Staff G, CNA on 7/19/2023 at approximately 4:30 AM who stated Resident #1 was missing from the facility. Staff I, CNA then drove to the facility and assisted staff in attempting to locate Resident #1 by searching inside and outside of the facility and near local businesses. Staff I, CNA stated law enforcement arrived during the search for Resident #1 and assisted in the search. Staff I, CNA stated Resident #1 was returned to the facility sometime before breakfast and appeared tired and walked out his socks, meaning Resident #1 had holes in the bottoms of his socks. Staff I, CNA spoke with Resident #1 following the incident, who stated he accessed the rear service hallway through the facility elevator, walked down the service hallway, pushed open the rear exit door and hit it, meaning he began walking down the street. Resident #1 stated to Staff I, CNA he was just going for a walk. Staff I, CNA stated Resident #1's memory comes and goes. A review of the facility policy titled Emergency Procedure - Missing Resident, revised in August of 2016, revealed under the section titled Policy Statement a resident elopement resulting in a missing resident is considered a facility emergency. The policy revealed under the section titled Policy Interpretation and Implementation residents at risk for wandering and/or elopement will be monitored, and staff will take necessary precautions to ensure their safety. Staff will implement the protocol for missing resident immediately upon discovering that a resident cannot be located. A review of a law enforcement report dated 7/19/2023 at 5:41 AM revealed law enforcement responded to the facility at approximately 6:11 AM for a report of a missing endangered person, who went missing around 6:00 PM on 7/18/2023. A search of the facility was conducted by law enforcement but Resident #1 was confirmed not on the facility grounds. The report revealed Staff H, CNA, who was the last caretaker to contact Resident #1, provided law enforcement with a description of the resident. Law enforcement received a service call at a residence approximately 3.1 miles from the facility involving a suspicious person matching Resident #1's description. Upon arrival at the residence, law enforcement observed Resident #1 in the backyard of the residence sitting on a trampoline. Resident #1 was returned to the facility and interviewed by law enforcement. Resident #1 told law enforcement he exited the facility around 4:30 PM on 7/18/2023 to go for a walk. A telephone interview was conducted on 8/16/2023 at 2:24 PM with Resident #1's responsible party (RP). The RP stated prior to being admitted to the facility, Resident #1 went missing in December of 2022 after getting lost and was found by law enforcement. The RP stated Resident #1 had gone missing several times and had to be located by law enforcement prior to admission to the facility and was not able to make medical decisions due to his dementia. A review of the facility policy titled Wandering and Elopements, revised in March of 2019, revealed under the section titled Policy Statement the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. The policy revealed under the section titled Policy Interpretation and Implementation if identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. An interview was conducted on 8/16/2023 at 2:40 PM with Resident #1 on the facility's dementia care unit. Resident #1 was observed lying in bed in his room. Resident #1 stated be remembered going for a walk and was gone from the facility for a few hours. Resident #1 was not able to recall details of the elopement and only stated he left through one of the exits and came back here. An interview was conducted on 8/16/2023 at 2:53 PM with the SSD and the facility's MDS Coordinator (MDS). The SSD stated when a resident is admitted to the facility, a welcome meeting or welcome conference is held with the resident and/or family to go over the resident's history. The MDS Coordinator stated the residents medications, baseline care plan, dietary preferences, allergies, and other care conditions are discussed during the meeting. The SSD stated if the resident is not alert and oriented, the resident's family is called to participate in the meeting. The SSD stated a welcome conference was conducted with Resident #1 upon admission and the RP was contact by phone to participate in the meeting. The SSD stated Resident #1 was his own responsible party upon admission. The RP told the SSD Resident #1 had an incident in December of 2022 where he went to the airport and got lost, but not much else. Telephone interviews were attempted on 8/16/2023 with Staff C, CNA, Resident #1's assigned CNA for the 11 PM to 7 AM shift on 7/18/2023, Staff B, LPN, the assigned facility supervisor for the 11 PM to 7 AM shift on 7/18/2023, Staff D, LPN, Resident #1's assigned nurse for the 11 PM to 7 AM shift on 7/18/2023, Staff J, CNA, Resident #1's assigned CNA for the 3 PM to 11 PM shift on 7/18/2023, and Staff E, Agency LPN, Resident #1's assigned nurse for the 3 PM to 11 PM shift on 7/18/2023. The staff members could not be reached. A review of Resident #1's preadmission Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form, with a Physician Certification date of 6/18/2023 revealed under Section C: Decision Making Capacity (Patient) Resident #1 required a surrogate for medical decision making. The transfer form revealed under Section E: Medical Condition, primary discharge diagnoses of altered mental status (AMS) and incompetence. A review of Resident #1's psychology evaluation notes dated 7/5/2023 revealed under the section titled Patient Consent This provider confirms that the written consent to treat was obtained from the patient Power of Attorney (POA) as patient is not capable of giving the consent. The note revealed under the section titled History of Present Illness Patient has history of depression, anxiety, and dementia. Patient stated, 'my memory is bad'. He reported he feels depressed, sad, and irritable since he was admitted to the facility . A review of Resident #1's care plan meeting minutes, dated 6/23/2023 revealed a Welcome Meeting was conducted with Resident #1 and Resident #1's RP via telephone. The care plan meeting minutes did not reveal documentation under the sections titled Behavioral Health/Activities or Resident/Family Concerns. Resident #1's diagnosis of dementia was not documented on the care plan meeting minutes. An interview and tour was conducted on 8/17/2023 at 11:15 AM with the facility's Maintenance Director and NHA near the facility elevator. The NHA stated modifications were made to the facility elevator to ensure residents of the facility could not access the rear service hallway through the elevator. The NHA stated a keypad would be installed for the elevator and anyone who used the elevator would be required to enter a code, which would not be provided to facility residents. The NHA stated the rear service hallway could be accessed through the 200 unit and required a code to access. An observation of the facility elevator revealed the buttons to access the rear service hallway were not able to be pressed due to being covered with a cap and black tape. The NHA stated the modifications were temporary until the elevator vendor could install the keypad. A tour was conducted of the rear service of the facility. The facility elevator cannot be accessed through the rear service hallway and was observed to be blocked with yellow caution tape. An observation of the rear exit door of the facility revealed signage posted on the door entrance temporarily closed use front entrance!! The rear exit door was locked and secured. Facility's immediate actions to remove the Immediate Jeopardy included: o Facility egress doors checked for alarming/functioning with no other issues identified. The door that resident exited from noted to not automatically close has been taken out of services. An outside vendor was contacted on 7/19/2023 by the NHA to replace the door. The rear elevator door was taken out of service on 7/19/2023 by blocking the buttons to open them. An outside vendor was contacted on 7/19/2023 by the NHA to service the elevator and put a code box on to prevent it from opening without putting in the code. o Elopement drills initiated on 7/19/2023 starting on 7:00 AM to 3:00 PM shift then conducted every shift for 3 days then weekly for 4 weeks then monthly. o Staff education was initiated 7/19/2023 on Abuse, Neglect and Exploitation Policy w/ emphasis on neglect to include reporting requirements, elopement standard and guidelines, shift to shift rounds and mid night census by the staff development coordinator, this education included actual visualization of each resident during these rounds this education was completed on 7/20/2023. Newly hired staff and agency staff will be educated during the orientation process. Staff will be educated on every 2-hour rounding on residents to include physical visualization of residents. Licensed nurses will validate that this rounding is being done and document attestation of rounding in the medication administration record. Education will be completed by the SDC, or designee. Residents that are evaluated to be at risk for elopement and not placed on the secured unit will have rounding with physical visualization every 1 hour or as indicated in their plan of care. The licensed nurse will validate that this rounding is being done and document attestation of rounding the medication administration record. o Residents currently residing in the facility were re-evaluated for elopement risk by the DON or Designee on 7/19/2023 to 7/25/2023. No new residents identified at risk for elopement. o An ad-hoc QAPI meeting was held on 7/19/2023 at 3:00 PM. o Elopement risk alert binders reviewed for accuracy and confirmed to have demographics present for all residents at risk for elopement based on Elopement Risk Evaluations on 7/19/2023. The binders were again reviewed on 7/25/2023, no new updates were needed. New admissions or residents with a change in behavior that increases risk for elopement will be reviewed during morning clinical meeting and placed in the elopement risk binders located at each nurses station and at the receptionist desk. o Care plans for residents at risk for elopement confirmed to be present on 7/20/2023. Updates were completed as needed. o Rounds are conducted throughout each shift, at shift change, during AM, PM care, during meal services and during care provision. Mid-night census sheet will be signed by the unit nurse and turned into the Director of Nurses each day. Verification of the facility's removal plan was conducted by the survey team on 8/18/2023. An attestation provided by the facility revealed on 7/19/2023, the former maintenance director ensured the rear service elevator door, and the rear exit door of the facility were taken out of service and outside vendors were contacted to service the elevator door and to replace the rear door of the facility. A sample of five residents at risk for elopement, including Resident #1, were reviewed for verification of new orders related to rounding, care plan including elopement risk, elopement risk evaluation, and presence in the facility elopement book. Review of the five residents revealed all residents had new orders related to rounding, care plan including elopement risk, updated elopement risk evaluation, and presence in the facility elopement book. A review of education conducted by the DON and the SDC revealed education related to resident rounding was conducted on 8/17/2023 for facility nursing staff. Education related to abuse/neglect and elopement procedures was conducted on 7/19/2023 and completed on 7/20/2023 with all staff educated. Post-test and competencies included as part of the facility training. A review of facility elopement drills revealed elopement drills were conducted from 7/19/2023 to 7/22/2023. Elopement drills completed on all shifts with documentation of participating staff. Interviews were conducted with 48 staff members, including 2 Registered Nurses, 7 LPNs, 13 CNAs, 7 dietary staff, 3 therapy staff, 6 housekeeping staff, and 10 other staff members. The staff members were able to state that they had been trained and were knowledgeable about the policies and procedures. Based on verification of the facility's Immediate Jeopardy removal plan the immediate jeopardy was determined to be removed on 8/18/2023 and the non-compliance was reduced to a scope and severity of D.

Based on observation, interview with facility staff, and review of medical records and facility policies it was determined the facility failed to ensure medications were contained in a locked compartment and accessible only to authorized personnel to prevent serious injury and subsequent death related to one resident (#1) obtaining and ingesting medications from an unsecured medication cart of three residents sampled for risk of wandering and rummaging behaviors. The facility assessed Resident #1 on [DATE] which revealed he had wandering tendencies. He was care planned for having a behavioral history of eating objects including cigarettes and paper. On [DATE] at approximately 8:50 p.m., Resident #1 an elderly, cognitively impaired resident, who self-propelled in a wheelchair, was able to access an unsecured medication cart undetected by facility staff. Facility investigation showed Resident #1 self-propelled himself to the cart and retrieved a bottle of Benadryl (and antihistamine medication) and a bottle of Aspirin (ASA) and placed them in his gown. He then self-propelled down the hallway to room [ROOM NUMBER] where he was found at approximately 9:50 p.m. by facility staff with pink stuff [Benadryl (Diphenhydramine) tablets are pink colored] on his shirt front and on the floor. Emergency Medical Services (EMS) were in the building for another resident and came to assess Resident #1. They transferred him to the emergency room (ER) where he was found to be in respiratory distress. Resident #1 was intubated and went into cardiac arrest for approximately 45 minutes. Resident #1 subsequently died on [DATE]. The death of Resident #1, as a result of the facility's failure to provide a secured medication cart resulted in findings of Immediate Jeopardy on [DATE], removed on [DATE], with the scope and severity reduced to a D after verification of implementation of immediacy removal actions. Findings included: Cross reference to F725. Record review of the hospital records showed Resident #1 was admitted to the hospital via EMS on [DATE] at 10:11 p.m. and was unresponsive. The [AGE] year-old man was brought to the ER (emergency room ) for an evaluation of decreased responsiveness with lethargy. The report revealed EMS was called to the nursing home for a different resident, and Resident #1 was discovered to be slumped over. There was a Benadryl bottle next to him and evidence of vomiting. When the resident arrived at the Emergency Department and transferred from the stretcher, he was found to be in respiratory distress. The decision was made to emergently intubate the resident; however, he was a difficult intubation due to swollen and edematous vocal cords. It is reported that his oxygen saturation levels dropped into the 30's (normal being ,d+[DATE]%) during the attempted intubation. The resident then went into cardiac arrest for approximately 45 minutes. It took two ER physicians to intubate the resident with a #6 ET tube [to keep the resident's airway open]. Due to the clinical findings, it is possible that the resident experienced an anaphylactic reaction causing swelling of the airways. The diagnoses included cardiac arrest, respiratory failure requiring intubation, possible anaphylactic shock, leukocytosis (high white blood cell count), Urinary Tract Infection (UTI), hyponatremia (low blood sodium levels), hyperglycemia (high blood glucose levels), lactic acidosis (excessive lactic acid in the bloodstream), transaminitis (high levels of certain liver enzymes). On [DATE], the hospital staff spoke with the family member who was the power of attorney (POA), and she asked for a Do Not Resuscitate Order (DNRO). The resident was unresponsive. There was no purposeful activity. The critical care team discussed the case with the POA. She requested a hospice consultation. Patient #1 was transferred to the Hospice Center to begin comfort measures only. His diagnoses included anoxic brain injury, post anoxic myoclonus (a movement disorder occurring after hypoxic brain events), cardiac arrest, respiratory failure requiring intubation, possible anaphylactic shock, UTI, normocytic anemia, hyperglycemia, transaminitis. An interview was conducted on [DATE] at 1:00 p.m. with the Director of Nursing (DON), Nursing Home Administrator (NHA), Risk Manager (RM) and Social Services Director (SSD). The RM stated the video of the incident was observed by these administrative staff members. The RM described the video and commented based on their investigation: On [DATE] at 2023 (8:23 p.m.) Resident #1 was brought to the nurses' station area by the assigned Staff B, Certified Nursing Assistant (CNA) in a wheelchair. Staff B had linen in her hands. She had attempted to put him in bed, but he did not want to go to bed. On the video, Resident #1 could be seen at the nursing station while both medication carts were sitting in front of the desk. He was sitting at the end of the wall facing the medication carts. Resident #1 then self-propelled to the medication cart. Staff A, Licensed Practical Nurse (LPN) was seen crushing and administering medications. She left her cart unlocked at about 8:32 p.m. She walked out of view of the camera. Staff A was then observed administering medication to Resident #2. Resident #1 was observed at 8:32 p.m. reaching into the medication cart and taking out two bottles. The two bottles in the video were identified by the Risk Manager as Benadryl and Aspirin. Resident #1 then placed the bottles inside his gown. Staff A returned to the cart where she could be observed tying Resident #1's gown. She then continued to pass medications. At 8:39 p.m., Resident #2 was observed falling from his wheelchair. Resident #1 was seen at that time self-propelling down the east wing of the nursing home (in the opposite direction of his own room). The aides and nurse were attending to the fallen resident. Resident #1 propelled into room [ROOM NUMBER] (on the east wing) at 8:50 p.m., which was not his room. During this time, one staff member was on break, Staff D, CNA. Staff A, LPN, Staff E, CNA, Staff C, CNA, and Staff B, CNA were all helping Resident #2 who had fallen. At 9:48 p.m., Staff D, CNA was seen taking Resident #5 down the hallway. They spoke to Staff F, CNA sitting in the hallway (she was on 1:1 [one to one] with the COVID [Coronavirus Disease 2019] residents). Staff D, CNA was observed coming out of the room [ROOM NUMBER] in urgency and panic and she was seen hollering and summoning Staff A, LPN. By the time she got to the hallway, you could see EMS coming on the floor. At 9:50 p.m., Staff A was observed entering room [ROOM NUMBER] and coming back out. Staff A led the EMS to the east wing and to Resident #1. Resident #1 was slumped in the wheelchair, right inside the doorway. EMS came in and got Resident #1 on the stretcher. They brought him out and could see pink stuff on his shirt. They were not doing cardiopulmonary resuscitation (CPR) or using an automatic defibrillator. Resident #1 was arousable and was talking to the EMS. Staff A was observed throwing away a bottle of medications, it was the second bottle of medication (ASA). EMS exited the facility with Resident #1 at the end of the video. The hospital records showed Resident #1 arrived at the hospital on [DATE] at 10:11 p.m. During a phone interview with Staff A, LPN, on [DATE] at 5:25 p.m., she stated she was the only nurse assigned to the first floor. She stated she had previously told the DON it was too much, and she needed another nurse with her. She stated there was no way to give meds(medications) when there were too many residents needing one to one. She said the night supervisor was present when she spoke with the DON about the staffing. She told the DON there had been too many close calls. That evening, two aides went to dinner at the same time, the aide on one-on-one and a floor aide, and we were short already. There were a bunch of residents at the nursing station. She stated she gave Resident #1 his meds and told the aide to take him back to his room. She stated she (Staff A) went to dinner afterwards. When she got back, the aide said she had to take care of her residents. The night before one of the residents kept hitting the aides. They could be aggressive/cussing (cursing) etc. and she kept telling the DON. She went to help the aide to get a resident from the chair to the bed. Resident #2 fell and hit his head, it was not bleeding, and we called 911. There was no printer downstairs and she had to go upstairs to print the paperwork for the EMS. They used to have a printer downstairs, but it broke, and it hasn't been replaced. She stated she had worked there 5 days a week for 2 or 3 weeks. She had to go upstairs to print the paperwork for Resident #2. The supervisor came down with her and they tried to find the CNA but could not find her. Staff B, CNA was the aide, and we could not find her, we kept calling and calling. EMS arrived. The aide said, oh my gosh, and Resident #1 was slumped over in a chair. We tried to wake him up. He was not responding. EMS had come to check on Resident #2, but they took Resident #1 instead. Resident #1 was responding, she stated she went up the elevator with him. A Benadryl bottle was found, and she noted she had Benadryl on one cart and not both. Staff I, CNA said they found some tablets and that she said, Both my carts are locked, the carts do not fully lock. She stated that she called later to ask about how Resident #1 was and she received no call back from the facility. She went into the facility and the RM questioned her about Benadryl. She said she had not given Benadryl to anyone. She told them it was their house stock; how would I know if it was in there (the cart). She was asked about the aspirin and said it was house stock too. The DON came in during the interview with the RM and told Staff A in the video Resident #1 obtained the medication from the cart. The DON told her, You did not attempt to lock it. She told the DON and the RM, If you saw it on the video, I guess it happened. She told the DON that they needed help, and this would not have happened. The facility staff would not call me back. She stated that she knew the facility had two nurses down on first floor now. I don't remember not locking the cart, it was not intentional. She stated that she was hung up on thinking they were accusing her of bringing the Benadryl into the facility. It was house stock - she did not bring it in. She said she had no orientation. She always worked downstairs in the facility (first floor). She had told her recruiter she was not going back to the facility. The residents were too aggressive, and they were not being medicated for their behaviors. She stated the RM and the DON asked her to read and sign the orientation paperwork on [DATE]. She had been telling the DON they needed more help downstairs. The supervisor was coming up and down that night. She said she was calling Staff B, CNA. Staff B, CNA was lying because she was on her phone. The DON and the RM told her they saw her working her butt off. The bottle she threw away was a Vitamin C bottle, and the Staff E, LPN supervisor was right there because she showed it to her. She stated she gave the Benadryl bottle to the supervisor. An interview was conducted on [DATE] at 2:16 p.m. with Staff E, LPN Supervisor. She stated she worked the 3:00 p.m. to 11:00 p.m. shift and was part-time on Monday, Tuesday, and Wednesday. She stated she was the supervisor that day ([DATE]). She got a call about 8:40 p.m. Staff A called her to let her know about Resident #2 falling. She stated she finished that conversation with the family on the phone and went downstairs. Resident #2 was on the floor on his right side. We assessed him and took him to his room. We decided to send him to the hospital because he kept saying his head was hurting. We called the MD and his family to let them know. She said she told Staff A to call 911. After the call was made, she went back to the DON's office to make more vaccination calls. The EMS came for Resident #2, and she had to open the door for EMS because it was locked at night. She took EMS downstairs. While they were looking at Resident #2 and an aide (Staff D) from down the hall started hollering, I need a nurse. We went down to the room, including EMS. Resident #1 was in a chair. He had pink all over and was leaning to one side. Staff E, LPN stated Resident #1 had gotten out of his wheelchair and into a chair. He was slumped over in a chair. He could not be seen from the door. Resident #1 was next to the curtain. EMS started to assess him and asked what the pink stuff was on his chest. There was pink on the floor. EMS started assessing and asked Staff A what medications he was on. When EMS saw the empty bottle of Benadryl, he looked at Staff A, and asked, Where did he get it? EMS took Resident #1 instead because he was a higher priority. Staff E stated that she walked EMS back upstairs to let them out then went back downstairs. Staff E found some pink pills on the floor and the bottle. She called the Risk Manager again and told her what she had found. She asked Staff A again, how he got the pills. Staff A, LPN told me she did not know how he got it. Staff A was calling the family. Staff E told the family there was a substance on his chest and did not know what happened. She stated she wrote a note after that. She asked Staff A if she had reached out to the doctor. She talked to the RM the next day and tried to follow up. She was told by the manager the next day what happened, that at that point it was not being discussed because of the situation. She stated that she went back and forth between upstairs and downstairs. She stated, Downstairs they need to keep eyes on them. The more hands you have the better, more needy, wander, move around. She stated she tended to stay there but had to go back and forth to deal with family members. She stated she found pills on the floor, 20 plus pills on the floor and the bottle was empty. He was a hoarder, he would hide things under his clothes such as, food, forks, etc. An interview was conducted on [DATE] at 2:49 p.m. with Staff B, CNA and Staff F, CNA. Staff F stated she was on break at about 8:00 p.m. and Resident #1 was in his wheelchair at the nursing station. She came back from break at about 8:35 p.m. or 8:40 p.m. Resident #1 was missing. Staff B, CNA was his aide that night and she thought Staff B had put him to bed. So, she went to sit with the COVID residents. Staff D was taking Resident #5 to her room (129) to put the resident back to bed and found Resident #1. She found him and summoned me (Staff F). Staff F stated, I had to ask her who it was, because no one else was supposed to be in that room. The EMS was coming in for a fall resident. Staff D told me it was Resident #1, and he was unresponsive. I ran to EMS and told him we needed them back here and the supervisor [Staff E], and [Staff A, LPN], we all went back to room [ROOM NUMBER]. EMS picked up Resident #1 and left. Staff A, LPN told me (Staff F) and Staff C, CNA, Because he takes another sleeping pill the Benadryl should be nothing for him. Staff B, CNA stated that night about 8:30 p.m. she had just finished doing patient care and had moved Resident #1 back to the nursing station. Staff A, LPN was at the cart and Staff C, CNA was at the nursing station. She sat Resident #1 next to the wall and went to give another resident care. A resident (Resident #2) had fallen while she was in room [ROOM NUMBER] giving care and did not hear them. When she came out Staff E, the supervisor had me sit with the other fall risk residents at the nursing station. She stated she asked Staff E, the supervisor and Staff C, CNA where Resident #1 was. Staff B stated, I don't like to let him out of my vision because he wanders into other people's rooms. She stated she put him at the nursing station to begin with so he would have supervision. She stated she was sitting at the nursing station with 3 or 4 residents (fall risk residents). The surveyor reviewed where the aides were at this time: Staff I was assigned on 1:1, Staff B with the fall risk residents, Staff F on break, Staff C at the nursing station, Staff D with Resident #5. Staff B stated that Resident #1 would eat anything, stick it in his mouth, shirt, blanket, anything. Resident #1 was going to wander and get in other's beds and rooms. She stated that Staff A, LPN was not a new nurse to the facility, she knew he wandered and put things in his mouth. Staff F stated that she could not figure out how he opened the bottle, he could not open a bag of chips. She said Staff A, LPN knew Resident #1 and his daily routine. She had been here a few weeks. On [DATE] at 3:04 p.m., during an interview with Staff C, CNA she stated Resident #1 was next to the nurse's cart when she went to help put another resident to bed. She stated Staff B, CNA was assigned to him for the evening. She saw Staff B was watching the fall risk residents. She stated Staff B asked her where Resident #1 was, and she told her she did not know because she had been caring for another resident. After that, she stated she went to go take care of another resident and then she heard Staff D saying, oh, my god oh, my god he's seizing. They were in room [ROOM NUMBER]. Resident #1 was in a chair bent over the chair with pink stuff coming out of his mouth. I saw pills on the floor. Staff C said he was in a regular chair not his wheelchair. She did not remember where the wheelchair was and said there were pills on the tray table and floor. She stated she did not see any other pill bottles. She said she asked Staff A if he was going to be okay, and the nurse said, He will be fine, he will just be sleepy. he said back to her, Doesn't look fine to me. Staff C stated she saw them wheel him out to the elevator. He would have outbursts at times, Shut up, shut up. She stated that she had never seen him grab stuff. He tried to get up and wander. He could not walk at all. He would put things in his mouth and hide things in his shirt like cups. When you were changing him, it would come out. An interview was conducted on [DATE] at 3:21 p.m. with Staff D, CNA over the phone. She walked into room [ROOM NUMBER] with Resident #5. She saw the curtain and it was moving and Resident #1 was behind it. He was shaking and was making a snoring noise and there was pink stuff on his mouth. There was Benadryl all over him. There were pills on the floor, crushed up. I Immediately went into the hall to get someone to come to the room. EMS needed to come down. They were there to get another resident, so we had them come down. EMS came down immediately and took vitals and took Resident #1 out. Staff A, LPN was running back to the med cart and said her cart was locked. Staff E, LPN Supervisor collected the bottle and the pills and counted the pills he had not eaten yet. Staff A left the room when the EMS came in. Staff E the supervisor helped me. Staff A kept saying her cart was locked and there was a Benadryl on one cart and not on the other. Staff A stated that she did not know if they had replaced the Benadryl or not. Resident #1 was a fall risk and staff usually kept him up at the front with the other falls. He did eat anything, and put cups in his clothes and tucked them in. In a second interview on [DATE] at 11:30 a.m., Staff D, stated that three CNAs were not enough but since the incident staffing had increased, and it had gotten much better. She stated that yesterday there were five aides plus an activity person ([DATE]). During an interview on [DATE] at 10:45 a.m. with Staff G, Activity Aide, she stated she would go home either Monday or Friday at 8:30 p.m. She mainly worked on the first floor with the dementia care residents. She mostly worked doubles Monday to Friday and stayed over on 3 to 11 so that the CNAs could perform their duties on the floor. She had been with activities for 4 to 5 months. She did not pass trays, not hands on. She stated, I'm not allowed to do that. She did not perform resident care. She may occasionally take a resident to their room, but that was it. She tried to leave at 8:30 PM. She felt stuck because she wanted to make sure the residents were OK when she left. When staff was low, it became a little complicated, speaking to when there's only 3 CNAs. Usually, two days out of the week there were three CNAs, mostly on 7 to 3. She felt that three CNAs were safe and it's enough for the floor. She had seen residents trying to get into the medication carts. She stated that one went for the milk shakes. Most residents just walk by. She had not witnessed any residents successfully access the medication cart. If witnessed, would run to medication cart, remove the resident from the area, and would stand over it until the nurse got back. She would let someone know to notify the nurse. If noticed the lock was out, she would click it closed and would notify the nurse when able to. She was familiar with Resident #1. She heard about it (the incident) when she came back to work. She left four residents that night and moved them close to the nurses' station. She let the CNAs know those residents needed to be watched and Resident #1 was one of them. She put them near the back wall toward the bathroom. A nurse (Staff A) and two CNAs were there at the time. The CNAs were Staff B, and Staff D. She heard the next morning Resident #1 had an incident and got a hold of medications. She said the resident was very calm most of the time and enjoyed snacks. He often put things in his mouth, including socks, wrappers, and rags. He would usually hold them in his mouth. She stated he would not try to eat it, just hold it in his mouth. He would also put a lot of items in his shirt. She was told Resident #1 was in the hospital because he got a hold of meds. She found out the next day the resident was on life support and was found in a room with the meds. Staff D, CNA found the resident in the room. She was told the resident was not coming back. The RM gathered the staff the next day and told the staff that they should make sure the medication cart remained closed and to make sure residents were changed timely. Resident #1 was admitted on [DATE] with a return date on [DATE]. The resident resided in room [ROOM NUMBER] at the end of the west wing. Record review showed diagnoses included but were not limited to head injury, muscle spasm, depression, diabetes (DM), insomnia, mood disorder, schizophrenia, and dementia. Review of the admission Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly individuals), could not be conducted, because Resident #1 was rarely or never understood. Section E - Behaviors showed other behaviors directed or not directed toward others, rejection of care, wandering 1 to 3 days. Section G - Functional Status showed he required limited to extensive assistance for bed mobility, transfers, and toileting. A progress note dated [DATE] at 11:11 p.m. showed the resident was noted with a change in condition at 9:55 p.m. a call was placed to the Medical Doctor (MD). The resident was sent to the ER. The ambulance was already on the unit and took the resident to the ER. The daughter was notified, and the Risk Manager was notified. Signed by Staff E, Licensed Practical Nurse (LPN) nurse supervisor. Record review of a Psych (psychological) Services progress note dated [DATE] showed Resident #1 was intolerant to being touched or moved and might cry out when touched. He had poor judgement, which was creating safety issues when left alone. Becomes agitated and might hit, kick, bite, scream or grab and was resistive to care. Patient's dementia symptoms continue. It was reported that these symptoms have worsened. The symptoms were chronically present. They were present during the whole day, some days they worsen after sundown. Record review of Psych Services progress note dated [DATE] showed making multiple attempts to self-ambulate. Resident re-directed several times. Review of the resident's medical record revealed his Care Plans included: A Behavioral care plan initiated on [DATE] for behavioral symptoms such as has a history of eating objects such as cigarettes and papers. Approaches included: administer and monitor the effectiveness and side effects of medications as ordered, intervene as needed to protect the rights and safety of others; approach in calm manner; divert attention, remove from situation, and take to another location as needed; observe behaviors and document, report to physician change in behavior and / or interventions ineffective; psych consult as needed. A cognitive loss/dementia initiated on [DATE]. Resident has impaired memory both long and short-term and was oriented to self. Approaches included but not limited to allow resident time to respond, encourage to attend small group activities and assist to and from as indicated, offer verbal reminders that may reduce anxiety and provide re-orientation aids. A Psychotropic Drug Use Care plan initiated on [DATE] showed the resident received antipsychotic and antidepressant medication. Approaches included but not limited to assess/record effectiveness of drug treatment, monitor and report signs of sedation, anticholinergic and/or extrapyramidal symptoms; attempt a gradual dose reduction; pharmacy consult review monthly; quantitatively and objectively document the resident's behavior. During an interview on [DATE] at 1:00 p.m. with the Director of Nursing (DON), Nursing Home Administrator (NHA), Risk Manager (RM) and Social Services Director (SSD), the RM stated that she received a call from Staff E, LPN supervisor reporting that Resident #1 was unresponsive and had pink stuff rolling down his body and that they were sending him out. Staff E, LPN called back and said Staff D, CNA had to take Resident #5 to her room and found Resident #1. Staff D, said he was seizing, and pink stuff was rolling down his mouth and chest. They found pink pills, Benadryl up under him. The RM stated the medication was Benadryl, it was a regular size over-the-counter pill bottle. The Benadryl would have been stored on the right-side lower drawer of the medication cart. Aspirin (ASA) was also there. Another Resident (#2) had fallen during this time and EMS was coming to take him to the ER. EMS took Resident #1 instead of the fallen resident. The facility staff assessed all the rooms on the floor and then the upper floor after finding out that Resident #1 had taken pills. No other pills were found in the rooms. We watched all other residents every 4 hours to check on them. Staff J, LPN was coming in on the 11:00 p.m. to 7:00 p.m. shift and started educating the nurses on locking their carts. The RM stated that they continued room checks for meds and checked on the residents every 4 hours throughout that shift. We did not know at that time how the meds got on the floor. A conference call with the RM, the DON, the SSD, the NHA and the Corporate QA (Quality Assurance) nurse occurred that night. The RM called the supervisor through the night to make sure everything was ok. The next morning, we checked the medication carts. We had viewed the video and got the actual events. The RM stated the Benadryl bottle was locked up in the DON's office by the supervisor for the next morning. They started education on securing medication carts. Staff A was suspended. They called her agency and told them she was suspended pending investigation. The RM came in the facility to make sure there was not any issues with med cart locks to make sure they were secure, no issues. The SSD stated that on [DATE] she reported to the required oversight agencies and law enforcement (LE). LE only gave a screen number. State Agency has an open case and will be calling LE also. The RM stated they started checking medication carts and security doors. Maintenance checked the carts and checked the locks, all secure locks. They did not have any unsecured carts. The nursing staff education was started regarding locking of medication carts. Audits were initiated for medication carts. Staff started looking to check each cart on the shift was locking and being locked. They started education immediately. Eleven nurses had all been educated on locking med carts. The (contracted) Agency staff were educated that night. A QA meeting occurred the next day. It was discussed to educate the staff, check the medication carts, and have scheduled monthly maintenance checks. Random medication pass audits had been started. The SSD reported and the DON nodded that education was not done for CNAs, Housekeeping, or Dietary staff on what to do if residents were seen rummaging through carts. The SSD reported the resident had passed away. The SSD stated Resident #1 was easily redirected. She said he had a history of eating cigarette butts at home according to his daughter. She stated she was not aware of him eating anything at the facility. The DON stated she had never heard of him going through things. The SSD stated he did have a history reported by the caregiver that he had a history of eating cigarettes. The RM stated Resident #1 had a fall prior. He was more of a fall risk than a behavior issue. He was at the nursing station due to fall risk. He kept trying to get out of his wheelchair. His room was at the end of hallway east, but he went to the end of hallway west that night. The SSD also stated Staff A, LPN was reported to the board of nursing. The DON stated Staff A, LPN was the only nurse assigned to the first floor that evening. Staff E, the supervisor was stationed downstairs. But yes, [Staff A] was the only nurse that evening. The supervisor did go up and down. No one had called off that evening. The first-floor residents are not necessarily a higher acuity, a higher fall risk but lower medication administration. The RM stated, They don't usually have g tubes or major wounds like upstairs. The residents are skilled upstairs. The RM said when she interviewed Staff A, LPN, she denied leaving the med cart unlocked. Staff A said she did not believe the pills were taken from her med cart. When Staff A called the doctor, she did not tell the doctor that Resident #1 was unresponsive or about the pills being taken. Staff A did not let the guardian know either. The physician and family thought he was unresponsive from a medical issue. The RM stated the incident documentation showed as such. The RM stated she told Staff A she saw her cart was open twice on the video. Staff A said she did not know where he got the meds out. Staff A denied she took the ASA out of the room and put it in the trash. The RM told her again she saw her on the video. She told Staff A that something had serious happened to Resident #1. Staff A sat down, and said, I don't know how it happened. The RM stated in an interview on [DATE] at 1:00 p.m. that either Staff A or Staff E had told the hospital that Resident #1 had taken Benadryl. He was responsive when he left. They had not put in an IV in. The RM stated that she found out later that he had coded at the hospital. They called the hospital, but she did not know if the EMS knew he had swallowed Benadryl and possibly ASA or not. The RM stated she thought he took the ASA also, all the ASA, and the nurse threw an empty bottle of ASA away. No ASA pills were found on the floor. It was the uncoated ASA. The DON disposed of the Benadryl bottle the next day. No one was scheduled to receive Benadryl on the first floor. The Benadryl bottle held one hundred 25 mg tablets. Five residents had orders for ASA on the first floor on [DATE]; two had delayed release and three had chewable ASA. An interview was conducted with Resident #1's attending physician on [DATE] at 10:26 a.m. via phone. He stated, they called me about the pills. The [RM] told me the story. She said Resident #1 got a hold of the pills and swallowed them. They performed a Root Cause Analysis and an investigation after he took the pills. He stated he was not aware of a history of taking pills or suicidal tendencies. He stated he had some behavior issues but not taking other resident's pills or others stuff. He was just doing age-appropriate things. The nurse should be locking the med cart. He found out that she had left it unlocked. The RM stated the nurse was not aware she left [TRUNCATED]

Based on observation, interview, and record review, the facility failed to provide the level of assistance needed to prevent an avoidable accident resulting in a fall with injury for one (Resident #4) out of three sampled residents. The facility did not ensure that care-planned interventions for safe transfer of the resident were implemented. Furthermore, the facility failed to ensure that physician-ordered and care-planned interventions for safe transfer and protection from injury related to falls were followed for Resident #4. Findings Included: Review of the facility policy and procedure titled Falls Prevention - Potential Interventions revised December 2007 revealed, Transfer and Ambulation .Identify and provide needed assistance for safe transfer and ambulation. Review of facility procedure titled, Lifting Machine, Using a Mechanical revised July 2017 revealed, At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. Review of facility procedure titled, Care Plans, Comprehensive Person-Centered revised December 2016 revealed, A comprehensive, person-centered care plan .is developed and implemented for each resident .The comprehensive, person-centered care plan will .Describe the services that are to be furnished to attain or maintain the resident's highest practicable, physical, mental, and psychosocial well-being .Incorporate risk factors associated with identified problems .Aid in preventing or reducing decline in the resident's functional status. A facility document titled All Falls for Facility provided on 10/14/20 found that Resident #4 was listed for 09/14/20 at 2:00 p.m. A facility document titled, Mechanical Lifts, provided on 10/14/20, revealed a list of residents that did not include Resident #4. A facility document titled Admit/Discharge Report, provided on 10/14/20, with resident names highlighted by the nursing home Administrator as those who had sustained falls with injury, revealed Resident #4's name, highlighted for the date of 09/14/20 along with the statement, discharged /transferred to hospital for inpatient care. A review of the medical record for Resident #4 was conducted on 10/14/20. It revealed that the resident was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The record revealed that the resident was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent completed Minimum Data Set (MDS) assessment for Resident #4 was dated 09/21/20 and revealed a Brief Inventory of Mental Status (BIMS) score of 5, which meant that the resident had severe cognitive impairment. The MDS also revealed that the resident required extensive physical assist of two or more persons for transfers (how resident moved between surfaces including to or from bed, chair, wheelchair). The care plan included a focus area for falls with a start date of 09/13/18. The interventions for this focus area included: X2 person assist for transfers . start date 07/30/2019; (mechanical) lift with two persons for all transfer, start date 09/23/20; Staff to gather all appropriate supplies and extra personnel needed before dismantling resident's wheelchair equipment, start date 09/14/20; Bilateral leg rest .calf pad with foot drop stop, floor mats at bed side, bed in lowest position, start date 09/13/19. The care plan also revealed focus areas for therapy services which included Physical Therapy for skilled rehab serves to help improve LE (lower extremity) strength, transfers start date 09/22/20 and Occupational Therapy related to recent hospitalization for a fall from wheelchair .review of mechanics of wheelchair .impaired ADL transfers start date 09/21/20. Review of the physician's orders for Resident #4 revealed: Bilateral leg rests to w/c (wheelchair) Every Shift .start date 11/20/17; Mats at bedside Every Shift .start date 11/20/17; Full mechanical lift for transfers .start date 09/23/20; (mechanical) lift for transfers with 2 staff members .start date 10/15/20. Progress notes revealed the following nursing note entries: 09/14/20 3:38 p.m. Resident fell from w/c (wheelchair) this afternoon, laceration approximately 2 cm bleeding .Ice applied. STAT (immediate) PT/INR (test of blood clotting time) ordered. Neuro (neurological function) checks in progress. MD (medical doctor) notified .Resting comfortable in bed. 09/14/20 6:47 p.m. Resident sent to the hospital, laceration kept bleeding and her o2 (oxygen) was 70 with the oxygen on at 3L (liters), Notified DR (doctor), He gave orders to send resident ASAP (as soon as possible) to the hospital. 911 called, ambulance came and took her to the hospital . 09/14/20 7:00 p.m. Resident return from hospital .Skin with bruises on bilateral arms, head hematoma . 09/24/20 2:05 p.m. Resident continues to be followed for a fall on 9/14, intervention added for staff to gather all appropriate supplies and extra personnel needed before dismantling resident w/c (wheelchair) equipment .now requires a total mechanical lift for transfers. On 10/14/20 at 9:40 a.m., an observation was made of Resident #4's room. The resident's bed was located next to the window, the privacy curtain was pulled, the resident was asleep, and there were no mats observed on the floor next to her bed. On 10/14/20 at 10:39 a.m. Resident #4 was observed asleep in her bed in her room and there were no mats on the floor around her bed or observed anywhere in the room. Resident #4 was observed, again, on 10/14/20 at 12:24 p.m.; she remained asleep and there were no floor mats observed in the room. At 1:18 p.m. on 10/14/20, the resident was observed out of bed and seated in a wheelchair at her bedside. Staff A, Patient Care Assistant (PCA) was present in the room and confirmed he had just transferred the resident out of bed. He stated that he was about to apply the leg rests with foot stops to her wheelchair and proceeded with doing so. There were no mats on the floor or in the room and Staff A stated he was not aware of any for the resident. There was no mechanical lift observed in the room and no other staff member was present. Regarding his transfer approach, Staff A said, it's my first time having her, and stated that he had transferred her alone using a stand-pivot technique and a gait belt. He confirmed that he had never used a lift of any kind with the resident. The resident was alert and engaged freely; however she was not able to provide concrete or coherent answers to questions. An interview was conducted in the therapy gym on 10/15/20 at 8:43 a.m. with the facility Director of Rehabilitation (DOR). She confirmed that her clinical credential was Occupational Therapist Registered/Licensed (OTR/L). She consulted the electronic medical record (EHR) for Resident #4 and confirmed that the resident was receiving occupational and physical therapy treatment at the facility. She stated that she was a regular member of facility meetings where falls were discussed and confirmed that she was aware of Resident #4's fall with injury on 09/14/20 and that the resident had fallen from her wheelchair. The DOR added, Apparently the CNA (Certified Nursing Assistant) had taken the footrests off (the wheelchair) to prepare (for transfer) and left room the room to get something, and she slid out of the chair. The DOR referred to physical therapy treatment notes in the EHR and revealed, Right now (they are) working on strengthening to prepare for readiness for max assist transfer .not safe currently .no other transfer approach besides two-person (mechanical) lift transfer should be used with (Resident #4) She confirmed that therapies were not advising any transfer approach other than a two-person mechanical lift transfer for Resident #4. During the interview with the DOR, Staff B, Certified Nursing Assistant (CNA), and Staff C, CNA, entered the room to speak with the DOR. They confirmed that they were lead CNAs for the facility and knew Resident #4 well. Both confirmed they were aware that Resident #4 had fallen on 09/14/20. Staff B stated she had not witnessed the fall but had arrived on the scene to help after the fall and assisted with the use of a mechanical lift to return the resident to bed. Staff B added that Resident #4 had silk pants on that day which contributed to her sliding out of the chair and onto the floor. Staff B said, We all got in-serviced after the incident on (mechanical) lift .always two people. Staff B confirmed that for all transfers, She (Resident #4) should have (mechanical lift). Staff C stated that the facility Risk Manager and therapy staff had provided in-services with staff after the incident on how to use the (mechanical) lift and said, we had to sign a document stating that you have to use (mechanical lift) or, if not, we can be automatically terminated. Staff C said, CNAs are supposed to read the care plan to know what to do (for care and transfers of residents) .they are responsible for reading the care plan (and) responsible to ask the nurse if questions. Staff C said, PCAs (Patient Care Assistants) has certain duties they can do .basically most of everything a regular CNA can do except for feeding .PCA can transfer with a gait belt but if they're using a (mechanical lift) they have to be with a CNA or another staff .same expectation for PCAs as CNAs to read care plan to know how to transfer resident. Staff C stated that CNAs and PCAs were required to document on any transfers performed every shift. Regarding the observed absence of mats on the floor in Resident #4's room, Staff C confirmed that it was the CNAs responsibility to ensure mats were on the floor if they were in the care plan and said, if care plan says mats on floor we must get mats on floor. Staff B stated that the mats probably didn't get moved when the resident came back from the hospital, and Staff E left the interview to go and investigate and returned at 9:12 a.m. and said, Brand new ones (are) on the floor now, confirming that she had gone and placed them there. She was not willing to confirm that they had not been there prior to her placing the new ones. Regarding Staff A not performing transfer with Resident #4 in accordance with orders and care plan on 10/14/20, Staff B and Staff C confirmed that he had come to them immediately after and reported that he thought he had done something wrong. Staff B & Staff C stated this was why they had come to find the DOR this morning to plan for in-servicing Staff A. They stated in the meantime they had assigned him as a sitter off the floor so that he would not be assigned to provide care until the in-service on transfer-training was completed. Staff C stated that Staff A was not normally assigned to Resident #4 and said he didn't really sit down and read the care plan like he should have .he admitted that and said 'I think I made a big booboo'. Staff C confirmed that Staff A had been trained to always read the care plan. At 10:15 a.m. on 10/15/20, the DOR brought the completed and signed in-service training documentation for Staff A which revealed the following content: When you get a resident you MUST read the profile .If pt (patient) is a mechanical lift, you must have 2 persons .If you are not completely confident and knowledgeable about use of lift - ask supervisor or lead CNA to train and assist you .Training & education in use of (mechanical lift) provided this date. The CNA and PCA documentation for transfers for Resident #4 was reviewed for the date range of 09/14/20 - 10/15/20: one entry revealed the resident was lifted mechanically with 1 person physical assist; one entry revealed the resident was transferred with a transfer aid with 1 person physical assist; four entries revealed the resident was lifted manually with 2+ person physical assist; five entries revealed the resident was lifted manually with 1 person physical assist; one entry revealed resident was lifted manually with no setup or physical help from staff. On 10/15/20 at 10:43 a.m. an interview was conducted with the facility Risk Manager, Licensed Practical Nurse (LPN) and the facility Social Services Director (SSD). They confirmed that Resident #4 sustained a fall with injury on 09/14/20 and confirmed that the incident had been reported and investigated. The SSD stated that based on statements from the CNA involved and her supervising nurse, the fall was a normal fall, that the CNA was attempting to transfer the resident back to her bed from the wheelchair and left the room during the process to get help and the resident slid out of the chair onto the floor while the CNA was out of the room. She confirmed that the investigation had revealed that before the CNA left the room, she had removed the leg rests from Resident #4's wheelchair. She stated that the CNA was suspended during the investigation and terminated at the close of investigation for failure to follow the care plan regarding transfers. Both parties confirmed that at the time of the fall, Resident #4 was care planned for requiring assistance of two for all transfers and for having leg rests in place when she was in her wheelchair. Both parties confirmed that following the fall, the Resident was admitted to the hospital, assessed to have a laceration to the head and a scalp hematoma, and received staple closure of the head wound. Both parties confirmed that facility nursing staff were educated on reading and following care plans for transfer status and on how to perform safe two-person transfers using a mechanical lift. The Risk Manager confirmed that the only things CNA or PCA documentation of transfers should reflect for Resident #4 would be mechanical lift transfer with two persons. An interview was conducted with the facility Director of Nursing (DON) on 10/15/20 at 12:23 p.m. She confirmed that Resident #4 was required to be transferred using a mechanical lift with two-person assist. She also confirmed that it was her expectation that facility CNAs ensure fall mats were in place for all residents ordered or care-planned for them as a fall injury prevention measure. She confirmed that it was the expectation that before providing care or transfer for any resident, all CNAs or PCAs should get a shift report and review the resident profile in their point of care documentation system which would reveal transfer and care approaches. She revealed the profile for Resident #4 which reflected clear documentation of the transfer requirements for mechanical lift with two person assist for all transfers. Regarding the inconsistencies discovered with review of PCA and CNA documentation, the DON confirmed that her expectation would be that all transfers for Resident #4 should be documented as a two-person mechanical lift, not manual lift and never without physical assist of two persons. Regarding the observation of Staff B performing one-person manual lift transfer with Resident #4 on 10/14/20 along with the inconsistencies in the CNA transfer documentation and observed absence of floor mats in Resident #4's room, the DON confirmed all of those things were of concern and said, actually before you came in (for interview) I was speaking to the Administrator about it and was about to pull the MDS coordinator to look at everybody's transfer status to ensure that all care plans and profiles are updated. She went on to stay, we've started the education (with staff) now .I'm having the MDS coordinator scrub the charts to see what our transfer instructions are for each resident and to update the profile to ensure every profile has clear instruction and information for transfers. Regarding CNA documentation, the DON said, we will audit documentation and do education on how to document. Regarding how facility staff were monitored following Resident #4s fall incident and associated education/training/interventions to ensure they were carrying things out properly the DON said, no auditing has been in place that I'm aware of but it will be and competencies will be put in place to ensure CNAs an demonstrate how to read profile, document, and transfer. Regarding whether the failures during the fall event on 09/14/20 with Resident #4 had resulted in any facility Quality Assurance Process Improvement (QAPI) initiatives, the DON said, we have not had yet the QA meeting for September .we will be QAing this process in our October meeting .this one (this event) would automatically trigger .anything we end up having to report we QA. The staff education and in-service record provided by the facility following Resident #4's fall on 09/14/20 were reviewed. The document was titled In-Service Record, dated 09/15/20, revealed Risk Manager as presenter, and revealed topic as Mechanical lifts requires two person to assist during transfer at all times. At 3:13 p.m. on 10/15/20 the Risk Manger and SSD were interviewed about the in-service document and whether education had been provided to 100% of the staff. The Risk Manager said, I can't say it was 100% .we're going to do that now .but I would say about 80-85%. The SSD revealed an additional document titled Inservice, dated 09/16/20, topics: following plan of care transfer status; mechanical transfers; care plan. She stated she had provided that education on 09/16/20 as the immediate education following the incident and stated she had identified the staff listed on the document as participants because they were all of the nursing staff assigned to Resident #4's unit on that day shift and stated that 100% of the nursing staff assigned to Resident #4 on 09/16/20 day shift were educated. At 3:25 p.m. on 10/15/20 the DON confirmed that education and in-servicing provided to facility staff following Resident #4's fall with injury on 09/14/20 was solely on mechanical lift procedure and did not include education on consulting the care plan/profile. She confirmed that she had not been aware of the in-service initiated by Staff C on 10/15/20. A telephone interview was conducted with the facility Medical Director on 10/15/20 at 4:31 p.m. He confirmed that he was both the facility Medical Director and the primary care physician (PCP) for Resident #4. Regarding the fall with injury incident on 09/14/20 he stated that he did not receive a report from the facility about the fall and said, I don t recall being told about it .I don't recall the facility calling me. He stated that was of concern to him because Resident #4 was on a blood thinner medication. When provided with the basic information of the incident and failure of Staff A to transfer the resident in accordance with her care plan, he said, there is no excuse for that .it is nursing 101. The medical director went on to say, I'm not there 24/7 so they're listening to what the DON and Administrator say. He said, I know the facility has been very involved with working with the COVID (coronavirus disease) .no excuse but sometimes that takes all the attention .most of our communication is about the COVID .sometimes other things aren't at the forefront of our list as they should be.

Based on observation, record review and interviews, the facility failed to implement effective supervision for fall prevention for 1 (#9) of 10 sampled residents. Resident #9 had 10 falls within 32 days. In addition, the facility failed to ensure that an approach of 1:1 supervision, listed for a fall risk intervention as of 08/16/19 was effective due to Resident #9 falling and receiving a laceration on her head that required stiches on 08/17/19. Findings Include: An observation conducted at 08/19/19, 3:30 p.m. of Resident #9, in wheelchair (w/c) with Staff A, Certified Nursing Assistant (CNA) at side and alternating pushing the resident. Observed the resident being taken to room to put on one of her socks by Staff A, CN[NAME] Resident #9 was observed to have a reddened left knee, bruised area on her knee cap. An observation was conducted on 08/19/19 at 6:12 p.m. of Resident #9. Resident #9 was in in a w/c with Staff A, CNA at her side. Resident #9 was observed to repeatedly attempt to get up out of the w/c as the chair halted. The CNA was observed to redirect her, engage her, and then push her thru the hallway with the resident remaining seated when the chair was moving. An interview was conducted at this time with Staff A, CN[NAME] She stated that Resident #9 fell over the weekend and that that is when the bruise to the left knee occurred. She stated that the resident fell and hit the back of her head. She stated that the resident has stitches on the back of her head. She did not have her at the time, but she is on 1:1 now. Staff A, CNA stated that the resident keeps trying to get up from the wheel chair. A review of Resident #9's clinical chart, documented admission of 03/13/18. The [DIAGNOSES REDACTED]. A review of Resident #9's Progress notes, 06/01/19 thru 08/19/19 found the following: 07/15/19, 4:25 p.m.: At 4:00 p.m., called to Solarium by visitor to find Resident sitting on her buttocks. VSS, (Vital Signs) ., (family) and MD (Medical Doctor) notified, and no new orders received. Will continue to monitor and observe. 07/21/19, 9:47 p.m.: Resident was witnessed wandering the hallway and became unstable when she was passing other residents and she started to lean toward another resident she grabbed onto her and they both fell to the floor. Assessed resident and she had no new skin issues observed. Resident refused to allow me to take her vital signs x 3 attempts. Resident was able to get herself up off the floor. (family) called about this incident . Dr. ( ) also notified. No new orders. We assisted resident to her room to lay down for a while. 08/02/19, 3:40 p.m.: CNA reports that the resident was walking leaning on her left side and lost balance and hit the floor, resident was picked up from the floor and was accommodated in bed. Resident didn't want to stay in bed and was just walking losing balance around the unit. Resident started to get agitated with staff member. Resident was turning pale and was sweating abnormal; her respiration rate went up and we weren't able to take her blood pressure because of her agitation and the medication wasn't effective. Resident was sent out to (local) Hospital via 911. 08/07/19, 4:58 p.m. (resident was documented to return to the facility at 3:05 p.m.). 08/07/19, 10:38 p.m.: At 9:00 p.m. noted this resident sitting on floor in front of w/chair, able to move all extremities, denies pain, VSS, ., no new bruises or skin tear or open area noted since admission. Denies pain. Dr. notified no new orders & (family) . 08/08/19, 2:02 p.m.: (family) reported that resident fall on the side of the bed when she turned onto the other side and landed on her buttocks. Resident with no injury and will keep monitoring for changes in condition or in behavior. 08/10/19, 8:25 p.m.: While in hallway I heard this resident call out. I went directly to the room (#) to find her sitting on her buttocks with her feet to the head of her bed and her back facing her bathroom wall. Left arm was towards her bed and her right arm was facing the wheelchair. She was able to move body parts and wiggle her buttocks. No noted skin tears, lacerations new bruising .family and doctor notified .placed aide with her for closer observations/ monitoring and assistance as needed due to weakness and not aware of her limitations at this time. 08/12/19, 6:08 p.m.: Called to room (#) bed B area to see that Resident was sitting up on her buttocks and was touching Bed B's linen on the side closest to the air conditioning .no injuries noted at this time .it was noted that she had urinated thru to her pants . 08/12/19, 6:27 p.m.: At 6:10 p.m. resident sat on floor in solarium after dinner. Able to move all extremities .no injury to skin .MD and family notified of both events. 08/15/19, 5:24 p.m., (Resident #9) did very well on 3-11 shift with her close supervision of her aide 08/16/19, 5:12 p.m.: Resident had an observed fall in the hallway from a standing position striking her head. She has a hematoma to the back of her head, is combative, screaming and will not cooperate with vital signs, neuro checks initiated.15 minutes after fall right pupil appeared 3mm and left pupil appeared 2mm. notified Dr. and received order to transport to ER for evaluation and treatment for [REDACTED]. 08/17/19, 2:55 a.m.: (Resident was documented to have returned to facility at 1:30 a.m.) 08/17/19, 6:05 p.m.: Resident is combative and has increased confusion. One on one care necessary to keep resident from harming self or others. Has run into walls. Vision does appear to be poor and reaches out blindly. When she makes contact then strikes out, pinches, kicks, attempts to bite. Called DR. to get resident evaluated at this time. 08/17/19, 7:22 p.m.: Client fell and has hit the back of her head. Laceration noted with med (medium) amt (amount) of bleeding. Will not allow anyone to touch her to clean area. Clammy and combative. Dr. states to send her out. 08/17/19, 7:36 p.m.: Called 911 for fall, bleeding [MEDICAL CONDITION], combativeness, inability to focus, and altered mental status continued to fight the EMS when got on the stretcher to transfer out with screaming. 08/17/19, 11:57 p.m., Returned from hospital . Interviews regarding Resident #9's most recent fall were conducted with the nurses. An interview was conducted on 08/20/9 at 5:55 p.m. with Staff D, Registered Nurse (RN), she stated that she filled out the paper work for the other nurse that had the resident for the event. She stated that she heard the resident fall but, she did not see the resident fall. An interview was conducted on 08/20/19 at 6:06 p.m. with Staff E, RN. She stated, I did not see the fall. I think that that was the night that I had a new admission and another event. She was asked, Were you in the proximity? She did not answer, but said, I felt the knot (when I was) on her bed; she had been taken from the hall way to her room. She was sweating. I stayed by her until the EMS persons came. I felt the knot on the back of her head. She came back, not sure, a couple of days later. I do not know who the aid was that was with the resident. A review of Resident #9's Care Plan, documented a Problem: Falls: Resident #9 is at risk for fall related to cognition, decreased muscle strength, requires more assistance than allowing staff to render. Goal: Resident will not sustain a major injury due to a fall by next review date. Approaches: As of 08/16/19, 1:1 observation. As of 08/15/19, Close observation of resident during frequent falling periods. As of 08/12/19, Labs ordered, notify MD of results. As of 08/02/19, Concave mattress to define parameters. As of 07/21/19, Order for labs, Medication review. Therapy screen As of 07/16/19, Offer rest periods, snacks, hydration Other approaches listed had a most recent start date of 12/01/18.

Based on interviews with a family member appointed as the Durable Power of Attorney (DPOA) and Health Care Surrogate, the attending physician, facility nursing staff and administration, and review of clinical records and facility policies, it was determined that the facility failed to ensure one (Resident #3) of 119 residents reviewed for code status was free from neglect when it failed to provide the required structures and processes necessary to meet the Advanced Directive of a Do Not Resuscitate (DNR) order in the event of the resident being found absent of pulse and respirations. The facility failed to implement their Advance Directives Policy when Resident #3 was admitted to the facility with a valid DNR order. The facility's DNR Order Policy failed to have provisions for executing a DNR order received at the time of admission. The facility obtained a physician order [REDACTED]. The facility staff initiated Cardio-Pulmonary Resuscitation (CPR) on Resident #3, an [AGE] year-old, severely impaired resident who was admitted with a signed Do Not Resuscitate (DNR) order completed by her DPOA and signed by a physician on [DATE]. The facility failed to protect Resident #3 from unwanted, potentially violent interventions in her last moments of life on [DATE], and she received CPR for a period of over 40 minutes. The facility neglected to provide the structures and processes needed to ensure staff responded in accordance with the advanced directive wishes for Resident #3. This failure resulted in findings of immediate jeopardy which was removed on [DATE] and reduced to the scope and severity of a D. Findings included: A review of the facility's policy revised (MONTH) (YEAR), title Abuse Prohibition/Investigation Policy revealed: The facility will prohibit abuse, neglect, misappropriation of resident property, and exploitation. The purpose of this policy is to ensure that the facility is doing all that is within its control to prevent occurrences of abuse/neglect. The Administrator is responsible for implementation of the policies and procedures that prohibit abuse, neglect, involuntary seclusion, and misappropriation of property. Actions to prevent abuse, neglect, involuntary seclusion, and misappropriation of property will include the following: Providing resident, families and staff information on how and to whom they may report concerns, incidents and grievances, without the fear of retribution, and provide feedback regarding the concern that they have expressed. Identifying, correcting and intervening in situations in which abuse, neglect and/or misappropriation of resident property are more likely to occur. Developing a care plan identifying appropriate intervention to prevent occurrences. Neglect; is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. On [DATE] at 11:32 a.m., a phone interview with Resident #3's daughter and DPOA revealed her mom's wishes were to go peacefully. The daughter believed that her mom's end of life wishes was honored. She stated that the nurse that called, told her she went in her mom's room that morning and she was gone. The daughter stated that she participated in the resident's admission process and there should have been a DNR already drawn up. The resident's daughter reported that Resident #3 was not able to make her own decisions. The resident's daughter did not indicate that she was asked about the resident's code status on the day she passed nor was she informed her mom had received CPR when found unresponsive. A review of a local law enforcement report dated [DATE] revealed, On [DATE] at 0638 hours (6:38 a.m.), I responded to (facility address) in reference to an AED (Automated External Defibrillator) assist with an unconscious subject. Upon arrival, I made contact with the reportee in (room #) who was giving chest compressions to the subject later identified as (Resident #3). I used my AED and placed the pads on (Resident #3) and received a No shock advised message. I continued chest compressions until EMS (Emergency Medical Services) arrived and took over. At approximately 0710 hours (7:10 a.m.) EMS declared (Resident #3) deceased . The reportee identified as (redacted text) stated that she last saw (Resident #3) breathing at 0230 hours (2:30 a.m.) when she gave her medication. She stated that she found (Resident #3) unresponsive at approximately 0630 hours (6:30 a.m.) and called 911 and began CPR A review of Resident #3's Admission Record revealed she was admitted to the facility from a local hospital on [DATE] with [DIAGNOSES REDACTED]. The Admission MDS dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 1 indicating severe cognitive impairment. The clinical record contained a DPOA and Health Care Surrogate designation, appointing her daughter, dated and signed by Resident #3 on [DATE]. Review of the form revealed .It is my specific intent that the power conferred on my Agent will be exercisable from the date of this instrument, notwithstanding my subsequent disability or incapacity, except as otherwise specifically provided by statute. Continued review of Resident #3's clinical record (paper chart) revealed documents from two skilled nursing facilities (SNF) that she had resided in prior to her admission at this facility, SNF A and SNF B. Progress notes from SNF A dated [DATE], 17 days prior to her admission at this facility, revealed a code status of DNR. A Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form indicated that the resident was transferred from SNF A to SNF B on [DATE]. This form also indicated that her advance care planning documentation included a DNR. Additionally, the Order Summary Report for Active orders as of [DATE] from SNF B revealed that the resident had a code status of DNR with an order date of [DATE], seven days prior to her admission at this facility. Record review of the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form from the hospital dated [DATE] indicated that the resident had advance care planning documentation for Do Not Resuscitate (DNR). A Florida DNR order (golden rod) dated [DATE] was also discovered in the paper chart. The order form was signed by the resident's daughter/DPO[NAME] The form reflected, .based upon informed consent, I, the undersigned, hereby direct that CPR be withheld or withdrawn. The form was signed by the physician, who was a hospitalist, prior to her admission to this facility. It reflected, .I hereby direct withholding or withdrawing of cardiopulmonary resuscitation from the patient in the event of the patient's cardiac or respiratory arrest. Contained in Resident #3's paper clinical record was a Plan of Care document from the resident's insurance company with an effective date of [DATE] and a review date of [DATE] indicating the resident had a DNR. A review of Resident #3's electronic clinical record showed that under the advanced directives section the DNR (golden rod) form had been scanned into the computer on [DATE]. However, a physician's orders [REDACTED]. Further review of the clinical record (electronic and paper chart) did not reveal documentation to support the decision of the facility to have a full code physician's orders [REDACTED]. A review of Resident #3's care plan for advance directives initiated on [DATE] indicated that Resident #3 had the following: Problem Start Date: [DATE]: Category: Advanced Directives (Resident #3) has the following Advanced Directives on record DPOA and full code status. The Long-Term Goal Target Date: [DATE] Advance Directive are in effect, and their wishes and directions will be carried out in accordance with their Advanced Directives. The interventions included but were not limited to, advise (Resident #3) and/or appointed health care representative to provide copies to the facility of any updated Advanced Directives, an Advanced Directive can be revoked or changed if the resident and/or appointed health care representative changes their mind about the medical care they want delivered, discuss advanced directives with Resident #3 and/or appointed health care representative, notify physician of (Resident #3's) wishes regarding life prolonging procedures, notify the physician to assess the capacity of (Resident #3) and certify capacity or incapacity, and the appointed health care representative will make all health care decisions if (Resident #3) is incapacitated. The facility had no documentation to demonstrate that Resident #3 and/or the resident's representative attended a care plan meeting related to this plan of care or had any participation in the development of this plan of care. A complete review of Resident #3's paper and electronic clinical record revealed no documentation was present to indicate a discussion was held with the resident and/or the resident's representative regarding the advance directive DNR order received at the time of admission and changed to a full code physician order [REDACTED]. The resident had no nursing notes or social service notes discussing code status or competency. An interview with Resident #3's Physician Assistant, who works for the Attending Physician, on [DATE] at 9:05 a.m. revealed he could not remember the resident off the top of his head. He stated, he had no clue about her code status and stated that we would have to contact the Attending Physician for more information. On [DATE] at 11:21 a.m., a phone interview with Resident #3's Attending Physician revealed that he saw the resident one time because she was only there for about a month. He reported that he did not know what her code status was. He stated that he saw a DNR form signed by a physician from the hospital. He reported that unless the patient has specific issues, he does not pay attention to the code status. He reported that he sees so many patients that he could not really remember anything. He reported that Resident #3 was severely demented. In regard to an incapacity statement, the physician stated that most of the time they have the form in a book, and they would let him know the form was in there and needed to be filled out. He did not recall ever being asked to complete an assessment on her capacity. A review of the physician progress notes [REDACTED]. A review of these three notes dated [DATE], [DATE], and [DATE] revealed no notation of the resident's code status. Additionally, notes from the Physical Medicine and Rehabilitation Physician on [DATE], [DATE], [DATE], and [DATE] all documented the resident's code status as Full Code. These notes did not contain any discussions about the code status with the resident/resident representative or the basis from which this code status originated. A review of the facility's policy, revised (MONTH) 2013 titled, Advance Directives, revealed: 1. Prior to or upon admission of a resident to our facility, the Social Services Director or designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives. 2. Each resident will also be informed that our facility's policies do not condition the provision of care or discriminate against an individual based on whether or not the individual has executed an advance directive. 3. Prior to or upon admission of the resident, and/or his/her family members, about the existence of any written advance directives. 4. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. 5. If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. The resident will be given the option to accept or decline the assistance, and care will not be contingent on either decision. Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline. 6. The Attending Physician will provide information to the resident and legal representative regarding the resident's health status, treatment options and expected outcomes during the development of the initial comprehensive assessment and care plan. 7. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. 8. The resident has the right to refuse treatment whether or not he or she has an advance directive. A resident will not be treated against his or her own wishes. 9. Depending on State requirements, the legal representative may also have the right to refuse or forego treatment. 10. If the resident or representative refuses treatment, the facility and care provider will: a. Reassess the resident for significant change of condition related to the refusal; b. Determine the decision making capacity of the resident and invoke the legal representative if appropriate to the situation; c. Document specifically what the resident/representative is refusing; d. Assess and document the stated reason for the refusal; e. Advise the resident of the consequences of refusal; f. Offer pertinent alternative treatments; and g. Modify the care plan as appropriate, providing all other appropriate services (i.e. those that will allow him or her to maintain the highest practicable physical, mental, and psychosocial well-being). 11. The resident's Attending Physician will clarify and present any relevant medical issues and decisions to the resident or legal representative as the resident's condition changes in an effort to clarify and adhere to the resident's wishes. 14. The Interdisciplinary Team will conduct ongoing review of the resident's decision-making capacity and communicate significant changes to the resident's legal representative. Such changes will be documented in the care plan and medical record. 16. Changes or revocations of a directive must be submitted in writing to the NH[NAME] The NHA may require new documents if changes are extensive. The Care Plan Team will be informed of such changes and/or revocations so that appropriate changes can be made in the resident assessment (Minimum Data Set - MDS) and care plan. 17. The Director of Nursing Services or designee will notify the Attending Physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. The Attending Physician will not be required to write orders for which he or she has an ethical or conscientious objection. Review of the facility's policy, revised (MONTH) 2013 titled, Do Not Resuscitate Order revealed: Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect. 1. Do not resuscitate orders must be signed by the resident's Attending Physician on the physician's orders [REDACTED]. 2. A Do Not Resuscitate Order (DNRO) form must be completed and signed by the Attending Phys8ician and resident (or resident's legal surrogate, as permitted by State law) and placed in the front of the resident's medical record. a. Use only State approved DNRO forms. b. If no State form is required, use facility approved form. 4. DNRO will remain in effect until the resident (or legal surrogate) provides the facility with a signed and dated request to end the DNR order. a. Verbal orders to cease the DNRO will be permitted when two staff members witness such request. Both witnesses must have heard the request and both individuals must document such information on the physician's orders [REDACTED]. b. The Attending Physician must be informed of the resident's request to cease the DNR order. 6. The resident's Attending Physician will clarify and present any relevant medical issues and decisions to the resident or legal representative as the resident's condition changes in an effort to clarify and adhere to the resident's wishes. 7. Inquiries concerning do not resuscitate orders/requests should be referred to the Administrator, Director of Nursing Services, or to the Social Services Director. Review of the facility's policy, revised (MONTH) (YEAR) titled, Emergency Procedure-Cardiopulmonary Resuscitation, revealed: 6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS (Basic Life Support) shall initiate CPR unless: a. It is knowing that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or b. There are obvious signs of irreversible death (e.g. rigor mortis). 7. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's orders [REDACTED]. The Do Not Resuscitate Order Policy, the Emergency Procedure - Cardiopulmonary Resuscitation Policy and the Advance Directives Policy contained no methods for how staff should verify or check the resident's code status in order to determine the correct course of action in the event of an emergency. A progress note dated [DATE] at 7:51 a.m. created by Staff A, Licensed Practical Nurse (LPN) revealed, I went in to do the resident's morning medication and I noticed that the resident was unresponsive. I called for another nurse to call the code blue and to call 911. We began CPR. The EMTs (Emergency Medical Technicians) arrived and took over the compressions. The physician was called for an order to release the body. The family was notified about their mom expiring. The family called back to notify us that they had called a cremation service to pick the resident up and they would be calling the facility for information. A progress note dated [DATE] at 12:00 p.m. created by Staff N, Registered Nurse (RN) revealed, the funeral home came to release the body. A family member was notified and came to pick up her belongings. The Recapitulation of Resident's Stay section of the Interdisciplinary Discharge Summary dated [DATE] revealed that Resident #3 expired. The Record of Death dated [DATE] revealed that the date of death was [DATE] at 7:10 a.m. (The date and time of [DATE] at 7:10 a.m., on the record of death, was inconsistent with the date and time recorded by facility staff in progress notes, staff interviews and a local law enforcement report, which all indicated the resident expired on [DATE] at approximately 7:10 a.m.). Continued review of Resident #3's clinical record revealed a progress note dated [DATE] at 12:51 a.m. created by Staff A, LPN and marked as a late entry on [DATE] at 1:30 a.m. The progress note revealed, Did walking rounds and observed the resident lying in bed, snoring, and turned on her right side. She also had a bowel movement and notified the CNA (Certified Nursing Assistant) about this issue. At 3:00 a.m., made a walking round on the hall and the resident was snoring. At 6:00 a.m. went in to give the resident her morning medication and she was unresponsive; medication not given. Went to verify the resident's code status on the computer and called code blue. (Based on interviews and further record review, the date of [DATE] was incorrect and should have been [DATE]). On [DATE] at 10:07 a.m., a phone interview with Staff A, LPN, revealed that she was doing morning medication pass with an orientee, Staff G, Registered Nurse (RN), when she found Resident #3 unresponsive. She told the orientee that she thought Staff H, LPN, had told her the resident was a DNR. Staff A, LPN stated, she looked up the code status up on the running sheet she had on her medication cart, and the running sheet indicated the letter D beside Resident #3's name. She stated, D meant DNR. She explained that the running sheet was a sheet they used to indicate all code statuses for the residents, and the running sheet indicated that she was a DNR. Staff A, LPN stated that if the resident had a room change, they may just cross out the name and may not change the other information on the sheet. The form was called a report sheet. Staff A, LPN said she then went to the computer to look up the code status, and it showed full code. She stated, Staff I, CNA, was directed to call a code blue and ask for a nurse from the second floor to come assist her because she was orienting the other nurse. Staff A, LPN and the orientee started CPR on Resident #3, and two CNAs came into the room as they were performing CPR. One of the CNAs told Staff A, LPN that she needed her to check on another resident because of a medical problem. She stated that she had Staff J, CNA, do the Ambu bag and the orientee was doing the compressions. She went to check on the other resident. Once finished, she went back to take over for Staff J, CN[NAME] She stated we did CPR for a long-time. Staff I, CNA, had called 911. Staff A, LPN stated that she called the Unit Manager, Staff E, LPN to tell her that Resident #3 had passed and told her that there was confusion with the code status. She stated that she contacted the Unit Manager because she remembered getting a report that Resident #3 was a DNR, but full code was in the computer system. She stated that they had already started CPR, so they had to finish it. When EMS arrived, they took over the CPR and code. Staff A, LPN stated that she went out to the nursing station and got the paperwork together. The EMT came out and told her that the resident had expired. Staff A, LPN reported that no one was writing anything down during the code because she and the orientee were doing the CPR. Staff A, LPN reported that she used a crash cart and a back board to do CPR. She stated that she was terminated from the facility and had just been reinstated on Saturday ([DATE]). Staff A, LPN stated that she was told the termination was because of the time frame between when she went to give the resident medications (approximately 6:00 a.m.) until the time EMS arrived (prior to 7:10 a.m.). She stated that she was the only nurse on the floor with an orientee and a census of about 52 residents. Staff A, LPN reported that she had not received any re-education on code status or code blue since this event occurred. On [DATE] at 6:46 a.m., Staff I, CNA, reported that she had Resident #3 on her assignment the night she expired. She stated, she came in late that night ([DATE]), about a quarter to 12:00 a.m. and checked all the rooms. Resident #3 was in bed snoring. At about 2:,[DATE]:30 a.m. ([DATE]), she put Resident #3's roommate back to bed. She stated that she had changed Resident #3 earlier. She reported that she started doing rounds again at about 4:00 a.m. something. At about 6 a.m., Staff A, LPN came to her and said Resident #3 was not responding. Staff A, LPN was about to give her morning meds (medications). Staff A, LPN went to see if Resident #3 was a full code. Staff A, LPN found out she was a full code and told her (Staff I) to call the code. Staff I, CNA notified Staff D, LPN, of the code. Staff D, LPN came downstairs and called 911. She stated they (the nurses) went to get the crash cart and started CPR. The ambulance was taking a long time to come. Staff A, LPN left the room to attend to another resident's urgent medical needs. Staff J, CNA, took over the CPR for Staff A, LPN. Then the EMT (Emergency Medical Technician) came and did CPR. By that time, Staff I, CNA stated, she left to care for another resident. On [DATE] at 9:59 a.m., Staff J, CNA, reported that she took over doing CPR for Staff A, LPN. She reported that she did the bag (Ambu bag) for breathing. Staff J, CNA stated that she and the other nurse (Staff G, RN/orientee) switched off because Staff G, RN/orientee said her arms were hurting. It was 15 or 20 minutes later maybe when EMS arrived, and the nurses told her she could go back to doing showers. She stated that there was no crash cart in the room. She stated that the resident was on the bed when she was doing compressions and no back board was used. An attempt was made to contact Staff G, RN/orientee on [DATE] at 1:48 p.m. via telephone. A voicemail message was left but no return call was received. On [DATE] at 7:07 a.m., Staff D, LPN, reported that she worked upstairs. She stated that after she finished med pass, a CNA (Staff I) called her on the phone to have her call a code. She stated that she ran downstairs to see what was going on because she was unfamiliar with the resident. She reported that when she went down to the first floor, two nurses (Staff A, LPN and Staff G, RN/orientee) were there performing CPR, so she then went to call the code. She reported that she started the transfer form so that when the ambulance came, that part would be completed. Staff D, LPN stated again that she did not know anything about the resident. She reported that she was not done with the form when the ambulance came. The police came first. She was called by the CNA about 6:20 a.m. or 6:30 a.m. Staff D, LPN was asked if there was confusion over the resident's code status and she stated, To me it was. Staff D, LPN stated that there were two charts in the computer. The first chart had nothing in the record, just the resident's name, so she scrolled down and the MDS Coordinator came to help her. She told the MDS Coordinator that she could not see what the code status was in the computer at all. The MDS Coordinator left the floor and came back with the paper (golden rod), stating that she (Resident #3) was a DNR. Staff D, LPN reported that there was nothing in the yellow book (used to hold resident DNR forms for that unit) for this resident. She did not know where the MDS Coordinator pulled the form from. She stated that she did not know how they knew she (Resident #3) was a full code. She stated that she freaked out because there was no information in the record. She did not see a paper chart that belonged to the resident. EMS stopped compressions because they reported she had expired. She stated, she did not know how Staff A, LPN knew to do a full code. The resident's name was in the computer twice. There were two charts and she did not know what chart to click on. Staff D, LPN stated that she did not think to click on the second chart. Staff D, LPN reported that she saw Staff G, RN/orientee doing compressions while Staff A, LPN was holding the backboard. On [DATE] at 11:36 a.m., the MDS Coordinator reported that she was in the building during Resident #3's code. She recalled walking in the building, clocking in, and hearing them call a code. The nurse, Staff D, LPN, was standing at the nurse's station. She reported that she went to help with the paperwork. She stated that Staff D, LPN reported that there were two entries in the computer, and she told her she could not find the orders. The MDS Coordinator reported that she printed out all the physician's orders [REDACTED]. There was no confusion with the code status. She knew there was a DNR form in the computer and when asked did she provide the DNR form to Staff D, LPN she stated no. She confirmed that she only printed off the orders and the face sheet. She reported that the banner for Resident #'s electronic record stated full code. On [DATE] at 11:01 a.m., the Nursing Home Administrator (NHA) was asked if she thought there was any confusion with the code status for Resident #3. She stated, I believe there was a lot of confusion. The NHA stated, The initial confusion was when the resident actually passed away, when did we know she passed away, and did we do the correct thing at the time. She reported that the Regional Nurse, who is now the Interim DON, Staff K, Staffing Coordinator who was the former DON, and the Risk Manager started the investigation. The police said it did not look suspicious. The only thing they could prove was that Staff A, LPN, documented that she gave medications to Resident #3 after the resident had expired. That in the end was why she agreed that the nurse should be terminated. The NHA did not know where the DNR form came from and recalled that the MDS Coordinator found it, but she did not know where she got the information from. The NHA could not explain how the resident went from a DNR to a full code and she stated that she did not know. She stated the DNRs were not completely accurate. The NHA stated that because the resident had not been deemed incapacitated and the daughter, signed the DNR that it was not valid. The NHA reported that her expectation was that when you see the BIMS score of 1 and the resident had not been deemed incapacitated, you get it corrected so her wishes could be met. She said, Did we take those steps? No. She stated that we had time to take the steps and we did not take the steps. She stated that the wishes of the resident may or may have not been met and they should have been. She was asked if anyone spoke with the family, and she stated that she would have to look. The DNR process was not a good system, stated the NH[NAME] On [DATE] at 9:10 a.m., Staff K, Staffing Coordinator, (previously the DON at the time of the incident), reported that she got a phone call from Staff E, Unit Manager saying that they were coding Resident #3 and to not be alarmed when she got here. Staff K, Staffing Coordinator stated the code was over when she got to the facility. She stated that she got in around 7ish (a.m.) and received the phone call around 6:30 a.m., somewhere around there. She was asked if Resident #3 was a DNR. Staff K, Staffing Coordinator stated that she was a full code and they started CPR. She stated, she did not do the investigation. The Risk Manager did the investigation. She stated that she does not remember if there was confusion with the code status or not. On [DATE] at 1:40 p.m., the Risk Manager, reported that on [DATE], we had a code and a nurse did CPR. She stated we always investigate when someone codes. She stated that she started the investigation on [DATE]. She called Staff A, LPN, on [DATE] to speak with her because she worked the night of [DATE]. She stated that the code was started between 5:40 a.m. and 6:30 a.m. She stated that she went to the local police department and got the narrative for a timeframe of the incident. She stated that CPR was started around 6:30 a.m. and the call went to the police at 6:38 a.m. She interviewed the CNAs and the nurses. The times were inconsistent. They were all saying between 6:00 a.m. and 6:30 a.m. Staff D, LPN, was called from another floor to assist with the code. Staff D, LPN was called at 6:20 a.m. The CNAs stated that it was after 6:00 a.m. The Risk Manager talked to the Unit Manager, Staff E, regarding the incident. Staff A, LPN had notified the Unit Manager that they were starting CPR. The day nurses stated that they heard her call the code. The police representative stated staff was in the process of doing CPR when they arrived. The police representative stated he put the Automated External Defibrillator (AED) on her, and it read no shock advised. They continue

Based on interviews with the facility's nursing and administrative staff, a family member appointed as the Durable Power of Attorney (DPOA) and Health Care Surrogate, the attending physician, and review of clinical records and facility policies, it was determined that the facility failed to protect the rights of residents related to advance directives and the right to refuse cardio-pulmonary resuscitation (CPR) consistent with the expressed end of life wishes, for two (Resident #3 and #13) of 119 residents reviewed for code status. The facility initiated CPR on Resident #3, an [AGE] year-old, severely impaired resident, without clarifying her wishes on admission and during the six weeks of her stay. This resident had a signed Do Not Resuscitate (DNR) order completed by her DPOA and signed by a physician on [DATE]. The facility called emergency services (EMS) for the resident and provided with unwanted treatments of cardiac compressions and artificial ventilation to prolong her life. The facility violated this resident's rights by failing to honor the resident/DPOA's wishes to have a peaceful and dignified death and failed to protect the resident from unwanted interventions at her last moments of life. The facility failed to clarify conflicting physician orders [REDACTED].#13 placing this resident at risk of not following advanced directives consistent with the resident's wishes due to the facility's system failure. Failure of the facility staff to correctly implement an advanced directive resulted in findings of immediate jeopardy which was removed on [DATE] and reduced to the scope and severity of a D. Findings included: A review of the facility's policy, revised (MONTH) 2013 titled, Advance Directives, revealed: 1. Prior to or upon admission of a resident to our facility, the Social Services Director or designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives. 2. Each resident will also be informed that our facility's policies do not condition the provision of care or discriminate against an individual based on whether or not the individual has executed an advance directive. 3. Prior to or upon admission of the resident, and/or his/her family members, about the existence of any written advance directives. 4. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. 5. If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. The resident will be given the option to accept or decline the assistance, and care will not be contingent on either decision. Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline. 6. The Attending Physician will provide information to the resident and legal representative regarding the resident's health status, treatment options and expected outcomes during the development of the initial comprehensive assessment and care plan. 7. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. 8. The resident has the right to refuse treatment whether or not he or she has an advance directive. A resident will not be treated against his or her own wishes. 9. Depending on State requirements, the legal representative may also have the right to refuse or forego treatment. 10. If the resident or representative refuses treatment, the facility and care provider will: a. Reassess the resident for significant change of condition related to the refusal; b. Determine the decision making capacity of the resident and invoke the legal representative if appropriate to the situation; c. Document specifically what the resident/representative is refusing; d. Assess and document the stated reason for the refusal; e. Advise the resident of the consequences of refusal; f. Offer pertinent alternative treatments; and g. Modify the care plan as appropriate, providing all other appropriate services (i.e. those that will allow him or her to maintain the highest practicable physical, mental, and psychosocial well-being). 11. The resident's Attending Physician will clarify and present any relevant medical issues and decisions to the resident or legal representative as the resident's condition changes in an effort to clarify and adhere to the resident's wishes. 14. The Interdisciplinary Team will conduct ongoing review of the resident's decision-making capacity and communicate significant changes to the resident's legal representative. Such changes will be documented in the care plan and medical record. 16. Changes or revocations of a directive must be submitted in writing to the NH[NAME] The NHA may require new documents if changes are extensive. The Care Plan Team will be informed of such changes and/or revocations so that appropriate changes can be made in the resident assessment (Minimum Data Set - MDS) and care plan. 17. The Director of Nursing Services or designee will notify the Attending Physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. The Attending Physician will not be required to write orders for which he or she has an ethical or conscientious objection. Review of the facility's policy, revised (MONTH) (YEAR) titled, Emergency Procedure-Cardiopulmonary Resuscitation, revealed: 6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS (Basic Life Support) shall initiate CPR unless: a. It is knowing that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or b. There are obvious signs of irreversible death (e.g. rigor mortis). 7. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's orders [REDACTED]. A review of Resident #3's Admission Record revealed she was admitted to the facility from a local hospital on [DATE] with [DIAGNOSES REDACTED]. The Admission MDS dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 1 indicating severe cognitive impairment. The clinical record contained a DPOA and Health Care Surrogate designation, appointing her daughter, dated and signed by Resident #3 on [DATE]. Review of the form revealed .It is my specific intent that the power conferred on my Agent will be exercisable from the date of this instrument, notwithstanding my subsequent disability or incapacity, except as otherwise specifically provided by statute. Continued review of Resident #3's clinical record (paper chart) revealed documents from two skilled nursing facilities (SNF) that she had resided in prior to her admission at this facility, SNF A and SNF B. Progress notes from SNF A dated [DATE], 17 days prior to her admission at this facility, revealed a code status of DNR. A Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form indicated that the resident was transferred from SNF A to SNF B on [DATE]. This form also indicated that her advance care planning documentation included a DNR. Additionally, the Order Summary Report for Active orders as of [DATE] from SNF B revealed that the resident had a code status of DNR with an order date of [DATE], seven days prior to her admission at this facility. Record review of the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form from the hospital dated [DATE] indicated that the resident had advance care planning documentation for Do Not Resuscitate (DNR). A Florida DNR order (golden rod) dated [DATE] was also discovered in the paper chart. The order form was signed by the resident's daughter/DPO[NAME] The form reflected, .based upon informed consent, I, the undersigned, hereby direct that CPR be withheld or withdrawn. The form was signed by the physician, who was a hospitalist, prior to her admission to this facility. It reflected, .I hereby direct withholding or withdrawing of cardiopulmonary resuscitation from the patient in the event of the patient's cardiac or respiratory arrest. Contained in Resident #3's paper clinical record was a Plan of Care document from the resident's insurance company with an effective date of [DATE] and a review date of [DATE] indicating the resident had a DNR. A review of Resident #3's electronic clinical record showed that under the advanced directives section the DNR (golden rod) form had been scanned into the computer on [DATE]. However, a physician's orders [REDACTED]. Further review of the clinical record (electronic and paper chart) did not reveal documentation to support the decision of the facility to have a full code physician's orders [REDACTED]. A review of Resident #3's care plan for advance directives initiated on [DATE] indicated that Resident #3 had the following: Problem Start Date: [DATE]: Category: Advanced Directives (Resident #3) has the following Advanced Directives on record DPOA and full code status. The Long-Term Goal Target Date: [DATE] Advance Directive are in effect, and their wishes and directions will be carried out in accordance with their Advanced Directives. The interventions included but were not limited to, advise (Resident #3) and/or appointed health care representative to provide copies to the facility of any updated Advanced Directives, an Advanced Directive can be revoked or changed if the resident and/or appointed health care representative changes their mind about the medical care they want delivered, discuss advanced directives with Resident #3 and/or appointed health care representative, notify physician of (Resident #3's) wishes regarding life prolonging procedures, notify the physician to assess the capacity of (Resident #3) and certify capacity or incapacity, and the appointed health care representative will make all health care decisions if (Resident #3) is incapacitated. A complete review of Resident #3's paper and electronic clinical record revealed no evidence that the resident's capacity status had been assessed by a physician during her stay at the facility. No documentation was present to indicate a discussion was held with the resident and/or the resident's representative to change or rescind the advance directive DNR order received at the time of admission. A progress note dated [DATE] at 7:51 a.m. created by Staff A, Licensed Practical Nurse (LPN) revealed, I went in to do the resident's morning medication and I noticed that the resident was unresponsive. I called for another nurse to call the code blue and to call 911. We began CPR. The EMTs (Emergency Medical Technicians) arrived and took over the compressions. The physician was called for an order to release the body. The family was notified about their mom expiring. The family called back to notify us that they had called a cremation service to pick the resident up and they would be calling the facility for information. A progress note dated [DATE] at 12:00 p.m. created by Staff N, Registered Nurse (RN) revealed, the funeral home came to release the body. A family member was notified and came to pick up her belongings. The Recapitulation of Resident's Stay section of the Interdisciplinary Discharge Summary dated [DATE] revealed that Resident #3 expired. The Record of Death dated [DATE] revealed that the date of death was [DATE] at 7:10 a.m. The date and time records on the record of death were inconsistent with the incident date and time recorded by facility staff, progress notes, and interviews. Continued review of Resident #3's clinical record revealed a progress note dated [DATE] at 12:51 a.m. created by Staff A, LPN and marked as a late entry on [DATE] at 1:30 a.m. The progress note revealed, Did walking rounds and observed the resident lying in bed, snoring, and turned on her right side. She also had a bowel movement and notified the CNA (Certified Nursing Assistant) about this issue. At 3:00 a.m., made a walking round on the hall and the resident was snoring. At 6:00 a.m. went in to give the resident her morning medication and she was unresponsive; medication not given. Went to verify the resident's code status on the computer and called code blue. (Based on interviews and further record review, the date of [DATE] was incorrect and should have been [DATE]). On [DATE] at 10:07 a.m., a phone interview with Staff A, LPN, revealed that she was doing morning medication pass with an orientee, Staff G, Registered Nurse (RN), when she found Resident #3 unresponsive. She told the orientee that she thought Staff H, LPN, had told her the resident was a DNR. Staff A, LPN stated, she looked up the code status up on the running sheet she had on her medication cart, and the running sheet indicated the letter D beside Resident #3's name. She stated, D meant DNR. She explained that the running sheet was a sheet they used to indicate all code statuses for the residents, and the running sheet indicated that she was a DNR. Staff A, LPN stated that if the resident had a room change, they may just cross out the name and may not change the other information on the sheet. The form was called a report sheet. Staff A, LPN said she then went to the computer to look up the code status, and it showed full code. She stated, Staff I, CNA, was directed to call a code blue and ask for a nurse from the second floor to come assist her because she was orienting the other nurse. Staff A, LPN and the orientee started CPR on Resident #3, and two CNAs came into the room as they were performing CPR. One of the CNAs told Staff A, LPN that she needed her to check on another resident because of a medical problem. She stated that she had Staff J, CNA, do the Ambu bag and the orientee was doing the compressions. She went to check on the other resident. Once finished, she went back to take over for Staff J, CN[NAME] She stated we did CPR for a long-time. Staff I, CNA, had called 911. Staff A, LPN stated that she called the Unit Manager, Staff E, LPN to tell her that Resident #3 had passed and told her that there was confusion with the code status. She stated that she contacted the Unit Manager because she remembered getting a report that Resident #3 was a DNR, but full code was in the computer system. She stated that they had already started CPR, so they had to finish it. When EMS arrived, they took over the CPR and code. Staff A, LPN stated that she went out to the nursing station and got the paperwork together. The EMT came out and told her that the resident had expired. Staff A, LPN reported that no one was writing anything down during the code because she and the orientee were doing the CPR. Staff A, LPN reported that she used a crash cart and a back board to do CPR. She stated that she was terminated from the facility and had just been reinstated on Saturday ([DATE]). Staff A, LPN stated that she was told the termination was because of the time frame between when she went to give the resident medications (approximately 6:00 a.m.) until the time EMS arrived (prior to 7:10 a.m.). She stated that she was the only nurse on the floor with an orientee and a census of about 52 residents. Staff A, LPN reported that she had not received any re-education on code status or code blue since this event occurred. On [DATE] at 6:46 a.m., Staff I, CNA, reported that she had Resident #3 on her assignment the night she expired. She stated, she came in late that night ([DATE]), about a quarter to 12:00 a.m. and checked all the rooms. Resident #3 was in bed snoring. At about 2:,[DATE]:30 a.m. ([DATE]), she put Resident #3's roommate back to bed. She stated that she had changed Resident #3 earlier. She reported that she started doing rounds again at about 4:00 a.m. something. At about 6 a.m., Staff A, LPN came to her and said Resident #3 was not responding. Staff A, LPN was about to give her morning meds (medications). Staff A, LPN went to see if Resident #3 was a full code. Staff A, LPN found out she was a full code and told her (Staff I) to call the code. Staff I, CNA notified Staff D, LPN, of the code. Staff D, LPN came downstairs and called 911. She stated they (the nurses) went to get the crash cart and started CPR. The ambulance was taking a long time to come. Staff A, LPN left the room to attend to another resident's urgent medical needs. Staff J, CNA, took over the CPR for Staff A, LPN. Then the EMT (Emergency Medical Technician) came and did CPR. By that time, Staff I, CNA stated, she left to care for another resident. On [DATE] at 9:59 a.m., Staff J, CNA, reported that she took over doing CPR for Staff A, LPN. She reported that she did the bag (Ambu bag) for breathing. Staff J, CNA stated that she and the other nurse (Staff G, RN/orientee) switched off because Staff G, RN/orientee said her arms were hurting. It was 15 or 20 minutes later maybe when EMS arrived, and the nurses told her she could go back to doing showers. She stated that there was no crash cart in the room. She stated that the resident was on the bed when she was doing compressions and no back board was used. She reported that she had not had any in-service or re-education on what to do if someone coded following this incident. An attempt was made to contact Staff G, RN, on [DATE] at 1:48 p.m. via telephone. A voicemail message was left but no return call was received. Staff G, RN was no longer employed by the facility at the time of survey. The termination of Staff G, RN was unrelated to this event or any disciplinary action. On [DATE] at 7:07 a.m., Staff D, LPN, reported that she worked upstairs. She stated that after she finished med pass, a CNA (Staff I) called her on the phone to have her call a code. She stated that she ran downstairs to see what was going on because she was unfamiliar with the resident. She reported that when she went down to the first floor, two nurses (Staff A, LPN and Staff G, RN/orientee) were there performing CPR, so she then went to call the code. She reported that she started the transfer form so that when the ambulance came, that part would be completed. Staff D, LPN stated again that she did not know anything about the resident. She reported that she was not done with the form when the ambulance came. The police came first. She was called by the CNA about 6:20 a.m. or 6:30 a.m. Staff D, LPN was asked if there was confusion over the resident's code status and she stated, To me it was. Staff D, LPN stated that there were two charts in the computer. The first chart had nothing in the record, just the resident's name, so she scrolled down and the MDS Coordinator came to help her. She told the MDS Coordinator that she could not see what the code status was in the computer at all. The MDS Coordinator left the floor and came back with the paper (golden rod), stating that she (Resident #3) was a DNR. Staff D, LPN reported that there was nothing in the yellow book (used to hold resident DNR forms for that unit) for this resident. She did not know where the MDS Coordinator pulled the form from. She stated that she did not know how they knew she (Resident #3) was a full code. She stated that she freaked out because there was no information in the record. She did not see a paper chart that belonged to the resident. EMS stopped compressions because they reported she had expired. She stated, she did not know how Staff A, LPN knew to do a full code. The resident's name was in the computer twice. There were two charts and she did not know what chart to click on. Staff D, LPN stated that she did not think to click on the second chart. Staff D, LPN reported that she saw Staff G, RN/orientee doing compressions while Staff A, LPN was holding the backboard. She stated that she had completed the education on where to find the code status. She stated she had completed the education on where to find the code status last night ([DATE] and this morning ([DATE]). She reported it was found in the profile and in the computer. On [DATE] at 11:36 a.m., the MDS Coordinator reported that she was in the building during Resident #3's code. She recalled walking in the building, clocking in, and hearing them call a code. The nurse, Staff D,LPN, was standing at the nurse's station. She reported that she went to help with the paperwork. She stated that Staff D, LPN reported that there were two entries in the computer, and she told her she could not find the orders. The MDS Coordinator reported that she printed out all the physician's orders [REDACTED]. There was no confusion with the code status. She knew there was a DNR form in the computer and when asked did she provide the DNR form to Staff D, LPN she stated no. She confirmed that she only printed off the orders and the face sheet. She reported that the banner for Resident #'s electronic record stated full code. On [DATE] at 11:21 a.m., a phone interview with Resident #3's attending physician revealed that he saw the resident one time because she was only there for about a month. He reported that he did not know what her code status was. He stated that he saw a DNR form signed by a physician from the hospital. He reported that unless the patient has specific issues, he does not pay attention to the code status. He reported that he sees so many patients that he could not really remember anything. He reported that Resident #3 was severely demented. In regards to an incapacity statement, the physician stated that most of the time they have the form in a book, and they would let him know the form was in there and needed to be filled out. He did not recall ever being asked to complete an assessment on her capacity. On [DATE] at 11:32 a.m., a phone interview with Resident #3's daughter and DPOA revealed her mom's wishes were to go peacefully. The daughter believed that her mom's end of life wishes were honored. She stated that the nurse that called, told her she went in her mom's room that morning and she was gone. The daughter stated that she participated in the resident's admission process and there should have been a DNR already drawn up. The resident's daughter reported that Resident #3 was not able to make her own decisions. The resident's daughter did not indicate that she was asked about the resident's code status on the day she passed nor was she informed her mom had received CPR when found unresponsive. On [DATE] at 1:40 p.m., the Risk Manager, was asked by the surveyor if she had conducted an investigation into the death of Resident #3. She reported that on [DATE], we had a code and a nurse did CPR. She stated we always investigate when someone codes. She stated that she started the investigation on [DATE]. She called Staff A, LPN, on [DATE] to speak with her because she worked the night of [DATE]. She stated that the code was started between 5:40 a.m. and 6:30 a.m. She stated that she went to the local police department and got the narrative for a timeframe of the incident. She stated that CPR was started around 6:30 a.m. and the call went to the police at 6:38 a.m. She interviewed the CNAs and the nurses. The times were inconsistent. They were all saying between 6:00 a.m. and 6:30 a.m. Staff D, LPN, was called from another floor to assist with the code. Staff D, LPN was called at 6:20 a.m. The CNAs stated that it was after 6:00 a.m. The Risk Manager talked to the Unit Manager, Staff E, regarding the incident. Staff A, LPN had notified the Unit Manager that they were starting CPR. The day nurses stated that they heard her call the code. The police representative stated staff was in the process of doing CPR when they arrived. The police representative stated he put the Automated External Defibrillator (AED) on her, and it read no shock advised. They continued compressions until EMS got to the facility. The Risk Manager stated that the resident was a full code. The surveyor asked the Risk Manager why the resident had a DNR form in her chart. The Risk Manager stated that the DNR form was not valid. On [DATE] at 3:10 p.m., the Risk Manager reported that code status was brought to Quality Assurance Performance Improvement (QAPI) meeting and they have done a code status audit on all the residents. The Risk Manager reported that the audits were completed a few days after the incident, but she was not sure exactly when. Immediately following this interview, the Interim Director of Nursing (DON) provided documentation of the audit described by the Risk Manager, said to be completed a few days following the [DATE] incident. Review of this document revealed it was only for one of the two units in the facility (200 unit) and it was dated [DATE], two months post incident. On [DATE] at 7:52 a.m., the Risk Manager stated that she did not remember anyone saying that there was confusion with finding the code status. The Risk Manager stated that she remembered Staff A, LPN, saying she went to the computer to get the code status and it was a full code. She stated that Staff D, LPN, went to the front to ask the MDS Coordinator for help with the paperwork. The MDS Coordinator was at the front entrance waiting to open the doors for EMS. She stated that Staff D, LPN reported that the resident was cool to the touch when she arrived downstairs. The Risk Manager reported that they knew where to find the code status, but the resident was in the computer twice and they immediately went to the second one. The first record did not have anything in it. The Risk Manager reported that Staff A, LPN was terminated because she had documented that she had given Resident #3 her medication at 6:00 a.m., and they said that was falsification of records. They decided to bring her back because of the Union. The Risk Manager was asked what she would do if she found a resident unresponsive and she stated that she would look on the banner in the computer as soon as you pull up the resident. If they were full code, she would do CPR. She stated that she did not know anything about the running sheet. She stated that education was not started right after the incident. She reported that she gave the information from the investigation to the Nursing Home Administrator (NHA) and the Regional staff member (currently the Interim DON). The Risk Manager reported that she talked to the Interim DON about the incident. The Risk Manager confirmed that she did not report the incident to any outside agencies. The Risk Manager confirmed that she did not talk to the family. She stated she knows there was a problem with the incapacity form. When they were doing the investigation that was when they found the problem. She talked to the Social Worker at that time of the investigation and asked if she talked to the family about Resident #3 no longer being a DNR. The Risk Manager stated she does not have proof that Resident #3 was a DNR. The Risk Manager confirmed that she did not talk to Resident #3's physician. She confirmed that they did not have a scribe, and no one was keeping track of the times during the code. The Risk Manager reported that she had copies of text messages that were exchanged between Staff A, LPN, and Staff E, Unit Manager, during the incident. The first message was sent to Staff E, Unit Manager at 6:30 a.m. The text stated that Resident #3 had expired and she could not get the doctor. Staff E, Unit Manager responded and asked if Resident #3 was a full code. Staff A, LPN, responded via text yes but she was cold. Staff E, Unit Manager called Staff A, LPN on the phone and that was at 6:32 a.m. Staff E, Unit Manager stated you know you have to do CPR and call 911. Staff A, LPN went to the computer to check the code. Staff I, CNA, heard Staff G, RN/orientee, tell Staff A, LPN, that she would have to start CPR. Staff A, LPN stated to Staff G, RN/orientee even if she was cold. The Risk Manager reported that she never received a written statement from Staff A, LPN, even after asking her for a couple of times. A review of a local law enforcement report dated [DATE] revealed, On [DATE] at 0638 hours (6:38 a.m.), I responded to (facility address) in reference to an AED (Automated External Defibrillator) assist with an unconscious subject. Upon arrival, I made contact with the reportee in (room #) who was giving chest compressions to the subject later identified as (Resident #3). I used my AED and placed the pads on (Resident #3) and received a No shock advised message. I continued chest compressions until EMS (Emergency Medical Services) arrived and took over. At approximately 0710 hours (7:10 a.m.) EMS declared (Resident #3) deceased . The reportee identified as (redacted text) stated that she last saw (Resident #3) breathing at 0230 hours (2:30 a.m.) when she gave her medication. She stated that she found (Resident #3) unresponsive at approximately 0630 hours (6:30 a.m.) and called 911 and began CPR On [DATE] at 9:10 a.m., Staff K, Staffing Coordinator, (previously the DON at the time of the incident), reported that she got a phone call from Staff E, Unit Manager saying that they were coding Resident #3 and to not be alarmed when she got here. Staff K, Staffing Coordinator stated the code was over when she got to the facility. She stated that she got in around 7ish (a.m.) and received the phone call around 6:30 a.m., somewhere around there. She was asked if Resident #3 was a DNR. Staff K, Staffing Coordinator stated that she was a full code and they started CPR. She stated, she did not do the investigation. The Risk Manager did the investigation. She stated that she does not remember if there was confusion with the code status or not. She stated that she had education on [DATE] on code status related to where you would go to find the code status. At that time, the staff were trained to either look at the yellow DNR book or the computer. A review of the facility's in-service records dated [DATE] at 2:30 p.m., just 7 days after the incident, revealed the topic discussed was Situation Background Assessment Recommendation (SBAR) and identification of resident's DNR status. The sign-in sheet included signatures for 11 out of 29 facility licensed nurses. A Mock Code Evaluation Checklist dated [DATE] was also provided. This form revealed a mock code was completed by four nurses. A review of the form revealed the scenario was Resident/Visitor Collapses. The form detailed the steps to be taken for performance of CPR and contained no steps to check the resident's code status prior to initiating CPR. Additionally, evaluation feedback and action plan revealed Staff needs more education on procedures during code. On [DATE] at 3:06 p.m., the Interim DON stated that Mock Codes were done four times, but they could not find the documentation for the other three mock codes. On [DATE] at 3:05 p.m., the Interim DON and the current Social Services Director (SSD) were asked if there was an incapacity statement for Resident #3? They both answered, No. When asked who was making decisions for the resident, they did not answer. The SSD reported that as of [DATE] they do welcome conferences within 48 hours of admission. The SSD reported that they did a full house audit to track incapacities. The SSD reported that they have had in-services, but no documentation was provided except for the [DATE] in-service and the [DATE] mock drill. The SSD confirmed that Resident #3 did not have an incapacity statement, no one was in charge of her care, and there was no documentation that the DNR was discussed with the resident or the resident representative. The SSD stated she did not work at the facility at the time of the event and could not speak to the specifi

Based on resident and facility record review, policy and procedure review, staff and administrative interviews, Job description review and observations, it was determined that the facility failed to be managed in a manner that enabled it to use its resources effectively to maintain the highest practicable physical well-being for 3 (#1, #2, #3) of 3 sampled residents, who were identified as needing closer supervision. The administration did not ensure that the direct functions and operations of the facility were in accordance with current regulations governing long term care facilities and facilities policies for resident supervision and neglect, as evidenced by the following: Resident #2 being found 1.5 miles from the facility, after being missing from the facility, for at least 45 minutes before the facility was aware of his elopement; Resident #1 was found in an unknown, empty vehicle in the facility parking lot; Resident #3 was found wandering in the facility parking lot unsupervised. The failure to ensure that staff properly implement interventions related to resident supervision, the failure to ensure the prevention of neglect and the failure to ensure that adequate supervision was provided to ensure resident safety for all residents resulted in the determination of Immediate Jeopardy on 11/28/12. The finding of Immediate Jeopardy was found to be removed on 11/29/12 at 12:20 p.m. and the severity and scope was reduced to a D. Findings include: 1. Review of the job description for the administrator with a signed date of 9/17/12 revealed the following relevant information: Basic Function: " Responsible for directing the overall operations of the facility ' s activities in accordance with current applicable federal, state and local standards, guidelines and regulations and as directed by the governing board and for ensuring that the highest degree of quality patient/resident care is maintained at all times. " Essential functions: " Establish and direct the implementation of written policies and procedures that reflect the goals and objectives of the facility. " " Recruit, select and train competent department supervisors and other auxiliary personnel " " Delegate authority, responsibility and accountability to other responsible persons. " Marginal Functions: " Responsible for the overall quality assessment and improvement program and the coordination of quality assessment and improvement activities. " " Ensure that the facility is maintained in as clean and safe manner for patient/resident comfort and convenience by assuring necessary equipment and supplies are maintained to perform each duties/services. " " Assist in the planning of purposeful in-service training classes and on-the-job training programs that will lead to better understanding of patient/resident needs. " " Review and check competence of the workforce and make necessary adjustments/corrections as required or that may become necessary. " Supervision exercised: " The administrator exercises administrative and functional supervision over the entire facility. " 2. An Interview with the Transport CNA, on 11/27/12 at approximately 10:37 a.m., revealed that at approximately 3:59 p.m. on 11/7/12, she was on her way back to the facility when she saw a male individual that resembled a resident who she knew to reside on the 2nd floor unit of the facility. She reported that this resident was approximately 1.5 miles from the facility and that he was walking in the opposite direction of the facility. The main road on which resident #2 was walking, is located about 300 feet away from the facilities parking lot and is a 2 lane road (1 lane in each direction), with a second 2 lane road connecting the main road to form a " T " intersection. The resident was observed on the second main road which indicated that he would have had to cross at least one of the roads to end up at the point where he was observed walking. The second road where the resident was observed walking has a side walk on one side of the road, and on the other side of the road there are grassy areas with no sidewalk. The Transport CNA reported that she stopped the vehicle, called the facility, and spoke to the Unit Manager on the 2nd floor to confirm that the resident was not in the building. The Transport CNA reported that she asked the resident where he was going and the resident reported that "he was going home" and that he refused to go back to the facility. The Transport CNA reported that the resident was observed stumbling a little. She reported that 2 unknown men pulled up in a van and asked if she needed assistance. She explained to the men that the resident was refusing to go with her back to the facility, and then one of the men asked the resident if he wanted a ride and the resident got into the van with the 2 men, who transported resident #2 back to the facility. The Transport CNA indicated that when the resident got back to the facility, he was observed to have a skin tear to his left hand. An Interview with the Unit Manager, for 2nd floor on 11/27/12 at approximately 10:46 a.m. revealed that resident #2 was relocated from the 1st floor secured unit to the 2nd floor a couple of weeks prior to the resident eloping and was placed on 15 minute checks. These checks were to be done by a CNA or the nurse. She reported that, on 11/7/12 she was in a care plan meeting and that she had seen resident #2 prior to the meeting, which was 30 minutes under way, when she received a call from the Transport CNA, who was questioning if resident #2 was in the building; the Unit Manager left the meeting to start a check of the facility, which resulted in the finding that resident #2 was not in the building. The Unit Manger reported that she informed the Transport CNA that the Social Worker would assist her. The Unit Manager reported that the aide came back to the facility, and that the resident was brought back to the facility by a stranger. An interview on11/27/12, at approximately 10:58 a.m., with the CNA assigned to provide care to resident #2 revealed that she came on shift at 2:45 p.m. and noted that resident #2 was a little agitated while speaking to someone on the phone. She reported that he refused vital signs and showers, and stayed in the hallway. The assigned CNA reported that she continued on to her next resident who needed to be showered. Additionally the assigned CNA reported that, apparently while she was showering another resident, resident #2 left the building. She reported that the resident was on fifteen minute checks at the time that he left the facility, and that the last time the check was done by her, was at 3:15 p.m. Forty five minutes later the resident was discovered 1.5 miles from the building. An Interview with the Risk Manager on 11/27/12, at approximately 10:08 a.m. revealed that on 11/7/12, at approximately 4:10 p.m. resident #2 was observed on a local road more than 1 mile away from the facility by a Transport CNA who was returning to the facility in the facility ' s van. She reported that the Transport CNA tried to get resident #2 in the facility van, but he refused. The Risk Manager reported that 2 men stopped, asked if they could help and took resident #2 back to the facility. The Risk Manger reported that the 2 men were unknown to the resident, facility and unknown to the Transport CNA and that the aide contacted the facility. The Risk Manager reported that the facility was unaware that resident #2 was not in the building until the facility received the call from the Transport CNA. The Risk Manger reported that the facility places, on the wrist or ankle of residents who are identified as an elopement risk, a wrist/ankle band that is green in color. This is used to identify residents who are at risk of elopement and in addition to the band, if the resident is identified as an elopement risk their picture is placed at the receptionist desk for identification of residents who may elope. She reported that both the picture and the wrist/ankle band were in place for resident #2 at the time that he eloped. A review of resident #2 ' s record revealed a resident face sheet dated 10/22/12, which indicated that the resident had current [DIAGNOSES REDACTED]. The resident ' s history and physical from the local hospital, prior to the resident ' s admission to a Skilled Nursing Facility (SNF), dated 10/14/12, revealed that, this resident was a [AGE] year old male with a history of dementia. Review of the section with the heading " Physical Examination " and the sub heading of " Neurologic " revealed that the resident was alert but disoriented. Review of the section with the heading " Assessment " #3 revealed that the resident had a " Worsening altered mental status " . Further review of resident #2 ' s record revealed a [DIAGNOSES REDACTED]. The Admission assessment dated [DATE], revealed that this resident was admitted to the first floor secured unit and was disoriented, forgetful and his balance/gait was unsteady. The hand written note on this form indicated the following: " 3-11, 7pm Resident continues to ambulate hallway seeking an exit " " Continue Q15 minutes. " , " 10pm in bed with eyes closed continue Q15 minute monitoring " . Review of resident #2 ' s history and physical, completed at the time of admission to the SNF, dated 10/17/12, revealed that the resident had dementia and was observed confused. He also had a history of [REDACTED]. The Care Conference summary, dated 10/31/12, indicated that resident #2 had confusion due to Dementia. Review of resident #2 ' s care plan, dated 10/31/12, revealed that the following concerns were identified and needed to be addressed: Elopement attempt, " Yells, I want out of here " and " I ' m going to see my lawyer about suing this doctor " ; Impaired thought process/Dementia/ Altered Mental Status. He has intermittent confusion with memory problems; Anxiety, worries about his home, packs his belongings daily; Decreased hearing; Decreased vision; at risk for falls. Nurse ' s notes dated 11/3/12, 11/4/12, 11/5/12, 11/6/12, and the morning of 11/7/12 revealed that resident #2 continues on Q15 (every fifteen) minute monitoring. However, there was no documentation in the Nurse ' s notes that would indicate the lapse of time during the elopement nor any reference to the resident leaving the building or being transferred to the first floor secured unit. The Social Service admission note, dated 10/25/12, revealed that resident #2 would pack his belongings daily and would say " today is the day, I ' m outta here " . The Minimum Data Set (MDS), dated [DATE], indicated the following: in section " G " with the heading of " Functional Status " , with the sub-heading of " 1. ADL Self -Performance " Section " F. locomotion off unit " the resident was coded a " 1 " which indicates that he requires supervision to complete this task; Sub-heading " G0300. Balance During Transitions and walking " , letter " B. walking " the resident was coded a " 1 " which indicates that he is " not steady, but able to stabilize without staff assistance " ; Section " I Active [DIAGNOSES REDACTED]. Additional active [DIAGNOSES REDACTED]. Senile Dementia " , section " E. Muscle Weakness " Section " F. Difficulty in Walking " and section " G. Lack of Coordination " Review of the Q 15 min Observations Safety Check Log revealed that the sheets have pre-printed times on them and was noted to have 92, 15 minute increments, starting at 12:15 and ending at 11:45. The directions on this form, indicated that, the staff are to " document on the resident in Q15 minute increments, initial each entry and document the behavior noted " . A review of resident #2 ' s Safety Check Log revealed the following: On 10/19/12, there were ten 15 minute checks with no initials and no behaviors documented; on 10/21/12, there were thirty 15 minute checks with no initials and no behaviors documented; on 10/23/12, there were thirty four 15 minute checks that had no initials and no behaviors documented; on 10/29/12, there were eighteen 15 minute checks that were initialed, however, the behavior sections of the entries were left blank. Additionally, there were twelve 15 minute checks that had no initials and had no behaviors documented; on 10/30/12, there were two 15 minute checks that were initialed, however the behavior sections of the entries were left blank, additionally, there were three 15 minute checks that had no initials and had no behaviors documented; on 11/2/12, there were eight 15 minute checks that were initialed, however, the behavior sections of the entries were left blank, in addition there were eighteen 15 minute checks that had no initials and had no behaviors documented; on 11/6/12, there were thirty one 15 minute checks that had no initials and had no behaviors documented. On 11/7/12 (The day that resident #2 eloped from the facility) there were 2 Safety Check Logs. The first one started at 12:15 a.m. and the last entry on this log was documented at 3:15 p.m. The second Safety Check Log, dated 11/7/12, indicated that the resident was transferred to the first floor secured unit at 4:30 p.m. and the first monitoring was noted to be done at 4:45 p.m. leaving a time frame of approximately 1.5 hours between the last documented safety check form and the beginning of the new safety check form. Additionally there were three 15 minute checks that had no initials and no behaviors documented from 11:15 p.m. to 11:45 p.m. On 11/8/12 there were two 15 minute checks that had no initials and had no behaviors documented; on 11/9/12, there were three 15 minute checks that had no initials and had no behaviors documented. Review of the 72 hour monitoring form with a start date of 11/7/12, at 4:10 p.m. indicated that the resident left the facility and was seen by a CNA as he was walking on the public road. The resident refused to get into the facility van; however the resident was brought back to the facility with assistance. On return to unit, the resident was noted with a skin tear to his left hand and complained of left shoulder pain. The form indicated that the physician was notified, new orders to " clean the skin tear to the left hand with wound cleaner, apply steri strip and x-ray the residents left shoulder " . Additionally the form indicated that the resident " remained alert and responsive, complained of pain to his left shoulder and stated that he hit his hand while getting out of the van. X-ray to the left shoulder was ordered. The resident was transferred to a secured unit room " . Resident #2 ' s x-ray report dated 11/7/12, indicated that the " views of the left shoulder demonstrates no fracture, dislocation or bony reaction " . The updated care plan for elopement, dated 10/31/12, with a revision date of 11/7/12 indicated that the resident eloped on 11/7/12 and was now being housed on the secure unit for safety and was to continue to have a green wrist/ankle band and his picture posted at the receptionist desk. A review of the Social service note dated 11/14/12, the physicians order dated 11/14/12, and the discharge form dated 11/14/12 revealed that Resident #2 was discharged to his son on this date, and was to move out of state to reside with his son. The facility ' s policy and procedure for Safety and Supervision of Residents with a revision date of December 2007 Under the heading of Resident-Oriented Approach to safety, #4 indicated that the facility is to " Implement interventions to reduce accident risks and hazards shall include the following: a. communicating specific interventions to all relevant staff; b. assigning responsibility for carrying out interventions; c. providing training, as necessary; d. ensuring that interventions are implemented; and e. documenting interventions. 3. Interview with the Activity CNA on 11/27/12, at approximately 11:30 a.m. revealed that resident #1 resided in a room on the secured unit on the 1st floor and that she was responsible for the resident at the time the resident exited the building. The Activity CNA reported that the resident was placed in the dining room on the second floor, awaiting an activity and that she left the resident in the dining room, unattended while she went to transport residents from the 2nd floor to the activity. The Activity CNA reported that when she got back to the dining room the resident was gone, she looked around, however, the resident was not in the room. When the Activity CNA looked out the French doors of the dining room the resident was being escorted back into the facility by an LPN. The Dining room is located in the front of the facility the outer wall of the dining room had French doors that lead out to a screened patio. The screened patio had 2 screen doors that exited into the parking lot. The French doors were observed to be approximately 20 feet from the paved parking lot. The Activity CNA reported that the resident could not have been in the parking lot for more than 5 minutes. An Interview on 11/27/12, at approximately 11:38 a.m. With the LPN who escorted the resident back into the building, revealed that she saw the resident outside trying to get into an unknown parked vehicle, she reported that she went outside and redirected the resident back into the facility. An Interview with the Risk Manager on 11/27/12, at approximately 10:08 a.m. revealed that on 10/14/12, at approximately 10:20 a.m. resident #1 was observed getting into an unknown persons car that was parked in the facility ' s parking lot. It was reported that there was no driver or passengers noted to be in the vehicle. She reported that the Activity CNA had left the resident in the dining room, unattended awaiting a church activity. A review of resident #1 ' s record revealed a resident face sheet dated 10/17/12, which indicated that the residents age was 57, she had [DIAGNOSES REDACTED]. The resident ' s physician admission note for a 10/10/12, hospital admitted d 10/10/12, revealed that this resident " had an acute [MEDICAL CONDITION] and that the patient had apparently tried to jump out of the car that she was riding in " . Resident #1 ' s [DIAGNOSES REDACTED]. The Admission Assessment, dated 10/14/12, revealed that this resident was admitted to a first floor room and was agitated. Resident #1 ' s Interim care plans, dated 10/12/12 and 10/13/12, revealed that the following concerns were identified as needing to be addressed: wandering, weakness, unsteadiness, Dementia, physically abusive, socially inappropriate, and resists care. The 72 hour monitoring form, dated 10/13/12 (The day before resident #1 was found in the parked car) at approximately 12:20 p.m., revealed that she was observed by a CNA on the West hall on her right side lying straight. A skin tear was noted to the resident ' s right ankle, the physician was notified and a new order given to cleanse with wound cleanser and apply dry dressing daily. An interview on 11/27/12, at approximately 3:50 p.m., with the Administrator (NHA) and the Director of Nursing (DON), reported that resident #1 should have been under closer supervision Review of the updated Interim care plan for elopement, dated 10/14/12, indicated that resident #1 was exit seeking, wanders and makes frequent requests to go home. The Approach was to obtain a picture for identification and 15 minutes checks until stable. 4. Resident #3 ' s record revealed a resident face sheet dated 6/6/11, which indicated that the resident ' s age was 99 and that the resident currently resided on the second floor. Resident #3 ' s [DIAGNOSES REDACTED]. An Interview with the Risk Manager, on 11/27/12, at approximately 10:08 a.m., revealed that on 10/10/12, resident #3 was found in the facility parking lot, and the resident reported that " she wanted to go outside " . The Unit Manager reported that a green bracelet was placed on the resident, on 10/10/12, after the incident occurred. In addition the resident ' s picture was placed at the front desk. The Risk Manager reported that this resident ' s family usually came to visit her several times a week and would always take her outside by the trees, which was the direction where the resident was heading when she was found outside. She reported that the plan was that on the days that the resident ' s family did not come to visit her in the facility, the resident would receive activities outside, which would be about 3 to 4 times a weeks. The Risk Manager reported, that prior to the incident, resident #3 had never vocalized to the facility staff that she wanted to go outside, she had never made any attempts to go outside alone, and was not considered an elopement risk. She reported that prior to the incident the resident did not have a green bracelet and did not have a picture placed at the front desk. The resident ' s family was notified of the incident and of changes to the resident ' s plan of care, on 10/10/12. Resident #3 ' s care plans dated 6/26/12, with a review date of 9/20/12, and a revision date of 10/10/12, revealed that this plan addressed the resident ' s short and long term memory deficits. On 10/10/12 the care plan was revised to include the resident ' s potential for exit seeking. Due to the fact that the resident was noted in the parking lot on 10/10/12. The approaches were to take the resident outside, she was given a green bracelet and a picture was placed at the front desk. Resident #3 ' s care plan dated 8/4/11 with revisions on 1/19/12, 1/24/12, 9/20/12 and 10/8/12 revealed that this care plan addressed the resident ' s potential for injury due to falls. An approach added on 10/11/12 indicated that the resident was to have activities outside 3 times a week. Resident #3 ' s care plan dated 8/4/11, with revisions on 1/19/12 and 4/12/12, revealed that this care plan addressed the residents need for " reminders to attend of her interests, spirituals and socials " . An approach added on 10/12/12 indicated that the resident was to be escorted outside 3-4 days per week for activities. The 72 hour monitoring form dated 10/10/12 revealed that resident #3 was noted propelling herself outside the front office parking lot and that the resident stated that " she wanted to go outside " . The Q 15 min Observations Safety Check Log revealed that this resident was placed on the 15 minute monitoring on 10/10/12 due to wandering outside unsupervised. The Safety check dated 10/10/12 (the same day of the incident) revealed that there was one 15 minute check which had a signature but no behaviors were documented, and thirteen 15 minute checks that had no initials and had no behaviors documented. The Safety Check dated 10/11/12 (the day after the incident) revealed that there were thirty four 15 minute checks that had no initials and had no behaviors documented. An interview on 11/27/12, at approximately 3:50 p.m., with the Administrator (NHA) and the Director of Nursing (DON), revealed, that the Q 15 minute checks were incorporated into the resident ' s plan of care, to address the risk of elopement. Additionally the DON, confirmed that, the Q 15 min Observations Safety Check Logs were incomplete. She reported, that based on documentation, it could not be determined that the 15 minute monitoring had been routinely implemented. 5. The facility initiated measures to remove the immediate jeopardy beginning on 11/28/12. The measures were as follows: An undated Policy and Procedure For Residents At Risk For Elopement was developed and presented to the surveyor on 11/29/12. This policy included assessing residents prior to admission and no less than quarterly, for changes in their mental status or exit seeking behaviors. The facility has a total of 155 staff persons. As of 11/29/12 at approximately 12:20 p.m. a total of 117 staff persons had been in-serviced on the Policy and Procedure on Neglect, the Policy and Procedure on Supervision of residents and the Policy and Procedure for Resident ' s at Risk for Elopement. For the remainder of the 38 staff persons who as of 11/29/12 at 12:20 p.m. were not yet in-serviced, the facility will do the following: The facility staff clock-in for duty process is completed by the staff person scanning their finger prints. Those staff persons who were identified as not yet receiving the in-services will have their names removed from the finger print scanning system which will not allow them to clock in for their shift. A posting will be left at the finger print scanning clock-in station, indicating to all staff that if the clock does not allow them to clock in, they are to see the DON or immediate supervisor to complete an in-service on elopement prevention. A staff member will be positioned at the front door 24 hours a day until a key-pad activated magnetic lock which is tied into the life safety system is able to be installed. To ensure resident safety, the first floor (secured unit) residents who have a potential for elopement will receive meals and activities on the first floor until magnetic locks are able to be installed on exit doors. There were 24 Random interviews conducted on 11/27/12 and 11/29/12 with staff persons identified as 9 CNA ' s and 4 nursing staff assigned to work between the first floor secured unit and the second floor unit, 5 dietary staff, 5 housekeeping staff and 1 therapy staff assigned to work the entire building. These random staff interviews revealed that these staff had been newly in- serviced from 11/27/12 to 11/29/12. These staff are knowledgeable about identifying residents who may be at risk of elopement and those are already identified as being at risk for elopement, elopement prevention and residents in need of supervision. Immediate Jeopardy was determined removed, on 11/29/12, and the severity was reduced to a D.

Based on interview with staff, a review of resident and facility records, and a review of the facility ' s policy and procedure for " Safety and Supervision of Residents, " it was determined that the facility failed to provide the level of supervision necessary to maintain the safety of 3 of 3 (#1, #2, #3) residents reviewed for elopement, despite the facility ' s own documented observations and assessments and that the residents were known to require close supervision. The facility failed to provide close supervision for residents #1, #2 and #3, as evidenced by resident #2 being missing from the facility for at least 45 minutes before the facility was aware of his elopement; resident #1 being found in an unknown vehicle in the facility parking lot; and resident #3 being found wandering in the facility parking lot unsupervised. Failure to provide the level of supervision required to ensure resident safety and meet needs resulted in the determination of Immediate Jeopardy on 11/28/12. The findings of Immediate Jeopardy were determined to be removed on 11/29/12 at 12:20 p.m. and the severity and scope was reduced to a D. Findings include: 1. An Interview with the Transport CNA, on 11/27/12 at approximately 10:37 a.m., revealed that at approximately 3:59 p.m. on 11/7/12, she was on her way back to the facility when she saw a male individual that resembled a resident whom she knew to reside on the 2nd floor unit of the facility. She reported that this resident was approximately 1.5 miles from the facility and that he was walking in the opposite direction of the facility. The main road on which Resident #2 was walking, is located about 300 feet away from the facilities parking lot and is a 2 lane road (1 lane in each direction), with a second 2 lane road connecting the main road to form a " T " intersection. The resident was observed on the second main road which indicated that he would have had to cross at least one of the roads to end up at the point where he was observed walking. The second road where the resident was observed walking had a side walk on one side of the road, and, on the other side of the road, there are grassy areas with no sidewalk. The Transport CNA reported that she stopped the vehicle, called the facility, and spoke to the Unit Manager on the 2nd floor to confirm that the resident was not in the building. The Transport CNA reported that she asked the resident where he was going and the resident reported that "he was going home" and that he refused to go back to the facility. The Transport CNA reported that the resident was observed stumbling a little. She reported that 2 unknown men pulled up in a van and asked if she needed assistance. She explained to the men that the resident was refusing to go with her back to the facility, and then one of the men asked the resident if he wanted a ride and the resident got into the van with the 2 men, who transported resident #2 back to the facility. The Transport CNA indicated that when the resident got back to the facility, he was observed to have a skin tear to his left hand. An Interview with the Unit Manager, for 2nd floor on 11/27/12 at approximately 10:46 a.m. revealed that Resident #2 was relocated from the 1st floor secured unit to the 2nd floor a couple of weeks prior to the resident eloping and was placed on 15 minute checks. These checks were to be done by a CNA or the nurse. She reported that, on 11/7/12 she was in a care plan meeting and that she had seen Resident #2 prior to the meeting, which was 30 minutes under way, when she received a call from the Transport CNA, who was questioning if Resident #2 was in the building; the Unit Manager left the meeting to start a check of the facility, which resulted in the finding that Resident #2 was not in the building. The Unit Manger reported that she informed the Transport CNA that the Social Worker would assist her. The Unit Manager reported that the aide came back to the facility, and that the resident was brought back to the facility by a stranger. An interview on11/27/12, at approximately 10:58 a.m., with the CNA assigned to provide care to Resident #2 revealed that she came on shift at 2:45 p.m. and noted that Resident #2 was a little agitated while speaking to someone on the phone. She reported that he refused vital signs and showers, and stayed in the hallway. The assigned CNA reported that she continued on to her next resident who needed to be showered. Additionally, the assigned CNA reported that, apparently while she was showering another resident, Resident #2 left the building. She reported that the resident was on fifteen minute checks at the time that he left the facility, and that the last time the check was done by her, was at 3:15 p.m. Review of the Nurse ' s notes for 11/7/2012 found entries timed for 12:00 a.m., which found the " resident resting," 10:00 a.m. which noted that Resident # 2 was ambulating ad lib, in no acute distress, and " continue q 15 min checks." The next entry was at 11/7/2012 at 10 pm and denoted, "Resident refused to go to bed. Continue q 15 min checks. " A late entry was entered after that for 7pm which reflected "UA abnormal send out to lab for c/s-new order." An 11 pm entry for 11/7/2012 followed that which reported "x ray results returned no fracture or dislocation noted of left shoulder. Mild degenerative joint disease." There was no reference in the Nurse's notes of 11/7/2012 of the resident leaving the building. An Interview with the Risk Manager on 11/27/12, at approximately 10:08 a.m. revealed that on 11/7/12, at approximately 4:10 p.m. Resident #2 was observed on a local road more than 1 mile away from the facility by a Transport CNA who was returning to the facility in the facility ' s van. She reported that the Transport CNA tried to get Resident #2 in the facility van, but he refused. The Risk Manager reported that 2 men stopped, asked if they could help and took Resident #2 back to the facility. The Risk Manger reported that the 2 men were unknown to the resident, facility and unknown to the Transport CNA and that the aide contacted the facility. The Risk Manager reported that the facility was unaware that Resident #2 was not in the building until the facility received the call from the Transport CNA. The Risk Manger reported that the facility places, on the wrist or ankle of residents who are identified as an elopement risk, a wrist/ankle band that is green in color. This is used to identify residents who are at risk of elopement and in addition to the band, if the resident is identified as an elopement risk their picture is placed at the receptionist desk for identification of residents who may elope. She reported that both the picture and the wrist/ankle band were in place for Resident #2 at the time that he eloped. A review of Resident #2 ' s record revealed a resident face sheet, dated 10/22/12, which indicated that the resident had current [DIAGNOSES REDACTED]. The resident's history and physical from the local hospital, prior to the resident ' s admission to a Skilled Nursing Facility (SNF), dated 10/14/12, revealed that, this resident was a [AGE] year old male with a history of dementia. Review of the section with the heading "Physical Examination" and the sub heading of "Neurologic" revealed that the resident was alert but disoriented. Review of the section with the heading "Assessment" #3 revealed that the resident had a "Worsening altered mental status." Further review of Resident #2 ' s record revealed a [DIAGNOSES REDACTED]. The Admission Assessment, dated 10/17/12, revealed that this resident was admitted to the first floor secured unit and was disoriented, forgetful and his balance/gait was unsteady. The hand written note on this form indicated the following: "3-11, 7pm Resident continues to ambulate hallway seeking an exit, continue Q15 minutes, 10pm in bed with eyes closed continue Q15 minute monitoring." Review of Resident #2's history and physical, completed at the time of admission to the SNF, dated 10/17/12, revealed that the resident had dementia and was observed confused. He also had a history of [REDACTED]. The Care Conference summary, dated 10/31/12, indicated that Resident #2 had confusion due to Dementia. Review of Resident #2's care plan, dated 10/31/12, revealed that the following concerns were identified and needed to be addressed: Elopement attempt, " Yells, I want out of here " and "I'm going to see my lawyer about suing this doctor" ; Impaired thought process/Dementia/ Altered Mental Status. He has intermittent confusion with memory problems; Anxiety, worries about his home, packs his belongings daily; Decreased hearing; Decreased vision; at risk for falls." Nurse's notes dated 11/3/12, 11/4/12, 11/5/12, 11/6/12, and the morning of 11/7/12 revealed that resident #2 continued on Q15 (every fifteen) minute monitoring. The Social Service admission note, dated 10/25/12, revealed that Resident #2 would pack his belongings daily and would say "today is the day, I ' m outta here." The Minimum Data Set (MDS), dated [DATE], indicated the following: in section " G " with the heading of "Functional Status" , with the sub-heading of " 1. ADL Self -Performance " Section " F. locomotion off unit " the resident was coded a " 1 " which indicated that he required supervision to complete this task; Sub-heading " G0300. Balance During Transitions and walking " , letter " B. walking " the resident was coded a " 1 " which indicates that he is " not steady, but able to stabilize without staff assistance " ; Section " I Active [DIAGNOSES REDACTED]. Additional active [DIAGNOSES REDACTED]. Senile Dementia " , section " E. Muscle Weakness " Section " F. Difficulty in Walking " and section " G. Lack of Coordination." Review of the Q 15 min Observations Safety Check Log revealed that the sheets have pre-printed times on them and was noted to have 92, 15 minute increments, starting at 12:15 and ending at 11:45. The directions on this form, indicated that, the staff are to "document on the resident in Q15 minute increments, initial each entry and document the behavior noted." A review of resident #2's Safety Check Log revealed the following: On 10/19/12, there were ten 15 minute checks with no initials and no behaviors documented; on 10/21/12, there were thirty 15 minute checks with no initials and no behaviors documented; on 10/23/12, there were thirty four 15 minute checks that had no initials and no behaviors documented; on 10/29/12, there were eighteen 15 minute checks that were initialed, however, the behavior sections of the entries were left blank. Additionally, there were twelve 15 minute checks that had no initials and had no behaviors documented; on 10/30/12, there were two 15 minute checks that were initialed, however the behavior sections of the entries were left blank, additionally, there were three 15 minute checks that had no initials and had no behaviors documented; on 11/2/12, there were eight 15 minute checks that were initialed, however, the behavior sections of the entries were left blank, in addition there were eighteen 15 minute checks that had no initials and had no behaviors documented; on 11/6/12, there were thirty one 15 minute checks that had no initials and had no behaviors documented. On 11/7/12 (The day that Resident #2 eloped from the facility) there were 2 Safety Check Logs. The first one started at 12:15 a.m. and the last entry on this log was documented at 3:15 p.m. As previously reported, the Transportation C.N.A. saw the resident at 3:59 p.m. that day on the road. The second Safety Check Log, dated 11/7/12, indicated that the resident was taken to the first floor at 4:30 p.m. and the first monitoring was noted to be done at 4:45 p.m. leaving a time frame of approximately 1.5 hours between the last documented safety check form and the beginning of the new safety check form. Additionally there were three 15 minute checks that had no initials and no behaviors documented from 11:15 p.m. to 11:45 p.m. On 11/8/12, there were two 15 minute checks that had no initials and had no behaviors documented; on 11/9/12, there were three 15 minute checks that had no initials and had no behaviors documented. Review of the 72 hour monitoring form with a start date of 11/7/12, at 4:10 p.m. indicated that the resident left the facility and was seen by a CNA as he was walking on the public road. The resident refused to get into the facility van; however the resident was brought back to the facility with assistance. On return to unit, the resident was noted with a skin tear to his left hand and complained of left shoulder pain. The form indicated that the physician was notified. New orders were received to "clean the skin tear to the left hand with wound cleaner, apply steri strip and x-ray the residents left shoulder." Additionally, the form indicated that the resident "remained alert and responsive, complained of pain to his left shoulder and stated that he hit his hand while getting out of the van. X-ray to the left shoulder was ordered. The resident was transferred to a secured unit room." Resident #2 ' s x-ray report, dated 11/7/12, indicated that the "views of the left shoulder demonstrated no fracture, dislocation or bony reaction." The updated care plan for elopement, dated 10/31/12, with a revision date of 11/7/12 indicated that the resident eloped on 11/7/12 and was now being housed on the secure unit for safety and was to continue to have a green wrist/ankle band and his picture posted at the receptionist desk. A review of the Social service note, dated 11/14/12, the physician's orders [REDACTED].#2 was discharged to his son on this date, and was to move out of state to reside with his son. 2. Resident #1 was admitted to the facility on [DATE], per the face sheet, and, within 48 hours, exited the building without escort. Interview with the Activity CNA on 11/27/12, at approximately 11:30 a.m. revealed that Resident #1 resided in a room on the secured unit on the 1st floor and that she was responsible for the resident at the time the resident exited the building. The Activity CNA reported that the resident was placed in the dining room on the second floor on 10/14/2012, awaiting an activity, and that she left the resident in the dining room, unattended while she went to transport residents from the 2nd floor to the activity. The Activity CNA reported that, when she got back to the dining room, the resident was gone. She looked around; however, the resident was not in the room. When the Activity CNA looked out the French doors of the dining room, the resident was being escorted back into the facility by an LPN at approximately 10:20 a.m. The Dining room is located in the front of the facility. The outer wall of the dining room had French doors that led out to a screened patio. The screened patio had 2 screen doors that exited into the parking lot. The French doors were observed to be approximately 20 feet from the paved parking lot. The Activity CNA reported that the resident could not have been in the parking lot for more than 5 minutes. An Interview on 11/27/12, at approximately 11:38 a.m. with the LPN who escorted the resident back into the building, revealed that she saw the resident outside trying to get into an unknown parked vehicle. She reported that she went outside and redirected the resident back into the facility. An Interview with the Risk Manager on 11/27/12, at approximately 10:08 a.m. revealed that on 10/14/12, at approximately 10:20 a.m. Resident #1 was observed getting into an unknown persons car that was parked in the facility's parking lot. It was reported that there was no driver or passengers noted to be in the vehicle. She reported that the Activity CNA left the resident in the dining room, unattended while awaiting a church activity, despite an interim care plan of 10/12/12 denoting wandering and dementia on 10/13/12. A review of Resident #1's record revealed a resident face sheet, dated 10/17/12, which indicated that the resident's age was 57. She had [DIAGNOSES REDACTED]. The resident's physician admission note for a 10/10/12, hospital admitted d 10/10/12, revealed that this resident "had an acute psychosis and that the patient had apparently tried to jump out of the car that she was riding in." Resident #1's [DIAGNOSES REDACTED]. The Admission Assessment, dated 10/14/12, revealed that this resident was admitted to a first floor room and was agitated. Resident #1's Interim care plans, dated 10/12/12 and 10/13/12, revealed that the following concerns were identified as needing to be addressed: wandering, weakness, unsteadiness, Dementia, physically abusive, socially inappropriate, and resists care. A 10/14/12 "Admission/Re-Admission" note of 10 a.m. indicated that Resident #1 was " alert with attention deficit and able to ambulate independently. Exit seeking. " The document was otherwise silent as to the event of 10/14/2012. The 72 hour monitoring form, dated 10/14/12 (The day resident #1 was found in the parked car), revealed that she was observed by a CNA on the West hall on her right side lying straight. A skin tear was noted to the resident ' s right ankle, the physician was notified and a new order given to cleanse with wound cleanser and apply dry dressing daily. An interview on 11/27/12, at approximately 3:50 p.m., with the Administrator (NHA) and the Director of Nursing (DON), reported that resident #1 should have been under closer supervision Review of the updated Interim care plan for elopement, dated 10/14/12, indicated that resident #1 was exit seeking, wanders and makes frequent requests to go home. The Approach was to obtain a picture for identification and 15 minutes checks until stable. 3. Resident #3's record revealed a resident face sheet, dated 6/6/11, which indicated that the resident's age was 99 and that the resident currently resided on the second floor. Resident #3's [DIAGNOSES REDACTED]. An Interview with the Risk Manager, on 11/27/12, at approximately 10:08 a.m., revealed that on 10/10/12, Resident #3 was found in the facility parking lot at approximately 1:30 p.m., and the resident reported that "she wanted to go outside." The Unit Manager reported that a green bracelet was placed on the resident, on 10/10/12, after the incident occurred. In addition, the resident ' s picture was placed at the front desk. The Risk Manager reported that this resident's family usually came to visit her several times a week and would always take her outside by the trees, which was the direction where the resident was heading when she was found outside. She reported that the plan was that on the days that the resident's family did not come to visit her in the facility, the resident would receive activities outside, which would be about 3 to 4 times a week. The Risk Manager reported, that prior to the incident, Resident #3 had never vocalized to the facility staff that she wanted to go outside, she had never made any attempts to go outside alone, and was not considered an elopement risk. She reported that prior to the incident the resident did not have a green bracelet and did not have a picture placed at the front desk. The resident's family was notified of the incident and of changes to the resident's plan of care, on 10/10/12. Resident #3's care plans, dated 6/26/12, with a review date of 9/20/12, and a revision date of 10/10/12, revealed that this plan addressed the resident ' s short and long term memory deficits. On 10/10/12 the care plan was revised to include the resident ' s potential for exit seeking, due to the fact that the resident was noted in the parking lot on 10/10/12. The approaches were to take the resident outside, she was given a green bracelet, and a picture was placed at the front desk. Resident #3's care plan, dated 8/4/11, with revisions on 1/19/12, 1/24/12, 9/20/12 and 10/8/12 revealed that this care plan addressed the resident's potential for injury due to falls. An approach added on 10/11/12 indicated that the resident was to have activities outside 3 times a week. Resident #3's care plan, dated 8/4/11, with revisions on 1/19/12 and 4/12/12, revealed that this care plan addressed the residents need for "reminders to attend activities of her interests, spirituals and socials." An approach added on 10/12/12 indicated that the resident was to be escorted outside 3-4 days per week for activities. The 72 hour monitoring form, dated 10/10/12, revealed that Resident #3 was noted propelling herself outside the front office parking lot and that the resident stated that "she wanted to go outside." The Q 15 min "Observations Safety Check Log" revealed that this resident was placed on the 15 minute monitoring on 10/10/12 due to wandering outside unsupervised. The Safety check, dated 10/10/12 (the same day of the incident), revealed that there was one 15 minute check which had a signature but no behaviors were documented, and thirteen 15 minute checks that had no initials and had no behaviors documented. The Safety Check, dated 10/11/12 (the day after the incident), revealed that there were thirty four 15 minute checks that had no initials and had no behaviors documented. An interview on 11/27/12, at approximately 3:50 p.m., with the Administrator (NHA) and the Director of Nursing (DON), revealed, that the Q 15 minute checks were incorporated into the resident's plan of care, to address the risk of elopement. Additionally the DON, confirmed that, the Q 15 min Observations Safety Check Logs were incomplete She reported, that based on documentation, it could not be determined that the 15 minute monitoring had been routinely implemented. 4.The facility's policy and procedure for Safety and Supervision of Residents with a revision date of December 2007, Under the heading of "Resident-Oriented Approach to safety," #4, indicated that the facility is to "Implement interventions to reduce accident risks and hazards & shall include the following: a. communicating specific interventions to all relevant staff; b. assigning responsibility for carrying out interventions; c. providing training, as necessary; d. ensuring that interventions are implemented; and e. documenting interventions." 5. The facility initiated measures to remove the immediate jeopardy beginning on 11/28/12. The measures were as follows: An undated Policy and Procedure For Residents At Risk For Elopement was developed and presented to the surveyor on 11/29/12. This policy included assessing residents prior to admission and no less than quarterly, for changes in their mental status or exit seeking behaviors. The facility has a total of 155 staff persons. As of 11/29/12 at approximately 12:20 p.m. a total of 117 staff persons had been in-serviced on the Policy and Procedure on Neglect, the Policy and Procedure on Supervision of residents and the Policy and Procedure for Resident's at Risk for Elopement. For the remainder of the 38 staff persons who as of 11/29/12 at 12:20 p.m. were not yet in-serviced, the facility will do the following: The facility staff clock-in for duty process is completed by the staff person scanning their finger prints. Those staff persons who were identified as not yet receiving the in-services will have their names removed from the finger print scanning system which will not allow them to clock in for their shift. A posting will be left at the finger print scanning clock-in station, indicating to all staff that if the clock does not allow them to clock in; they are to see the DON or immediate supervisor to complete an in-service on elopement prevention. A staff member will be positioned at the front door 24 hours a day until a key-pad activated magnetic lock which is tied into the life safety system is able to be installed. To ensure resident safety, the first floor (secured unit) residents who have a potential for elopement will receive meals and activities on the first floor until magnetic locks are able to be installed on exit doors. There were 24 Random interviews conducted on 11/27/12 and 11/29/12 with staff persons identified as 9 CNA's and 4 nursing staff assigned to work between the first floor secured unit and the second floor unit, 5 dietary staff, 5 housekeeping staff and 1 therapy staff assigned to work the entire building. These random staff interviews revealed that these staff had been newly in- serviced from 11/27/12 to 11/29/12. These staff are knowledgeable about identifying residents who may be at risk of elopement and those are already identified as being at risk for elopement, elopement prevention and residents in need of supervision. Immediate Jeopardy was determined removed, on 11/29/12, and the severity was reduced to a D.

Based on staff interview, facility and resident record review and a review of policy and procedure for Safety and Supervision of Residents, the facility failed to ensure that each resident ' s written plan of care was implemented for 3 of 3 (#1, #2, #3) residents reviewed, as evidenced by resident #2 being found 1.5 miles from the facility, after being missing from the facility, for at least 45 minutes before the facility was aware of his elopement; Resident #1 was found in an unknown vehicle in the facility parking lot; Resident #3 was found wandering in the facility parking lot unsupervised. The facility demonstrated a lack of action and commitment in implementing identified interventions to adequately address the needs of residents #1, #2 and #3, who based on the facility ' s own documented care plans, observations and assessments were known to require close supervision. Failure to implement the written plan of care to provide the level of supervision required to ensure resident safety resulted in the determination of Immediate Jeopardy on 11/28/12. The finding of Immediate Jeopardy was determined to be removed on 11/29/12 at 12:20 p.m. and the severity and scope was reduced to a D. Findings include: 1. Review of resident #2 ' s care plan, dated 10/31/12, revealed that the following concerns were identified: Elopement attempt, " Yells, I want out of here " and " I ' m going to see my lawyer about suing this doctor " ; Impaired thought process/Dementia/ Altered Mental Status. He has intermittent confusion with memory problems; Anxiety, worries about his home, packs his belongings daily; Decreased hearing; Decreased vision; at risk for falls. The relevant approaches to the resident altered mental status was: Re-orient PRN; Provide consistent caregiver on all shifts; evaluate the need for physical restraint use; keep resident environment free of clutter and safety hazards; monitor and document resident behavior and status at least daily. The relevant approaches to anxiety was: talk with resident in a calm voice when behavior is disruptive; Provide/offer activities when the resident is packing; Refocus conversation with the resident when he expresses he is going home, Remind him that his son will be coming for him soon. The relevant approaches to the residents fall risk was: Remind resident to ask for assist for all ambulation; Monitor for changes in residents condition that may warrant increased supervision/assistance and notify the physician. The Care Conference summary, dated 10/31/12, indicated that resident #2 had confusion due to Dementia. The resident ' s history and physical from the local hospital, prior to the resident ' s admission to a Skilled Nursing Facility (SNF), dated 10/14/12, revealed that, this resident was a [AGE] year old male with a history of dementia. Review of the section with the heading " Physical Examination " and the sub heading of " Neurologic " revealed that the resident was alert but disoriented. Review of the section with the heading " Assessment " #3 revealed that the resident had a " Worsening altered mental status " . Further review of resident #2 ' s record revealed a [DIAGNOSES REDACTED]. The Admission assessment dated [DATE], revealed that this resident was admitted to the first floor secured unit and was disoriented, forgetful and his balance/gait was unsteady. The hand written note on this form indicated the following: " 3-11, 7pm Resident continues to ambulate hallway seeking an exit " " Continue Q15 minutes. " , " 10pm in bed with eyes closed continue Q15 minute monitoring " . The Social Service admission note, dated 10/25/12, revealed that resident #2 would pack his belongings daily and would say " today is the day, I ' m outta here " . The Minimum Data Set (MDS), dated [DATE], indicated the following: in section " G " with the heading of " Functional Status " , with the sub-heading of " 1. ADL Self -Performance " Section " F. locomotion off unit " the resident was coded a " 1 " which indicates that he requires supervision to complete this task; Sub-heading " G0300. Balance During Transitions and walking " , letter " B. walking " the resident was coded a " 1 " which indicates that he is " not steady, but able to stabilize without staff assistance " ; Section " I Active [DIAGNOSES REDACTED]. Additional active [DIAGNOSES REDACTED]. Senile Dementia " , section " E. Muscle Weakness " Section " F. Difficulty in Walking " and section " G. Lack of Coordination " . There was no documentation of inappropriate behavior identified on the MDS An Interview with the Risk Manager on 11/27/12, at approximately 10:08 a.m. revealed that on 11/7/12, at approximately 4:10 p.m. resident #2 was observed on a local road more than 1 mile away from the facility by a Transport CNA who was returning to the facility in the facility ' s van. She reported that the Transport CNA tried to get resident #2 in the facility van, but he refused. The Risk Manager reported that 2 men stopped, asked if they could help and took resident #2 back to the facility. The Risk Manger reported that the 2 men were unknown to the resident, facility and unknown to the Transport CNA and that the aide contacted the facility. The Risk Manager reported that the facility was unaware that resident #2 was not in the building until the facility received the call from the Transport CNA. The Risk Manger reported that the facility places, on the wrist or ankle of residents who are identified as an elopement risk, a wrist/ankle band that is green in color. This is used to identify residents who are at risk of elopement and in addition to the band, if the resident is identified as an elopement risk their picture is placed at the receptionist desk for identification of residents who may try to elope. She reported that both the picture and the wrist/ankle band were in place for resident #2 at the time that he eloped. An Interview with the Transport CNA, on 11/27/12 at approximately 10:37 a.m., revealed that at approximately 3:59 p.m. on 11/7/12, she was on her way back to the facility when she saw a male individual that resembled a resident who she knew to reside on the 2nd floor unit of the facility. She reported that this resident was approximately 1.5 miles from the facility and that he was walking in the opposite direction of the facility. The main road on which resident #2 was walking, is located about 300 feet away from the facilities parking lot and is a 2 lane road (1 lane in each direction), with a second 2 lane road connecting the main road to form a " T " intersection. The resident was observed on the second main road which indicated that he would have had to cross at least one of the roads to end up at the point where he was observed walking. The second road where the resident was observed walking has a side walk on one side of the road, and on the other side of the road there are grassy areas with no sidewalk. The Transport CNA reported that she stopped the vehicle, called the facility, and spoke to the Unit Manager on the 2nd floor to confirm that the resident was not in the building. The Transport CNA reported that she asked the resident where he was going and the resident reported that "he was going home" and that he refused to go back to the facility. The Transport CNA reported that the resident was observed stumbling a little. She reported that 2 unknown men pulled up in a van and asked if she needed assistance. She explained to the men that the resident was refusing to go with her back to the facility, and then one of the men asked the resident if he wanted a ride and the resident got into the van with the 2 men, who transported resident #2 back to the facility. The Transport CNA indicated that when the resident got back to the facility, he was observed to have a skin tear to his left hand. An Interview with the Unit Manager, for 2nd floor on 11/27/12 at approximately 10:46 a.m. revealed that resident #2 was relocated from the 1st floor secured unit to the 2nd floor a couple of weeks prior to the resident eloping and was placed on 15 minute checks at that time. These checks were to be done by a CNA or the nurse. She reported that, on 11/7/12 she was in a care plan meeting and that she had seen resident #2 prior to the meeting, which was 30 minutes under way, when she received a call from the Transport CNA, who was questioning if resident #2 was in the building; the Unit Manager left the meeting to start a check of the facility, which resulted in the finding that resident #2 was not in the building. The Unit Manger reported that she informed the Transport CNA that the Social Worker would assist her. The Unit Manager reported that the aide came back to the facility, and that the resident was brought back to the facility by a stranger. An interview on 11/27/12, at approximately 10:58 a.m., with the CNA assigned to provide care to resident #2 revealed that she came on shift at 2:45 p.m. and noted that resident #2 was a little agitated while speaking to someone on the phone. She reported that he refused vital signs and showers, and stayed in the hallway. The assigned CNA reported that she continued on to her next resident who needed to be showered. Additionally the assigned CNA reported that, apparently while she was showering another resident, resident #2 left the building. She reported that the resident was on fifteen minute checks at the time that he left the facility, and that the last time the check was done by her, was at 3:15 p.m. , 45 minutes prior to the resident being found 1.5 miles away from the facility. The CNA Reported that she was aware that she should have completed the 15 minute checks, but that she wanted to complete the shower for another resident. Nurse ' s notes dated 11/3/12, 11/4/12, 11/5/12, 11/6/12, and the morning of 11/7/12 revealed that resident #2 continues on Q15 (every fifteen) minute monitoring. Review of the Q 15 min Observations Safety Check Log revealed that the sheets have pre-printed times on them and was noted to have 92, 15 minute increments, starting at 12:15 and ending at 11:45. The directions on this form, indicated that, the staff are to " document on the resident in Q15 minute increments, initial each entry and document the behavior noted " . A review of resident #2 ' s Safety Check Log revealed the following: On 10/19/12, there were ten 15 minute checks with no initials and no behaviors documented; on 10/21/12, there were thirty 15 minute checks with no initials and no behaviors documented; on 10/23/12, there were thirty four 15 minute checks that had no initials and no behaviors documented; on 10/29/12, there were eighteen 15 minute checks that were initialed, however, the behavior sections of the entries were left blank. Additionally, there were twelve 15 minute checks that had no initials and had no behaviors documented; on 10/30/12, there were two 15 minute checks that were initialed, however the behavior sections of the entries were left blank, additionally, there were three 15 minute checks that had no initials and had no behaviors documented; on 11/2/12, there were eight 15 minute checks that were initialed, however, the behavior sections of the entries were left blank, in addition there were eighteen 15 minute checks that had no initials and had no behaviors documented; on 11/6/12, there were thirty one 15 minute checks that had no initials and had no behaviors documented. On 11/7/12 (The day that resident #2 eloped from the facility) there were 2 Safety Check Logs. The first one started at 12:15 a.m. and the last entry on this log was documented at 3:15 p.m. The second Safety Check Log, dated 11/7/12, indicated that the resident was taken to the first floor secured unit at 4:30 p.m. and the first monitoring was noted to be done at 4:45 p.m. leaving a time frame of approximately 1.5 hours between the last documented safety check form and the beginning of the new safety check form. Additionally there were three 15 minute checks that had no initials and no behaviors documented from 11:15 p.m. to 11:45 p.m. on 11/7/12. There was no documentation in the nurse ' s notes that would indicate the lapse of time during the elopement and transfer to the first floor secured unit. On 11/8/12 there were two 15 minute checks that had no initials and had no behaviors documented; on 11/9/12, there were three 15 minute checks that had no initials and had no behaviors documented. An interview on 11/27/12, at approximately 3:50 p.m., with the Administrator (NHA) and the Director of Nursing (DON), revealed, that the Q 15 minute checks were incorporated into the resident ' s plan of care, to address the risk of elopement. Additionally the DON, confirmed that, the Q 15 min Observations Safety Check Logs were incomplete She reported, that based on documentation, it could not be determined that the 15 minute monitoring had been routinely implemented. The updated care plan for elopement, dated 10/31/12, with a revision date of 11/7/12 indicated that the resident eloped on 11/7/12 and was now being housed on the secure unit for safety and was to continue to have a green wrist/ankle band and his picture posted at the receptionist desk. A review of the Social service note dated 11/14/12, the physicians order dated 11/14/12, and the discharge form dated 11/14/12 revealed that Resident #2 was discharged to his son on this date, and was to move out of state to reside with his son. 2. Resident #1 ' s Interim care plans, dated 10/12/12 and 10/13/12, revealed that the following concerns were identified: wandering, weakness, unsteadiness, Dementia, physically abusive, socially inappropriate, and resists care. The relevant approaches to wandering, physically abusive, socially inappropriate, and resists care were: Intervene as needed to protect the rights and safety of others; Approach in a calm manner; Divert attention; Remove from situation and take to another location as needed; Administer and monitor for effectiveness and side effects of medications as ordered. A review of resident #1 ' s record revealed a resident ' s face sheet dated 10/17/12, which indicated that the resident ' s date of admission was 10/12/12 and her age was 57, she had [DIAGNOSES REDACTED]. The resident ' s physician admission note for a 10/10/12 hospital admission, dated 10/10/12, revealed that this resident " had an acute [MEDICAL CONDITION] and that the patient had apparently tried to jump out of the car that she was riding in " . An Interview with the Risk Manager on 11/27/12, at approximately 10:08 a.m. revealed that on 10/14/12, at approximately 10:20 a.m. resident #1 was observed getting into an unknown persons car that was parked in the facility ' s parking lot. It was reported that there was no driver or passengers noted to be in the vehicle. She reported that the Activity CNA had left the resident in the dining room, unattended, awaiting a church activity. Interview with the Activity CNA on 11/27/12, at approximately 11:30 a.m., revealed that resident #1 resided in a room on the secured unit on the 1st floor and that she was responsible for the resident at the time the resident exited the building. The Activity CNA reported that the resident was placed in the dining room on the second floor, awaiting an activity. She left the resident in the dining room, unattended while she went to transport other residents from the 2nd floor to the activity. The Activity CNA reported that when she got back to the dining room the resident was gone, she looked around, however, the resident was not in the room. When the Activity CNA looked out the French doors of the dining room the resident was being escorted back into the facility by an LPN. The Dining room was located in the front of the facility the outer wall of the dining room had French doors that lead out to a screened patio. The screened patio had 2 screen doors that exited into the parking lot. The French doors were observed to be approximately 20 feet from the paved parking lot. The Activity CNA reported that the resident could not have been in the parking lot for more than 5 minutes. An Interview on 11/27/12, at approximately 11:38 a.m., with the LPN who escorted the resident back into the building, revealed that she saw the resident outside trying to get into an unknown parked vehicle, she reported that she went outside and redirected the resident back into the facility. The 72 hour monitoring form, dated 10/13/12 (The day before resident #1 was found in the parked car) at approximately 12:20 p.m., revealed that she was observed by a CNA on the West hall on her right side lying straight. A skin tear was noted to the resident ' s right ankle, the physician was notified and a new order given to cleanse with wound cleanser and apply dry dressing daily. The Q 15 min Observations Safety Check Log revealed that this resident was placed on the 15 minute monitoring on 10/13/12, due to a potential for falls. Review of the Safety Check dated 10/14/12 revealed that the form was completed appropriately. The nurses notes dated 10/14/12, revealed that there was no documentation related to the incident, of the resident being found in an unknown parked car on 10/14/12. An interview on 11/27/12, at approximately 3:50 p.m., with the Administrator (NHA) and the Director of Nursing (DON), reported that resident #1 should have been under closer supervision, as she was identified as an elopement risk. Review of the updated Interim care plan for elopement, dated 10/14/12, indicated that resident #1 was exit seeking, wanders and makes frequent requests to go home. The Approach was to obtain a picture for identification and 15 minutes checks until stable. 3. Resident #3 ' s care plan, dated 6/26/12 with a review date of 9/20/12 and a revision date of 10/10/12, revealed that this plan addressed the resident ' s short and long term memory deficits, with the following relevant approaches: Provide reality orientation; Observe for changes in cognitive status; Praise resident for each decision made. On 10/10/12 the care plan was revised to include the resident ' s potential for exit seeking. Due to the fact, that the resident was noted in the parking lot on 10/10/12. The approaches were to take the resident outside, she was given a green bracelet and a picture was placed at the front desk. Resident #3 ' s care plan, dated 8/4/11 with revisions on 1/19/12, 1/24/12, 9/20/12 and 10/8/12, revealed that this care plan addressed the resident ' s potential for injury due to falls. The relevant approaches to this care plan was as follows: Give verbal reminders not to ambulate or transfer without assistance; Do not leave resident unattended without safety device; Monitor for unsafe activity and intervene as needed. On 1/19/12 an approach that was added, was a Sensor Alarm to the residents wheelchair and bed, staff were to check placement and function every shift. On 1/24/12 and 9/24/12 due to the residents alarm sounding and attempts to to transfer without assistance the following approach was added: Continue POC and Encourage resident to call for assistance. An approach added on 10/11/12 indicated that the resident was to have activities outside 3 times a week. Resident #3 ' s care plan dated 8/4/11, with revisions on 1/19/12 and 4/12/12, revealed that this care plan addressed the residents need for " reminders to attend of her interests, spirituals and socials " . An approach added on 10/12/12 indicated that the resident was to be escorted outside 3-4 days per week for activities. Resident #3 ' s record revealed a resident face sheet dated 6/6/11, which indicated that the resident ' s age was 99 and that the resident currently resided on the second floor. Resident #3 ' s [DIAGNOSES REDACTED]. An Interview with the Risk Manager, on 11/27/12, at approximately 10:08 a.m., revealed that on 10/10/12, resident #3 was found in the facility parking lot, and the resident reported that " she wanted to go outside " . The Unit Manager reported that a green bracelet was placed on the resident, on 10/10/12, after the incident occurred. In addition the resident ' s picture was placed at the front desk. The Risk Manager reported that this resident ' s family usually came to visit her several times a week and would always take her outside by the trees, which was the direction where the resident was heading when she was found outside. She reported that since the incident, the plan was that on the days that the resident ' s family did not come to visit her in the facility, the resident would receive activities outside, which would be about 3 to 4 times a weeks. The Risk Manager reported, that prior to the incident, resident #3 had never vocalized to the facility staff that she wanted to go outside, she had never made any attempts to go outside alone, and was not considered an elopement risk. She reported that prior to the incident the resident did not have a green bracelet and did not have a picture placed at the front desk. The 72 hour monitoring form dated 10/10/12 revealed that resident #3 was noted propelling herself outside in the front office parking lot and that the resident stated that " she wanted to go outside " . The Q 15 min Observations Safety Check Log revealed that this resident was placed on the 15 minute monitoring on 10/10/12 due to wandering outside unsupervised. The Safety check dated 10/10/12 (the same day of the incident) revealed that there was one 15 minute check which had a signature but no behaviors were documented, and thirteen instances, at various times of the day where 15 minute checks that had no initials and had no behaviors documented. The Safety Check dated 10/11/12 (the day after the incident) revealed that there were thirty four 15 minute checks, from 3:15 p.m. to 11:45 p.m. that had no initials and had no behaviors documented. An interview on 11/27/12, at approximately 3:50 p.m., with the Administrator (NHA) and the Director of Nursing (DON), revealed, that the Q 15 minute checks were incorporated into the resident ' s plan of care, to address the risk of elopement. Additionally the DON, confirmed that, the Q 15 min Observations Safety Check Logs were incomplete She reported, that based on documentation, it could not be determined that the 15 minute monitoring had been routinely implemented. 4. The facility ' s policy and procedure for Safety and Supervision of Residents with a revision date of December 2007 Under the heading of Resident-Oriented Approach to safety, #4 indicated that the facility is to " Implement interventions to reduce accident risks and hazards shall include the following: a. communicating specific interventions to all relevant staff; b. assigning responsibility for carrying out interventions; c. providing training, as necessary; d. ensuring that interventions are implemented; and e. documenting interventions. 5. The facility initiated measures to remove the immediate jeopardy beginning on 11/28/12. The measures were as follows: An undated Policy and Procedure For Residents At Risk For Elopement was developed and presented to the surveyor on 11/29/12. This policy included assessing residents prior to admission and no less than quarterly, for changes in their mental status or exit seeking behaviors. The facility has a total of 155 staff persons. As of 11/29/12 at approximately 12:20 p.m. a total of 117 staff persons had been in-serviced on the Policy and Procedure on Neglect, the Policy and Procedure on Supervision of residents and the Policy and Procedure for Resident ' s at Risk for Elopement. For the remainder of the 38 staff persons, who as of 11/29/12 at 12:20 p.m. were not yet in-serviced, the facility will do the following: The facility staff clock-in for duty process is completed by the staff person scanning their finger prints. Those staff persons who were identified as not yet receiving the in-services will have their names removed from the finger print scanning system which will not allow them to clock in for their shift. A posting will be left at the finger print scanning clock-in station, indicating to all staff that if the clock does not allow them to clock in; they are to see the DON or immediate supervisor to complete an in-service on elopement prevention. A staff member will be positioned at the front door 24 hours a day until a key-pad activated magnetic lock which is tied into the life safety system is able to be installed. To ensure resident safety, the first floor (secured unit) residents who have a potential for elopement will receive meals and activities on the first floor until magnetic locks are able to be installed on exit doors. There were 24 Random interviews conducted on 11/27/12 and 11/29/12 with staff persons identified as 9 CNA ' s and 4 nursing staff assigned to work between the first floor secured unit and the second floor unit, 5 dietary staff, 5 housekeeping staff and 1 therapy staff assigned to work the entire building. These random staff interviews revealed that these staff had been newly in- serviced from 11/27/12 to 11/29/12. These staff were knowledgeable about identifying residents who may be at risk of elopement and those are already identified as being at risk for elopement, elopement prevention and residents in need of supervision. Immediate Jeopardy was determined removed, on 11/29/12, and the severity was reduced to a D.

Based on staff interview, facility and resident record review and a review of the facility's abuse prohibition policy and the policy and procedure for " Safety and Supervision of Residents," the facility failed to provide goods and services necessary to ensure the safety of 3 of 3 (#1, #2, #3) sampled residents through knowledge of their whereabouts and supervision to meet their needs. Between the dates of October 10, 2012 to November 7, 2012, Residents # 1, 2, and 3 were all able to exit the building unescorted. Resident #2 was found 1.5 miles from the facility, after being missing from the facility, for at least 45 minutes before the facility was aware of his elopement; Resident #1 was found in an unknown vehicle in the facility parking lot; and Resident #3 was found wandering in the facility parking lot unsupervised. The facility demonstrated a lack of action and commitment to protect and supervise residents #1, #2 and #3 who, based on the facility ' s own documented observations and assessments, were known to require close supervision. By failing to provide the level of needed supervision, the facility demonstrated a lack of action and commitment to protect all residents from the possibility of neglect and to ensure that all residents' needs for supervision were met, which resulted in the determination of Immediate Jeopardy on 11/28/12. The finding of Immediate Jeopardy was found to be removed on 11/29/12 at 12:20 p.m. and the severity and scope was reduced to a D. Findings include: 1. An Interview with the Risk Manager on 11/27/12, at approximately 10:08 a.m. revealed that on 11/7/12, at approximately 4:10 p.m. Resident #2 was observed on a local road more than 1 mile away from the facility by a Transport CNA who was returning to the facility in the facility's van. She reported that the Transport CNA tried to get Resident #2 in the facility van, but he refused. The Risk Manager reported that 2 men stopped, asked if they could help and took resident #2 back to the facility. The Risk Manger reported that the 2 men were unknown to the resident, facility and unknown to the Transport CNA and that the aide contacted the facility. The Risk Manager reported that the facility was unaware that resident #2 was not in the building until the facility received the call from the Transport CNA. The Risk Manger reported that the facility places, on the wrist or ankle of residents who are identified as an elopement risk, a wrist/ankle band that is green in color. This is used to identify residents who are at risk of elopement and in addition to the band, if the resident is identified as an elopement risk their picture is placed at the receptionist desk for identification of residents who may elope. She reported that both the picture and the wrist/ankle band were in place for resident #2 at the time that he eloped. An Interview with the Transport CNA, on 11/27/12 at approximately 10:37 a.m., revealed that at approximately 3:59 p.m. on 11/7/12, she was on her way back to the facility when she saw a male individual that resembled a resident who she knew to reside on the 2nd floor unit of the facility. She reported that this resident was approximately 1.5 miles from the facility and that he was walking in the opposite direction of the facility. The main road on which resident #2 was walking, is located about 300 feet away from the facility ' s parking lot and is a 2 lane road (1 lane in each direction), with a second 2 lane road connecting the main road to form a " T " intersection. The resident was observed on the second main road which indicated that he would have had to cross at least one of the roads to end up at the point where he was observed walking. The second road where the resident was observed walking has a side walk on one side of the road, and on the other side of the road there are grassy areas with no sidewalk. The Transport CNA reported that she stopped the vehicle, called the facility, and spoke to the Unit Manager on the 2nd floor to confirm that the resident was not in the building. The Transport CNA reported that she asked the resident where he was going and the resident reported that "he was going home" and that he refused to go back to the facility. The Transport CNA reported that the resident was observed stumbling a little. She reported that 2 unknown men pulled up in a van and asked if she needed assistance. She explained to the men that the resident was refusing to go with her back to the facility, and then one of the men asked the resident if he wanted a ride and the resident got into the van with the 2 men, who transported resident #2 back to the facility. The Transport CNA indicated that, when the resident got back to the facility, he was observed to have a skin tear to his left hand. An Interview with the Unit Manager, for the 2nd floor on 11/27/12 at approximately 10:46 a.m. revealed that resident #2 was relocated from the 1st floor secured unit to the 2nd floor a couple of weeks prior to the resident eloping and was placed on 15 minute checks. These checks were to be done by a CNA or the nurse. She reported that, on 11/7/12 she was in a care plan meeting and that she had seen resident #2 prior to the meeting, which was 30 minutes under way, when she received a call from the Transport CNA, who was questioning if resident #2 was in the building; the Unit Manager left the meeting to start a check of the facility, which resulted in the finding that resident #2 was not in the building. The Unit Manger reported that she informed the Transport CNA that the Social Worker would assist her. The Unit Manager reported that the aide came back to the facility, and that the resident was brought back to the facility by a stranger. An interview on 11/27/12, at approximately 10:58 a.m., with the CNA assigned to provide care to resident #2 revealed that she came on shift at 2:45 p.m. and noted that resident #2 was a little agitated while speaking to someone on the phone. She reported that he refused vital signs and showers, and stayed in the hallway. The assigned CNA reported that she continued on to her next resident who needed to be showered. Additionally the assigned CNA reported that, apparently while she was showering another resident, resident #2 left the building. She reported that the resident was on fifteen minute checks at the time that he left the facility, and that the last time the check was done by her, was at 3:15 p.m. A review of resident #2's record revealed a resident face sheet, dated 10/22/12, which indicated that the resident had current [DIAGNOSES REDACTED]. The resident's history and physical from the local hospital, prior to the resident's admission to a Skilled Nursing Facility (SNF), dated 10/14/12, revealed that, this resident was a [AGE] year old male with a history of dementia. Review of the section with the heading "Physical Examination" and the sub heading of "Neurologic" revealed that the resident was alert but disoriented. Review of the section with the heading "Assessment" #3 revealed that the resident had a "Worsening altered mental status." Further review of resident #2's record revealed a [DIAGNOSES REDACTED]. The Admission Assessment, dated 10/17/12, revealed that this resident was admitted to the first floor secured unit and was disoriented, forgetful and his balance/gait was unsteady. The hand written note on this form indicated the following: "3-11, 7pm Resident continues to ambulate hallway seeking an exit, continue Q15 minutes, 10pm in bed with eyes closed continue Q15 minute monitoring." Review of resident #2's history and physical, completed at the time of admission to the SNF, dated 10/17/12, revealed that the resident had dementia and was observed confused. He also had a history of [REDACTED]. The Social Service admission note, dated 10/25/12, revealed that resident #2 would pack his belongings daily and would say "today is the day, I'm outta here." The Minimum Data Set (MDS), dated [DATE], indicated the following: in section " G " with the heading of " Functional Status " , with the sub-heading of " 1. ADL Self -Performance " Section " F. locomotion off unit " the resident was coded a " 1 " which indicates that he requires supervision to complete this task; Sub-heading " G0300. Balance During Transitions and walking " , letter " B. walking " the resident was coded a " 1 " which indicates that he is " not steady, but able to stabilize without staff assistance " ; Section " I Active [DIAGNOSES REDACTED]. Additional active [DIAGNOSES REDACTED]. Senile Dementia " , section " E. Muscle Weakness " Section " F. Difficulty in Walking " and section " G. Lack of Coordination " The Care Conference summary, dated 10/31/12, indicated that resident #2 had confusion due to Dementia. Review of resident #2's care plan, dated 10/31/12, revealed that the following concerns were identified and needed to be addressed: Elopement attempt, "Yells, I want out of here" and "I'm going to see my lawyer about suing this doctor" ; Impaired thought process/Dementia/ Altered Mental Status. He has intermittent confusion with memory problems; Anxiety, worries about his home, packs his belongings daily; Decreased hearing; Decreased vision; at risk for falls. Nurse's notes dated 11/3/12, 11/4/12, 11/5/12, 11/6/12, and the morning of 11/7/12 revealed that resident #2 continued on Q15 (every fifteen) minute monitoring. Review of the Q 15 min Observations Safety Check Log revealed that the sheets have pre-printed times on them and was noted to have 92, 15 minute increments, starting at 12:15 and ending at 11:45. The directions on this form, indicated that, the staff are to "document on the resident in Q15 minute increments, initial each entry and document the behavior noted." . A review of resident #2's Safety Check Log revealed the following: On 10/19/12, there were ten 15 minute checks with no initials and no behaviors documented; on 10/21/12, there were thirty 15 minute checks with no initials and no behaviors documented; on 10/23/12, there were thirty four 15 minute checks that had no initials and no behaviors documented; on 10/29/12, there were eighteen 15 minute checks that were initialed, however, the behavior sections of the entries were left blank. Additionally, there were twelve 15 minute checks that had no initials and had no behaviors documented; on 10/30/12, there were two 15 minute checks that were initialed, however the behavior sections of the entries were left blank, additionally, there were three 15 minute checks that had no initials and had no behaviors documented; on 11/2/12, there were eight 15 minute checks that were initialed, however, the behavior sections of the entries were left blank, in addition there were eighteen 15 minute checks that had no initials and had no behaviors documented; on 11/6/12, there were thirty one 15 minute checks that had no initials and had no behaviors documented. On 11/7/12 (The day that resident #2 eloped from the facility) there were 2 Safety Check Logs. The first one started at 12:15 a.m. and the last entry on this log was documented at 3:15 p.m. The second Safety Check Log, dated 11/7/12, indicated that the resident was taken to the first floor at 4:30 p.m. and the first monitoring was noted to be done at 4:45 p.m. leaving a time frame of approximately 1.5 hours between the last documented safety check form and the beginning of the new safety check form. Additionally there were three 15 minute checks that had no initials and no behaviors documented from 11:15 p.m. to 11:45 p.m. Review of the Nurse's notes for 11/7/2012 found entries timed for 12:00 a.m., which found the "resident resting," 10:00 a.m. which noted that Resident # 2 was ambulating ad lib, in no acute distress, and "continue q 15 min checks." The next entry was at 11/7/2012 at 10 pm and denoted, "Resident refused to go to bed. Continue q 15 min checks." A late entry was entered after that for 7pm which reflected "UA abnormal send out to lab for c/s-new order." An 11 pm entry for 11/7/2012 followed that which reported "x ray results returned no fracture of dislocation noted of left shoulder. Mild [MEDICAL CONDITION] joint disease." There was no reference in the Nurse's notes of 11/7/2012 of the resident leaving the building. On 11/8/12, there were two 15 minute checks that had no initials and had no behaviors documented; on 11/9/12, there were three 15 minute checks that had no initials and had no behaviors documented. An interview on 11/27/12, at approximately 3:50 p.m., with the Administrator (NHA) and the Director of Nursing (DON), revealed, that the Q 15 minute checks were incorporated into the resident's plan of care, to address the risk of elopement. Additionally the DON, confirmed that, the Q 15 min Observations Safety Check Logs were incomplete She reported, that based on documentation, it could not be determined that the 15 minute monitoring had been routinely implemented. Review of the 72 hour monitoring form with a start date of 11/7/12, at 4:10 p.m. indicated that the resident left the facility and was seen by a CNA as he was walking on the public road. The resident refused to get into the facility van; however the resident was brought back to the facility with assistance. On return to unit, the resident was noted with a skin tear to his left hand and complained of left shoulder pain. The form indicated that the physician was notified, new orders to "clean the skin tear to the left hand with wound cleaner, apply steri strip and x-ray the residents left shoulder." Additionally, the form indicated that the resident "remained alert and responsive, complained of pain to his left shoulder and stated that he hit his hand while getting out of the van. X-ray to the left shoulder was ordered. The resident was transferred to a secured unit room." The physician's orders [REDACTED]. Monitor skin tear left hand for signs and symptoms of infection q shift, x-ray left shoulder." Resident #2's x-ray report, dated 11/7/12, indicated that the "views of the left shoulder demonstrates no fracture, dislocation or bony reaction." The updated care plan for elopement, dated 10/31/12, with a revision date of 11/7/12 indicated that the resident eloped on 11/7/12 and was now being housed on the secure unit for safety and was to continue to have a green wrist/ankle band and his picture posted at the receptionist desk. A review of the Social service note, dated 11/14/12, the physician's orders [REDACTED].#2 was discharged to his son on this date, and was to move out of state to reside with his son. 2. An Interview with the Risk Manager on 11/27/12, at approximately 10:08 a.m. revealed that on 10/14/12, at approximately 10:20 a.m. Resident #1 was observed getting into an unknown persons car that was parked in the facility's parking lot. It was reported that there was no driver or passengers noted to be in the vehicle. She reported that the Activity CNA had left the resident in the dining room, unattended awaiting a church activity. Interview with the Activity CNA on 11/27/12, at approximately 11:30 a.m. revealed that Resident #1 resided in a room on the secured unit on the 1st floor and that she was responsible for the resident at the time the resident exited the building. The Activity CNA reported that the resident was placed in the dining room on the second floor, awaiting an activity and that she left the resident in the dining room, unattended while she went to transport residents from the 2nd floor to the activity. The Activity CNA reported that when she got back to the dining room the resident was gone, she looked around, however, the resident was not in the room. When the Activity CNA looked out the French doors of the dining room the resident was being escorted back into the facility by an LPN. The Dining room is located in the front of the facility. The outer wall of the dining room had French doors that lead out to a screened patio. The screened patio had 2 screen doors that exited into the parking lot. The French doors were observed to be approximately 20 feet from the paved parking lot. The Activity CNA reported that the resident could not have been in the parking lot for more than 5 minutes. An interview on 11/27/12, at approximately 11:38 a.m. with the LPN who escorted the resident back into the building, revealed that she saw the resident outside trying to get into an unknown parked vehicle, she reported that she went outside and redirected the resident back into the facility. A review of Resident #1's record revealed a resident face sheet, dated 10/17/12, which indicated that the resident's age was 57. The resident's physician admission note for a 10/10/12, hospital admission, dated 10/10/12, revealed that this resident "had an acute [MEDICAL CONDITION] and that the patient had apparently tried to jump out of the car that she was riding in." Resident #1's [DIAGNOSES REDACTED]. The Admission Assessment, dated 10/14/12, revealed that this resident was admitted to a first floor room and was agitated. Resident #1's Interim care plans, dated 10/12/12 and 10/13/12, revealed that the following concerns were identified as needing to be addressed: wandering, weakness, unsteadiness, Dementia, physically abusive, socially inappropriate, and resists care. The 72 hour monitoring form, dated 10/14/12 (The day resident #1 was found in the parked car), revealed that she was observed by a CNA on the West hall on her right side lying straight. A skin tear was noted to the resident's right ankle, the physician was notified and a new order given to cleanse with wound cleanser and apply dry dressing daily. The Q 15 min Observations Safety Check Log revealed that this resident was placed on the 15 minute monitoring on 10/13/12, due to a potential for falls. Review of the Safety Check dated 10/14/12 revealed that the form was completed. An interview on 11/27/12, at approximately 3:50 p.m., with the Administrator (NHA) and the Director of Nursing (DON), reported that resident #1 should have been under closer supervision. A 10/14/12 " Admission/Re-Admission " note of 10 a.m. indicated that Resident #1 was "alert with attention deficit and able to ambulate independently. Exit seeking." The document was otherwise silent as to the event of 10/14/2012. Review of the updated Interim care plan for elopement, dated 10/14/12, indicated that resident #1 was exit seeking, wanders and makes frequent requests to go home. The Approach was to obtain a picture for identification and 15 minutes checks until stable. 3. An Interview with the Risk Manager, on 11/27/12, at approximately 10:08 a.m., revealed that on 10/10/12, Resident #3 was found in the facility parking lot at approximately 1:30 p.m., and the resident reported that "she wanted to go outside." The Unit Manager reported that a green bracelet was placed on the resident, on 10/10/12, after the incident occurred. In addition the resident's picture was placed at the front desk. The Risk Manager reported that this resident's family usually came to visit her several times a week and would always take her outside by the trees, which was the direction where the resident was heading when she was found outside. She reported that the plan was that on the days that the resident's family did not come to visit her in the facility, the resident would receive activities outside, which would be about 3 to 4 times a weeks. The Risk Manager reported, that prior to the incident, Resident #3 had never vocalized to the facility staff that she wanted to go outside, she had never made any attempts to go outside alone, and was not considered an elopement risk. She reported that prior to the incident the resident did not have a green bracelet and did not have a picture placed at the front desk. The resident's family was notified of the incident and of changes to the resident's plan of care, on 10/10/12. A facility summary, dated 10/10/12, revealed the following: On 10/10/12, Resident #3 was noted propelling herself outside the front office parking lot. The Risk Manager wrote that the resident stated that "she wanted to go outside." The recommendation was to place a green bracelet on resident #3 and place a picture for elopement at the front desk and the resident was to be taken outside for activities. Resident #3's record revealed a resident face sheet, dated 6/6/11, which indicated that the resident's age was 99 and that the resident currently resided on the second floor. Resident #3's [DIAGNOSES REDACTED]. Resident #3's care plans, dated 6/26/12, with a review date of 9/20/12, and a revision date of 10/10/12, revealed that this plan addressed the resident's short and long term memory deficits. On 10/10/12, the care plan was revised to include the resident's potential for exit seeking due to the fact that the resident was noted in the parking lot on 10/10/12. The approaches were to take the resident outside, she was given a green bracelet, and a picture was placed at the front desk. Resident #3's care plan, dated 8/4/11 with revisions on 1/19/12, 1/24/12, 9/20/12 and 10/8/12, revealed that this care plan addressed the resident ' s potential for injury due to falls. An approach added on 10/11/12 indicated that the resident was to have activities outside 3 times a week. Resident #3's care plan, dated 8/4/11, with revisions on 1/19/12 and 4/12/12, revealed that this care plan addressed the resident's need for "reminders to attend of her interests, spirituals and socials." An approach, added on 10/12/12, indicated that the resident was to be escorted outside 3-4 days per week for activities. The 72 hour monitoring form, dated 10/10/12, revealed that resident #3 was noted propelling herself outside the front office parking lot and that the resident stated that "she wanted to go outside." The Q 15 min Observations Safety Check Log revealed that this resident was placed on the 15 minute monitoring on 10/10/12 due to wandering outside unsupervised. The Safety check, dated 10/10/12 (the same day of the incident), revealed that there was one 15 minute check which had a signature but no behaviors were documented, and thirteen 15 minute checks that had no initials and had no behaviors documented. The Safety Check, dated 10/11/12 (the day after the incident), revealed that there were thirty four 15 minute checks that had no initials and had no behaviors documented. An interview on 11/27/12, at approximately 3:50 p.m., with the Administrator (NHA) and the Director of Nursing (DON), revealed, that the Q 15 minute checks were incorporated into the resident's plan of care, to address the risk of elopement. Additionally the DON, confirmed that, the Q 15 min Observations Safety Check Logs were incomplete She reported, that based on documentation, it could not be determined that the 15 minute monitoring had been routinely implemented. 4. The facility's policy and procedure for Safety and Supervision of Residents with a revision date of December 2007 Under the heading of Resident-Oriented Approach to safety, #4 indicated that the facility is to "Implement interventions to reduce accident risks and hazards shall include the following: a. communicating specific interventions to all relevant staff; b. assigning responsibility for carrying out interventions; c. providing training, as necessary; d. ensuring that interventions are implemented; and e. documenting interventions." The facility's Abuse Prohibition/Investigative Policy, with a revision date of February 2010, under the heading of Definitions with the sub-heading of Neglect indicated that neglect is the withholding of services from any resident unable to provide for self the services necessary to maintain physical and mental health. Under the heading of Prevention under the 2nd bullet, indicated that identifying, correcting, and intervening in situations in which abuse/neglect are more likely to occur. 5. The facility initiated measures to remove the immediate jeopardy beginning on 11/28/12. The measures were as follows: An undated Policy and Procedure For Residents At Risk For Elopement was developed and presented to the surveyor on 11/29/12. This policy included assessing residents prior to admission and no less than quarterly, for changes in their mental status or exit seeking behaviors. The facility has a total of 155 staff persons. As of 11/29/12 at approximately 12:20 p.m. a total of 117 staff persons had been in-serviced on the Policy and Procedure on Neglect, the Policy and Procedure on Supervision of residents and the Policy and Procedure for Resident ' s at Risk for Elopement. For the remainder of the 38 staff persons who, as of 11/29/12 at 12:20 p.m. were not yet in-serviced, the facility will do the following: The facility staff clock-in for duty process is completed by the staff person scanning their finger prints. Those staff persons who were identified as not yet receiving the in-services will have their names removed from the finger print scanning system which will not allow them to clock in for their shift. A posting will be left at the finger print scanning clock-in station, indicating to all staff that if the clock does not allow them to clock in, they are to see the DON or immediate supervisor to complete an in-service on elopement prevention. A staff member will be positioned at the front door 24 hours a day until a key-pad activated magnetic lock which is tied into the life safety system is able to be installed. To ensure resident safety, the first floor (secured unit) residents who have a potential for elopement will receive meals and activities on the first floor until magnetic locks are able to be installed on exit doors. There were 24 Random interviews conducted on 11/27/12 and 11/29/12 with staff persons identified as 9 CNA ' s and 4 nursing staff assigned to work between the first floor secured unit and the second floor unit, 5 dietary staff, 5 housekeeping staff and 1 therapy staff assigned to work the entire building. These random staff interviews revealed that these staff had been newly in- serviced from 11/27/12 to 11/29/12. These staff are knowledgeable about identifying residents who may be at risk of elopement and those are already identified as being at risk for elopement, elopement prevention and residents in need of supervision. Immediate Jeopardy was determined removed, on 11/29/12, and the severity was reduced to a D.

Based on record review and interview, the facility failed to provide adequate supervision for one of 12 sampled residents who was displaying a significant change in behavior (resident #1). Failure to provide adequate supervision to resident #1 led to a physical altercation between resident #1 and resident #2 resulting in physical injuries to resident #2 Findings include: 1. Review of resident #1's clinical record revealed a face sheet which indicated a [AGE] year old male resident was admitted to the facility on [DATE] to the secured dementia unit. The face sheet documented the following medical Diagnosis: [REDACTED]. 2. Review of the admission physician order [REDACTED]. Restoril 30 mg by mouth at hour of sleep (HS) for insomnia at 9:00 p.m. Buspar 10 mg by mouth at HS for anxiety at 9:00 p.m. Librium 10 mg by mouth twice a day (BID) for dementia with behavior disturbances at 9:00 a.m. and 5:00 p.m. Ativan 2 mg by mouth every 8 hours as needed (PRN) In addition, a telephone order was written on 11/1/11 to add Namenda 5 mg by mouth twice a day (this medication is used to treat the symptoms of Alzheimer's disease according to the manufacturer's web site at www.namenda.com). A telephone order was also written on 11/2/11 for behavioral consult and treatment. 3. Review of an initial assessment dated [DATE] revealed the following chief complaint/problem/referral issues: "[AGE] year old white male referred for (behavioral) med review. Recently hospitalized for [REDACTED]. Sent here for rehab. Wife his primary caregiver is unable to care for him at home due to worsening dementia." Continued review of the assessment revealed the resident posed no risk or harm to self or others and a clinical status of: "recurrence of longstanding condition." The consulting physician documented the following clinical impressions: "[AGE] year old white male with dementia recently baker acted for paranoid behavior. He was just admitted two days ago and needs time to adjust to the milieu. Would hold off any changes until I re-evaluate him next week, allowing him to get used to his new environment. So far, he has not presented with any negative behaviors. He is cooperative with staff and is easily redirected." A follow up consult visit was documented by the consulting physician on 11/14/11 for the following chief complaint/problem: "patient seen for med review. Patient has adjusted well to placement, no behavior issues per staff. Pleasantly confused, well groomed, easily redirected, walks unassisted." This evaluation & management note continues on to state the resident poses no risk of harm to self or others. The resident was assessed as stable with a [DIAGNOSES REDACTED]. The treatment plan was documented as will try to discontinue Librium and switch to an atypical antipsychotic to manage behaviors. Start Seroquel 25 mg every morning and at 5:00 p.m. Duplicate Ativan orders: would simplify with Ativan 1 mg by mouth every 8 hours PRN. 4. Review of the telephone orders following this visit revealed the following relevant information: 11/14/11 Ativan 1 mg/0.5 ml intramuscularly every 8 hours as needed for increased agitation. Discontinue Librium and Ativan 2 mg every 8 hours PRN. Seroquel 25 mg by mouth every morning and at 5:00 p.m. for a [DIAGNOSES REDACTED]. 5. Telephone interview with the consultant on 12/6/11 at 11:13 a.m. and review of the consultant's evaluation and management note on 12/1/11 revealed the resident was seen for a routine/follow up visit. During this visit nursing reported an increase in evening agitation and restlessness. The resident did better on low dose Librium than Seroquel. Would discontinue Seroquel and restart Librium at prior dose. The consultant noted the resident posed no risk of harm to self or others at the time of her visit. Review of telephone orders for 12/1/11 revealed an order was written at 10:00 a.m. to discontinue Seroquel and start Librium 10 mg by mouth BID with a [DIAGNOSES REDACTED]. 6. Review of the medication administration record (MAR) for December 2011 revealed the Seroquel had already been administered at 9:00 a.m. on 12/1/11 when the new order was received. The Seroquel was discontinued appropriately after this dose. The Librium 10 mg BID was documented on the MAR for administration at 9:00 a.m. and 5:00 p.m. The 5:00 p.m. dose was not administered on 12/1/11. The medication was started at 9:00 a.m. on 12/2/11. 7. Interview on 12/5/11 at 3:13 p.m. with the registered nurse assigned to resident #1 on 12/1/11 from 3:00 p.m. - 11:00 p.m. revealed the Librium which was ordered on [DATE] had not been delivered on her shift that day and therefore it was not available for her to administer it. This nurse also stated that on the night of 12/1/11 she remembered resident #1 was wandering and the resident's certified nurse's aide (C.N.A.) had informed her the resident was refusing his shower. She recalled telling the C.N.A. to leave him alone and go back again later. Around 8:00 p.m. the C.N.A. returned to the nurse again and said she is trying to take resident #1 to the shower, and he is not cooperating. The nurse administered Ativan 1 mg by mouth to the resident at that time and told the C.N.A. to let the Ativan work which should take about 30 minutes. Around 8:15 p.m. the C.N.A. went back to the resident without the nurses knowledge. The nurse stated that the C.N.A. informed her later that the resident looked calmer to her so she re-approached him about the shower, and he agreed to walk with her hand in hand to the shower room. The C.N.A. reported that while she was walking with the resident he put his hand around her neck . The nurse did not see this incident but was informed of it when the C.N.A. was observed with another C.N.A. walking resident #1 back to his room. He was very agitated. The nurse informed the nursing supervisor who came down to assess the situation. The resident was placed in bed and the nurse providing this interview administered Ativan 1 mg intramuscularly at 8:30 p.m. Continued interview with this nurse revealed that a little while later staff, including herself, heard banging on the resident's room door. All the staff proceeded to run down the hallway to see what was going on. Staff were unable to get through the resident's door because he was behind the door pounding on it. The nurse stated that staff did not want to push the door and knock the resident down so someone went through the connecting bathroom from the room next door and got the resident away from the door and laid him down on the bed. This nurse then entered the resident's room through his regular room door. As soon as she entered the room, the resident kicked her in the stomach. Resident #1 left a shoe print on her clothes but she did not sustain any injury. The doctor was called and an order was received for Haldol 5 mg intramuscularly around 9 p.m. The Haldol was administered immediately following this order. The resident calmed down and went back to bed. A C.N.A. was assigned to keep an eye on the resident every 15 minutes beginning 9:00 p.m. with documentation maintained of the residents whereabouts and mood state. At approximately 9:35 p.m. the nurse heard the resident's C.N.A. screaming for help. Staff immediately responded. When the nurse arrived, she saw resident #2 (who resides in the room connected to resident #1's bathroom) on the floor in a kneeling position and another C.N.A. was holding onto resident #1. Prior to this incident of 9:35 p.m. resident #2 was last seen by this nurse in bed. The nurse stated that resident #2 has no history of physical behaviors nor did resident #1 prior to this day. Resident #1 was placed on 1 to 1 care/observation following the resident to resident altercation. The physician was called for both resident #1 and resident #2 to inform him of the incident (the same physician was on call for both residents). Resident #1 did not sustain any physical injuries. Resident #2 was assessed by the nurse as having a laceration to the corner of his eye and some scratches and a bruise on his head in the crown area. The resident also had some scratch marks on his legs and one on the abdomen. First aide was provided to resident #2. The families of both residents were called an informed of the incident. The physician gave orders to send Resident #2 to the hospital as a precautionary measure because he was receiving Coumadin. 8. Interview on 12/5/11 at approximately 3:40 p.m. with resident #1 and resident #2's C.N.A. from the 3:00 p.m. - 11:00 p.m. shift on 12/1/11 revealed she regularly works the assignment for both residents for the past 2 years. She recalled resident #1 being a little upset on 12/1/11 at about 3:00 p.m. when she first arrived that day. She remembered the resident was looking for a supervisor's office, but he calmed down and was sitting by the nurses station. She had taken the resident's blood pressure and everything was fine. Later she told the resident she had a surprise for him, she did not say a shower because the resident does not like getting showers. She talked to the resident about his whiskers (facial hair) being long and he was walking with her and holding her hand. Suddenly, he let go of her hand stepped behind her and grabbed her with one hand around her neck and the other hand against the side of her head (in a headlock). The C.N.A. yelled out for another C.N.A. who immediately responded and got the resident off of her. As soon as the other C.N.A. grabbed at the resident he released her. After this, both the C.N.A.'s walked resident #1 to his room and put him down on the bed. Resident #1 laid down like he was going to go to sleep and acted like everything was okay. She informed resident #1's nurse of the incident as she was bringing him back to bed. Approximately 10 to 15 minutes later the C.N.A. noticed resident #1 was scooting towards the end of the bed. She informed the nurse that the resident was getting ready to get out of bed and the C.N.A. continued to get her other residents ready for bed. The next thing the C.N.A. remembered was hearing resident #1 slamming the door shut and hearing his roommate's voice so she knew he woke his roommate up. She also heard something hitting the door repeatedly. The C.N.A. tried to open the door but resident #1 was not letting her open the door. She then went to the resident room next door and entered resident #1's room through the adjoining bathroom. She saw that the object he was hitting the door with was a shoe. Another C.N.A. entered the room with this C.N.A. and reported that the resident came at them with the shoe. The C.N.A.'s managed to get the shoe from the resident and they set resident #1 back in bed. At that time, the resident's nurse entered the room through the regular room door. Resident #1 proceeded to kick the nurse in the stomach as she entered in the doorway. The C.N.A. thinks the nurse gave him a shot then but she was not sure. Following the shot she recalled the resident laying back down like everything was "fine and dandy". Once things had calmed down she informed the nurse that she was going on her break. (Review of the C.N.A.'s time card revealed she took a break on 12/1/11 from 9:09 p.m. - 9:33 p.m. When the C.N.A. returned from her break, she went to start her rounds. She started her rounds in resident #2's room, the room which shares a bathroom that adjoins to resident #1's room. When she entered the room, she saw resident #2 face down on the floor next to his recliner. Resident #1 was sitting sideways on the small of resident #2's back. Resident #1 had the pant legs of resident #2 and was stabbing the plastic coat hanger into the residents leg. She saw blood on resident #1 and called for help. The nurse and two aides came through the bathroom and pulled resident #1 off of resident #2. Two nurses attended to resident #2 and took over. Resident #1 was separated into an empty sitting room where he was placed on 1 to 1. The C.N.A. recalled signing off on the 15 minute check sheet but could not recall the specifics of the 15 minute checks prior to the resident going on 1:1. 9. Telephone interview on 12/7/11 at 10:51 a.m. with the C.N.A. who documented the Q (every)15 minute checks on 12/1/11 at 9:15 p.m. and 9:30 p.m. revealed she stayed with the resident until he had fallen asleep that night. Once the resident fell asleep she just looked in on him here and there while she took care of the residents on her assignment. The C.N.A. stated resident #1 had calmed down and then all of a sudden he started up again. This C.N.A. was familiar with resident #1 from the past and had never seen him behave this way prior to the incidents on 12/1/11. 10. Review of the facility's investigation, nurses notes, and staff statements related to the incidents occurring on 12/1/11 revealed the following time line of events. A. 12/1/11 8:00 p.m. resident #1 received Ativan 1 mg by mouth for increased anxiety. B. 12/1/11 8:15 p.m. resident #1 placed hand around the neck of the C.N.A. The resident placed in bed and resident's nurse/nurse supervisor notified of incident. C. 12/1/11 8:30 p.m. resident #1 received Ativan 1 mg intramuscularly for increased agitation/anxiety. The resident calmed down and laid down in bed. D. 12/1/11 8:55 p.m. resident #1 slammed door and started banging on door with shoe. Staff took shoe from the resident and placed him in bed. Nurse entered room to check on resident and was kicked in the stomach by the resident. Staff remained with resident in the room. E. 12/1/11 9:00 p.m. physician for resident #1 was contacted and informed of the two incidents and escalation in behavior. A new order was received for Haldol 5 mg intramuscularly one time dose now and every 6 hours as needed. F. 12/1/11 9:00 p.m. Haldol administered to resident #1 and resident placed on 15 minute checks. G. 12/1/11 9:00 p.m. resident #1's C.N.A. documented on 15 minute check paperwork resident "in bed." H. 12/1/11 9:09 p.m. resident #1's C.N.A. went on break. I. 12/1/11 9:15 p.m. & 9:30 p.m. the C.N.A. covering resident #1's assignment documented on Q 15 minute checks "in bed." J. 12/1/11 9:33 p.m. the C.N.A. for resident #1 returned from break. K. 12/1/11 9:35 p.m. the C.N.A. for resident #1 entered the room for resident #2 to provide routine care and found resident #1 on top of resident #2 who was face down on the floor. Resident #1 was on top of resident #2 and stabbing at his legs with a plastic coat hanger. L. Immediately following this, resident #1 was moved to a sitting room and placed on 1 to 1 where he proceeded to fall asleep. Resident #2 was administered first aide and the physician was called for both resident #1 and resident #2. M. 12/1/11 at 11:05 p.m. orders received to send resident #2 to the hospital for evaluation and treatment. 11. Review of the hospital CT scan of the sinus/facial bones without contrast revealed no evidence for acute fracture...No nasal bone injury is seen. Orbital floors appear intact... of an old medial orbital wall fracture. No acute injury is present..." 12. Observation of resident #2 on 12/5/11 at approximately 11:00 a.m. revealed scratches on his nose, a scratch on the corner of his left eye, redness to the inside of his left eye, and scratches to his cheeks. The resident was also noted to have a large bruise across his abdomen underneath his belly button. The resident refused to allow a nurse surveyor to perform a full body check on 12/6/11 at 1:40 p.m.