Every finding on record at Lancaster Nursing & Rehabilitation

Based on observations, interviews and record review the facility failed to post a list of names, address and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency and State licensure office for one of one facility reviewed. The facility failed to update the required facility postings identifying HHSC as the pertinent state agency. This failure could affect the residents' ability to identify and contact the appropriate state agencies. Findings Included: During an observation on 03/06/26 at 09:25am, the facility posting How to File a Complaint was observed hanging on the wall. The posting stated The Texas Department of Disability Services (DADS) hopes that you are satisfied with the care and/or services provided at this facility. However, if you are dissatisfied, we urge you to voice your complaints to the manager of this facility, and/or call DADS at the numbers listed below. The phone number listed was [PHONE NUMBER]. The poster listed the website www.dads.state.tx.us and was dated July 2007. During an observation on 03/06/26 at 09:27am, a facility posting titled Notice was observed hanging on the wall. The posting stated Complete information on inspections and surveys made by representatives of the Texas Department of Aging and Disability Services must be posted at this facility for public inspection. The poster listed the website www.dads.state.tx.us and was dated June 2006. During an observation on 03/06/26 at 09:28am, a facility posting titled Reporting Reasonable Suspicion of a Crime Rights and Responsibilities under Federal Law was observed hanging on the wall. A contact number for the local police department was listed, and the Department of Aging and Disability Services number, [PHONE NUMBER]. The poster was not dated. A review of the website dads.state.texas.us on 03/06/26 at 09:45am revealed the website is not in service and the agency DADS dissolved in 2017. A review of the phone number [PHONE NUMBER] revealed it is the contact number for complaint and incident intake for HHSC. During an interview with the Administrator on 03/06/26 at 10:31am, she stated she started at the facility four months ago and had not reviewed the postings since she started working at the facility. The Administrator further stated she was not sure how she would know they were outdated. During an interview with the Administrator on 03/06/2026 at 11:12am, the Administrator was asked if she knew who her facility liaison was, and she stated she did, and she was in the process of ordering updated posters from HHSC. During an interview with the Administrator on 03/06/26 at 3:45pm, the Administrator stated she did not think having outdated postings would affect the residents because the number was the same and that's what matters, not the difference between the agencies. The Administrator was asked via email on 03/09/26 at 3:24pm if the facility had a policy regarding postings. The Administrator replied on 03/09/26 at 3:40pm there was not a policy.

Based on interviews, and record review the facility failed to provide activities based on the care plan designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 2 (Resident #2 and Resident #20) of 5 residents on the secured unit who were reviewed for activities. The facility failed to provide posted activities to Resident #2 and Resident # 20 on the memory care unit. These failures placed residents at risk of becoming apathetic (marked indifference to the environment), having a depressed mood and a decreased quality of life.Findings included: Review of Resident # 2's Face Sheet dated 01/07/2026 reflected he was a 66 year- old male who was admitted to the facility on [DATE] with diagnoses including COPD( Chronic Obstructive Pulmonary Disease), type II diabetes, acute kidney failure, schizophrenia and unspecified dementia (a group of symptoms that affect a person's ability to think, remember and perform daily activities). Review of Resident #2's MDS dated [DATE] reflected a BIMS score of 4, indicating he had severe cognitive impairment.Review of Resident #2's MDS Assessment, dated 04/14/2025 reflected that it was very important for him to go outside and get fresh air and to participate in religious services. Record Review of Resident #2's care plan dated 12/03/2025 revealed there were no care plans that addressed the resident's preferences related to activities. Review of Resident #20's face sheet dated 01/07/2025 reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease with late onset, dementia and major depressive disorder. Review of Resident # 20's MDS dated [DATE] reflected a BIMS of 00 indicating he was severely impaired. Review of Resident #20's admission MDS Assessment, dated 09/04/2025 reflected it was important to him to listen to music and doing favorite activities. Review of Resident # 20's care plan dated 10/23/2025 reflected there were no care plans that addressed the resident's preferences related to activities. In an observation on 01/06/2026 at 10:20 AM in the memory care unit revealed that Resident # 2 was in his wheelchair with his head on the table. Resident # 20 was in a chair with his head down and sleeping. The TV was on and no staff member was present. There was no activity calendar posted in the memory care unit. There was no evidence of activities (puzzles, books, coloring books, pencils, crayons) within the memory care unit. Review of the activity calendar reflected Stretch and Flex was scheduled at 10 AM. In an observation on 01/06/2026 at 2:24 PM in the memory care unit revealed Resident # 2 was in his wheelchair asleep and Resident #20 was in the same chair asleep with music playing. There were no staff members present. Review of the activity calendar reflected Bean Bag Toss was scheduled at 2 PM. In an observation on 01/07/2026 at 11:05 AM Resident #2 was in his wheelchair facing the courtyard and was asleep. Resident #20 was observed in a lounge chair also asleep. There were color sheets and crayons on the dining table, but no one was using them. Review of the activity calendar reflected that Poetry Reading was scheduled at 11 AM. In an observation on 01/07/2026 at 3:11 PM revealed Resident #20 was asleep in a lounge chair; Resident #2 was awake and looking outside into the courtyard. In an observation and interview on 01/07/2026 at 3:13 PM, CNA A was sitting in the dining area looking at an electronic device. She stated she was only on the unit this date and didn't normally work there and couldn't speak to whether or not there were activities provided. Review of the activity calendar revealed that BINGO was scheduled at 3 PM. In an interview on 01/08/2026 at 12:37 PM with CNA D revealed she had been working at the facility for a little over 2 months. She stated they do have activities and she thought there were maybe 3 per week. She stated sometimes she will do an activity like listening to music or coloring. She stated she did not know if there was an activity calendar in the dining room. She couldn't recall when the Activity Director was on the memory care unit. She stated the risk of not having activities for the residents was they could become combative with each other or bored with nothing to do. In an interview on 01/08/2026 at 1:20 PM with the Administrator and the Activity Director revealed she had been at the facility since December 2025 and was new to the role. She stated there was not a separate calendar for memory care unit and that her intentions were to create one but had not done that yet. She stated the risk of not having activities for residents in memory care was they would have nothing to do. The administrator stated they have considered having staff on the unit to assist in providing activities, but it had not been implemented yet. She stated there should be activities provided for the memory care residents. Review of Activity Programming Policy Procedure Manual 2011 reflected in part, Resident's or family's expressed needs and interests are included in the development of programs. Input from residents may be done individually or discussed at Resident Advisory Council meeting. Activity programs are based on residents' leisure interests and implemented to meet the needs (physical, cognitive, creative, social, spiritual, independent, and sensory) of the residents.Programs will be geared to maintain functional ADL's, provide social interaction and, at the same time, protect residents from environmental over stimulation.

Based on interviews and record review the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) level 1 residents with mental illness were provided with a PASRR level 2 evaluation for 1 of 3 residents (Resident #34), reviewed for resident assessment.Resident #34's PASRR level 1 screening form did not reflect mental illness, and the resident did not have a PASRR level II evaluation.This could place residents at risk of not receiving necessary specialized services to meet their individual needs. The findings were:Record review of Resident #34's quarterly MDS assessment, dated 12/06/2025, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The resident's BIMs score was 15 indicating the resident's cognition is intact. His diagnoses included Bipolar Disorder (mental condition marked by alternating periods of elation and depression), Generalized Anxiety Disorder (disorder characterized by feelings of worry, anxiety, or fear that are enough to interfere with one's daily activities), Hypertension (a condition in which the blood against the artery wall is too high), and Seizures (a sudden burst of electrical activity in the brain).Record review of Resident #34's PASARR level 1 screening, dated 05/31/2025, reflected the resident did not have a serious mental illness and serious mental illness was checked as no.Record review of Resident #34's Care Plan dated 11/20/2025 reflected:06/02/2025: The resident was taking antidepressants to assist with his diagnosis of Depression.Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness. Monitor/document/report to MD prn ongoing s/sx of depression unaltered by antidepressant meds: Sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, neg. mood/comments, slowed movement, agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, constant reassurance.06/022025: The resident was taking medications to assist with Mood Disorder.Staff to Monitor/record occurrence of for target behavior symptoms (Specify: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others. etc.) and document per facility protocol.11/20/2025: The resident was taking medications for Anxiety.Give anti-anxiety medications ordered by physician. Monitor/document side effectsand effectiveness. The resident is taking Anti-anxiety meds which are associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia, falls, broken hips and legs. Monitor for safety.An interview on 01/08/2026 at 12:34 PM with MDS Nurse A revealed he did not know why Resident #34 had a negative PASRR level 1 screening. MDS Nurse A stated, he was responsible for ensuring the accuracy of PASARRs and was not aware that it was coded incorrectly. He said the resident was at risk of delay in services and not having correct care and management with a negative PASARR level 1 screening.An interview on 01/08/2026 at 1:43 PM with the DON revealed she did not know why Resident #34 had a negative PASARR Level 1 screening. She said the MDS staff were responsible for checking for accuracy and the resident was at risk of not receiving services he could qualify for.Review of the facility policy, PASRR Level 1 Screen Policy and Procedure, dated 03/06/2019, reflected: The PL1 Screening Form is completed by the RE (referring entity) using the paper copy of the PL1Screening Form.The Facility will review the PL1 Screening Form for completion and correctness prior to admissionand submit the PL1 form per regulations. The Type of admission is reviewed for correctness.Ensure the Name, SS number, Medicare/Medicaid numbers and DOB is correct. The Date of thePL1 is correct (i.e. correct day, month and year) and review each item on the PL1 to ensureaccuracy and prevent a regulatory problem.

Based on observation, record review, and interview, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene, for 2 (Resident #2 and Resident #20) of 10 residents reviewed for ADLs. The facility failed to provide nail care for Resident #2 and Resident #20. This failure placed residents who required assistance with ADLs at risk of a decline in their quality of life.Findings included: Review of Resident # 2's Face Sheet dated 01/07/2026 reflected he was a 66 year- old male who was admitted to the facility on [DATE] with diagnoses including COPD( Chronic Obstructive Pulmonary Disease), type II diabetes, acute kidney failure, schizophrenia and unspecified dementia (a group of symptoms that affect a person's ability to think, remember and perform daily activities). Review of Resident #2's MDS dated [DATE] reflected a BIMS score of 4, indicating he had severe cognitive impairment. Review of Resident #2's Care Plan revised on 01/06/26 reflected that Resident #2 has an ADL Self Care performance deficit and needed assistance with personal hygiene as required. Review of Resident #20's face sheet dated 01/07/2025 reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease with late onset, dementia and major depressive disorder. Review of Resident # 20's MDS dated [DATE] reflected a BIMS score of 00 indicating he was severely impaired. Review of Resident #20's Care Plan revised on 10/22/2025 reflected that Resident #20 had an ADL Self Care performance deficit and required staff participation with personal hygiene as required. Observation on 01/06/2026 at 10:22 AM revealed Resident #2 was in his wheelchair in the dining room. His nails on both hands were about 1/2 inches long with a black substance underneath the nails. He did not answer when asked if his nails not being clipped bothered him or not. Resident #20 was also in the dining room and his nails were approximately 1/2 inches long with a black substance underneath the nails. He also did not respond to the question about his nails being clipped. In an observation on 01/07/2026 at 2:10 PM revealed Resident #2 and Resident #20 were in the dining room and their nails had not been clipped. In an interview on 01/07/2026 at 2:15 PM RN B revealed that if the resident was a diabetic, it was his responsibility to clip the nails. He stated that it had been around 3 weeks since he had trimmed the resident's nails and that it was his bad that they had not been clipped. He stated that Resident #2 and Resident # 20 were both diabetics. He stated the risk to the resident of not having their nails trimmed was the nails could get infected. In an interview on 01/08/2026 at 2:46 PM with the DON revealed that it was her expectation that the nurse clips the fingernails if the resident was a diabetic. She stated that the podiatrist will trim the toenails. She stated the risk to the residents was they could get skin tears, bacteria could get under the nails and cause an infection. Review of the facility's current policy and procedure Nail Care, undated, reflected in part: Nail management is the regular care of the fingernails to promote cleanliness, to prevent infection and injury from scratching. Goals: Nail care will be performed regularly and safely.

Based on observations, interviews, and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, for 3 of 5 Residents (Resident#12, Resident#8 and Resident#17), reviewed for respiratory care. The facility failed to ensure that Resident#8, oxygen tubing's was changed and dated per physician orders. The facility failed to ensure that Resident#12, and Resident#8's Oxygen tubing's, were bagged in a plastic bag and stored in a drawer which was consistent with professional standards.The facility failed to ensure that Resident#17's nebulizer mask was bagged in a plastic bag and stored in a drawer which was consistent with professional standards. This failure had the potential to affect residents receiving oxygen therapy by increasing their risk of health - associated infections. 1.) Record review of Resident #12's MDS Assessment, dated 12/23/2025 reflected the resident was a [AGE] year-old male, had a BIMs score of 01 indicating he was cognitively impaired. The resident had diagnoses which included Coronary Artery Disease, Heart Failure and Non-Alzheimer's Dementia. Record review of Resident #12's Comprehensive Care Plan revealed a care plan for Congestive Heart Failure Date Initiated: 12/22/2025 Facility intervention includes: Monitor/document/report to MD PRN any s/sx of Congestive Heart Failure: dependent edema of legs and feet, periorbital edema, SOB upon exertion, cool skin, dry cough, distended neck veins, weakness, weight gain unrelated to intake, cracklesand wheezes upon auscultation of the lungs, Orthopnea, weakness, and/or fatigue,increased heart rate (Tachycardia) lethargy and disorientation. Record review of Resident #12's Active 12/22/2025 Oxygen at 2 l/m to 4 l/m per nasal cannula every 1 hour as needed for SOB. 1/6/2026 at 11:05AM Observation of Resident# 12 revealed the oxygen tubing was not dated or labeled and hanging on the concentrator. Oxygen tubing was bagged in a plastic bag and stored in a drawer. 2.) Record review of Resident #8's Quarterly MDS Assessment, dated 12/23/2025, reflected the resident was a [AGE] year-old male, had a BIMs score of 09 indicating he was moderately cognitively impaired. The resident had diagnoses which included anemia, pneumonia, Asthma, Chronic Obstructive Pulmonary Disease, and respiratory failure. Record review of Resident #8's Comprehensive Care Plan, reflected [NAME] requires Oxygen Therapy Date Initiated: 01/05/2026: Facility interventions include usual oxygen delivery method after the meal. Monitor for s/sx of respiratory distress and report to MD PRN: Respirations, Pulse oximetry, Increased heart rate (Tachycardia), Restlessness, Diaphoresis(sweating), Headaches, Lethargy, Confusion, Atelectasis, Hemoptysis, Cough, Pleuritic pain, Accessory muscle usage, Skin color. Notify the nurse if the oxygen is off the resident Oxygen at 2-4____lpm per nasal canula to keep spo2 above 94% Record review of Resident #8's Physician orders start date 05/30/2025 reflected CHANGE 0XYGEN TUBING Q NIGHT SHFFT every night shift every Sat PLEASE PUT DATE ON TUBING Verbal Active. Record review of Resident #8's Physician orders start date 09/03/2025 reflected Continuous Oxygen at 2LPM Via: Nasal Cannula every shift. 1/6/2026 at 11:17AM Observation of Resident# 8 revealed the oxygen tubing was not dated and was on the resident's nightstand. Oxygen tubing was bagged in a plastic bag and stored in a drawer. 1/6/2026 at 1:34PM interview with RN A revealed that oxygen tubing was supposed to be changed on Saturday night shift. She stated she usually checked the oxygen tubing to make sure they were dated. She stated she was not aware that Resident# 8's oxygen tubing was not dated. She stated the importance of dating oxygen tubing was to track its age so it can be replaced according to the recommended schedule. She stated that she had been in serviced on infection control and oxygen tubing care. 3.) Record review of Resident #17's Quarterly MDS Assessment, dated 12/3/2025, reflected the resident was a [AGE] year-old male, had a BIMs score of 14 indicating he was cognitively intact. The resident had diagnoses which included anemia(low red blood cells), Heart Failure(the heart can't pump enough oxygen-rich blood to meet the body's needs), Asthma a chronic lung condition causing inflamed, narrowed airways, leading to symptoms like wheezing, coughing, chest tightness, and shortness of breath, often worsening at night or with exercise ), Chronic Obstructive Pulmonary Disease (COPD), (Chronic Obstructive Pulmonary Disease (COPD) is a progressive lung condition causing airflow obstruction, leading to shortness of breath, cough (often with mucus), and wheezing, primarily from lung damage due to smoking or irritant exposure). Record review of Resident #17's Comprehensive Care Plan, Date Initiated 08/07/2023, Revision 01/17/2024 has COPD (Chronic Obstructive Pulmonary Disease (COPD) is a progressive lung condition causing airflow obstruction, leading to shortness of breath, cough (often with mucus), and wheezing, primarily from lung damage due to smoking or irritant exposure) r/t Smoking receives Symbicort Inhalation Aerosol, Albuterol Sulfate HFA Inhalation Aerosol Solution. Facility interventions: Monitor/document for anxiety. Offer support, encourage resident to vent frustrations and fears. Reassure. Give PRN medications for anxiety as ordered. Monitor/document/report to MD PRN any s/sx of respiratory infection: Fever, Chills, increase in sputum (document the amount, color, and consistency), chest pain, increased difficulty breathing (Dyspnea), increased coughing, and wheezing Record review of Resident #17's Physician orders start date 07/20/2023 reflected, Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML inhale orally every 4 hours as needed for SOB or Wheezing via nebulizer. 1/6/2026 at 11:30AM Observation of Resident# 17 revealed nebulizer mask was not dated and was on the night stand it was not bagged and stored in a drawer. 1/6/2026 at 1:02PM interview with RN B revealed that he was Resident#12 and Resident#17's nurse. He stated that he was not aware that Resident #12's oxygen tubing and Resident #17's nebulizer mask were not dated. He stated that he usually checked the oxygen tubing to make sure they were dated. He stated that the oxygen tubing and nebulizer masks were changed every week on Saturday night and PRN. He stated it was important to date all tubing so that everyone track when the tubing was last changed. He stated that it was important to change tubing every week, and store tubing and nebulizer masks in plastic bags and place in the drawers to prevent contamination and infections. He stated that he had been in serviced on infection control and oxygen tubing care. 1/7/2026 at 4:30PM interview with the DON revealed her expectation was the nurse assigned should check the oxygen tubing and nebulizer masks as part of overall assessment make sure, they are functioning properly. She stated the facility policy was to change oxygen tubing when they become dirty or contaminated. She stated that the tubing should be stored in plastic bags in the drawers to prevent them from getting contaminated. She stated the risk to the resident if tubing was not stored in sanitary ways, was infection. She stated that the nurses had been in serviced on infection control and oxygen tubing care. She stated that when tubing is changed the nurse should document the treatment administration record. Record review of the facility policy titled Oxygen Administration Revised 02/13/ 2017 reflected: GoalsThe resident will maintain oxygenation with safe and effective delivery of prescribed oxygen.The resident will maintain an effective breathing pattern with administration of oxygen.The resident will be free from infection. ProcedureBecome familiar with the type of oxygen administration, medical diagnosis, and reason for oxygen, intermittent or continuous use of oxygen, amount to be delivered.Change the tubing (including any nasal prongs or mask) that is in use on one patient when it malfunctions or becomes visibly contaminated.Oxygen concentrators should be cleaned according to manufacturer recommendations.Change or clean oxygen concentrator filters according to manufactures' recommendations.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering, and securing of 1 medication on 1 medication cart of 2 medication carts reviewed for pharmacy services.The facility failed to ensure proper storage and disposal of Resident#11's tramadol 50 hcl mg (controlled medication) by taping a narcotic medication and retaining a discontinued narcotic in medication cart. These failures could place residents at risk of medication error due to administration of medication without physician order and at risk of pills contamination due to broken seals.Findings included: Review of Resident #11's Quarterly MDS Assessment, dated 12/12/25, reflected the Resident#11 was a [AGE] year-old male and had a BIMs score of 13 considered intact or normal. The resident had diagnoses which included hypertension (high blood), Anemia (a condition marked by a deficiency of red blood cells or of hemoglobin in the blood, resulting in pallor and weariness), heart failure (a condition when the heart muscle doesn't pump blood as well as it should), renal insufficiency (means the kidneys aren't working at full capacity, filtering waste and fluids less effectively), hemiplegia (is paralysis that affects only one side of your body), cerebral vascular Accident (a serious medical event where blood flow to part of the brain is suddenly interrupted, causing brain cells to die from lack of oxygen and nutrients, potentially leading to permanent disability or death). Review of Resident #11's Comprehensive Care Plan, dated 12/09/2025, reflected [NAME] requires pain management (chronic) pain r/t Lupus (a chronic autoimmune disease where the immune system mistakenly attacks healthy tissues and organs, causing inflammation affecting skin, joints, kidneys, brain, heart, and lungs).Date Initiated: 02/28/2019 Revision on: 02/01/2022: Interventions included to Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. Review of Resident #11's active physician orders Dated: [DATE], reflected the resident had no active orders for tramadol hcl oral tablet 50 mg. Review of Resident #11's discontinued physician orders reflected Tramadol hcl oral tablet 50 mg give 1 tablet by mouth every 8 hours as needed for pain was discontinued 6/19/2025. An observation on 01/06/2026 at 11:45 AM of the Nurses Cart station1 revealed the medication blister pack for Resident #11's Tramadol hcl oral tablet 50 mg had 1 blister seal broken. The damaged blister had the pill still inside secured with tape at the time the surveyor inspected the medication cart; the count for Resident#11 Tramadol hcl oral tablet 50 mg, the actual number of pills counted was 24. In an interview on 06/10/26 at 11:50 AM, RN A stated she was unaware when the blister pack seal was broken and stated that Resident#11 had not taken the medication (Tramadol hcl oral tablet 50 mg) for a while. She stated that the risk of a damaged blister would be potential for drug diversion and contamination of the medication. She stated the nurses were responsible for checking the medication blister packs for broken seals during the count of narcotics during the change of shift. She stated she did not see the broken blister during the count. RN A stated discontinued narcotics should be removed from the nurse cart as soon as they were discontinued and given to the DON. She stated she had been in serviced on medication storage. In an interview on 01/06/26 at 3:29PM with ADON revealed she audited the 100-hall medication cart weekly. She stated the last time she audited the medication cart was two weeks prior to the recertification survey. She stated she was not aware Resident#11's Tramadol 50 mg was secured with taped. She stated that no narcotics should be taped due to risk of infection. She stated that medication with broken bubble seal should be wasted and witnessed by two nurses. She stated no medication without orders should be in the cart be because it could lead to medication errors. In an interview on 01/07/26 at 1:04 PM, the DON stated if the blister pack seal was broken on any controlled medications the pill should be discarded witnessed by two nurses. The DON stated it was not acceptable to keep a pill in a blister pack that was opened. She stated that if a blister pack seal was broken it should not be tapped over with tape. The DON stated all discontinued controlled narcotics should be removed from the cart immediately and given to her for secure storage until it is destroyed by the pharmacist. The DON stated the risk would be losing the medication because the seal was broken and having medication that has been discontinued could lead to medication error when the medication is given without an order. She stated nurses were responsible for checking the medication blister packs for broken seals during the count on the change of shifts. The DON stated the ADON and wound nurse audit the medication carts weekly, then the pharmacy consultant checks the medication room and the medication cart every other month and the last time the audited the carts was in November 2025.She stated the nurses had been in serviced on medication storage and that narcotics were not to be taped if the blister seal was broken. Review of the facility's policy Medication Storage in the Facility edited P&P v3-2025 reflected the following: Medications and biologicals are stored safely, securely, and properly following manufacturers' recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff. members lawfully authorized to administer medications.Procedure[Pharmacy] dispenses medications in containers that meet legal requirements, including requirements of good manufacturing practices where applicable. Medications are kept and stored in these containers. Transfer of medications from one container to another is done only by a pharmacist.9. Each States rule vary on securing the classes of controlled substances the facility will adhere to their individual State's rules as it relates, some states require that ALL classes of controlled substances be stored in the lock-box located in the medication cart to adhere to the required double locked/secured storage.13. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to the procedures for medication destruction, and reordered from the pharmacy, if a current order exists.

Based on interviews and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C to the maximum extent practicable to avoid duplicative testing and effort for 1 (Resident #1) of 3 residents reviewed for PASARR services and assessments. The facility failed to submit a complete and accurate request for nursing facility specialized services (NFSS) in the LTC Online Portal within 20 business days after the date of the Interdisciplinary Team Meeting for Resident #1. This failure placed residents at risk of not receiving needed specialized services that could impact their healing.Findings included: Review of Resident #1's Annual MDS Assessment, dated 09/04/25, reflected the resident had a BIMs score of 13 and was cognitively intact. She was admitted to the facility on [DATE]. Her diagnoses included seizure disorder, schizophrenia (severe mental disorder that affects how a person thinks, feels, and behaves, often leading to hallucinations, delusions, and disorganized thinking), post-traumatic stress disorder, and mild intellectual disabilities. Review of Resident #1's Comprehensive Care Plan reflected there were no care plans for PASARR services. Review of Resident #1's PASRR Level 1 Screening, dated 05/21/25, reflected the resident tested positive for mental illness and intellectual disabilities. Review of Resident #1's PASARR Comprehensive Service Plan Form reflected the initial interdisciplinary team meeting for the resident was held on 06/11/25 and Medicaid eligibility was not found. An interview on 11/21/25 at 10:15 am with Resident #1 revealed she did not know if she was receiving PASARR services and did not know if she was supposed to be receiving PASARR services. An interview on 11/21/25 at 10:55 am with the MDS Nurse revealed he was new to the role of MDS Nurse. He said he did not know why the facility did not submit a complete and accurate request for nursing facility specialized services in the Long-Term Care Online Portal within 20 business days after the date of the Interdisciplinary Team meeting. He said he did not know the date of Resident #1's interdisciplinary team meeting. He said he did not think the resident was receiving PASARR services and failure to submit documentation on the on-line portal could prevent the resident from receiving necessary services. He said he did not know what services the resident was supposed to be receiving. An interview on 11/21/25 at 12:10 PM with the DON revealed she thought Resident #1 was receiving PASSAR services. The DON said the resident was Medicaid pending and was waiting to get a new wheelchair and was scheduled to have a meeting on 12/04/25 to move to the community. The DON said the MDS Nurse was in charge of PASSAR services at the facility. The DON said she did not know why the facility failed to submit a complete and accurate request for nursing facility specialized services (NFSS) in the LTC Online Portal within 20 business days after the date of the Interdisciplinary Team meeting. She said this failure could lead to depression and anxiety for the resident. An interview on 11/21/25 at 12:55 PM with the Regional Reimbursement Nurse revealed he did not know why the facility failed to submit a complete and accurate request for nursing facility specialized services (NFSS) in the LTC Online Portal within 20 business days after the date of the Interdisciplinary Team meeting. He said on-line portal showed the resident had an IDT meeting on 06/11/25, but the facility did not submit the NFSS Request form. The Regional Reimbursement Nurse said the form would be submitted immediately. He said failure to submit the form could result in the resident not receiving appropriate services. A follow-up call was received from the Regional Reimbursement Nurse on 11/21/25 at 1:15 PM and he said Resident #1 did not have Medicaid and did not qualify for PASSAR services. Review of the facility policy, PASRR Level 1 Screen Policy and Procedure, revised 03/06/19, reflected: The IDT will determine which specialized services the resident will receive. After the IDT meeting, the NF must submit the information from the IDT meeting on the LTC Online Portal .

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and received adequate supervision 2 of 9 residents (Resident's #1 and #2) reviewed for accident hazards.1. The facility failed to immediately fix a broken window in the Memory Care Unit's dayroom. Resident #1 grabbed a shard of the glass and attempted to remove it. The Surveyor intervened to get the resident to stop grabbing it.An Immediate Jeopardy (IJ) was identified on 07/17/25. The IJ template was provided to the facility on [DATE] at 4:55 PM . While the IJ was removed on 07/18/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.2. The facility failed to ensure Resident #2 did not elope from the facility on 06/05/25. The resident was returned to the facility by the police on 06/05/25.An Immediate Jeopardy (IJ) was identified on 07/31/25. The IJ template was provided to the facility on [DATE] at 11:00 AM. While the IJ was removed on 08/01/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.These failures could place residents at risk for injury up to and including death due to the sharp glass and elopement.Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and residents received adequate supervision for 2 of 9 residents (Residents #1 and #2) reviewed for accident hazards.1. The facility failed to immediately fix a broken window in the Memory Care Unit's dayroom. Resident #1 grabbed a shard of the glass and attempted to remove it. The Surveyor intervened to get the resident to stop grabbing it.An Immediate Jeopardy (IJ) was identified on 07/17/25. The IJ template was provided to the facility on [DATE] at 4:55 PM. While the IJ was removed on 07/18/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.2. The facility failed to ensure Resident #2 did not elope from the facility on 06/05/25. The resident was returned to the facility by the police on 06/05/25.An Immediate Jeopardy (IJ) was identified on 07/31/25. The IJ template was provided to the facility on [DATE] at 11:00 AM. While the IJ was removed on 08/01/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.These failures could place residents at risk for injury up to and including death due to the sharp glass and elopement.The findings included:1. Record review of Resident #1's quarterly MDS assessment, dated 06/17/25, revealed the resident was a [AGE] year-old male admitted on [DATE]. His BIMS score was 3 indicating his cognitive ability was severely impaired. His diagnoses included seizure disorder and schizophrenia (a serious mental health condition that affects how people think, feel and behave. It may result in a mix of hallucinations, delusions, and disorganized thinking and behavior.) The resident required set-up assistance for wheelchair mobility.Record review of Resident #1's Care Plan, dated 06/19/25, reflected:The resident was at risk for falls.Facility interventions included:The resident needed a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, and personal items within reach.An observation and interview on 07/17/25 at 10:50 AM revealed Resident #1 was in the Memory Care Unit dayroom with 2 other residents. Resident #1 was in his wheelchair sitting next to a table close to the exit door. The window next to the exit door was broken and had a large piece of triangle shaped glass sticking straight up. There were also multiple pieces of glass sticking up and there was one large piece of glass laying in the windowsill. Pictures of the window were taken. Resident #1 said the window had been broken for 2-3 days after an unknown resident in a wheelchair hit it. The resident said he had never cut himself on the window.An interview on 07/17/25 at 10:53 AM with LVN A in the Memory Care Unit revealed she did not know the window was broken. She was walking through the day room. LVN A left the Memory Care Unit.An observation and interview on 07/17/25 at 10:55 AM revealed CNA B entered the day room. She sat in a chair at the table that was blocking the window. She said she would be staying in the day room until maintenance came to fix the window. Resident #1 was in his wheelchair next to her. She said she did not know about the broken window. The Surveyor walked around the corner to the nurse station. An interview with RN C revealed the window was broken 2-3 days ago and she did not know how it happened. She said none of the residents had cuts or injuries. The Surveyor returned to the day room, but CNA B was not there. Resident #1 was next to the broken window and grabbed the largest piece of triangle shaped glass, separate from the other pieces of glass, easily reached by the resident, and tried to remove it. The Surveyor told him to stop. The resident grabbed it again and said he needed to remove it so no one would get hurt. The Surveyor said stop and CNA B returned to the dayroom and told him to stop also. The resident stopped after he was told Maintenance was coming to fix it. The Maintenance Director entered the day room and said the window had been broken for 2 days and he thought the broken glass was removed. He said two days prior the window did not look as bad, and he said it looked like someone hit the window again. The Maintenance Director removed the glass pieces and said he would cover it with a piece of cardboard. He left the room. CNA B had also left the room. The window had a gaping hole with sharp edges. The Surveyor stayed with the window and Resident #1 to make sure he did not touch the window again. The 2 other residents in the day room were still in their same spot.An observation and interview on 07/17/25 at 11:03 AM revealed the Maintenance Director returned. He said there were no cameras in the dayroom. The Maintenance director said he was told that there was just a crack in the window, and he did not know the hole had gotten so big. He placed cardboard over the window and said he had called the window company 2 days ago to fix it, but they had not arrived yet.An interview on 07/17/25 at 11:12 AM with the DON revealed she did not know about the broken window in the dayroom prior to 07/17/25. She said she did not know how it happened. She said the nurse was assessing the residents in Memory Care for cuts and injuries. She said it was everyone's responsibility to check windows and environment issues and report them to be fixed. She said a broken window put residents at risk for harm.An interview on 07/17/25at 12:42 PM with the Administrator revealed he did not know about the broken window and would contact the Maintenance Director. He said staff were supposed to notify him about the broken window.Review of the facility policy, Preventive Maintenance not dated, reflected:The facility will ensure that a comprehensive preventive maintenance program is in place for essential operating equipment. Preventive maintenance will be completed routinely and according to protocol by the Maintenance Supervisor or qualified designee. The facility will maintain documentation of all preventive maintenance.Review of the facility policy, Facility Assessment dated 08/08/24, reflected: The facility assessment addresses the following.A facility-based and community-based risk assessment, utilizing an all- hazards approach.This was determined to be an IJ on 07/17/25. The Administrator and the DON were notified. The Administrator was provided with the IJ template on 07/17/25 at 4:55 PM. The Plan of Removal was accepted at 8:35 AM on 07/18/25 and reflected the following:Interventions:The window referenced on the secure unit was repaired on 07/17/25 by the maintenance director.All windows in the facility and secure unit were inspected by the maintenance director. No additional windows needed repair. Completed 07/17/25.All residents in the secure unit were assessed for injuries by the DON and ADON on 07/17/25. No new injuries were noted.New Process: If there is a window or any area in the in facility that needs repair and presents as an accident/hazard, staff will ensure that someone remains at the site to protect residents from harm. The administrator, maintenance director, or ADON will be notified immediately. If repairs cannot be completed immediately, the administrator will contact the Area Director of Operations for guidance. The process will begin 07/17/25 and ongoing.The Maintenance Director, Administrator, or designee will inspect all windows in the facility weekly to ensure all windows are intact and functioning. Windows that need repair will be addressed immediately. Start date will be 07/17/25 and ongoing.The Administrator, DON, Maintenance Director and ADON were in-serviced 1:1 by the Regional Compliance Nurse and completed as of 07/17/25 on the following:New Process: If there is a window or any area in the in facility that needs repair and presents as an accident/hazard, the staff will ensure that someone remains at the site to protect residents from harm. The administrator, maintenance director, or ADON will be notified immediately. If repairs cannot be completed immediately, the administrator will contact the Area Director of Operations for further guidance in ensuring the safety of the residents.Abuse and Neglect failure to repair a broken window immediately could be considered neglect and be a potential hazard to staff and residents.The Medical Director was notified of the immediate jeopardy citation on 07/17/25 by the DON.An ADHOC QAPI meeting was conducted as of 07/17/25 to review the immediate jeopardy citations and subsequent plan of removal.In-services:The Regional Compliance Nurse, Administrator, DON, and ADON will in-service all staff on the following topics below. All staff not present for the in-services will not be allowed to work their next shift until the in-services are completed. All new hires will be in-serviced during orientation prior to working their shift. All agency staff will be in-serviced prior to assuming scheduled shift. In-servicing began on 7/17/25. Completion date will be 7/18/25.New Process: If there is a window or any area in the in facility that needs repair and presents as an accident/hazard, staff will ensure that someone remains at the site to protect residents from harm. The administrator, maintenance director, or ADON will be notified immediately. If repairs cannot be completed immediately, the administrator will contact the Area Director of Operations for guidance in ensuring the safety of the residents.Abuse and Neglect failure to repair a broken window immediately could be considered neglect and be a potential hazard to staff and residents.Monitoring of the facility's Plan of Removal included the following:Record reviews of the facility Plan of Removal In-services reflected:25 staff were in-serviced on: In Service Training Attendance Roster, dated May 2025, reflected: Service Training Topic:New Process: If there is a window or any area in the in facility that needs repair and presents as an accident/hazard, staff will ensure that someone remains at the site to protect residents from harm. The administrator, maintenance director, or DON will be notified immediately. If repairs cannot be completed immediately, the administrator will contact the Area Director of Operations for guidance in ensuring the safety of the residents.Abuse and Neglect failure to repair a broken window immediately could be considered neglect and be a potential hazard to staff and residents.Observations on 07/18/25 from 9:30 AM to 1:00 PM of the facility, including the Memory Care Unit revealed no broken windows or safety hazards. The broken window in the Memory Care Unit was fixed. Residents in the Memory Care Unit did not have visible cuts or scrapes.Interviews with staff from 07/18/25 at 10:00 AM to 07/18/25 at 1:00 PM were completed. 11 staff were interviewed in person/on the phone who worked all shifts at the facility. The interviewed staff were RN C, LVN A, Activity Director, Housekeeper D, LVN E, CNA F, CNA G, Maintenance Director, LVN H, DON, and the Administrator. The staff were able to verbalize they were in-serviced on the new process. If there was a window or any area in the facility that needed repair and presented as an accident/hazard, staff would ensure that someone remained at the site to protect residents from harm. The administrator, maintenance director, or DON would be notified immediately. Also, they were able to verbalize that failure to repair a broken window immediately could be considered neglect and be a potential hazard to staff and residents.An interview with the Maintenance Director on 07/18/25 at 12:46 PM revealed he was in-serviced regarding the POR for the broken window. The Maintenance Director said he inspected all windows on 07/17/25 and no additional windows needed repair. He said he was supposed to report to the Administrator and Supervisor and get it fixed ASAP if he found a broken window. He said he or staff had to stay with the resident until the window was fixed. He said he had to look everyday to make sure no windows were broken and failure to repair the window could be neglect and present a potential hazard to the residents.An interview with the DON on 07/18/25 at 12:25 pm revealed her role in the Plan of Removal was to ensure staff were in-serviced and assist with in-services. She said if a broken window was found, she would direct staff to stay with the residents until the window was fixed. She said if staff found a broken window, they were to stay with the residents and call the Administrator, DON, and Maintenance Director. She said staff were supposed to check daily for broken windows. The DON said failure to fix a broken window and stay with the resident posed a potential hazard and neglect.An interview on 07/18/25 at 12:10 PM with the Administrator revealed his role in the Plan of Removal was to supervise and make sure the facility stayed in compliance. The Administrator said he would contact the Area Director of Operations if a window was found broken and could not be fixed. He said he would monitor to ensure the Maintenance Director was checking for broken windows and fixing them immediately. The Administrator said if staff found a broken window, they were supposed to stay with the resident and notify the Maintenance Director, DON, and Administrator about the broken window. He said failure to stay with the resident and fix the broken window was a potential accident hazard and neglect. The Administrator said the issue was also discussed at the QAPI meeting held with facility administration.The Administrator and DON were informed the Immediate Jeopardy was removed on 07/18/25 at 2:15 PM. On 07/17/25 at 4:55 PM, an IJ was identified. While the IJ was removed on 07/18/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.2. Record review of Resident #2's admission MDS assessment, dated 06/16/25, revealed the resident was a [AGE] year-old male admitted on [DATE]. His BIMS score was 3 indicating his cognitive ability was severely impaired. His diagnoses included metabolic encephalopathy (brain dysfunction caused by underlying metabolic disturbances, leading to symptoms like confusion, memory loss, and altered consciousness) and delirium (a serious change in mental abilities. It results in confused thinking and a lack of awareness of someone's surroundings). The resident required set-up assistance for ambulating. Record review of Resident #2's Care Plan, not dated, reflected:The resident was at risk for wanderingFacility interventions included:If the resident is exit seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system, etc.Record review of Resident #2's elopement assessment, dated 06/06/25, reflected the resident was severely impaired and verbalized the desire to leave the facility after his elopement on 06/05/25. The resident ambulated independently and was a new admission to the facility. Record review of Resident #2's incident report, dated 06/05/25, and completed by the DON, reflected:Resident removed plexi-glass next to exit door at the back of the unit and left facility. Police saw the resident walk down the street near the facility and brought him back. The police said they spoke to the resident and assumed that he had psychiatric issues. The police returned him to the facility. The resident was unharmed and was immediately placed on 1:1 monitoring.Record review of Resident #2's Provider Investigation Report, dated 06/05/25, reflected: Resident left facility by pushing out a window next to the exit at the back of the building. Last seen in hallway at about 8:30 PM by charge nurse. Returned to facility at 9:45 PM.Skin, trauma, pain and elopement assessments were completed. Assessments were normal. No signs or symptoms of mental or physical distress.Resident put on 1:1 observation. Maintenance repaired window and put up braces so that window could not be pushed out again. Safe surveys obtained. Residents' family, Medical Director, Compliance Nurse, DON, and Administrator contacted.Safe surveys obtained. In-services on elopement, abuse and neglect, resident rights, trauma informed care, and behavior management were given to staff.An observation on 07/17/25 at 10:30 AM revealed Resident #2 was not at the facility. The memory care unit exit doors were locked and there were no windows visible next to the exit doors.An interview on 07/17/25 at 3:15 PM with RN I revealed he had worked at the facility for a year. He said the cameras in the memory Care Unit did not work. He said Resident #2 was admitted on [DATE] between 6:30 PM -7:00 PM. RN I said that he supervised the residents in the memory Care Unit and he saw the resident at about 8:30 PM wandering up and down the halls of the Memory Care Unit. RN I said at 9:15 PM the police arrived with Resident #2. RN I said he was not aware that the resident had eloped from the facility. He said the police told him Resident #2 was found wandering around the neighborhood. RN I said he did not realize that Resident #2 was going to elope. He said when the resident returned, RN I searched the Memory Care Unit to see how the resident eloped. He said he noticed the plexi-glass window next to the back exit door was pushed out. RN I said when the resident returned, they placed him on 1:1 monitoring and did a head count and followed the facility elopement policy. RN I said the resident discharged from the facility on 06/24/25 and was on 1:1 until he discharged . He said Resident #2 did not have any further elopements and no other residents had eloped. RN I said the facility covered the windows next to the exit door with walls.An interview on 07/31/25 at 1:55 PM with CNA K revealed Resident #2 was in the Memory Care Unit when she arrived to work at 6:00 PM on 06/05/25. She said she saw him walking around the unit at 9:15 PM and the police brought him back between 9:45 PM - 10:00 PM. She said the police asked if they were missing anyone. CNA K said she did a head count and realized Resident #2 was not in his room. CNA K stated RN I described him to the police and the police brought him back into the unit. CNA K said they started searching the unit to see how he got out. CNA K said she was checking everything to see how he got past her, and she saw the window next to the back exit door was pushed out. The window was not broken or anything. He just slid out through the opening. She said Resident #2 was being supervised by her and RN I and he was constantly walking around and looking out the windows. He was placed on 1:1 monitoring when he returned to the Memory Care Unit.An interview on 07/17/25 at 2:15 PM with the DON revealed there were no other elopements after Resident #2 on 06/05/25. She said at the time he eloped, he pushed out the plexi-glass window that was next to the exit door, but the staff did not realize he had eloped until the police brought him back. She said RN I saw the resident last at around 8:30 PM.Record Review of Resident #2's 1:1 monitoring from date of elopement to date of discharge revealed he remained on 1:1 observation.Record Review of Resident #2's updated care plan, not dated, reflected:At risk for elopement or has had an actual elopement due to metabolic encephalopathy, and delirium.Resident pushed out plexi-glass on wall and stepped through it.Facility interventions: Resident to remain on 1:1 services until further notice, or until resident discharges from the facility. Window was immediately repaired so others were not at risk for leaving.Review of the facility policy, Elopement Prevention not dated, reflected: Policy StatementEvery effort will be made to prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement.The Elopement Risk Assessment will be completed upon admission. The assessment should be completed by reviewing the resident's medical history and social history. Information may be obtained by reviewing current medical records, if available, interview with resident/family, or conference with the interdisciplinary team member. The assessment tool should be completed, and interventions implemented as indicated. The Elopement Risk Assessment is to be completed at least quarterly and upon change of condition.All residents who are at risk for harm because of wandering (elopement) will be assessed by the interdisciplinary care planning team.The resident's current chart and assessments will be reviewed to determine what changes have occurred that would trigger elopement episodes.The resident's care plan will be modified to indicate the resident is at risk for elopement episodes.Interventions into elopement episodes will be entered onto the resident's care plan and medical record.Should an elopement episode occur, the contributing factors, as well as the interventions tried, will be documented on the nurses' notes. Director of Risk Management and\or Director of Nursing Services should be notified of elopement.If a resident is discovered to be missing, a search shall begin immediately. (See policy entitled Elopement Response.)Identify the cause of wanderingWandering may reflect the need to use the bathroom, relieve hunger, thirst, physical discomfort, or desire for exercise.Wandering may be an indication of worsening of confusion secondary to dehydration, infection, congestive heart failure, or medication side effects.Wandering may be in response to uncomfortable temperature, excess stimulation, sensory deprivation, or uncomfortable clothing.The wanderer may be seeking a fulfillment of unmet psychological needs by acting out a habitual routine.The wanderer may be a person who handles stress by being physically active.The wanderer may be simply unable to find his/her room or the bathroom.Intervention StrategiesReduce physical discomfort (e.g., analgesia to reduce pain, more comfortable seating, and scheduled toileting).Use personal items, family photos, or familiar objects to label resident's room clearly.Maintain familiar routines as much as possible.Schedule regular ambulation program or opportunity for exercise.Reduce excess sensory stimulation (sensory overload), decrease noise level and confusion.Use simple, clear language. Tell the resident what you want him/her to do, not what you don't want them to do. (e.g., come with me instead of don't go outside)Approach the resident in non-threatening manner.Do not confront or argue with the resident. Acknowledge the resident's concerns and gently redirect the resident.Follow the resident to see where he/she goes. If the destination is safe, consider use of volunteer companion or family member as a suitable escort.Give resident something to do that makes him/her feel useful (e.g., winding yarn or folding towels).Allow verbalization of feelings.Obtain information from family on pattern of physical activity, daily home routine, style of coping with stress, etc.Environmental ModificationAllow the resident to wander in a safe and secure setting (e.g., closed courtyard or hallway free from obstacles or stairs).Use large signs or pictures to help residents identify his/her room or bathroom.Use full-length mirrors, black doormats, or black tape grid pattern on floor to discourage demented residents from approaching doors.Use signs with large letter stating No/No Entry/Sorry, Door Closed.Use door locks that are out of reach/sight to prevent wanderers from opening doors.Use door alarms or monitoring devices to notify staff when residents try to leave the facility.Consider putting wandering residents on the same unit with a single exit near the nursing station.If applicable, consider the resident for a secured unitStress During AdmissionIdentify barriers to effective communication (e.g., hearing loss, aphasia, language barrier, dysarthria , etc.).Make sure the resident has all prescribed assistive devices (e.g., glasses, hearing aid, dentures, walking aids, etc.).Obtain information from family and friends on the resident's prior behavior, personal preferences, and routines.Determine the resident's need for assistance in mobility (transfers, gait, or wheelchair mobility) and the ability to follow and remember instructions.Consider teaming the new resident with another resident who is comfortable and oriented in the facility (i.e., the buddy system).Interventions to Reduce StressWhenever possible, maintain the resident's familiar routine.Adjust bedroom and bathroom to resident's functional capacity.Use personal items, photographs and familiar objects from home, to make the new environment less strange.Encourage visits by the family members and friends.Orient the resident to the daily routine.Allow the resident to participate as much as possible in daily decision making.Allow time for new information to be absorbed.Acclimate resident to the new environment.Provide reassurance and support. Physical PlantAll facility exits that residents have access to will have a device in place to alert staff of possible elopement attempts. Examples of these devices:Wanderguard System (locking or alarming)Placement of the residents' device to alarm the system will be verified each shift and documented on a treatment or other flow record.Function of the resident's device will be verified at least daily and documented on a treatment of other flow record.Function of the alarm system will be verified each week and documented in a maintenance log. Keypad exit magnetic locksKeyed AlarmsSecured UnitOr a combination of the aboveAll other exits not considered fire exits will be locked when not occupied by staff members.All exit devices will be maintained by the manufacturer's recommendations and function of each door device will be verified weekly and a log maintained.Staff TrainingStaff will receive training during their orientation process and then annually regarding: Elopement prevention Operation of all exit devices Actions to take if elopement occursThis was determined to be an IJ on 07/31/25. The Administrator and the DON were notified. The Administrator was provided with the IJ template on 07/31/25 at 11:55 AM.The Plan of Removal was accepted at 10:28 AM on 08/01/25 and reflected the following:Plan of RemovalProblem: Elopement InterventionsResident #2 was immediately assessed and placed on 1:1 supervision until discharged from the facility on 6/24/25.All windows on the secured unit were inspected and repaired by the maintenance director. Completed on 7/17/25All exit doors in the facility were checked by the Maintenance Director and Administrator for proper alarming and functioning. No issues were identified. Completed on 6/5/25.Elopement risk assessments for all residents in the facility were completed and reviewed by the DON/ADON/Regional Compliance Nurse on 6/6/25. Completed on 6/6/25.All residents that were determined high risk for elopement based on the assessments had their care plans reviewed and updated by DON, Regional Compliance Nurse and ADON for appropriate interventions to prevent elopement. Care plans will be reviewed and updated upon admission, quarterly, and as needed by the DON, ADON or MDS Nurse. Completed on 6/6/25.The Charge Nurse on shift will be responsible for completing elopement risk assessments on all residents upon admission, quarterly, and residents who demonstrate exit seeking behavior or verbally express the desire to elope from the facility. The resident will be placed on 1:1 supervision as delegated by the charge nurse. The charge nurse or designee will notify the administrator or DON immediately for further guidance on appropriate interventions to ensure the safety of the residents. The resident's care plan will be reviewed and updated with the appropriate interventions. Completed on 6/6/2025 and will continue indefinitely.Elopement Risk Assessments for all new admissions, quarterly assessments, and residents who demonstrate exit seeking behavior or verbally express the desire to elope from the facility will be reviewed by the Interdisciplinary Team daily during the morning clinical meeting to ensure that appropriate supervision and interventions were implemented. The administrator and DON will be responsible for ensuring that any late and/or incomplete assessments are completed immediately after the meeting. Completed on 6/6/2025 and will continue indefinitely.New Process: If there is a window or any area in the facility that needs repair and presents as an accident/hazard, staff will ensure that someone remains at the site to protect residents from harm. The administrator, maintenance director, DON or ADON will be notified immediately by the charge nurse or designee. If repairs cannot be completed immediately by the maintenance director, interventions specific to the hazard will be implemented to ensure the safety of the residents. The administrator will contact the Area Director of Operations to assist in hiring any third-party contractors to complete repairs immediately or as soon as possible. Completed on 7/17/25 and will continue indefinitelyThe Regional Compliance Nurse in-serviced the DON and Administrator 1:1 on the following policies below. Completed on 7/17/25.Abuse and Neglect: failure to repair a broken window immediately could result in a missing resident, neglect, and be a potential safety hazard to staff and residents.Elopement Prevention and Response Policies: to include properly functioning windows and doors to prevent residents from eloping or harm.Behavior Management Policy: a resident who is exit seeking or expressing a desire to elope will remain on 1:1 supervision until the Administrator or DON is notified to give further guidance to ensure the safety of the resident.New Process: If there is a window or any area in the facility that needs repair and presents as an accident/hazard, staff will ensure that someone remains at the site to protect residents from harm. The administrator, maintenance director, DON or ADON will be notified immediately by the charge nurse or designee. If repairs cannot be completed immediately by the maintenance director, interventions specific to the hazard will be implemented to ensure the safety of the residents. The administrator will contact the Area Director of Operations to assist in hiring any third-party contractors to complete repairs immediately or as soon as possible.The Medical Director was notified of the immediate jeopardy citation on 7/31/25 by

Based on interview and record review, the facility failed to ensure the transfer or discharge is documented in the medical record for one (Resident #1) of four residents reviewed for clinical records. The facility (RN A) failed to complete a Transfer/Discharge Form on 03/03/25 when he sent Resident #1 for evaluation to the Emergency Room. This failure could put residents at risk of arriving at the emergency room without information regarding their medical conditions or needs. Findings included: Record review of an undated Face Sheet revealed Resident #1 was a [AGE] year-old man admitted to the facility on [DATE]. Resident #1 diagnoses included Anemia (not enough healthy red blood cells to carry oxygen throughout the body), Hypotension (blood pressure is significantly lower than normal), End Stage Renal Disease (the kidneys have permanently lost most of their ability to function), Malignant Neoplasm of the Kidney (cancerous tumor that develops in the kidney), Ulcerative colitis (chronic inflammatory bowel disease that affects the large intestine), Cerebral Infarction (blood flow to the brain is interrupted), Type 2 Diabetes (does not produce enough insulin, resulting in high blood sugar levels), and Shortness of Breath. Record review of Resident #1's MDS assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) of 15 meaning he was cognitively intact. Under Section G, Function Status revealed Resident #1 required extensive assistance with all ADL's, except eating where he only required setup. Under Section O, Special Treatments, Procedures, and Programs revealed Resident #1 required oxygen therapy. Record review of Resident #1's care plan revised on 1/06/2025 revealed he suffered from shortness of breath. Under goal revealed [Resident #1] will maintain normal breathing pattern as evidenced by eupnea (normal, good, healthy and unlabored breathing), normal skin color, and regular respiratory rate/pattern through the review date. Under interventions included monitor/document changes in orientation, increased restlessness, anxiety, and air hunger and notify the nurse if the resident is having trouble breathing. Record review of Resident #1's care plan revised on 7/17/2024 revealed [Resident #1] has hypotension r/t Medication use (Midodrine 15mg). Some of the interventions included: Give medications as ordered. Monitor for side effects and effectiveness. Monitor vital signs as ordered and record. Report significant abnormalities to MD. Monitor/document/report to MD PRN any s/sx of hypotension: dizziness, fainting, syncope (temporary loss of consciousness that occurs when the brain does not receive enough blood flow), blurred vision, lack of concentration, nausea, fatigue, cold clammy pale skin. Record review of Resident #1's Nursing Note by RN A dated 3/3/2025 at 10:45 pm revealed [Resident #1] sent to hospital on FM's request [Family Name]. [Resident #1] was at baseline that is consistent with steady decline and low blood pressure managed with Midodrine 15 mg. In an interview on 3/5/2025 FM A stated she was not sure if Resident #1 was supposed to be on oxygen all the time. FM A stated she lived in [City] and had not seen Resident #1 in almost one year. Resident #1 stated she communicated with Resident #1 over the phone. FM A stated she did not know if Resident #1's vitals had been taken, but when the staff member entered the room, he said he had just started his shift and had not taken Resident #1's vitals yet. In an interview on 3/5/2025 at 02:00 pm with the MD, he stated the facility notified him that FM A wanted Resident #1 sent out to the hospital. The MD stated Resident #1 was mostly bed-bound with many diagnoses including, hypotension, ESRD, shortness of breath, cardiac diagnosis, etc. The MD stated Resident #1 had a guarded prognosis because there are so many medical problems. The MD stated Resident #1 was high risk for rehospitalizations and high risk for complications just due to his frequent blood transfusions and frequent infections. The MD stated Resident #1 was a colonizer of resistant organisms as well. The MD stated Resident #1 was a very high risk individual for decompensation. The MD stated Resident #1 had anemia which they are trying to figure out because he had a history of gastrointestinal leaks, but he refused colonoscopies a couple of times while in the hospital. The MD stated the only concern with Resident #1's dialysis was due to his low BP. The MD stated sometimes they were not able to dialyze him due to his BP not holding, and he was on Midodrine 15 gms to help regulate it. The MD stated Resident #1's blood pressure was a big issue because he ran low blood pressure and was on medication to keep it up. In an interview on 3/5/2025 at 2:25 pm with the DON, she stated RN A called and informed her that FM A wanted Resident #1 sent out. The DON stated when RN A assessed Resident #1, his blood pressure was low and FM A insisted he be sent to the hospital. The DON stated RN A informed her that Resident #1 was alert and oriented x 1 at the time and he was normally alert and oriented x 4. The DON stated Resident #1's blood pressure was last checked at 12:53 PM with a reading of (83/53 mmHg). The DON stated Resident #1's oxygen was PRN and his O2 must remain above 92%. The DON stated Resident #1's O2 had never been less than 95%. The DON stated Resident #1's blood pressure ranged between 83/53 mmHg and 98/56 mmHg, and sometimes 101/52 mmHg depending on the days he went to dialysis. The DON stated if the top number were over 120 mmHg and the bottom number was over 80 mmHg, they would hold the medication. The DON stated anything under those numbers, Resident #1 was administered his Midodrine 15 mg medication. The DON stated anytime a resident was sent out to the hospital, the Nurse was required to complete an eTransfer form. The DON stated if the nurse failed to do so, they would not know the exact time, reason, nor who transported the Resident if it was not documented in the nurse's notes. The DON stated her expectation was for the nursing staff to adhere to policy and complete the eTransfer Form every time a resident was sent out to the hospital. The DON stated staff was supposed to complete and print the eTransfer Form and give it to the EMTs along with the resident's face sheet, the DNR form and a list of their diagnoses and orders. The DON stated starting today (3/5/2025), they were going to make sure the eTransfer Forms were completed entirely and properly. In an interview and record review on 3/5/2025 at 3:10 pm with RN A, he stated Resident #1's blood pressure reading was 97/57 mmHg. RN A stated whenever Resident #1's blood pressure decreased, he was administered 15mg of Midodrine which in turn elevated Resident #1's blood pressure within 30 minutes. RN A stated he called 911 due to the instruction of FM A. RN A stated he called the doctor and the DON. RN A stated the facility policy says, You are supposed to send an eTransfer and the SBAR forms to the hospital. RN A stated the only thing different he would have done was adhered to policy and completed the eTransfer form. In an interview and record review on 3/5/2025 at 5:05 pm with the ADM, he stated RN A was required to complete the eTransfer Form, the SBAR Form, print Resident #1's face sheet, a list of medications and diagnosis, so the hospital could determine quickly what needed to be done. The ADM stated RN A should have completed the eTransfer Form, especially if he were sending a resident to the hospital. The ADM stated if any resident needed to be sent out, the nursing staff should have all the correct paperwork available to hand over to EMS to take with the resident. Record Review of the facility's policy, Notifying the Physician of Change in Status with a revised date of 3/11/2013 revealed, . 10. If a resident is transferred to the hospital, complete a transfer form. Record Review of the facility's policy, Documentation with a revised date of May 2013 revealed, Documentation is the recording of all information, both objective and subjective, in the clinical record of an individual resident. Goal . 1. The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets. 2. The facility will ensure that information is comprehensive and timely and properly signed. Procedure . 6. Document completed assessments in a timely manner and per policy.

Based on interviews and record review, the facility failed the have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident and determined by considering the number, acuity, and diagnoses of the facility's resident population for 2 (Resident #1 and Resident #2) of 5 residents reviewed for sufficient staffing. The facility failed to ensure the facility had sufficient staffing to meet the needs of Resident #1 and Resident #2. This failure could place the residents at risk of their needs, safety, and psychosocial well-being not being met. Findings include: 1.) Review of Resident #1's Face Sheet, dated 02/19/25, reflected she was a [AGE] year-old female, who most recently admitted to the facility on [DATE]. Resident #1 had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominate side (when a person has experienced a stroke (cerebral infarction) which has resulted in paralysis (hemiplegia) or significant weakness (hemiparesis) on the left side of their body). Review of Resident #1's MDS Assessment, dated 01/15/25, reflected she had moderate cognitive impairment. Resident #1 was identified as being dependent upon staff for toileting, showering/bathing, and dressing her lower body. Review of Resident #1's Care Plan, dated 12/04/24, reflected Resident #1 had an ADL self-care deficit and required extensive assistance for bathing/showering three times per week, as well as on an as-needed basis. Review of Resident #1's Shower Sheets from 02/06/25 to 02/18/25 reflected no evidence that Resident #1 received her scheduled showers on 02/13/25 or 02/15/25. Review of a Resident Grievance form, dated 01/31/25, reflected Resident #1 reported her call light had not been answered in a timely manner and that she would like more showers. During an interview with Resident #1 on 02/19/25 at 11:30 AM, she stated she had been having issues with both call light response time and scheduled showers. Resident #1 stated there had been times recently in which she was having to wait for hours for her call light to be answered. Resident #1 also stated that although she received her scheduled shower yesterday (02/18/25), facility staff had not been ensuring that she was receiving them regularly and as scheduled. 2.) Review of Resident #2's Face Sheet, dated 02/19/25, reflected he was a [AGE] year-old male, who most recently admitted to the facility on [DATE]. Resident #2 had diagnoses including central pain syndrome (a chronic neurological condition that affects how you feel pain) and lack of coordination (the inability to move smoothly and control your body's movements). Review of Resident #2's MDS Assessment, dated 01/14/25, reflected he was cognitively intact. Resident #2 was identified as requiring either supervision or touching assistance by staff for toileting, showering/bathing, and for positioning from sitting to standing. Review of Resident #2's Care Plan, dated 10/31/24, reflected he had limited physical mobility due to chronic pain. During an interview with Resident #2 on 02/19/25 at 2:00 PM, he stated the facility recently cut back on the number of staff they assigned to work each shift. He stated because of this, he often had to wait a long time (upwards of one hour) for his call light to be answered. He had filed a grievance regarding this issue, but there had not yet been a resolution. Review of the facility's Resident Roster, provided by the Administrator in Training on 02/19/25, reflected a current census of 41 residents. A total of 10 of these residents required 2+ staff members for ADL assistance. Review of the facility's Nurse Staffing disclosure, provided by the Interim Administrator on 02/19/25 and identified as being the facility's current staffing pattern, reflected the facility scheduled 3 CNAs to work the 6:00AM-6:00PM shift, and 2 CNAs to work the 6:00PM-6:00AM shift. During an interview with the ADON on 02/19/25 at 11:40 AM, she stated the facility recently decreased the number of staff per shift due to budgetary reasons. Prior to the decrease, there were 4 CNAs assigned to work the 6:00AM-6:00PM shift, and 3 CNAs assigned to work the 6:00PM-6:00AM shift. The facility decreased the total number of CNAs per shift by one; meaning that there were now 3 CNAs assigned to work the 6:00AM-6:00PM shift, and 2 CNAs assigned to work the 6:00PM-6:00AM shift. She stated this change required one CNA to cover both the secured unit and part of the non-secured unit on the night shift. She stated since this decrease in staffing occurred, residents had complained of not receiving timely care and missing ADL care, such as showers. Staff had complained of not being able to provide timely care, as well. The ADON stated both she and the DON acted as the facility's Staffing Coordinators. She stated she felt as though the facility needed to increase the number of staffing to ensure residents received quality care. During an interview with the DON on 02/19/25 at 12:05 PM, she also stated the facility decreased the number of staff per shift due to budgetary reasons, which went into effect on 02/10/25. Prior to the decrease, there were 4 CNAs assigned to work the 6:00AM-6:00PM shift, and 3 CNAs assigned to work the 6:00PM-6:00AM shift. The facility decreased the total number of CNAs per shift by one; meaning that there were now 3 CNAs assigned to work the 6:00AM-6:00PM shift, and 2 CNAs assigned to work the 6:00PM-6:00AM shift. She stated since this decrease in staffing occurred, residents, families, and staff had complained about staff not being able to provide timely care. There had been multiple complaints regarding call light response time. The DON stated she provided in-servicing regarding call light response time, but without increased staffing, the issue was unlikely to resolve. The DON stated she was aware that Resident #1 reported not receiving her scheduled showers. She stated review of her shower sheets indicated no evidence that she received her scheduled showers on 02/13/25 or 02/15/25. During an interview with CNA A on 02/19/25 at 12:15 PM, he stated he had worked at the facility for approximately one year. He stated following the facility's annual survey in October of 2024, the facility increased staffing as a part of their Plan of Correction. However, CNA A stated the facility had been gradually decreasing the number of scheduled CNAs since that time. He stated currently, the facility only scheduled 3 CNAs to work the 6:00AM-6:00PM shift. CNA A stated he did not feel as though the facility maintained enough staff to meet resident needs. He stated a lot of the residents at the facility required an increased amount of care, and because of the decreased number of staff available, residents did not receive timely care. He stated it could take up to an hour for a resident's call light to be answered. CNA A stated both residents and families had complained about the timeliness and quality of care, since the number of assigned staff had decreased. During an interview with CNA B on 02/19/25 at 12:24 PM, she stated she had worked at the facility for approximately seven years. She stated she did not feel as though the facility maintained enough staff to meet resident needs. She explained that over the past few weeks, the facility had decreased the assigned number of scheduled CNAs per shift due to budgetary reasons. She stated because of this, residents were receiving less quality care than they were previously receiving. She stated there were several residents who required 2+ staff assist; these residents often had to wait a significant amount of time for assistance. She stated both residents and families had complained about the timeliness and quality of care, since the number of assigned staff had decreased. During an interview with CNA C on 02/19/25 at 12:35 PM, she stated she had worked at the facility for approximately one year. She stated she did not feel as though the facility maintained enough staff to meet resident needs. She said approximately two weeks ago, the facility decreased the scheduled number of CNAs per shift. She stated due to this, she was personally responsible for providing care on both the secured unit and the non-secured unit. She stated when she was working on the secured unit, she had no idea if her assigned residents on the non-secured unit had activated their call lights and/or if they needed assistance until she completed her resident rounds (a visual check on every assigned resident) every two hours. During an interview with the Administrator in Training (AIT) on 02/19/25 at 1:00 PM, she stated she had been employed by the facility for approximately 2.5 months. She stated when she first started working at the facility, the census was around 43-44 residents. She stated currently, the census was 42 residents. She stated the facility recently decreased the number of staff per shift due to the decrease in census (per the Administrator in Training, the decrease in census was a total of 1-2 residents). The Administrator in Training stated the risk of insufficient staffing included a lack of timely care. She said since the decrease in staffing took place, she had received complaints from residents regarding the timeliness of care. She stated she was not aware of any adverse effects toward residents. During an interview with the Interim Administrator on 02/19/25 at 2:15 PM, he stated he had worked at the facility for approximately one week. He stated the facility did not have a policy and procedure related to sufficient staffing.

Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for one (Resident #1) of five residents reviewed for ADLs. The facility failed to provide showers or bed baths consistently for Resident #1 per the facility bathing schedule in February 2025. This failure placed residents who were dependent on staff for bathing at risk for poor personal hygiene, odors, and a decline in their quality of life. Findings include: Review of Resident #1's Face Sheet, dated 02/19/25, reflected she was a [AGE] year-old female, who most recently admitted to the facility on [DATE]. Resident #1 had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominate side (when a person has experienced a stroke (cerebral infarction) which has resulted in paralysis (hemiplegia) or significant weakness (hemiparesis) on the left side of their body). Review of Resident #1's MDS Assessment, dated 01/15/25, reflected she had moderate cognitive impairment. Resident #1 was identified as being dependent upon staff for toileting, showering/bathing, and dressing her lower body. Review of Resident #1's Care Plan, dated 12/04/24, reflected Resident #1 had an ADL self-care deficit and required extensive assistance for bathing/showering three times per week, as well as on an as-needed basis. Review of Resident #1's Shower Sheets from 02/06/25 to 02/18/25 reflected no evidence that Resident #1 received her scheduled showers on 02/13/25 or 02/15/25. During an interview with Resident #1 on 02/19/25 at 11:30 AM, she stated she had been having issues with both call light response time and scheduled showers. Resident #1 stated that although she received her scheduled shower yesterday (02/18/25), facility staff had not been ensuring that she was receiving them regularly and as scheduled (three times per week on Tuesdays, Thursdays, and Saturdays). During an interview with the DON on 02/19/25 at 12:05 PM, she stated she was aware that Resident #1 reported not receiving her scheduled showers. She stated review of her shower sheets indicated no evidence that she received her scheduled showers on 02/13/25 or 02/15/25. The DON indicated she felt as though this was likely due to an underlying staffing issue within the facility. A telephone interview was attempted with CNA D, who was responsible for ensuring Resident #1 received her scheduled showers on 02/13/25 and 02/15/25, on 12/19/25 at 4:07 PM. The telephone call was not returned. A policy related to ADL care, including showers/bathing, was requested but was not received at the time of exit.

Based on observations, interviews, and record review, the facility failed to notify residents or their representatives on how to file a grievance in an anonymous manner, and the information of who the facility named as the Grievance Official for 5 residents out of 5 residents interviewed for grievances. 1.The facility failed to notify Residents or their representatives either individually or through prominent postings throughout the facility on how to file a grievance or complaint in an anonymous manner. 2.The facility failed to follow their grievance policy by providing the correct information as to who the facility identified as the Grievance Official for 5 resident. These failures could affect resident's ability to file a grievance without the fear of discrimination, reprisal, retribution, and their right to request a written decision regarding the resolution of their grievance. Findings Included: Review of the document titled, [Facility Name] Grievance List, dated for 10/08/24 for the time frame of 7/1/24-8/10/24 with one resident listed as filing a grievance. Observation of entries to the facility on [DATE] at 9:25am revealed no grievance forms, or any type of container that held grievances. Interview with five residents during Resident Counsel on 10/10/2024 at 10:30 AM residents revealed they did not know how to file grievances and were unaware where any grievance forms were located. The residents stated that they did not know who to tell if they had a concern or who the grievance official was. Interview with LVN D on 10/10/24 at 11:24am revealed that she worked the 100 hall. LVN D revealed if a resident wanted to file a grievance, she would give them a form to fill out. LVN D did not have a response for what a resident would do if they wanted to fill out a grievance anonymously. LVN D could not locate any grievance forms in entry or the adjacent nursing station where she worked. Interview with the Social Worker on 10/10/24 at 1:30pm revealed if a resident or representative requested to file a grievance, the receiving staff member should document the grievance in the facility's electronic medical record system to alert the necessary department heads to follow-up or complete a facility grievance form. Interview with the DON on 10/10/24 at 1:00pm revealed the residents were told to tell someone their concern, then the staff documents the concern and gives it to the department head. The DON did not have an answer as to what a resident would do if a resident wanted to be anonymous in filing their grievance. DON stated she did not know who the grievance official was for the facility, she stated the facility did not have grievance log. In an interview with the facility's DON on 10/10/24 at 3:30pm revealed that there had been no concerns with residents being able to file a grievance or filing a grievance in an anonymous manner. Review of the facility's policy titled, Grievances dated November 2016 revealed that, the The resident has the right to voice grievances to the facility or other agency or entity that hears. grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents; and other concerns regarding their LTC facility stay. The facility will notify residents on how to file a grievance orally, in writing, or anonymously, with postings in prominent locations. Review of the Resident's Rights subsection Grievances revealed. The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents; and other concerns regarding their LTC facility stay. The facility must make information on how to file a grievance or complaint available to the resident. 47030

Based on interviews record reviews the facility failed to ensure residents in the locked memory care unit were free from involuntary seclusion for 1 (Resident #45) of 8 residents reviewed for involuntary seclusion. The facility failed to ensure Resident #45 was free from physical restraints. Facility staff placed Resident #45 in the secure unit for staff convenience. This failure could place residents at risk for a decreased quality of life, a decline in physical functioning, and injury. Findings included: Record review of Resident #45's quarterly MDS assessment dated [DATE] reflected Resident #45 was a [AGE] year-old female admitted to the facility on [DATE]. The MDS reflected Resident #45 had a BIMS score of 01 which indicated severe cognitive impairment. The resident had no behaviors. The resident's diagnoses included Alzheimer's disease and heart failure. The resident had no falls and physical restraints were not used. Record review of Resident #45's care plan , dated 04/15/24, reflected: The resident was at risk for falls. Facility interventions included: Anticipate and meet the resident's needs, keep the call light in reach and remind the resident to use it, educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. The resident is at risk for malnutrition. Facility interventions included: Resident likes to eat in dining room in secure unit. The resident did not have a care plan to be in the secure unit. An observation and interview on 10/08/24 at 10:32 AM revealed Resident #45 was in the memory care unit. She was seated at a table in the day room/dining room. She was not eating. There were other residents scattered around the room. RN D said she was the nurse for the Memory Care Unit and Hall 200. RN D said she moved Resident #45 from Hall 200 to the memory care unit so that she could watch her more closely. RN D said the resident was at risk for falls. An observation on 10/08/24 at 12:04 PM revealed Resident #45 was still seated in the same place in the memory care unit. She was not eating. An observation and interview on 10/08/24 at 12:33 PM with Resident #45 revealed she was eating lunch and said she liked the memory care unit. She said staff was respectful to her. She said she would like to stay in her room on Hall 200, but it did not really matter to her. She said the staff took good care of her. An observation on 10/08/24 at 2:00 PM revealed Resident #45 was still seated in the same place in the memory care unit. The resident was not eating. An observation on 10/09/24 at 10:00 AM revealed Resident #45 was seated in the same chair and the same table as on 10/08/24. She was not eating. An interview on 10/09/24 at 4:37 PM with the family of Resident #45 revealed she did not know the resident was being kept on the memory care unit. The family member said the resident was supposed to be on Hall 200 and she did not want the resident kept in the memory care unit. An interview on 10/09/24 at 12:28 PM with the DON revealed Resident #45 was only supposed to go to the secure unit for meals. She said the resident was not at risk for elopement and keeping her in the secure unit was a physical restraint. She said the resident did not have an order for restraints. The DON said restraining a resident on the secure unit when they were not supposed to be there could lead to behavioral problems including acting out and becoming aggressive. Record review of the facility's Abuse/Neglect policy, dated 03/29/18 reflected: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

Based on observation, interview, and record review, the facility failed to provide activities based on the comprehensive assessment and care plan, designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident for 2 (Resident #11 and Resident #38) of 4 residents on the secured unit who were reviewed for activities. The facility failed to consistently provide posted activities to Resident #11 and Resident #38 that were age/cognition appropriate, and the facility did not consistently provide encouragement and assistance to participate in any provided activities. These failures placed residents at risk of becoming apathetic (marked indifference to the environment), isolated from others, having a depressed mood, boredom, loneliness, and a decreased quality of life. Findings included: 1.) Review of Resident #11's Face Sheet, dated 10/10/24, reflected she was a [AGE] year-old female, who originally admitted to the facility on [DATE], with diagnoses including dementia (a group of symptoms that affect a person's ability to think, remember, and perform daily activities), senile degeneration of the brain (a progressive decline in cognitive function that occurs with age, often leading to memory loss and difficulty with daily activities), major depressive disorder (a serious mood disorder that affects how a person feels, thinks, and acts), and anxiety (intense, excessive, and persistent worry and fear about everyday situations). Review of Resident #11's MDS Assessment, dated 03/03/24, reflected she enjoyed listening to music, reading books, and keeping up with the news. Review of Resident #11's MDS Assessment, dated 09/27/24, reflected she had a BIMS score of 10, indicating she had moderate cognitive impairment. Review of Resident #11's Care Plan, dated 09/27/24, reflected she had little or no activity involvement due to disinterest. Goals included for Resident #11 to express satisfaction with the types of activities provided and her level of activity involvement. 2.) Review of Resident #38's Face Sheet, dated 10/10/24, reflected he was a [AGE] year-old male, who admitted to the facility on [DATE], with diagnoses including personal history of traumatic brain injury (a brain injury that is caused by an outside force). Review of Resident #38's MDS Assessment, dated 08/09/24, reflected he had a memory problem and severely impaired cognitive skills for daily decision making. Review of Resident #38's Care Plan, dated 09/25/24, reflected the following goal, .[Resident #38 will] not have feelings of isolation and will feel safe and secure in the care received while on the SecureCare Unit . Interventions for this goal included, .Engage resident in group activities and provide them with individualized meaningful projects that they will accomplish throughout the day . and .Involve resident in daily activities designed for SecureCare Unit . 3.) Review of the facility's activity calendar for the secured unit, dated October 2024, reflected the following scheduled activities for 10/08/24: 9:45AM - Music 10:15AM - Picture Art 11:00AM - Appetizer 2:15PM - Movie and Snack 3:30PM - Chit Chat Review of the facility's activity calendar for the secured unit, dated October 2024, reflected the following scheduled activities for 10/09/24: 9:45AM - Music 10:15AM - What Am I? 11:00AM - Appetizer 2:15PM - Picture Art 3:30PM - Chit Chat 4.) Observation of the secured unit on 10/08/24 from 9:20AM to 10:25AM revealed no structured activities were occurring. There were coloring sheets available for residents to utilize, but no instruction or encouragement was given to residents to participate. Resident #11 and Resident #38 were observed sitting quietly in the common area of the secured unit, not participating in any activity. During an interview with Resident #11 on 10/08/24 at 9:53AM, she stated she did not like to color. She said she liked participating in activities such as Bingo. Resident #11 did not provide any additional information about her activity preferences or participation. Observation of the secured unit on 10/08/24 from 11:00AM to 11:30AM revealed no structured activities were occurring. Observation of the secured unit on 10/08/24 from 1:30PM to 2:25PM revealed no structured activities were occurring. Resident #11 and Resident #38 were observed sitting quietly in the common area of the secured unit, not participating in any activity. Observation of the secured unit on 10/09/24 at 10:55AM revealed residents were given a coloring sheet and crayons. Resident #38 attempted to put a crayon in his mouth. CNA E told the resident to stop putting the crayon in his mouth and then took the coloring sheet and crayon from him. No alternate activities were provided for Resident #38. An interview was attempted with Resident #38 on 10/09/24 at 11:10AM; however, he was unable to participate in an interview due to cognitive impairment. 5.) During an interview with CNA E on 10/08/24 at 10:10AM, she stated activities provided to residents in the secured unit mainly consisted of coloring sheets. She said the Activity Director provided board games for staff to play with the residents as time allowed. CNA E indicated games were not often played with residents; coloring was residents' main form of activity. During an interview with the Activity Director on 10/08/24 at 2:25PM, she stated although she was responsible for creating the activity calendar for the secured unit, it was the responsibility of the nurses and aids who worked on the secured unit to provide activities for residents. The Activity Director stated she supplied secured unit staff with games and puzzles to complete with residents. She stated there were times in which she had parties for residents on the secured unit or took residents from the secured unit to Bingo on the non-secured side of the building, but for the most part, activities were supposed to be provided by secured unit staff. The Activity Director stated she previously allowed Resident #11 to participate in Bingo on the non-secured side of the building, but stopped because it was too hard of a transition for her to go back into the secured unit following the completion of the game. During an interview with the Director of Nursing on 10/10/24 at 3:29PM, she stated the expectation was for the Activity Director to provide structured activities for the residents on the secured unit. She stated prior to the survey occurring, she had not identified any issues with activities on the secured unit. The Director of Nursing stated the risk of residents not being provided individualized, structured activities included a decreased quality of life. 6.) Review of the facility's Activity Program Variety policy, dated 2019, reflected, .The Activity Director and staff will provide a variety of programs to meet the needs and interests of the residents . and The Activity Director assists the resident in maintaining, improving or stimulating his/her: 1. Physical capabilities through programs using body movement. i.e. exercise, movement to music, etc. 2. Cognitive capabilities through programs that promote the use of opinion, mental stimulation, and education. i.e. current events, trivia, discussion groups, etc. 3. Creative ability through programs of self expression, incorporating a variety of the arts. i.e. painting, drawing, crafts, drama, music, etc. 4. Social abilities and the pleasure of the company of others i.e. parties, socials, teas, etc. 5. Spiritual / Cultural interests through programs that promote practicing his/her religious and spiritual beliefs. i.e. rosary, Sunday mass, bible study, etc. 6. Hobby interests i.e. independent crafts, letter writing, etc. 7. Orientation level through current events, memory games etc. 8. Self-esteem and sense of well-being through validations, hug therapy, manicures, make-overs, back rubs, etc. 9. Community participation through local events, projects, voter registration etc .

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents, as well as that residents' environment remained as free of accident hazards as was possible, for 7 (Residents #5, #9, #11, #18, #20, #38, and #40) of 16 residents reviewed for accidents and supervision. 1.) The facility failed to ensure Resident #9 disposed of his cigarette in a safe manner on 10/08/24. Resident #9 disposed of his cigarette, which was still lit, in a regular trashcan that had other waste in it. The cigarette continued to smoke for approximately 10 minutes after it had been disposed of in the regular trashcan. 2.) The facility failed to have sufficient staff available to provide resident care and supervision for the secured unit on the 6:00AM to 2:00PM shift on 10/09/24. This failure could place residents at risk of being injured due to unsafe smoking practices. Findings included: 1.) Review of Resident #9's Face Sheet, dated 10/10/24, reflected he was a [AGE] year-old male who was admitted to the facility on [DATE], with diagnoses including dementia (a group of symptoms that affect a person's ability to think, remember, and perform daily activities), nicotine dependence (a state of substance dependence on nicotine), and lack of coordination (a condition that occurs when a person has trouble controlling their muscles, which can lead to jerky or unsteady movements). Review of Resident #9's MDS Assessment, dated 09/03/24, reflected his BIMS score was 6, indicating he had severe cognitive impairment. Review of Resident #9's Care Plan, dated 10/08/24, reflected he was identified as being a smoker. Resident #9's goals included .[Resident #9] will not suffer injury from unsafe smoking practices through the review date . Observation on 10/08/24 at 11:05AM revealed RN D took Resident #9 outside to the designated smoking area and supervised him while he smoked a cigarette. The smoking area was observed to have both a designated smoking receptacle and a regular, plastic trashcan available for use. Resident #9 was observed to smoke his cigarette without incident. When Resident #9 was finished smoking his cigarette at 11:10AM, he was observed to throw the cigarette butt in the regular, plastic trashcan that was outside. It was noted that the trashcan had other waste in it (including both paper and plastic), and the cigarette butt was still partially lit. There was smoke observed coming out of the plastic trashcan until approximately 11:20AM. During an interview with RN D on 10/08/24 at 11:17AM, she stated she was aware Resident #9 put his cigarette butt in the regular, plastic trashcan that was located outside. She stated the regular, plastic trashcan was an acceptable place for cigarette butts to be discarded. She observed the cigarette butt in the trashcan and noted that it had landed in a plastic cup (waste that had been previously thrown away) and was still smoking. RN D stated this was okay because the trashcan could not catch on fire, as it was made out of hard plastic. During an interview with the Maintenance Supervisor on 10/08/24 at 11:25AM, he stated cigarette butts were to be discarded in designated smoking receptacles. He stated these were located in the designated smoking areas and could be easily identified by being red in color. The Maintenance Supervisor stated it would not be appropriate for a cigarette butt to be discarded in any other manner, as there would be a risk of fire. The Maintenance Supervisor stated he had noted facility staff were not consistently requiring residents to discard their cigarette butts in designated smoking receptacles; he regularly spoke with staff regarding the importance of this. Review of the facility's Smoking Policy, dated 11/2017, reflected, .Ashtrays of noncombustible materials and safe design will be provided in all areas where smoking is permitted. Ashtrays will be a metal container with a self-closing cover device into which ash trays may be emptied. Ashtrays will be readily available in all areas where smoking is permitted . 2.) Observation of the facility's only secured unit on 10/08/24 reflected a total of 7 residents resided on the secured unit (Residents #5, #9, #11, #18, #20, #38, and #40). Observation of the facility's only secured unit on 10/09/24 at 11:40AM revealed there were no staff members present on the secured unit. There were five residents in the common area of the secured unit, sitting at tables but not participating in any structured activity. During an interview with CNA E on 10/09/24 at 12:07PM, she stated she was assigned to work on the secured unit during the 6:00AM to 2:00PM shift that day (10/09/24). She said she left her assigned station on the secured unit to assist a resident who did not reside on the secured unit with lunch. She stated she was advised to do this by another (unnamed) Charge Nurse; she assumed someone would have covered for her in the secured unit while she was gone. CNA E stated she was away from her assigned station on the secured unit for approximately 10-15 minutes. During an interview with the Administrator on 10/09/24 at 12:50PM, he stated he expected for a staff member to always be present on the secured unit. He said there was a lapse in communication amongst staff, which was what caused the secured unit to be temporarily without a staff member. The Administrator stated potential risks of the secured unit being improperly staffed included increased accidents, such as falls and/or resident-to-resident incidents. The Administrator stated the facility was implementing a new procedure in which a Department Head would be officed on the secured unit indefinitely, to provide a higher level of supervision on the unit. A policy related to staffing on the secured unit was requested from the Administrator on 10/10/24 at 4:02PM but was not received at the time of exit.

Based on interview and record review, the facility failed to ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for one (Resident #13) of eight residents reviewed for unnecessary medications. The facility failed to ensure Resident #13 was not prescribed to take Clonazepam and Lorazepam which are both in the same class of medication (benzodiazepines -medications that work in the central nervous system to treat various medical conditions) This failure could affect residents by placing them at risk for possible adverse side effects, a decreased quality of life and continued use of possible unnecessary medications. Findings included: Review of Resident #13's MDS assessment, dated July 31, 2024, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. The resident's cognitive status was severely impaired. His diagnoses included Alzheimer's Disease and Traumatic Brain Injury (TBI) with loss of consciousness, Unspecified Intracranial Injury Without Loss of Consciousness, Essential (Primary) Hypertension, unsteadiness on feet, Dysphagia, Oropharyngeal Phase Cognitive Communication Deficit, Muscle Wasting and Atrophy; not elsewhere classified, Multiple Sites other lack of coordination, insomnia (unspecified), Candidiasis of skin and nail, Abnormalities of Gait and Mobility, need for assistance with personal care, Mild Protein-Calorie Malnutrition, Muscle Weakness (Generalized), Anxiety Disorder (Unspecified), Personal history of other mental and behavioral disorders, Anemia, Schizoaffective Disorder, Bipolar type unspecified psychosis not due to a substance or known physiological condition, functional intestinal disorder, hypotension (unspecified). Review of Resident #13's Physician Progress Note, with a date of service of September 4, 2024, reflected Resident #13's active medications: Klonopin Oral Tablet 0.5 MG Give 0.5 mg by mouth three times a day Lorazepam Oral Tablet 0.5 MG Give 1 tablet by mouth every 6 hours as needed. Lorazepam Oral Tablet 1 MG Give 1 mg by mouth two times a day. Record review of Resident #13's Psychotropic Medication Utilization Report/Pharmacist Summary, dated 08/30/2024 reflected: o Lorazepam 1 MG, 1 tablet by mouth two times a day ordered on 5/15/2024. o Clonazepam 0.5 MG, 1 tablet by mouth three times a day, ordered on 11/17/2022, last GDR on 4/7/2024, decreased in July 2024. Record review of Resident #13's Progress Note dated 9/10/2024 reflected that Resident #13 had new order to increase Lorazepam to three times a day. An interview with the Physician on 10/10/24 revealed Resident #13 was taking clonazepam for anxiety and aggression and the resident was also taking lorazepam which also treated anxiety. The Physician said he did not think the resident needed to be taking both medications and he would adjust the resident's orders. Record review of the facility policy titled, Consultant Pharmacist, reflected: The Mediation Regimen Review (MRR) is an important component of the overall management and monitoring of a resident's medication regimen. The pharmacist must review each resident's medication regimen at least once a month to identify irregularities and to identify clinically significant risks and/or actual or potential adverse consequences which may result from or be associated with medications. The pharmacist cannot delegate the medication regimen reviews to other staff that are not pharmacists. The pharmacist's findings are considered part of each resident's medical record and as such are available to the resident/representative upon request. If documentation of the findings is not in the active record, it is maintained within the facility and is readily available for review. Procedure: d. The use of a medication in an excessive dose (including duplicate therapy) or for excessive duration, thereby placing the resident at greater risk for adverse consequences or causing existing adverse consequences; and . 3. Unnecessary drug is defined as any drug used; a. In excessive dose (including duplicate drug therapy); or b. For excessive duration; or c. Without adequate monitoring; or d. Without adequate indications for its use; or e. In the presence of adverse consequences which indicate the dose should be reduced or f. discontinued .

37028 Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for five (Resident #147, Resident #19, Resident #42, Resident #21, and Resident #30) of eight residents observed for infection control. 1. The facility failed to post proper signage and put out PPE for Resident #21 who was on enhanced barrier precautions. 2. LVN A failed to perform hand hygiene and clean the blood pressure cuff between uses for Resident #147 and Resident #19. 3. CNA B failed to perform hand hygiene while performing incontinence care for Resident #30. 4. LVN C failed to don the appropriate PPE prior to providing wound care to Resident #42 These failures could place residents at risk for healthcare associated cross contamination and infections. Findings included: 1. Record review of Resident #21's face sheet, not dated, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included stroke and diabetes. Record review of Resident #21's care plan, dated 08/12/24, reflected the resident was on enhanced barrier precautions because he had a Foley catheter. Facility interventions included: Gloves and gown should be donned if any of the following activities are to occur: linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, catheter care, bathing, or other high-contact activity. An observation on 10/08/24 at 8:48 AM of Resident #21 revealed the resident was asleep and laying in his bed. His door was open. The resident had a Foley catheter full of yellow urine. There was not a sign posted for enhanced barrier precautions and there was no PPE outside of the resident's door. 2. Record review of Resident #147's face sheet, not dated, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included end stage renal disease and diabetes. Record review of Resident #19's face sheet, not dated, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included congestive heart failure. An observation on 10/09/24 at 9:02 AM revealed LVN A was preparing to administer medications to Resident #147. LVN A put on gloves, removed the blood pressure cuff from the medication cart and took it into Resident #147's room. LVN A took the resident's blood pressure and returned the blood pressure cuff back to the medication cart. LVN A did not clean the blood pressure cuff. LVN A removed his gloves but did not perform hand hygiene. LVN A prepared and administered medications to Resident #147. LVN A did not perform hand hygiene. An observation on 10/09/24 at 9:28 AM revealed LVN A was preparing to give medications to Resident #19. LVN A put on gloves, took the blood pressure cuff off the medication cart, used it on the resident, and returned it back to the medication cart. LVN A did not clean the blood pressure cuff. LVN A removed his gloves but did not perform hand hygiene. LVN A then bagged up the trash from the medication cart and took it to the Housekeeper. LVN A did not put on gloves on perform hand hygiene. LVN A put a new trash liner in the trash can on the medication cart. LVN A then administered medication to Resident #19. After administering Resident #19's medications, LVN A washed his hands. An interview on 10/09/24 at 10:12 AM with LVN A revealed he was supposed to clean the blood pressure cuff between uses and perform hand hygiene before and after administering medications to a resident. LVN A said he thought he did perform hand hygiene when administering medications. He said cleaning equipment and performing hand hygiene was important to prevent the spread of infection. 3. Record review of Resident #30's face sheet, not dated, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Huntington's disease. An observation on 10/09/24 at 10:48 AM revealed CNA B was preparing to perform incontinence care for Resident #30. CNA B washed her hands and put on gloves. CNA B folded down the resident's brief, cleaned her peri-area, removed her gloves, went to find hand sanitizer, used the hand sanitizer, and put on clean gloves. CNA B positioned the resident and cleaned her buttocks which were soiled. CNA B folded the soiled brief underneath the resident. CNA B did not change her gloves or perform hand hygiene. CNA B used the same gloves to get new drawsheet and put down new brief. CNA B positioned the resident, removed the dirty brief with a brown-tan substance on it, and fastened the clean brief. CNA B removed the soiled linen with the same gloves and repositioned the resident's blanket back on her. An interview on 10/09/24 at 10:55 am with CNA B revealed she was supposed to change gloves and perform hand hygiene after cleaning the resident's buttocks and before putting on a clean brief. She said she did not this time, because she did not have hand sanitizer in the room. CNA B said hand hygiene was important because she was going from a dirty area to a clean area. 4. Record review of Resident #42's face sheet, not dated, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included stage IV pressure ulcer. An observation and interview on 10/10/24 at 3:13 PM revealed LVN C was preparing to perform wound care on Resident #42. The resident had signage on his door indicating PPE was required to provide care to the resident. PPE was available outside the door. LVN C entered the room without a gown. LVN C washed her hands and put on gloves. LVN C positioned the resident and removed the soiled dressings and cleaned the wounds. LVN C removed her gloves, washed her hands and left the room. LVN C re-entered the room wearing a gown. LVN C said she was supposed to have had a gown on prior to starting wound care for the resident to protect the resident from getting germs from her into his wound. She said he was on enhanced barrier precautions because he had a wound. An interview on 10/09/24 at 4:21 PM with the DON revealed staff had notified her regarding their infection control issues. The DON said Resident #21 should have had enhanced barrier protection signage posted and PPE available because he had a Foley catheter. She said she did not know why it was not posted and said maybe the signage fell . She said nursing staff was responsible for ensuring the signage was posted and the enhanced barrier protection was important to protect the resident from infection. She said staff were responsible for wearing the appropriate PPE prior to walking into a resident's room to provide care. The DON said hand hygiene was important to perform while administering medications and when going from a dirty area to a clean area while performing incontinence care. Record review of the facility policy, Infection Control Plan, dated 2024, reflected: Infection Control The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. The facility will establish an Infection Control Program under which it - Investigates, controls, and prevents infections in the facility. Decides what procedures, such as isolation, should be applied to an individual resident . Uses appropriate hand hygiene prior to and after all procedures . Ensures that reusable equipment is appropriately cleaned, disinfected, or reprocessed.

Based on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 (Resident #21) of 8 resident rooms reviewed for cleanliness. The facility failed to ensure that Resident #21's room was thoroughly cleaned. This failure could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. Findings included: Review of Resident #21's Face sheet, not dated, reflected he was a [AGE] year-old-male admitted to the facility on [DATE]. His diagnoses included dementia and diabetes. An observation on 10/08/24 at 8:48 AM revealed Resident #21 had a dirty bedside table across his bed. It looked like spilled food and drink. The resident was lying on a torn mattress. There was not a sheet on the mattress and it did not require a sheet because it was a bariatric specialty mattress. An observation and interview on 10/08/24 at 11:54 AM revealed Resident #21 was still lying in bed and was awake. He said the torn mattress with no sheet on it caused his skin to itch. He said he did not have any skin irritations. He said he did not like the bedside table being dirty and that staff did not clean it. He said he did not ask staff to clean it. An interview on 10/10/24 at 1:10 PM with the Housekeeping Director revealed he started working at the facility in August 2024 and Resident #21's mattress had been torn since he started employment, but he had not mentioned it to anyone. He said the staff were supposed to clean off his lap tray table daily. He said failure to clean the room could be an infection control issue for the resident. An interview on 10/10/24 at 3:55 PM with the DON revealed Resident #21's mattress was torn because the resident received bed baths in bed. She said the water damaged the mattress. The DON said they ordered a new mattress for the resident. The DON was asked to show the receipt for the new mattress at that time, but it was not received prior to exit. The DON said she would provide it, but never did. Record review of the facility's policy, Standard Operation Procedures For Housekeeping, reflected: Purpose: To keep facilities clean and odor free, while providing the residents, their families, and staff with the safest environment possible and projecting a positive image. Frequency: Perform all tasks daily. 2. Resident Room(s) o Each Room (including Closets)

Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 3 residents (Resident #1) reviewed for neglect reporting. The facility failed to report an allegation of neglect to the State Agency when Resident #1 sustained a serious injury. This failure could place residents at risk for not having allegations of neglect reported which could lead to injury or worsening of condition. Findings included: 1. Review of Resident #1 MDS assessment, dated July 31, 2024, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. The resident's cognitive status was severely impaired. His diagnoses included Alzheimer's Disease and Traumatic Brain Injury (TBI). Review of Resident #1's Care Plan, dated 08/07/24, reflected: o Resident has an ADL self-care performance deficit related to debility. o Resident is at moderate risk for falls related to gait/balance problems, psychoactive drug o Resident is a risk for falls, has had an actual fall with minor injury related to poor balance o Resident has laceration, 4 staples to head. Resident hit head on dresser near refrigerator in room. Review of Resident #1's Nurse Note , dated 08/09/2024 at 9:36 PM, reflected: The nurse found resident #1 in his room with head injury and bleeding noted. When asked how the incident happened, resident was unsure on how he hit his head. The note reflected the type of injury as laceration, located back of head, and 3 centimeters in size. The note reflected that resident was oriented and indicated no levels of pain. Vital signs taken. Blood pressure 105/65, temperature 97.7, pulse 89, respirations 18. Physician notified of incident. Review of Resident #1's Transfer Form, dated 08/09/2024 at 9:12 PM, reflected: Resident #1 was emergency transferred to the hospital at 8:50 PM due to head laceration. Review of Resident #1's Nurse Note , dated 8/10/2024 at 2:08 PM reflected: Resident returned from Hospital at 2:00 AM on a stretcher accompanied by two transport employees from the Ambulance service. Upon arrival resident's blood pressure was 112/69 pulse 102, respirations 18 and temperature 97.6. Oxygen saturation 92% on room air. Received report from Charge nurse at hospital, Resident had a superficial laceration on scalp with four staples, labs normal and new orders states that staples should be removed in 10 days. Resident denies pain and is up currently. An observation and interview on 10/10/24 at 10:39 AM with Resident #1 revealed Resident was playing Bingo in the dining room. Resident was observed to be well-groomed and in appropriate clean and fitting clothing. Resident was alert and willing to speak to surveyor. Surveyor asked resident if he could tell surveyor how he received staples to the back of his head. Resident said he hurt his head by falling down. He said his head hit the wall. Resident said he went to the doctor for it. An interview on 10/09/2024 at 12:40 PM with the DON revealed she was informed that Resident #1 hit his head on the dresser near his refrigerator. The DON said that there were no witnesses to the fall. She said she was not sure why this incident was not self-reported. The DON said it was determined Resident #1 fell and hit his head on the dresser because there was blood found on the dresser. An interview on 10/10/2024 at 1:00 PM with the Administrator revealed that the incident involving Resident #1 was not self-reported. He said if he had been the administrator during that time, he would have reported the incident. Review of the facility policy Reporting Events; Home Office and State, reflected: The following guidelines will be followed at this facility regarding reporting of incidents and variances that occur within the facility property. The home office, risk management and legal team will assist the facility with appropriate responses to the variance. The team approach and early intervention may prevent an event from becoming a liability for the facility. Reporting Guidelines to Home Office. The following variances will be reported immediately to the facility ADO, facility Compliance Nurse, VP of Clinical Services, VP of Risk Management, and the Chief Operations Officer. Report: 1. All hospitalization s resulting from an injury or an unusual occurrence. 51181

Based on observation, interview and record review, the facility failed to ensure that an alleged violation involving neglect was thoroughly investigated for 1 (Resident #13) of 8 residents reviewed. The facility failed to have evidence of a thorough investigation as there was no documented evidence provided of an investiation, when Resident #13 went to the hospital as a result of an injury of an unknown source that occured on 08/09/24. This failure could place residents at risk of abuse, neglect, and/or exploitation. Findings included: 1. Review of Resident #13's MDS assessment, dated July 31, 2024, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. The resident's cognitive status was severely impaired. His diagnoses included Alzheimer's Disease and Traumatic Brain Injury (TBI). Review of Resident #13's Care Plan, dated 08/07/24, reflected: Resident had an ADL self-care performance deficit related to debility. Resident was at moderate risk for falls related to gait/balance problems, psychoactive drug Resident was at risk for falls and had an actual fall with minor injury related to poor balance Resident had a laceration, 4 staples to head. Resident hit head on dresser near refrigerator in room. Review of Resident #13's Nurse Note, dated 08/09/2024 at 9:36 PM, reflected: The nurse found resident #13 in his room with head injury and bleeding noted. When asked how the incident happened, resident was unsure on how he hit his head. The note reflected the type of injury as laceration, located back of head, and 3 centimeters in size. The note reflected that the resident was oriented and indicated no levels of pain. Vital signs taken. Blood pressure 105/65, temperature 97.7, pulse 89, respirations 18. Physician notified of incident. Review of Resident #13's Transfer Form, dated 08/09/2024 at 9:12 PM, reflected: Resident #13 was emergency transferred to the hospital at 8:50 PM due to head laceration. Review of Nurses' Note, dated 8/10/2024 at 2:08 PM reflected: Resident returned from Hospital at 2:00 AM on a stretcher accompanied by two transport employees from the Ambulance service. Upon arrival resident's blood pressure was 112/69, pulse 102, respirations 18, temperature 97.6, and 92% oxygen saturation on room air. Received report from charge nurse at hospital, Resident had a superficial laceration on scalp with four staples, labs normal and new orders states that staples should be removed in 10 days. Resident denies pain and is up currently. An interview on 10/10/24 at 10:39 AM with Resident #13 revealed: Resident was observed playing Bingo in the dining room. Resident was observed to be well-groomed and in appropriate clean and fitting clothing. Resident was alert and willing to speak to surveyor. Surveyor asked resident if he could tell surveyor how he received staples to the back of his head. Resident said he hurt his head by falling down. He said his head hit the wall. Resident said he went to the doctor for it. An interview on 10/09/2024 at 12:40 PM with the DON revealed she was informed that Resident #13 hit his head on the dresser near his refrigerator. The DON said that there were no witnesses to the fall. She said she was not sure why this incident was not self-reported. The DON said it was determined resident #13 fell and hit his head on the dresser was because there was blood found on the dresser. An interview on 10/10/2024 at 1:00 PM with the Administrator, the Surveyor asked the Administrator if an investigation was conducted for Resident #13's head injury. The Administrator said there were times when he could piece together what happened without conducting a full investigation. The Administrator said there was no actual investigation for the incident, only a risk management. The Administrator stated he reported the incident to the state on 10/09/2024 after the Surveyor brought the issue to his attention. Review of the facility policy Reporting Events; Home Office and State, reflected: The following guidelines will be followed at this facility regarding reporting of incidents and variances that occur within the facility property. The home office, risk management and legal team will assist the facility with appropriate responses to the variance. The team approach and early intervention may prevent an event from becoming a liability for the facility. Reporting Guidelines to Home Office. The following variances will be reported immediately to the facility ADO, facility Compliance Nurse, VP of Clinical Services, VP of Risk Management, and the Chief Operations Officer. #26. Complete a thorough investigation. Obtain witness statements if needed as soon as possible. Forward investigation results to the facility ADO, facility Compliance Nurse, VP of Clinical Services, VP of Risk Management and the Chief Operations Officer. 51181

Based on observations, interviews, and record review, the facility failed to ensure each resident received adequate supervision and that the resident's environment remained as free of accident hazards as possible for one (Resident #1) of five residents reviewed for elopement on the facility's secured unit. The facility failed to adequately supervise, monitor, and implement interventions to prevent Resident #1 (who was assessed with severe cognitive impairment and as being at risk for elopement) from eloping from the facility unsupervised on [DATE] where he remained unaccounted for overnight. The resident was located on [DATE], 2.6 miles from the facility. The facility failed to ensure the door to the secure unit was properly functioning as the door did not fully close and/or lock consistently. On [DATE] at 5:25 p.m. an Immediate Jeopardy was identified. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a severity level of potential for more than minimal harm that is not immediate jeopardy and at a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure could place residents at risk for injury and/or death from elopement-related harm, including vehicular accidents, falls, missing medications, and extreme weather exposure. Findings included: Review of Resident #1's active physician orders dated [DATE] revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1's diagnoses included cocaine abuse, intracerebral hemorrhage (type of stroke, interruption of blood flow to a part of the brain either by a blockage or rupture of a blood vessel) and encephalopathy (encephalopathy-a group of conditions that cause brain dysfunction. Brain dysfunction can appear as confusion, memory loss, personality changes, and/or coma in the most severe form). Review of Resident #1's quarterly MDS assessment, dated [DATE], revealed he was ambulatory without the use of a device, required supervision and/or physical assistance with hygiene, dressing, and toileting. The MDS assessment reflected the resident's BIMS score was a 3 indicating severe cognitive impairment. Review of Resident #1's care plan with a review date of [DATE] revealed the resident's risk for elopement due to poor safety awareness was addressed. Goals included the resident would not leave the facility or the property unattended. The only intervention was to house the resident on the secured unit for safety. The care plan addressed the resident's elopement on [DATE] but did not include any additional interventions. Review of Resident #1's current Elopement Risk Assessments dated [DATE] and [DATE] reflected the resident had been assessed to be at risk for elopement. Observation on [DATE] at 11:20 a.m. of the secured unit entrance door located on Hall 200 revealed no code was required for entry. Entrance only required pressing the crash bar on the door. A code was required to exit and there was no alarm on the door. In an interview on [DATE] at 2:45 p.m. the Administrator stated Resident #1 exited the secured unit and eloped from the facility on the evening of [DATE]. She stated she was notified at approximately 10:00 p.m. on [DATE] that the resident was missing. The police were notified, and staff searched inside, outside the facility, and the surrounding neighborhood. The search continued through the morning of [DATE] and the resident was located at approximately 11:00 a.m. on [DATE], 2.6 miles from the facility. Resident #1 was assessed and evaluated at the hospital without injury. The Administrator stated the resident possibly exited the secured unit as staff were entering or leaving the unit without closing the door. The Administrator stated the crash bar on the door to the secured unit that leads to Hall 200 had been previously checked and according to the installer the door was functioning properly. She further stated staff had to make sure the door closed and locked when exiting and entering the secured unit. In an interview on [DATE] at 3:30 p.m. LVN A stated he was the charge nurse on duty during the evening shift on [DATE] when Resident #1 eloped from the facility. He stated he last saw the resident at approximately 6:30 p.m. sitting in the secured unit dining room. LVN A stated he went to pass medications to residents residing outside the secured unit on Hall 200 at approximately 6:00 p.m. After he completed his medication pass, he went outside for a 15-minute break and returned to the unit. He stated at the time he took his break he could not say who remained on the secured unit to supervise the residents. He stated when he heard the alarm (unable to recall what time) he did not know what the sound was and was not going to leave the residents on the unit as the evening CNA (CNA G) was late and had not arrived yet. When the evening CNA arrived (unable to recall what time) she told him the alarm was a door alarm. He confirmed he did not go check to see what door was alarming but provided no explanation when asked why he did not go check. LVN A stated he noticed Resident #1 was missing sometime around 8:00 p.m. or 9:00 p.m. The staff searched the inside and outside of the facility. After staff were unable to locate Resident #1, he called the code for missing resident (code purple) and notified the DON. All staff began searching all areas in the facility. LVN A stated while he was providing care on Hall 200 outside the secured unit it was possible that someone could have entered and/or exited the unit and not ensured the door fully closed and locked. He further stated there was no issue with the secured unit door when exiting, but when entering the secured unit from Hall 200 there was a problem with the crash bar and the door did not always automatically close or lock. He stated everyone in the facility was aware of the problem with the door to include administrative staff. LVN A stated there should always be someone on the secured unit at all times, but he had to take care of residents on Hall 200. In an interview on [DATE] at 10:18 a.m. LVN B stated she had worked at the facility since ,d+[DATE] and the door to the secured unit had always had problems of not closing and locking. She stated at times the door would close and lock and at times it would not. LVN A stated staff had to be sure to physically close the door and ensure it locked. LVN A stated two men had repaired the door earlier in the day. Observation on [DATE] at 10:26 a.m. a visitor entered the secured unit to speak with the charge nurse (LVN B). When the visitor exited the door, the door remained ajar and unlocked. The nurse immediately closed the door and the lock engaged. Observation revealed the door was still not functioning properly. Observation on [DATE] at 10:29 a.m. the DON entered the secured unit to speak with the charge nurse, LVN B. The DON left the unit without the nurse reporting that the door was still not functioning properly. In an interview on [DATE] at 10:33 a.m. LVN C was queried about how long the door to the secured unit had not been closing and locking. She stated the door had not closed and locked properly since it had been installed last year. She stated all staff were aware of the problem with the door and had reported the problem to the Administrator. LVN C further stated the Administrator told staff to always check to ensure the door closed and locked. In an interview on [DATE] at 10:38 a.m. LVN E, the charge nurse for Hall 100, stated she occasionally worked the secured unit. She was aware that sometimes the door to enter the secured unit from Hall 200 would not always fully close or lock. She stated she made sure to check the door when entering/exiting and pulled or pushed the door to ensure it closed all the way. She stated she never reported the problem with the door to the administrative staff but had informed the unit charge nurses in the past. LVN E was unable to recall when or what charge nurse she reported the problem to. In an interview on [DATE] at 10:45 a.m. CNA D stated she had worked at the facility for four days. She stated she was told by facility staff to check to ensure the door to the secured unit closed and locked. She stated she noticed the door would at times bounce back and not fully close or lock. She further stated she did not report the door because all staff seemed to be aware and had told her about the door. Review of staff training records dated [DATE] and [DATE] provided by the Administrator on [DATE]. The records reflected staff received training related to the facility's elopement policy/procedure to include what to do when a resident was missing, observed attempting to leave the facility, and what to do when a missing resident returned to the facility. The training addressed reporting, assessments, and care planning for elopement risk. Review of staff training records dated [DATE] and an undated training record revealed staff received training related to the secure unit doors remaining closed and locked at all times. Training records dated [DATE] reflected topics included the secured unit, but no information related to what was included in the training. Review of training records dated [DATE], [DATE], and [DATE] revealed the procedure for responding to door alarms was addressed. In an interview on [DATE] at 11:54 a.m. the Administrator stated she had no in-service training related to the secure unit door not closing or locking consistently. She stated she had not been informed of any problems with the door. She further stated the facility's contractor was last in the building [DATE] and he had checked several things in the facility including the door to the secured unit and it was Ok. When queried about why the contractor had checked the secured unit door, she stated the contractor was in the facility to conduct warranty checks and randomly checked other things in the facility. The Administrator stated she made rounds in the facility and had never seen any problems with the door. In an interview with the Environmental/Maintenance Supervisor on [DATE] at 12:04 p.m. revealed he had worked at the facility for approximately one month. He stated the facility's contractor visited the facility in [DATE], adjusted the latch and the tension of the closer on the secured unit door to help the door close and lock. He stated in the past several nurses and CNAs had reported to him that the door did not always close and lock properly. He stated he reported the issue to the Administrator, and the Administrator contacted the contractor. He stated there had been no other reports related to problems with the door and he had not seen any problems with the door. Review of current maintenance logs revealed they were dated from [DATE] to [DATE]. There was nothing listed in the logs related to the secured unit door. In an interview with the Environmental/Maintenance Supervisor on [DATE] at 12:28 p.m. revealed there were no additional maintenance logs other than what was provided ([DATE]-[DATE]). He stated he performed no routine checks of the secured unit doors. He only made note of issues when he saw an issue on the secured unit. In an interview on [DATE] at 12:32 p.m. CNA F stated she was on duty during the evening of [DATE] when Resident #1 eloped. She stated she was assigned to Hall 200 and arrived to work at approximately 6:30 p.m. When she entered the facility through the side door on Hall 100, she could hear an alarm sounding very low. When she entered the secured unit, the sound was louder but did not last long so she thought someone must had turned the alarm off. The charge nurse was at the desk (LVN A) on the secured unit, and she proceeded to take residents out to the patio for their 15-miunte smoke break. She stated alarms sounded in the facility often at random times. When queried about checking on the alarm she stated she thought the charge nurse (LVN A) would check on the alarm. She stated staff had reported to the charge nurses and to the Administrator multiple times that the door to the secured unit did not always close or lock and the door had been that way since she began working at the facility one year ago. CNA F further stated there were times when visitors and other residents entered the secured unit without checking to ensure the door closed and locked behind them. Observation rounds on the secured unit with Region 3 LSC Program Manager revealed the following: At 12:45 p.m. when the crash bar on the secured unit door was pushed the door opened, closed, and locked without difficulty. At 12:56 p.m. facility staff were entering and exiting the secured unit. Staff physically pushed and pulled with force to ensure the door closed and the lock engaged behind them. On [DATE] at 1:05 p.m. the LSC Program Manager informed the Administrator that the door to the secured unit should close and lock all the time and staff should not have to turn around and physically close the door. In an interview on [DATE] at 3:00 p.m. CNA G stated she worked the evening shift on [DATE] when Resident #1 eloped. She stated she had worked at the facility for one week and [DATE] was the first time she had worked on the secured unit. CNA G stated she arrived to work late at approximately 8:00 p.m. and was informed by staff that Resident #1 had possibly eloped. Staff searched all over the facility to include inside and outside. She stated some staff drove around in their cars searching for the resident. During the evening of [DATE] she saw one of the residents on the secured unit going towards the secured unit door and noticed the door was partially open. She stated she redirected the resident and closed the door. She stated she phoned the Maintenance Supervisor, told him about the door and he came to the facility. The Maintenance Director told her he had to contact the company that installed the door. She did not know how long the door had not been closing and locking. In an interview on [DATE] at 3:19 p.m. CNA H stated she had worked at the facility for three days and the only time she had worked on the secured unit was during the day shift (6:00 a.m. to 6:00 p.m.) on [DATE]. She stated she left the faciity on [DATE] at approximately 6:02 p.m. and Resident #1 was sitting in the day area. She further stated no one was on the unit with the residents when she left but as she was leaving the charge nurse (LVN A) was coming inside the facility through the front door. CNA H further stated the door to the secured unit did not always close and lock. She never reported the problem with the door to anyone because all staff were aware and had told her about the door. When queried about leaving the residents on the unit unsupervised, CNA H stated she did not feel comfortable but had to leave. She stated if she had not seen the nurse coming inside, she would have gone back to the unit. CNA H stated she did not know if the nurse went directly back to the unit. In an interview on [DATE] at 3:58 p.m. Staff I stated she was the OTA and had worked in the facility since February 2024. She stated she was working in the therapy gym on the evening of [DATE] when Resident #1 eloped. She stated she heard the door alarm sounding sometime after 6:30 p.m. but before 7:15 p.m. and the alarm had been sounding for approximately ,d+[DATE] minutes. She stated she was busy at the time but as soon as she could she went to the side door near the therapy gym where the door alarm was sounding but did not see anyone. Staff I stated she went outside, looked around but still did not see anyone. When she came inside, she saw Resident #2 in the hallway and the resident told her he saw a tall man leaving out of the side door and he believed it was a family member. She then went to the secured unit but did not see any staff. Staff I stated she did not call out to anyone but walked down the hall about halfway and did not see any staff on the unit. Staff I stated there had always been problems with the door to the secured unit closing well and she had noticed the door did not always close and lock. She never reported it because she felt administrative staff were aware as facility nurses told her about the door when she stared working at the facility in February 2024. In an interview on [DATE] at 4:15 p.m. Resident #2 stated his room was located on Hall 200 next to the side door where Resident #1 left the facility. He stated the therapy gym was also near the same door. He stated on the night of [DATE] at approximately 7:00 p.m. a tall Black man carrying a bag walked past his room and shortly after the door alarm sounded. He stated he thought the man was a visitor leaving through the wrong door by accident. Resident #2 stated a lady from therapy came out and asked if someone had gone through the door and he told her he thought it was a family member. He stated the alarm sounded for approximately ,d+[DATE] minutes before the lady from therapy turned it off. He stated he had been on the secured unit before because that was where his Hall 200 nurse was located. He had observed the door to the unit not always closing and locking. In an interview on [DATE] at 11:58 a.m. the DON stated she had worked at the facility since February 2024, and sometimes if the crash bar on the secured unit door was not hit hard enough it would not close or lock. She stated the problem with the door had existed for at least two months. The DON stated she thought she had reported the problem with the door to the Administrator sometime in [DATE]. The DON further stated the door installer had come out to check the door and he said the door was, Ok. The installer felt staff were not hitting the crash bar hard enough. She stated she had no further concerns related to the door. Staff were aware to check the door to make sure it closed and locked. In an interview on [DATE] at 12:56 p.m. the facility's Medical Director stated he was not familiar with the staffing patterns on the secured unit. When informed that the nurses and CNAs assigned to the secured unit were also assigned residents who resided outside of the unit, he stated it would be best to have one CNA designated for the unit. When queried why this would be better, he stated it would be better so that staff would not have to leave the unit to provide care. Observation on [DATE] at 1:25 p.m. revealed Resident #1 was ambulating on the secured unit speaking unintelligently to staff. In an interview on [DATE] at 1:43 p.m. medical records staff stated he was on duty and working on Hall 100 during the evening of [DATE] when Resident #1 eloped. He stated just before he heard the alarm, he saw two dietary staff going out of the side door on Hall 100 and thought they had caused the alarm to sound. He stated the alarm only sounded for a couple of minutes and someone had to have manually silenced it. In an interview on [DATE] at 6:00 p.m. The DON stated it was important that there were staff on the secured unit at all times. She stated residents on the secured unit did not have the mental capacity to make safe judgements and if no staff were on the unit to supervise the residents the residents would be at risk for harm. The DON stated it was important for the door on the secured unit to close and lock properly to prevent residents from leaving because the locked door was a safety measure put into place to maintain safety of the residents. The DON stated if the secured unit door did not close and lock properly residents could exit, get lost and be harmed. Review of the facility's policy/procedure entitled Wandering Residents/Secure Unit Resident revised [DATE] revealed every effort would be made to prevent wandering episodes while maintaining the least restrictive environment for residents who were at risk for elopement. Interventions would be entered onto the resident's care plan and medical record. The resident would be placed on the secure unit after receiving a physician's order and obtaining consent. The policy/procedure reflected if an elopement incident occurred, contributing factors would be investigated and remedied to prevent a reoccurrence. Review of the facility's policy/procedure entitled Safety and Supervision of Residents revised [DATE] revealed employees would be trained on potential accident hazards, demonstrate competency on how to identify/report accident hazards, and try to prevent avoidable accidents. Resident supervision was listed as the core component of the systems approach to safety. The type and frequency of resident supervision would be determined by the individual resident's assessed needs and identified hazards in the environment. Risk and environmental hazards included unsafe wandering. Review of the facility's undated procedure entitled Door Alarms revealed staff were to go outside and walk around the facility to check for a resident if an alarm sounded. If no resident was located outside, the charge nurse was to be notified that an alarm was going off and the outside had been checked. The charge nurse should complete a total head count of residents. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 5:25 p.m. The Administrator was informed of an IJ in the area of accidents/supervision and was provided with the IJ template via email on [DATE] at 5:28 p.m. The following Plan of Removal submitted by the facility was accepted on [DATE] at 1:25 p.m.: On [DATE] Elopement Risk Assessment completed for each resident in the facility, All residents identified to be at risk for elopement orders have been verified and secure unit placement confirmed. To remedy concerns regarding resident elopement at the facility implemented the following changes, 1. In-service for all staff initiated by the Administrator on [DATE] to educate staff on proper response to ensure resident safety when facility door alarm sounds. 2. Staff who have not signed in-service will be contacted and are not allowed to work until signatures and education is complete. 3. Administrator and Maintenance Supervisor met at facility on [DATE] after notification of missing resident. Each door was checked and worked as intended. 4. Facility implemented Policy and Procedure with specific staff instructions on guidance for Elopement Procedure if Alarm Sounds or it is identified we have a missing resident. 5. Administrator and RDO checked the following exit doors on [DATE] to ensure proper functioning of door alarm, mag lock, code alert or keypad, and push bar on Secure Unit Doors on 200, Hall Large Dining Room, and 200 Hall Secure Unit Entrance will be replaced. 6. Secure Unit Doors for 200 Hall Large Dining Room and 200 Hall Secure Unit will be continuously monitored by staff until push bars are replaced. The facility is anticipating arrival of new push bars on [DATE] in the late afternoon. Plan is to have the new push bars installed [DATE]. 7. The DON completed a head count of all secure unit residents on [DATE] at 5:40 and all residents were accounted for. 8. A new order was added [DATE] for all residents on the Secure Unit which will require visual checks along with documentation that every resident is present and accounted for on Secure Unit. The facility Medical Director was notified on [DATE]st of facility action plan and to offer any suggestions. This plan was implemented [DATE]. This action plan will be monitored through personal observation by the Administrator and verbal reports to the Regional Director of Operations. Review of in-service training material and logs dated [DATE] and [DATE] revealed education included the facility's elopement policy/procedure, maintenance logs, door alarm response procedures, and that there should be staff on the secured unit at all times. Staff were provided training related to visual checks of residents on the secured unit and new orders for all residents on the secure to document residents were present and accounted for each shift. Interviews were conducted with facility staff from various shifts on [DATE] from 5:00 p.m. to 5:45 p.m. Staff interviewed were LVN B, LVN C, CNA J, CNA K, LVN L, CNA M, LVN N, dietary aide O, and the Dietary Manager. Interviews with the staff revealed they verbalized comprehension of the in-service training. They stated they had been in-serviced on responding to all alarms to ensure resident safety, how to check the panel on the halls to determine what door alarm was sounding, conducting a resident head count, full searches inside/outside of the facility, and ensuring they searched each side of the building outside. Nurses were aware that all residents on the secured unit had new physician orders to check and ensure the residents were accounted for each shift. Staff verbalized understanding that both the CNA and nurse could not be off the secured unit at the same time under any circumstance to ensure residents were being supervised at all times. The Administrator was informed the Immediate Jeopardy was removed on [DATE] at 6:20 p.m. The facility remained out of compliance at the severity level of potential for more than minimal harm that is not immediate jeopardy and at a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observations, interviews, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment for 11 of 11 residents (Resident #1, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, and Resident #12) residing on the secured unit. 1. The facility failed to assign designated staff for the secured unit, frequently leaving Resident #1, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, and Resident #12 who were all cognitively impaired and at risk for elopement, unattended for indeterminate amounts of time when assigned staff provided care to residents in other parts of the building. 2. The facility failed to ensure staff was available to supervise residents on the secured unit when Resident #1 eloped from the facility on 04/30/24. On 05/02/24 at 10:51 a.m. an Immediate Jeopardy was identified. While the Immediate Jeopardy was removed on 05/02/24, the facility remained out of compliance at a severity level of potential for more than minimal harm that is not immediate jeopardy and at a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. These failures placed residents at risk of inadequate supervision, an unsafe environment, falls, serious harm, injury, abuse, and death. Findings included: 1. Review of Resident #1's active physician orders dated 05/2024 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included cocaine abuse, intracerebral hemorrhage (type of stroke, interruption of blood flow to a part of the brain either by a blockage or rupture of a blood vessel), and encephalopathy (encephalopathy-a group of conditions that cause brain dysfunction. Brain dysfunction can appear as confusion, memory loss, personality changes and/or coma in the most severe form). Review of Resident #1's quarterly MDS assessment, dated 03/12/24, revealed the resident's BIMS score was 3 indicating severe cognitive impairment. Review of Resident #1's care plan dated reviewed 04/30/24 revealed the resident's risk for elopement due to poor safety awareness was addressed. Goals included the resident would not leave the facility or the property unattended. The only intervention was to house the resident on the secured unit for safety. The care plan addressed the resident's elopement on 04/29/24 but did not include any additional interventions. Review of Resident #1's current Elopement Risk Assessments dated 10/26/24 and 04/30/24 reflected the resident had been assessed to be at risk for elopement. Observation on 05/02/24 at 1:25 p.m. revealed Resident #1 was ambulating on the secured unit speaking unintelligently to staff. 2. Review of Resident #3's undated Admission Record revealed the resident was an [AGE] year-old male with admitted s of 05/01/23 and 04/15/24. His diagnoses included Alzheimer's disease. Resident #3's current MDS assessment dated [DATE] reflected a BIMS score of 8 indicating moderately impaired cognition. Review of Resident #3's care plan revised 04/30/24 revealed the resident's risk for elopement was addressed. Goals included the resident not leaving the facility or the property unattended. The only intervention was to house the resident on the secured unit. Review of Resident #3's current Elopement Risk Assessments dated 04/30/24 revealed the resident had been assessed to be at risk for elopement. 3. Review of Resident #4's undated Admission Record revealed the resident was a [AGE] year-old male with an admitted [DATE]. His diagnoses included dementia (a progressive or persistent loss of intellectual functioning). Resident #4's current MDS assessment dated [DATE] reflected a BIMS score of 2 indicating severe cognitive impairment. Review of Resident #4's care plan revised 04/30/24 revealed the resident's risk for elopement due to poor safety awareness was addressed. Goals included the resident not leaving the facility or the property unattended. The only intervention was to house the resident on the secured unit. Review of Resident #4's current Elopement Risk Assessments dated 04/30/24 revealed the resident had been assessed to be at risk for elopement. Observation on 05/02/24 at 2:06 p.m. Resident #4 was ambulating on the secured unit, assisted to the bathroom by CNA M, and much encouragement was required. The CNA stated the resident was incontinent at times. 4. Review of Resident #5's undated Admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included traumatic brain injury (happens when a sudden, external, physical assault damages the brain). Resident #5's current MDS assessment dated [DATE] reflected cognitive skills for daily decision making were severely impaired. Review of Resident 5's care plan revised 05/02/24 revealed the resident's risk for elopement due to poor safety awareness was addressed. Goals included maintaining the resident's safety and interventions included housing the resident on the secured unit. Review of Resident #5's current Elopement Risk Assessments dated 04/30/24 revealed the resident had been assessed to be at risk for elopement. Observation on 05/02/24 at 2:22 p.m. Resident #5 was resting in bed and noted to be incontinent of urine. 5. Review of Resident #6's undated Admission Record revealed the resident was a [AGE] year-old female with admitted s of 02/13/24 and 02/21/24. Her diagnoses included Alzheimer's disease. Resident #6's current MDS assessment dated [DATE] reflected a BIMS score of 2 indicating severe cognitive impairment. Review of Resident 6's care plan revised 04/30/24 revealed the resident's risk for elopement due to poor safety awareness was addressed. Goals included the resident not leaving the facility or the property unattended. The only intervention was to house the resident on the secured unit. Review of Resident #6's current Elopement Risk Assessments dated 04/30/24 revealed the resident had been assessed to be at risk for elopement. Observation on 05/02/24 at 2:10 p.m. Resident #6 was ambulating on the secured unit. The resident had experienced an incontinent episode and was combative and resistant to care. 6. Review of Resident #7's undated Admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included dementia. Resident #7's MDS assessment dated [DATE] reflected the resident's cognitive skills for daily decision making were modified independence. Review of Resident 7's care plan revised 04/30/24 revealed the resident's risk for elopement was addressed. Goals included the resident not leaving the facility or property unattended. The only intervention was to house the resident on the secured unit. Review of Resident #7's current Elopement Risk Assessments dated 04/30/24 revealed the resident had been assessed to be at risk for elopement. 7. Review of Resident #8's undated Admission Assessment revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included dementia. Resident #8's current MDS assessment, dated 03/08/24, reflected the resident's BIMS score was 1 indicating severe cognitive impairment. Review of Resident 8's care plan revised 04/30/24 revealed the resident's risk for elopement due to poor safety awareness was addressed. Goals included the resident not leaving the facility or the property unattended. Interventions included the resident was housed on the secured unit for safety. An intervention dated 05/02/24 was that the resident would be present and accounted for on the secured unit. Review of Resident #8's current Elopement Risk Assessments dated 04/30/24 revealed the resident had been assessed to be at risk for elopement. 8. Review of Resident #9's undated Admission Record revealed the resident was an [AGE] year-old male with an admitted [DATE]. His diagnoses included dementia. Resident #9's current MDS assessment dated [DATE] reflected the resident's cognitive skills for daily decision making were moderately impaired. Review of Resident #9's care plan revised 03/12/24 revealed the resident's risk for elopement was addressed. The goal was that the resident would not leave the facility or property unattended. The only intervention was to house the resident on the secured unit. Review of Resident #9's current Elopement Risk Assessments dated 04/30/24 revealed the resident had been assessed to be at risk for elopement. 9. Review of Resident #10's undated Admission Record revealed the resident was a [AGE] year-old male with admitted s of 11/10/23 and 02/07/24. His diagnoses included encephalopathy. Resident #10's current MDS assessment dated [DATE] reflected a BIMS score of 9 indicating moderately impaired cognition. Review of Resident #10's care plan revised 04/30/24 revealed the resident's risk for elopement was addressed. The goal was that the resident would not leave the facility or property unattended. The only intervention was to house the resident on the secured unit. Review of Resident #10's current Elopement Risk assessment dated [DATE] revealed the resident had been assessed to be at risk for elopement. 10. Review of Resident #11's undated Admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Alzheimer's disease and dementia. Resident #11's current MDS assessment, dated 04/12/24, reflected the resident's BIMS score was 2 indicating severe cognitive impairment. Review of Resident #11's care plan revised 05/19/23 revealed the resident's risk for elopement due to poor safety awareness was addressed. Goals included the resident not leaving the facility or the property unattended. The only intervention was to house the resident on the secured unit for safety. Review of Resident #11's current Elopement Risk Assessments dated 04/30/24 revealed the resident had been assessed to be at risk for elopement. 11. Review of Resident #12's undated Admission Record revealed the resident was a [AGE] year-old female with admitted s of 11/29/23 and 06/24/23. Her diagnoses included dementia. Resident #12's current MDS assessment dated [DATE] reflected a BIMS score of 2 indicating severe cognitive impairment. Review of Resident #12's care plan revised 04/30/24 revealed the resident's risk for elopement was addressed. Goals included the resident not leaving the facility or the property unattended. The only intervention was to house the resident on the secured unit. Review of Resident #12's current Elopement Risk Assessments dated 04/30/24 revealed the resident had been assessed to be at risk for elopement. Observation on 04/30/24 at 11:20 a.m. of the secured unit entrance door located on Hall 200 revealed no code was required for entry. Entrance only required pressing the crash bar on the door. A code was required to exit and there was no alarm on the door. There was one nurse and one CNA working on the unit. In an interview on 04/30/24 at 11:20 a.m. LVN B stated there was one nurse assigned to the secured unit and one CNA. She stated she was also assigned to Hall 200 directly outside the unit and the CNA was assigned to additional residents on Hall 100 outside the unit. LVN B further stated when she left the unit to provide care on Hall 200 the CNA stayed on the unit to monitor the residents. In an interview on 04/30/24 at 2:45 p.m. the Administrator stated Resident #1 exited the secured unit and eloped from the facility on the evening of 04/29/24. She stated she was notified at approximately 10:00 p.m. on 04/29/24 that the resident was missing. The police were notified, and staff searched inside, outside the facility, and the surrounding neighborhood. The search continued through the morning of 04/30/24 and the resident was located at approximately 11:00 a.m. on 04/30/24, 2.6 miles from the facility. Resident #1 was assessed and evaluated at the hospital without injury. In an interview on 04/30/24 at 3:30 p.m. LVN A stated he was the charge nurse on duty during the evening shift on 04/29/24 when Resident #1 eloped from the facility. He stated he last saw the resident at approximately 6:30 p.m. sitting in the secured unit dining room. LVN A stated he went to pass medications to residents residing outside the secured unit on Hall 200 at approximately 6:00 p.m. After he completed his medication pass, he went outside for a 15-minute break and returned to the unit. He stated at the time he took his break he could not say who remained on the secured unit to supervise the residents. LVN A stated he noticed Resident #1 was missing sometime around 8:00 p.m. or 9:00 p.m. The staff searched the inside and outside of the facility. After staff were unable to locate Resident #1, he called the code for missing resident (code purple) and notified the DON. All staff began searching all areas in the facility. LVN A stated while he was providing care on Hall 200 outside the secured unit it was possible that someone could have entered and/or exited the unit and not ensured the door fully closed and locked. LVN A stated there should always be someone on the secured unit at all times, but he had to take care of residents on Hall 200. He stated staffing on the secured unit was always one nurse and one CNA as it was on 04/29/24 . In an interview on 05/01/24 at 12:32 p.m. CNA F stated CNAs assigned to the secured unit were also assigned to provide care to residents residing outside the unit on Hall 100. She stated staff have been asking for an extra person so that the CNA assigned to the unit could remain on the secured unit. She stated, usually the nurse, or the CNA would stay on the unit while the other provided care for their assigned residents residing outside the unit. She stated it was not always possible for there to be at least one staff on the unit at all times. She stated the CNA that worked the secured unit also took care of residents on the bottom section of Hall 100. CNA F further stated after Resident #1's elopement on 04/29/24 the assignment had changed to one CNA assigned and designated to work only on the secured unit. In an interview on 05/01/24 at 3:19 p.m. CNA H stated she had worked at the facility for three days and the only time she had worked on the secured unit was during the day shift (6:00 a.m. to 6:00 p.m.) on 04/29/24. She stated she left the faciity on [DATE] at approximately 6:02 p.m. and Resident #1 was sitting in the day area. She further stated no one was on the unit with the residents when she left but as she was leaving the charge nurse (LVN A) was coming inside the facility through the front door. CNA H when queried about leaving the residents on the unit unsupervised, CNA H stated she did not feel comfortable, but she had to leave. She stated if she had not seen the nurse returning inside the facility, she would have gone back to the unit. CNA H stated she did not know if the nurse went directly back to the unit when she saw him entering the facility. In an interview on 05/01/24 at 3:35 p.m. the Administrator stated facility staffing patterns for all shifts on the secured unit were one nurse who was also the charge nurse for Hall 200. There was one CNA who worked the secured unit and the bottom half of Hall 100. She stated the staffing pattern for the secured unit had changed since Resident #1's elopement on 04/29/24. The new staffing pattern implemented for the secured unit was that one CNA assigned would be solely designated to the unit. The Administrator further stated during a staff meeting today (05/01/24) she had reiterated the importance of there being at least one staff on the secured unit at all times for resident safety . Training records dated 09/28/22 reflected topics included the secured unit, but no information related to what was included in the training. In an interview on 05/02/24 at 11:58 a.m. the DON stated her expectation was that there should be a staff member on the secured unit at all times. The staff on the secured unit should work as a team and cover for each other when one has to leave the unit. The DON further stated staff should make alternate rounds to ensure one staff was present on the unit at all times. Her expectations included nurses making walking rounds when they arrive to work and before they leave. The DON stated there was no documented evidence, but she had verbally informed all staff of her expectations. In an interview on 05/02/24 at 12:56 p.m. the facility's Medical Director stated he was not familiar with the staffing patterns on the secured unit. When informed that the nurses and CNAs assigned to the secured unit were also assigned residents who resided outside of the unit, he stated it would be best to have one CNA designated for the unit. When queried why this would be better, he stated it would be better so that staff would not have to leave the unit to provide care . In an interview on 05/02/24 at 6:00 p.m. the DON stated it was important that there was staff on the secured unit at all times. She stated residents on the secured unit did not have the mental capacity to make safe judgements and if no staff were on the unit to supervise the residents the residents would be at risk for harm. Review of the facility's Assessment Tool dated 06/19/23 revealed staffing on the secured unit was not listed. Review of the facility's policy/procedure entitled Staffing dated revised 10/2017, revealed the facility's policy statement reflected the facility would provide sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. This was determined to be an Immediate Jeopardy (IJ) on 05/02/24 at 10:51 a.m. The Administrator was informed of an IJ in the area of sufficient staffing and the IJ template via email at 11:12 a.m. The following Plan of Removal submitted by the facility was accepted on 05/02/24 at 4:31 p.m. and reflected: On 5/2/24, the Administrator initiated in-service for all Nursing Staff that there must be a Nursing Employee (RN, LVN, or Aide) on the Secure Unit at all times. On 5/2/24 the DON changed aide assignments to ensure there is 1 Aide Staffed in the Unit at all times. On 5/2/24 the DON initiated in-service with all aides regarding new assignment that an aide must remain on Secure Unit at all times. To remedy concerns regarding Secure Unit Staffing at [facility name] the facility implemented the following changes, 1. Nursing staff who have not signed in-services will be contacted and are not allowed to work until completed 2. Administrator to monitor schedule on a daily basis during facility IDT (Interdisciplinary Team) Meeting to ensure aide is assigned at all times on Secure Unit. The facility Medical Director [physician name] was notified on May 2nd of facility action plan and to offer any suggestions. This plan was implemented May 2,2024. This action plan will be monitored through personal observation by the Administrator and verbal reports to the RDO. Review of in-service training material and logs dated 04/29/24 and 05/01/24 revealed education included the facility's elopement policy/procedure, dedicated staff assigned to the unit, coordination between the nurse and CNA to ensure there would be staff on the secured unit at all times to supervise residents. Interviews were conducted with facility staff on 05/02/24 from 5:00 p.m. to 5:45 p.m. Staff interviewed were LVN B, LVN C, CNA J, CNA K, LVN L, CNA M, LVN N, dietary aide O, and the Dietary Manager . Interviews with the staff revealed they verbalized comprehension of the in-service training. They stated they had been in-serviced on new physician orders to check and ensure and document residents on the secured unit were accounted for each shift. Staff verbalized understanding that both the CNA and nurse could not be off the secured unit at the same time under any circumstance to ensure residents were being supervised at all times. The Administrator was notified on 05/02/24 at 6:20 p.m. that the Immediate Jeopardy was removed. However, the facility remained out of compliance at the severity level of potential for more than minimal harm that is not immediate jeopardy and at a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for eight (Residents #1, #2, #3, #4, #5, #6, #7, & #8) of eight residents reviewed for infection control. The facility failed to isolate COVID-19 positive Residents #1, #2, #3, and #4 after they tested positive for COVID-19 and continued to cohort them in the same room with residents who had tested negative for COVID-19 . An Immediate Jeopardy (IJ) was identified on 10/07/21 at 6:05 PM. The Administrator was provided with the IJ template on 10/07/21 at 6:05 PM. While the IJ was removed on 10/08/21, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy and a scope of pattern because the facility was still monitoring the effectiveness of their Plan of Removal. These failures placed residents at risk for exposure to COVID-19 which could result in serious illness, hospitalization , and/or death. Findings Included : Review of Resident #1's MDS, dated [DATE], revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's MDS, dated [DATE], revealed he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's MDS, dated [DATE], revealed he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's MDS, dated [DATE], revealed he was an [AGE] year-old female admitted to the facility on [DATE]. His diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's MDS, dated [DATE], revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6's MDS, dated [DATE], revealed he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #7's MDS, dated [DATE], revealed he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #8's MDS, dated [DATE], revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility resident tracking log on 10/07/21, titled COVID+ Residents, undated, revealed, Resident #1, Resident #2, Resident #3, and Resident #4 were COVID-19 tested on [DATE] and positive test results were received on 10/06/21 . In an observation on 10/07/21 at 11:15 AM revealed the facility consisted of two halls; the 100 and the 200 hall. The Warm unit was the entire 100 hall and the COVID-19 unit was the first six rooms on the 200 hall. The following residents were roommates on the same hall: Resident #1 and Resident #5; Resident #2 and Resident #6; Resident #3 and Resident #7; and Resident #4 and Resident #8. The room doors for the shared resident's were open to the hall. There were signs informing staff how to don and doff PPE throughout the hall. There were PPE carts containing face shields and gowns located throughout the hall. There were boxes of gloves located in every room on the hall. The staff were observed wearing N95 masks, face shields, gowns, and gloves while providing care to negative and positive COVID-19 residents. The staff were observed donning and doffing PPE in between residents. In an interview on 10/07/21 at 11:21 AM with LVN A revealed there were COVID-19 positive residents cohorting with COVID-19 negative residents. She stated the night shift was informed on 10/06/21 Resident #1, Resident #2, Resident #3, and Resident #4 tested positive for COVID-19. She stated the Administrator informed her the COVID-19 positive residents would be moved to the COVID unit some time during the day. She stated she was informed by the Administrator to don and doff PPE in between each resident . She stated she did not know why Resident #1, Resident #2, Resident # 3, and Resident #4 had not been moved to the COVID unit. In an interview on 10/07/21 at 11:53 AM with the Administrator revealed Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, and Resident #8 were tested for COVID-19 in house on 10/05/06. She stated a staff member tested positive for COVID-19 and as a result all residents in the facility were tested for COVID-19 on 10/05/06. She stated Resident #1, Resident #2, Resident #3, and Resident #4 tested positive for COVID-19 on 10/06/21. She stated Resident #5, Resident #6, Resident #7, and Resident #8 tested negative for COVID-19 on 10/06/21. She stated Resident #5, Resident #6, Resident #7, and Resident #8 would be retested for COVID-19 due to exposure on 10/08/21 . She stated all the residents in the facility are tested on ce a week in house for COVID-19. She stated all staff are tested twice a week in house for COVID-19. She stated the facility has a COVID unit and warm hall. She stated the facility was in the process of moving Resident #1, Resident #2, Resident #3, and Resident #4 to the COVID unit, but she was preoccupied with other facility tasks. She stated Resident #5, Resident #6, Resident #7, and Resident #8 would remain on the warm unit. She stated COVID-19 positive residents were to be moved to the COVID unit within 2 to 4 hours of receiving positive test result. She stated the residents' COVID-19 test results were received around 10:00 PM on 10/06/21. She stated she informed staff COVID-19 positive residents were to remain in their current rooms and would be moved to the COVID unit in the morning . She stated the facility needed to expand the size of their current COVID unit to accommodate Resident #1, Resident #2, Resident #3, and Resident #4. She stated she directed staff to wear face shields, N95 masks, gloves, and gowns with all residents and to change PPE in between residents . Review of the facility's policy on 10/07/21, titled COVID-19 Suspected or Confirmed In-House, undated, revealed, A resident with known or suspected COVID-19, immediate infection prevention and control measures will be put into place. Immediate isolation with PPE is set up for suspected or confirmed cases. Cohort residents identified with same symptoms/COVID-19 confirmation if a private room is unavailable. The Administrator was notified on 10/07/21 at 6:05 PM an IJ situation was identified due to the above failures and an IJ template was provided. The Plan of Removal was accepted on 10/08/21 at 1:32 PM and reflected : The following is a plan of removal, which has been immediately implemented at [facility name], to remedy the immediate jeopardy regarding infection control which was imposed on 10/7/2021. Immediately: To correct the negative finding regarding cohorting of negative COVID and positive COVID residents *All COVID positive residents were reviewed for correct isolation placement according to policy and procedure. *All COVID positive residents were moved to the hot zone-hall 200. *A complete census was reviewed 10/7/21 according to current COVID lab result for isolation *All negative COVID residents on hall 100 were reviewed to ensure correct placement according to [lab provider] diagnostic lab result. *Current staff in the facility were in-service immediately regarding isolation protocol, PPE, a positive COVID result for immediate isolation, and hand washing. These in-services continue for future on-coming shifts. *To prevent future occurrence of the negative finding the facility will follow the current isolation policy and procedure regarding co-horting of residents. Hall 200 (hot zone) has been designated as the COVID positive hall for all COVID positive residents. 1. All COVID positive results will be reviewed by the administrator, Regional Director of Operations and the Corporate nurse via [lab provider] lab portal and correlated with the current census to review room placement. This will be completed 10/7/21 by 12:00 a.m. 2. All COVID pending results will be monitored by the administrator pending completion for a direct phone call to the corporate nurse. [Lab provider] was contacted on 10/7/21 at 9:00 p.m. by the administrator regarding this process. 3. An in-service regarding [facility name] policy and CDC guidelines will be presented by the corporate nurse and the current administrator pertaining to infection control and isolation protocol. This will be completed with all nursing staff including PRN and agency nursing. The in-service will begin 10/7/21 and resume until all oncoming shifts are completed. All PRN staff and staff that are not assigned to upcoming shifts will be completed 10/8/21 by 5:00 p.m. All nursing staff for the current shift will be in-serviced immediately regarding positive COVID results and isolation criteria. Those staff that are unable to attend the infection control in-service regarding isolation protocol will receive the training prior to accepting assignment at [facility name]. These staff will not be able to work in the facility until completion. This process will be monitored and completed by the current administrator and corporate nurse. *[Online training program name] Training will be assigned Infection Control: Isolation Course Description-An important part of preventing the spread of infection from one resident to others is the proper placement of residents within the facility. Early detection of infections and isolation of residents minimizes the risk of transmission and the prevention of an outbreak. This course discusses the guidelines for the use of isolation and provides examples of isolation types for specific diseases. It also discusses how cohorting works in infection prevention. You will learn that without the use of isolation and cohorting of residents, infections can spread, causing adverse treatment outcomes. The goal of this course is to educate nursing professionals in long-term care facilities on the use of isolation and cohorting to help prevent the spread of infections. This course includes a competency knowledge check. This [online training program name] training will be assigned to all nursing staff for completion 10/8/2021 and required completion will be mandated before accepting next assigned shift. This process will be monitored for completion by the current administrator and corporate nurse until all nursing staff are completed. 4. All facility staff including PRN and agency will be in-serviced by the corporate nurse regarding PPE utilization during an outbreak according to CDC guidelines starting 10/7/21 at 8:30 pm and will continue until 10/8/21 at 5:00 pm. Those staff that are unable to attend the infection control in-service regarding PPE utilization will be completed before accepting assigned shift. This process will be monitored by the administrator and corporate nurse. https://www.cdc.gov/coronavirus/2019-ncov/hcp/using-ppe.html *Return demonstration regarding PPE will be used to determine competency. 5. All facility nursing staff including PRN and agency will be in-serviced by the corporate nurse regarding hot, cold, warm zones within a facility and preventing the spread of infection per current policy. This in-service will begin on 10/7/21 and continue until 10/8/21 at 5:00pm for completion. Those staff that are unable to attend the infection control in-service regarding PPE utilization will be completed before accepting assigned shift. Staff will be required to complete this before being allowed to work in the facility. This process will be monitored by the administrator and corporate nurse. 6. Any negative findings by the lab will be immediately reported directly to the administrator for immediate correction/action. 7. All residents identified as sharing a room with a COVID positive resident lab result 10/6/21 at 9:35 p.m. will be tested [DATE] and will be monitored for signs and symptoms of COVID-19 every 4 hours until lab result obtained . Q 4 hour monitoring will continue during outbreak status for all residents. 8. [Lab provider name] was telephone on 10/7/21 at 9:00 pm and informed to immediately notify administrator regarding lab results for the next 90 days. [Lab provider name] will still be required to alert the current charge nurse for the resident of result as well. This will be evaluated by the IDT at the end of the 90 day period for further duration need. 9. The administrator at [facility name], the corporate nurse for [facility name], and the regional director for [facility name] are responsible for monitoring the completion of this POR. The Medical Director was initially made aware of the immediate jeopardy 10/7/21 at 7:15 p.m. while in the facility and has been involved in the development of the plan to remove. These conversations are considered a part of the QA process. To monitor for compliance the Administrator and/or designee will continue lab result review daily in addition to [lab provider name] calls. The IDT will continue weekly meetings especially during facility COVID outbreak and/or as needed to discuss any changes in a resident's status, COVID pending results, and COVID positive results. Members of this meeting are to include the Administrator, Corporate Nurse, Assistant Director of Nursing, MDS Coordinator, and Regional Director of Operations. Any negative findings will be forwarded to the Administrator and the QA committee. This plan was initially implemented 10/7/2021 and will be monitored through completion by corporate and regional staff. Plan of Removal completion date is 10/8/2021. Monitoring of the plan of removal revealed : In an observation on 10/08/21 at 9:00 AM revealed the facility moved all COVID-19 negative residents to the Warm unit on the 100 hall and moved all COVID-19 positive residents to the COVID unit on the 200 hall. Review of Resident #1's, #2's, #3's, #4's, #5's, #6's, #7's, and #8's NAR, dated 10/01/21 to 10/31/21, revealed the residents were being monitored for chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, or diarrhea every shift (Day, Evening, and Night) for COVID-19 screening. Review of Resident #1's, #2's, #3's, #4's, #5's, #6's, #7's, and #8's nursing progress notes, dated 10/07/21 to 10/08/21 revealed the residents were being monitored for signs and symptoms of COVID-19. Review of the facility's in-service on 10/07/21 and 10/08/21, titled Inservice Sign-in, dated 10/07/21, revealed, staff were educated on COVID-19 active case policy and procedure, definitions for policy interpretation, HHSC reporting process, isolation categories, standard precautions, PPE donning and doffing, and hand hygiene. Interviews conducted from 10/07/21 to 10/08/21 with staff across all shifts (6:00 AM to 2:00 PM, 2:00 PM to 10:00 PM, and 10:00 PM to 6:00 AM), included with ADON, RN C, LVN A, LVN B, LVN K, CNA D, CNA E, CNA F, CNA G, CNA H, CNA I, and CNA, J. Staff confirmed they received in-service training on 10/07/21 and 10/08/21 to include training on: - Hot, cold, warm zones within a facility and preventing the spread of infection per current policy; - PPE utilization during an outbreak according to CDC guidelines; - Return demonstration regarding PPE will be used to determine competency - [Facility name] policy and CDC guidelines pertaining to infection control and isolation protocol; - Positive COVID results and isolation criteria; - Notified on 10/08/21 to complete online training program; - Hand hygiene; and - HHSC reporting process. Interview with the Administrator on 10/08/21 at 3:10 PM revealed the IJ occurred because the infection control policies and procedures were not followed. She stated she observed staff and residents while walking around the facility. She stated she walked around the facility several times a day. She stated she had staff complete competencies regarding infection control such as quizzes, exams, and return demonstrations. She stated the corporate nurse completed the staff competences and return demonstrations. She stated she supervised administrative staff by completing competencies with return demonstrations, having constant communication, and having administrative staff follow up with their department staff . She stated to prevent the occurrence of another IJ, staff were in-serviced on the facility COVID-19 plan and the size of the COVID unit was increased to prevent the delay of isolating COVID-19 positive residents. An Immediate Jeopardy (IJ) was identified on 10/07/21 at 6:05 PM. While the IJ was removed on 10/08/21 at 1:32 PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of pattern because the facility was still monitoring the effectiveness of their Plan of Removal.

Based on interview and record review, the facility must ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (Resident #1) of five residents reviewed for change of condition. The facility failed to assess, monitor or treat a wound to Resident #1's left toe based on the physician's recommendation. Resident #1's wound became infected and resulted in a partial amputation of her toe. An Immediate Jeopardy (IJ) was identified to have occurred from 10/13/20 to 10/23/2020. This was determined to be a Past Noncompliance IJ due to the facility having implemented actions that corrected the noncompliance prior to the investigation. This failure placed residents at risk of not receiving the necessary care and services which could lead to infection, serious illness, hospitalization , or death. Findings included : Record review of Resident #1's electronic record face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's care plan, undated, revealed she had actual impairment to skin integrity related to decreased mobility, poor circulation and incontinence. Interventions were to: Follow facility protocols for treatment of [REDACTED]. Review of Resident #1's skin assessment on 10/18/20, completed by LVN D, indicated the resident did not have any skin issues (though the wound on the toe was identified on 10/13/20). Resident #1's skin assessment on 10/23/20 indicated there were two pressure areas to the resident's left great toe that-measured 1.2 X 0.3 X 0.5 and 4 X 3 X 0.7 Review of Resident #1's electronic nurses notes revealed the following entry by LVN A related to the resident's wound: 10/23/2020 at 11:02 Late Entry: 10/13/2020 Nurse was informed by podiatry Dr. that during podiatry visit resident noted to have a opening to top of left great toe, nurse took resident to room to assess and upon assessment resident presented with what appeared to be a shearing on top of great toe, nurse applied dressing to prevent rubbing against sock, c/o pain to lower extremity during position but no c/o pain when dressing applied to toe, physician to be notified for orders. Review of Resident #1's electronic nurses notes revealed the following entry by the ADON related to the resident's wound:: 10/23/2020 at 10:35 Late Entry: Nurse was called to shower room r/t resident has an area to left foot. Entered shower room to assess resident. Resident lying on shower cart. Assessed resident and noticed that resident had an area to left great toe. Open area to left great toe with drainage noticed. # 1 1.2 x 0.3 x 0.5 # 2 4 x 3 x 0.7. Immediately notified DON and MD. New order as follows Keflex 500mg one capsule po bid x 14 days. Acidophilus one-tab po bid r/t wound. Vitamin C one-tab po qd. Clean left great toe with NS pat dry apply collagen sheet qd until resolved. MAR and TAR updated. Family attempted to be notified. No success. Will continue to notify family member. In an interview with LVN A on 10/28/20 at 11:02 AM she stated she took care of Resident #1. LVN A stated Resident #1 was alert and oriented to person and place and she was able to voice her needs. She stated Resident #1 was non-ambulatory and needed assistance by two staff with transfer. LVN A stated Resident #1 had shearing on the toe on 10/13/20, she noted the shearing when the podiatrist made a visit and informed her. LVN A assessed Resident #1's toe on 10/13/20 and the top of the toe was open from the shear and blood was on to the sock. LVN A cleaned the area and she applied a dressing. LVN A stated the podiatrist informed her to monitor the area on the toe and if it got worse to notify the physician. LVN A stated she was to assess Resident #1's left toe every shift, with the other charge nurses. LVN A stated she only verbally informed the 2:00 PM-10:00 PM charge nurse of Resident #1's toe wound. She stated she did not document the wound or the Podiatrist's instructions in the 24 hour report or in the resident's chart. LVN A stated she did not inform the ADON, DON or the primary care provider. LVN A stated she did not know if the 2:00 PM-10:00 PM nurse monitored Resident #1's toe.The LVN A stated she monitored the shear for 2-3 days after it was first noted and it appeared to be the same. She stated the wound had some redness and swelling on the toe, but normally Resident #1 had some swelling on the leg. Resident #1 did not complain of pain to the left toe. LVN A stated she changed the dressing on the left toe but she did not have the order for the dressing change because she had not notified the primary care provider. LVN A stated she stopped monitoring the left toe after three days. She stated she just dropped the ball. LVN A stated she worked from 10/13/20 -10/16/20, was off from 10/17/20 -10/18/20 and then worked again from 10/19/20-10/21/20. She stated she did not assess Resident #1's toe from 10/19/20-10/21/20. LVN A stated the left toe could have gotten worse if it was not assessed as recommended and if it needed dressing changes. LVN A stated there was a possibility of the left toe getting infected due to proper measures not being put in place. LVN A stated she failed to notify the primary care provider to receive orders for the treatment of [REDACTED].#1's condition change she was supposed to notify the responsible party, the primary care provider and DON/ADON. LVN A stated she was supposed to document the condition of the toe after assessment on 10/13/20 in Resident #1's chart. She also stated she was supposed to document in the 24 hours report book, so all the charge nurses would be aware of the toe condition and be able to monitor. In an interview with LVN D (2-10 charge nurse) on 10/28/20 at 2:15 PM, she revealed she took care of Resident #1. She stated Resident #1 required total assistance with activities of daily needs. LVN D stated the charge nurses completed skin assessments weekly. LVN D stated she completed the 10/18/20 skin assessment on Resident #1. LVN D stated Resident #1 had socks on and she did not take them off to assess Resident #1's feet. LVN D stated she failed to assess the skin per facility policy. She said she was supposed to assess all the skin. She stated she did not take time to take off Resident #1's socks to assess the feet and missed assessing Resident #1's toes. LVN D stated LVN A had verbally informed her the podiatrist had completed foot work on Resident #1, but she could not remember the date. She stated LVN A didn't say the resident had any issues to her left toe. LVN D said she was not aware of the condition of Resident #1's left toe and she had not seen the toe. She stated Resident did not complain about the left toe. LVN D stated the expectation was if there were any skin issues the charge nurse was to notify the ADON, DON, PCP, RP, and document the skin condition. LVD D stated her failing to assess the skin correctly might have caused her to miss skin issues and if there were any skin issue, it might have gotten worse. She stated if the skin assessment was done correctly the issues could have been addressed before they got worse. LVN D stated if wound care was not addressed timely, it would lead to infection, necrosis [MEDICAL CONDITION]. In an interview with CNA C on 10/28/20 at 11:51 AM, she stated she completed showers for the whole facility. She stated Resident #1 needed total assistance with showers and was transferred with a Hoyer lift. Resident #1 had showers on Monday, Wednesday and Friday. CNA C stated she had noted a sore to Resident #1's left toe about three weeks ago and she reported it to LVN A. LVN A assessed Resident #1's toe and put a dressing on the toe. She stated the toe was swollen, the top of the toe was open (dime size) and the wound bed was pink. CNA C stated every time the she took the resident to the shower she had a dressing on the left toe. CNA C stated on 10/23/20 she was giving Resident #1 a shower when the dressing on the left toe came off, she could not remember if the dressing was dated. CNA C stated the left toe was swollen and had a wound and that was the reason she notified the ADON. CNA C stated after the resident developed the wound on her toe she would complain of the left toe hurting. She stated Resident #1 would say don't touch my toe because it is sore. In an interview on 10/28/20 at 10:44 AM, the ADON revealed Resident #1 was alert and oriented and she was able to voice her needs. The ADON stated skin assessments were completed weekly by the charge nurses. The ADON stated she was seated at the nurse's station (on 10/23/20) around 10:15 am when CNA B came to her and asked her to go look at Resident #1's toe. Resident #1 was in the shower room. The ADON assessed Resident #1's left toe and noted redness, swelling, an open area to the tip of the toe, the toe nail was not there, and a small amount of clear drainage. Resident #1 did not complain of pain to the toe. The ADON stated the toe had signs and symptoms of infection because it was swollen, warm to touch and had drainage. The ADON stated she informed the DON and the resident's primary care physician. The primary care physician gave orders for a doppler study, antibiotics and to clean the left toe with normal saline and apply collagen sheet daily until healed. The initial antibiotic dose was administered at 1:00 pm on 10/23/20 and wound care treatment was completed. In an interview on 10/28/20 at 1:43 PM with the DON, she revealed on Friday (10/23/20) CNA C reported Resident #1's swollen left toe to the ADON. The DON stated she and the ADON assessed Resident #1's left toe and noted the toe was slightly red, swollen and a dark spot was noted to the tip of the left toe. She stated Resident #1 did not complain of pain and the left toe was a little warm to touch, it did not have drainage. She stated the size of the wound was approximately less than dime size. She stated the primary care provider was notified of Resident #1's toe and he ordered stat labs, antibiotic and a stat Doppler. The facility followed up with the doppler company and were informed the earliest the doppler study could be completed was 10/26/20. The facility transferred Resident #1 to the local hospital for evaluation, as ordered by the primary care physician. The DON stated when she interviewed LVN A regarding the incident, LVN A stated she was aware of the open area on Resident#1's left toe as of 10/13/20. Per the podiatrist recommendation the facility was to observe the Resident #1's left toe and if there were any changes to the toe, the facility was to report to the primary care provider or podiatrist. The DON stated she reviewed Resident #1's chart and it indicated the staff did not monitor the Resident #1's left toe. She stated monitoring consisted of documenting any changes, notifying the wound care nurse (ADON), notifying the responsible party and the primary care provider. The DON stated from 10/13/20- 10/23/20, there was no indication the staff knew the status of Resident #1's left toe. The DON also stated the staff failed to complete an accurate full skin assessment on 10/18/20 as the skin assessment indicated the resident did not have any skin issues. The DON stated she believed the skin issues that were identified on 10/13/20 could have gotten worse if proper measures were not put in place. The DON expected the staff to report the issues on 10/13/20 and put measures in place to ensure the wound received wound care treatment per primary care provider. She stated lack of proper measures led to partial ambulation of Resident #1's left great toe. DON stated, failure of LVN A to follow the podiatrist recommendations and follow facility protocol on the treatment of [REDACTED]. In an interview on 10/28/20 at 10:00 AM the Administrator stated he was made aware of the incident on 10/23/20. It was reported on 10/23/20 the podiatrist came to see the residents in the facility and Resident #1 was seen too. The Podiatrist gave recommendations for the staff to monitor Resident #1's left toe and if there were any changes to notify her primary care provider or the podiatrist. LVN A did not document the conversation with the podiatrist in Resident #1's chart or the 24-hour report book. On 10/23/20 CNA C took Resident #1 to the shower and took off her socks. She noted Resident #1's left toe was swollen and looked infected. CNA C reported the incident . The Administrator stated Resident #1 was transferred to the local hospital after a doppler study was not able to be completed in the facility timely. The Administrator stated the hospital where Resident #1 was admitted called the facility and reported Resident #1 was diagnosed with [REDACTED]. The Administrator stated per facility protocol LVN A was supposed to notify the ADON/DON, responsible party and the primary care provider of Resident #1's change of condition and document in the resident's chart, and all the charge nurses were to monitor the residents toe. If there was a change of condition the charge nurse was supposed to notify the DON, primary care provider and the RP. He stated Resident #1 was supposed to receive appropriate care to prevent major complications. In an interview with the Podiatrist on 10/28/20 at 3:21 PM, she stated she assessed Resident #1's feet on 10/13/20. She stated Resident #1 was diabetic and her feet required trimming by the podiatrist. She stated she assessed Resident #1's left toe and noted [MEDICAL CONDITION] on the tip of the left toe and medial area. The Podiatrist stated the toe was not draining but looked like it needed a type of dressing because the [MEDICAL CONDITION] were not dry. She stated she asked if Resident #1 was being followed by a wound care consult. The podiatrist stated she needed the area to be monitored because it was a pressure area and due to the open [MEDICAL CONDITION]. She stated failure of the facility to provide the resident care and services needed could have led to the left toe being infected and other problems and major complications such as bone infections. In an interview with Resident #1's primary care provider on 10/29/20 at 4:03 PM, he stated he had not been in the facility for about three and half weeks because he was not feeling well. He stated he took care of Resident #1 and he was not aware of the her having any skin/wound issues until 10/23/20. He stated the facility called him and informed him of Resident #1's swollen left toe and wound on the toe. He stated he ordered some labs and antibiotic medications. He stated if Resident #1 had any skin issue/wound the staff were to notify the wound care doctor and wound care team, so they could have addressed the issue in a timely manner and documented the progress of the wound. He stated failure of the facility to complete wound care per orders or recommendations would be a violation of duty and the wound would be infected. Review of the facility policy Revised June 2005 titled Change in a Resident's Condition or Status, reflected, The facility shall notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's condition and /or status . 3. Except in medical emergencies, notifications will be made within twenty -four (24) hours of a change occurring in the resident's condition or status . 5. A nurse will record in the resident's medical record any significant changes in the resident's symptoms or medical condition or status. Policies and procedures governing assessment, charting, and documentation are covered in the other policies. Review of the facility policy, undated and titled Weekly Skin Assessment Policy, reflected, .1. Head to toe assessment to be performed weekly by Charge Nurse with the assistance on Nurse Aide if necessary. 2. The Physician will be notified by fax and/or telephone of any skin issues and will be documented in the Resident's chart. 4. Treatment protocol will be initiated until Wound Care Nurse is notified and assumes care. 5. The Wound Care Nurse will be notified as soon as practicable of skin issues and measurements. Wound Care Nurse will assess, document, review treatments and recommend subsequent treatment changes. 6. All Residents at risk for skin issues, including dehydration, shearing, and skin tears will be monitored closely and preventative measures will be implemented, including but not limited to; heel protectors, elbow protectors, arm sleeves, therapeutic mattress, wheelchair cushions, heel floats, turning/repositioning a minimum of every two hours, dietary and medication interventions, referrals to dietician, Wound Care Consultant, Physical & Occupational Therapists if deemed necessary. The facilities action plan to address the deficient practice included the following: Assessed Resident #1 and notified the primary care provider and initiated treatment In-serviced nursing staff on wound care / Skin assessments on 10/23/20 In-serviced nursing staff on Reporting issues to the primary care provider and responsible party on 10/23/20 In-serviced nursing staff on obtaining wound care orders on 10/23/20 In-serviced nursing staff on weekly head to toe skin assess and follow up on 10/23/20 Facility competed one-on-one in-service with the staff involved (LVN A and LVN D) 100% Skin assessment on 10/23/20 on all the residents in the facility, and no new skin issues was noted Facility Monitoring; Making sure skin assessments were completed and reviewed to be completed by ADON/DON Scheduling skin assessments on specific days to be completed by ADON/DON Random checks on the resident skin, especially the ones who were bed bound to be completed by ADON/DON Interviews on 10/28/20 - 10/29/20 with staff nurses representing multiple shifts revealed they had received training in skin assessment and acknowleged understanding on weekly head to toe assessment, wound care, reporting of change in condition to the primary care provider and obtaining wound care orders. Interviewed staff included LVN A, ADON, DON, LVN D, CNA C , CNA B, CNA D and the Administrator. An Immediate Jeopardy (IJ) was identified to have occurred on 10/13/20 to 10/23/20. This was determined to be a Past Noncompliance IJ due to the facility having implemented actions that corrected the noncompliance prior to the investigation.

Based on observation, interview, and record review the facility failed to ensure residents had the right to be free from involuntary seclusion for one (Resident #1) of three residents reviewed for isolation. The facility failed to ensure Resident #57 was not involuntarily secluded by remaining on contact isolation for an extended period of time after she was no longer showing signs and symptoms of [MEDICAL CONDITION] (c. diff) or was to have completed the antibiotic. Resident #57 suffered emotional distress due to the extended seclusion. This failure placed residents at risk of unnecessary isolation, leading to a decreased quality of life, low self-esteem, and distrust of staff. Findings included: Review of Resident #57's face sheet, dated [DATE], revealed she was a [AGE] year-old female originally admitted to the facility on [DATE], and readmitted [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #57's reentry MDS assessment, dated [DATE], revealed the resident had clear speech, could understand others and could be understood by others, and her cognition was moderately impaired. Resident #57 required extensive assistance with bed mobility, transfers, eating, toilet use, and personal hygiene. The MDS assessment reflected Resident #57 required total assistance with dressing and bathing. The MDS assessment further reflected Resident #57 was on isolation while not a resident and while a resident at the facility. Review of Resident #57's hospital records, with a print date of 12/09/19, revealed she was in the hospital 11/25/19 through 12/09/19. The records reflected Resident #57 was positive for [DIAGNOSES REDACTED] and was to continue on [MEDICATION NAME] until [DATE]. Review of the after visit summary notes, printed on 12/09/19, reflected Resident #57's medication list which included [MEDICATION NAME] 25 mg/ml solution, 5 ml four times a day, for 10 days. Review of Resident #57's Progress Notes (department notes) revealed, RN B documented on 12/09/19 at 6:53 PM the resident arrived at the facility from the hospital with an admitting [DIAGNOSES REDACTED].#57 tested positive for [DIAGNOSES REDACTED] prior to return and was on [MEDICATION NAME] 25 mg/ml solution. She was to take 5 ml by mouth four times a day for 10 days. The physician was notified, and the medications were verified. Review of Resident #57's Progress Notes (department notes) revealed the SW documented on [DATE] at 6:33 PM he spoke to the resident in reference to her being on isolation. The SW explained to Resident #578 why she was on isolation, which had been explained to her by nursing staff. The resident told the SW she felt closed in. The SW suggested to the resident that during the day she could ask the aide or nurse to open her blinds to let in the sunlight. The SW also explained to the resident that staff would be completing 30-minute checks to ensure that any needs she had would be met. Review of Resident #57's Progress Notes (department notes) revealed the AD documented on [DATE] at 1:42 PM she went to speak to Resident #57 about any in room activity preferences she might have while on isolation. Resident #57 told the AD she watched television in her room and she was fine. Resident #57 was tearful during the visit stating she just wanted to get out of the room and she missed her family. Resident #57 told the AD she was not going to be able to see them during the holidays and she was sad about that. The AD continued to talk with Resident #57 and reassure her that even though she could not be with her family at this time the staff were there and cared about her very much. Review of the December 2019 Medication Regimen Review revealed the pharmacist made a recommendation on [DATE] to obtain a stop date for Resident #57's [MEDICATION NAME] order. Next to the recommendation was a hand-written note which reflected call out to physician. Review of Resident #57's Progress Notes (department notes) revealed, LVN A documented on 01/06/20 at 12:54 PM she was looking at the [MEDICATION NAME] order and did not see there was a stop date. She reviewed the hospital records from where Resident #57 returned from and saw a stop date of 12/09/19. LVN A discontinued the [MEDICATION NAME] order. Resident #57's family was visiting the resident at her bedside and inquired when the resident may come off isolation. LVN A was unsure and stated she would have to check with the physician. Review of Resident #57's January 2020 physician orders [REDACTED]. The order reflected the end date was indefinite. The discontinue date reflected 01/06/20. The order was originally created by RN B. Observation on 01/07/20 at 9:51 AM revealed Resident #57 was in isolation. PPE was outside of her room. Interview with Resident #57 at this time revealed she was on isolation due to [DIAGNOSES REDACTED] (infection of the large intestine). She stated she was almost done taking the antibiotic. In an interview on [DATE] at 9:15 AM LVN A stated the medication aide (no name provided) noticed there was not a stop date for Resident #57's [MEDICATION NAME] order. She stated the medication aide brought it to her attention. She stated she stopped the medication and notified the DON and the physician. LVN A stated she was waiting for the resident to have a bowel movement so a stool culture could be done (to determine if the resident was still positive for [DIAGNOSES REDACTED]). When asked about the stop date being documented as 12/09/19 in her 01/06/20 nurse's note, LVN A stated she meant to document the stop date as [DATE] but accidentally put 12/09/19. Review of Resident #57's physician progress notes [REDACTED]. [DIAGNOSES REDACTED]: Continue PO (by mouth) [MEDICATION NAME] until [DATE], monitor. Observation on [DATE] at 9:52 AM revealed Resident #57 was still on isolation. In an interview at this time Resident #57 stated she had been on isolation for about three weeks. She stated she did not like it and she felt like she was off limits to everyone and like she was contagious. The resident began to cry and was visibly upset. Resident #57 stated when she came back to the facility from somewhere she was told she had to be on isolation and was on an antibiotic. Resident #57 denied she was told how long she would be on the antibiotic. When asked if she was informed the antibiotic was supposed to be discontinued a few weeks ago she stated she was not. Resident #57 stated she was supposed to see her grandchildren during the holidays, but she was not able to due to being on isolation. She stated prior to isolation she did not attend activities, but she did not stay in her room all day either. She stated she was sad about being on isolation and it made her feel bad due to having to stay in her room. She stated she felt claustrophobic (fear of confined spaces). In an interview on [DATE] at 11:08 AM the DON stated Resident #57 had been on [MEDICATION NAME] for a while. She stated Resident #57's order, in the electronic health record, reflected no stop date and reflected indefinite. She stated the medication should have been discontinued on [DATE]. She stated Resident #57 was still on isolation and they were waiting to get a stool sample from the resident to get her clear to come off isolation. In an interview on [DATE] at 12:49 PM Physician C stated Resident #57 had been in the hospital recently due to [MEDICAL CONDITION]. He stated he saw Resident #57 on [DATE]. He stated Resident #57 was on oral [MEDICATION NAME] when she returned to the facility. He stated the medication was supposed to be discontinued on [DATE]. He stated generally when a person started forming stools the isolation could be stopped. In an interview in [DATE] at 1:55 PM LVN A stated Resident #57 came off isolation today ([DATE]). She stated Resident #57 was made aware she was no longer on isolation. LVN A revealed Resident #57 had been on isolation since 12/09/19. She stated the resident had made it known she was upset about being on isolation. She stated the resident had alleged no one had visited her but her family had while she was on isolation. She stated prior to isolation, Resident #57 would get up in her geri-chair and sit in the small dining room which was something she liked. She stated the resident would attend activities but did not really participate. Review of Resident #57's January 2020 physician orders [REDACTED]. An attempt was made on 0[DATE] at 9:00 AM to contact RN B which was unsuccessful. In an interview on [DATE] at 11:46 AM CNA E stated Resident #57 came off isolation today ([DATE]). She stated the resident could not wait to come off isolation but did not appear angry or sad about being on isolation. She stated it was not the norm for the resident to stay in her room most of the day when not on isolation. She stated at times she would attend activities when not on isolation. In an interview on [DATE] at 12:10 PM CNA F stated Resident #57 recently came off isolation. She stated the resident had gone to the hospital and when she returned she was placed on isolation. She stated the resident did not want to be on isolation. She stated the resident said she was claustrophobic. CNA F stated prior to going onto isolation Resident #57 would come out of her room. In an interview on 01/09/19 at 3:11 PM the AD stated Resident #57 liked being out of her room. She stated she liked music and liked to talk. She stated she also enjoyed watching television. She stated prior to isolation the resident did come out of her room. She was more passive and observed during activities, but she just wanted to be out with others. She stated Resident #57 liked to sit in the front lobby and people watch. She stated she did visit her during isolation and thought the SW or ADM had asked her to speak with the resident. She stated Resident #57 was sad and slept a lot. She stated she was told the resident was tearful. She stated she asked Resident #57 if there was anything she could bring her, and the resident said she had the television and she missed her family. The AD stated Resident #57's family was not visiting as often, and the resident wanted to be out of her room. She was tired of being on isolation. The AD stated Resident #57 was visibly upset when she spoke with her; she was tearful. She stated Resident #57 had verbalized she was tired of being stuck in her room. In an interview on 0[DATE] at 1:53 PM CNA E stated Resident #57 did not get to come out of her room while on isolation. She stated she could not attend activities outside of the room. She stated she provided her playing cards. She stated the resident was bathed in her room. She stated the resident preferred bed baths. In an interview on 0[DATE] at 1:57 PM CNA F stated Resident #57 was not allowed out of her room while on isolation. She stated she did not know if in-room activities were provided to the resident. She stated she did not provide personal care to Resident #57, but she did feed her during meals. She stated she did not think Resident #57 liked bed baths because she would say she did not like them and wanted to be in the shower room. In an interview on 0[DATE] at 3:16 PM LVN A stated while on isolation, Resident #57 did not come out of her room for any reason not even for showers. She stated Resident #57 received bed baths in her room. She stated she asked if Resident #57 was allowed to get bathed in the shower room and she was told 'no.' LVN A stated Resident #57 preferred to have a shower but understood she had to have a bed bath. She stated the resident would typically take a shower in the shower room when not on isolation. LVN A added Resident #57 had attended an activity today (0[DATE]). In an interview on 0[DATE] at 3:18 PM CNA G stated when Resident #57 was on isolation she was not allowed out for any reason. She stated Resident #57's family did visit while she was on isolation. CNA G stated she provided care to Resident #57 while on isolation. CNA G stated Resident #57 did say she wanted to be out of her room. She said, It was understandable because who wants to be in their room [ROOM NUMBER]/7. In an interview on 0[DATE] at 2:22 PM the DON stated isolation was determined by the type of infection a resident had and the physician would give the order to place a resident on isolation. She stated Resident #57 returned to the facility with [DIAGNOSES REDACTED]. She stated she did not know if the hospital records indicated isolation. She stated the CDC guidelines for [DIAGNOSES REDACTED] called for contact insolation and they default to CDC recommendations. The DON stated the determination to remove a resident from isolation was made when a resident was cleared of the infection and the physician would give the order to take them off of isolation. She stated once someone had a formed stool and was no longer on the antibiotic, the resident could be removed from isolation . When asked what was done to mitigate the psychological impact to a resident when on isolation, the DON stated the AD rounded on residents on isolation and they also had nursing staff that rounded throughout the shift. She stated the resident would get personal contact and socialization. She stated when Resident #57 returned from the hospital, she made comments about being on isolation, but it was explained to her why she was on isolation. She stated at the time the resident was still having diarrhea. She stated Resident #57 had an active infection and was still on the antibiotic. She stated she spoke to Resident #57 about being on isolation and the resident appeared to understand. She stated nothing else regarding Resident #57 being upset about being on isolation was brought to her attention. The DON stated Resident #57's family had visited during the holidays. She stated she was not at the facility at the time but that was the report she got from nursing. The DON stated Resident #57 was provided bed baths while on isolation. She stated the type of infection she had would not have allowed her to shower in the shower room and while on isolation she was not allowed out of her room. Review of the Center for Disease Control Clostridioides difficile (c. diff) obtained from https://www.cdc.gov/cdiff/clinicians/cdi-prevention-strategies.html on 0[DATE] reflected: .For patients with confirmed CDI, maintain contact precautions for at least 48 hours after diarrhea has resolved, or longer, up to the duration of hospitalization . Review of the facility's Residents Rights policy, undated, reflected The right to be free from physical, psychological, and sexual abuse or punishment, and/or involuntary seclusion. Review of the facility's Isolation- Categories of Transmission Based Precautions policy, dated September 2005, revealed, The facility shall make every effort to use the least restrictive approach to managing individuals with potentially communicable infections. Whenever possible, precautions shall be used that do not involve isolation of the resident. Isolation shall only be used when transmission cannot be reasonably prevented by less restrictive measures. Review of the facility's Discontinuing Isolation policy, dated September 2005, revealed, Isolation precautions will be discontinued when it is determined that a resident no longer requires such precautions. On 01/13/20 at 11:11 AM the facility was unable to provide a policy on involuntary seclusion.

Based on interview and record review, the facility failed to ensure each resident was free from neglect for one (Resident #1) of ten residents reviewed for neglect. The facility failed to immediately transfer Resident #1 to the emergency room per her physician's orders [REDACTED]. When Resident #1 got to the hospital, she was diagnosed with [REDACTED]. An Immediate Jeopardy (IJ) was identified to have occurred on 07/14/17 to 07/28/17. This was determined to be an IJ at past noncompliance due to the facility having implemented actions that corrected the noncompliance prior to the beginning of the survey. This failure could affect the facility's 75 residents who were all at risk for changes in condition by placing them at risk for delayed care and treatment and death. Findings included: Review of Resident #1's Face Sheet, dated 07/26/17, reflected she was a [AGE] year-old female who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #1's Care Plan, undated, reflected she had a self-care deficit and required staff assistance for ADLs. Resident #1's Care Plan reflected, .notify MD, family/responsible party as needed . Review of Resident #1's MDS assessment, dated 05/26/17, reflected Resident #1 had moderately impaired cognition. She was identified as having an active [DIAGNOSES REDACTED]. She was also identified as having an active [DIAGNOSES REDACTED]. She was identified as requiring limited to extensive assistance for ADLs. Review of the facility's Provider Investigation Report, dated 07/25/17, reflected the facility initiated an investigation after an allegation was made by Resident #1's family on 07/19/17 that there was a delay in sending Resident #1 to the hospital when she was displaying signs and symptoms of a stroke. The results of the investigation confirmed a facility failure occurred and that it appeared as though there was unclear communication between LVN C (the assigned Charge Nurse for Resident #1), the ADON, and the DON. During an interview with CNA A on 08/09/17 at 2:06 p.m., she stated on 07/14/17 at approximately 10:00 a.m., Resident #1 pushed her call light and wanted to go to the restroom. CNA A stated Resident #1 was not able to stand by herself when using a sit-to-stand lift. She put Resident #1 back in bed and notified LVN C, who stated she would check on the resident. Resident #1 almost immediately pressed the call light again, and CNA A noted Resident #1 appeared to be limp when she attempted to get her out of bed for the second time. She stated she again notified LVN C. CNA A stated Resident #1 was then taken to therapy by Restorative Aide B. During an interview with Restorative Aide B on 08/09/17 at 12:35 p.m., she stated on 07/14/17 at approximately 10:30 a.m., she assisted Resident #1 into her wheelchair to take her to therapy. She noted Resident #1 was not talking as much, and she had to provide more assistance for the transfer than usual. Restorative Aide B stated it appeared as though Resident #1 was tired, which was why she thought Resident #1 required more assistance. When they got to the therapy room, Restorative Aide B said she noted Resident #1 was holding her arm straight out. The Director of Rehabilitation arrived, and Restorative Aide B asked her to look at the resident. They then noted Resident #1's mouth had a droop to one side, and she was not speaking normally (reportedly, it sounded as though Resident #1 was talking through her teeth). Resident #1 stated her arm was heavy, and she was unable to move her extremities like normal. Restorative Aide B stated she immediately took Resident #1 back to her room and notified LVN C, who contacted the physician. During an interview with the Director of Rehabilitation on 08/09/17 at 12:49 p.m., she stated on 07/14/17 at approximately 10:30 a.m., Resident #1 was brought into the therapy room by Restorative Aide B. Restorative Aide B asked the Director of Rehabilitation to screen the resident, as she did not feel the resident was at her normal level of functioning. The Director of Rehabilitation stated she did a quick screen and noted Resident #1 appeared to have right-sided weakness. She told Restorative Aide B to notify her Charge Nurse of the resident's status immediately, which Restorative Aide B did. During an interview with LVN C on 08/10/17 at 11:55 a.m., she stated she was the assigned Charge Nurse for Resident #1. She said on 07/14/17 at approximately 10:00 a.m., she was notified by CNA A that Resident #1 appeared to be weak. LVN C stated she was providing care for a different resident, but she assessed Resident #1 as soon as she completed the care. She noted Resident #1 was slightly weaker than normal, but there were no other abnormalities noted. She sent a text message to Resident #1's physician. As this occurred, Resident #1 was taken to therapy by Restorative Aide B. When Resident #1 got to the therapy room, her right hand became weak and her speech was slurred. Resident #1 stated she felt as though something was not right. Restorative Aide B took Resident #1 back to her room and immediately notified LVN C of the situation. LVN C stated these symptoms had not occurred prior to Resident #1 going to therapy. She stated she then notified Resident #1's physician of her new change in condition. Resident #1's physician immediately responded with an order for [REDACTED].#1's change in condition, including her display of signs/symptoms of a stroke, as well as the physician's orders [REDACTED]. The ADON and the DON assessed Resident #1 and stated she did not appear to have a change in condition. They advised LVN C to request additional labs and IV fluids. LVN C stated she followed the chain of command and sent a request to Resident #1's physician. The physician denied the request and stated Resident #1 needed to go to the emergency room . LVN C stated she notified the ADON, who said she would notify the DON. LVN C stated she asked the Director of Rehabilitation if Resident #1 sustained a change in condition and notified her of the physician's orders [REDACTED].#1, who said she did not want to go the hospital. The ADON advised LVN C to contact Resident #1's daughter for permission to send her to the hospital. LVN C stated she did this and then arranged for transportation via transport service. LVN C stated she should have sent Resident #1 out immediately upon receiving the physician's orders [REDACTED].>During an interview with the Director of Rehabilitation on 08/09/17 at 12:49 p.m., she stated on 07/14/17 at approximately 2:00 p.m. LVN C asked the Director of Rehabilitation to screen Resident #1 for signs/symptoms of a stroke due to the physician's orders [REDACTED]. Review of a SBAR Communication Form, completed by LVN C and dated 07/14/17, revealed Resident #1 demonstrated increased weakness and was unable to perform ADLs without assistance. She was identified as having a history [MEDICAL CONDITIONS]. The SBAR report reflected that Resident #1's physician was notified of the situation on 07/14/17 at 11:15 a.m. Resident #1's physician recommended for Resident #1 to be sent to the ER for evaluation of a stroke. Review of text messages, identified by the Administrator on 08/09/17 as a conversation that took place on 07/14/17 between LVN C and Resident #1's physician revealed the following: LVN C: .Resident #1 has generalized weakness, she's alert but unable to do anything for herself. She's already on restorative program. I want to order CBC and CMP for her. A subsequent text message stated, The restorative aide says that her right hand is heavy and she's having slurred speech and her mouth is drooling to the right . Resident #1's Physician: ER stroke . LVN C: Ok. A subsequent text message stated, DON doesn't want her to go out. She wants you to order STAT labs, CBC, CMP, U/A C&S and IV fluids. Resident #1's Physician: Send her out if she has signs of a stroke that's stupid. A subsequent text message stated, Right sided weakness and slurring speech . During an interview with Resident #1's physician on 08/09/17 at 2:57 p.m., he stated on 07/14/17 at 11:14 a.m., he received a text message from LVN C stating Resident #1 was showing signs and symptoms of a stroke including a new onset of weakness and a facial droop. Resident #1's physician stated he immediately gave an order for [REDACTED].#1 in-house. He denied the request and stated Resident #1 needed to be sent to the emergency room . Resident #1's physician stated that was where his conversation with LVN C ended. He said he did not learn about the delay in Resident #1 being transferred to the emergency room until after the fact, when the facility initiated the investigation. He said a facility failure most definitely occurred. Resident #1's physician stated the facility should have sent Resident #1 out immediately upon her change in condition via 911. Review of Departmental Notes (Nurse's Notes), dated 07/14/17, reflected at 2:24 p.m., Resident #1 is noted to have had a significant change in condition, unable to sit upright without help, unable to get out of bed to go to the bathroom, difficulty with lifting her right hand, drooling noted on the left side of her mouth. Mini mental assessment done, AOX3, denies pain. Physician notified, new order to send the resident to the ER for evaluation of stroke. Responsible party daughter notified, okay with resident to go to Hospital. DON and ADON notified. [MEDICATION NAME] ambulance called and scheduled transportation. Will continue to monitor. V/S 98.7, 109/60, 65, 18, 97%. A subsequent note, dated 07/14/17, reflected at 3:34 p.m., Resident going to hospital awake family at bedside, skin intact only bruise to left hand from previous fall. Review of hospital records regarding Resident #1 reflected she arrived at the emergency roiagnom on [DATE] at 4:02 p.m. with presenting symptoms including a facial droop and weakness of the extremities. Lab work including a Stroke Complete Blood Count and a Stroke Renal Profile came back as abnormal. She was diagnosed as having a [MEDICAL CONDITIONS]. tPA (an enzyme that works by dissolving the clot and improving blood flow to the brain) was unable to be administered due to the onset of Resident #1's symptoms being greater than 4.5 hours. Resident #1 was admitted to the hospital. Review of information from the Centers for Disease Control and Prevention's website reflected, .tPA improves the chances of recovering from a stroke. Studies show that patients with ischemic [MEDICAL CONDITION] who receive tPA are more likely to recover fully or have less disability than patients who do not receive the drug . During an interview with the Administrator on 08/09/17 at 8:40 a.m., she stated an investigation was initiated after Resident #1's family raised concerns on 07/19/17 that Resident #1 was not sent to the hospital in a timely manner when she was displaying signs/symptoms of a stroke. The investigation revealed that LVN C and Resident #1's physician spoke on the morning of 07/14/17 about Resident #1 demonstrating signs/symptoms of a stroke. Resident #1's physician ordered for Resident #1 to be sent to the emergency room . The Administrator stated the ADON and the DON both assessed Resident #1 between the time the physician gave the first and second orders for Resident #1 to be sent to the hospital. She stated both the ADON and the DON were terminated due to the lack of communication that occurred. The DON's license was also referred, as the facility felt she should have contacted Resident #1's physician directly when the situation was occurring. During an interview with the ADON on 08/09/17 at 1:05 p.m., she stated on 07/14/17 at approximately 11:00 a.m., LVN C notified her that she was sending Resident #1 to the hospital. The ADON said she asked why Resident #1 was being sent to the hospital, and LVN C stated Resident #1 was weak. The ADON said LVN C did not advise her of concerns of a stroke or the physician's orders [REDACTED].#1's room to complete an assessment. Resident #1 sat up in bed, grabbed the ADON's hands, and spoke clearly. She stated Resident #1 was not displaying any abnormalities. The DON observed the same thing upon her arrival to Resident #1's room. They did not understand why LVN C felt as though Resident #1 was weak, so they advised LVN C to contact Resident #1's physician and request further in-house testing. After lunch, the ADON stated she checked on Resident #1 again. During this time, LVN C stated the physician denied the request for labs and stated to send Resident #1 to the hospital for further evaluation. The ADON stated she notified Resident #1 of the physician's orders [REDACTED]. The ADON stated she advised LVN C to contact Resident #1's family for permission to send her to the hospital. The ADON stated she notified the DON of the physician's orders [REDACTED].#1's room, Resident #1 and her family were talking and waiting for the ambulance to arrive (the ambulance had already been called). Several days later, the Administrator asked for timelines to be completed. At that point, the ADON and the DON realized that LVN C did not relay all of the information from the physician as it occurred that day. The ADON stated she should have asked more questions and probed as to what was said between LVN C and Resident #1's physician in order to ensure Resident #1 received appropriate care and treatment. During an interview with the DON on 08/09/17 at 1:35 p.m., she stated on 07/14/17 at approximately 11:30 a.m., she was called to Resident #1's room by the ADON to assess the resident for generalized weakness. When she went into Resident #1's room, she observed Resident #1 sitting up in bed and rubbing the ADON's hands. She was assessed and demonstrated no abnormal findings nor any signs/symptoms of a stroke. Resident #1 was answering questions and talking normally. The DON stated she and the ADON advised LVN C to request labs and a urine analysis due to generalized weakness. On 07/14/17 at approximately 2:00 p.m., the DON stated she was notified that the physician denied the request for additional testing and stated to send Resident #1 to the hospital. The DON stated she did not know anything about Resident #1 displaying signs/symptoms of a stroke or a delay in sending her out until the Administrator initiated an investigation and timelines were completed. LVN C stated she notified the ADON of the physician's orders [REDACTED]. The DON stated she did not feel as though she should have done anything differently in this situation. She stated it was never communicated to her that Resident #1 was having stroke-like symptoms, nor was it communicated to her that Resident #1's physician gave an order for [REDACTED]. During an interview with the Administrator on 08/10/17 at 12:35 p.m., she stated the facility did not have a policy and procedure related to following physician's orders [REDACTED]. Review of the facility's Abuse and Neglect Policy, dated 06/26/14, reflected, .Neglect - Failure to provide goods or services necessary to avoid physical harm, mental anguish or mental illness . Review of the facility's Quality Assurance Program Standard of Practice policy and procedure, dated 11/16, reflected, .Family and physician will be notified of all changes of condition . It was determined the above failures put Resident #1 in an IJ from 07/14/17 until 07/28/17. An IJ was identified at past non-compliance and the Administrator was notified of this on 08/23/17 at 12:09 p.m. The facility took the following actions to correct the deficient practice. Review of the facility's Provider Investigation Report, dated 07/25/17, reflected the ADON, and the DON. LVN C received disciplinary action including a write up. The ADON and the DON were terminated by the facility. Staff members were in-serviced on assessing residents; changes in condition; signs and symptoms of a stroke with a pre-test and a post-test; communication with the physician; communication and notification of resident changes to nursing staff for immediate follow-up; SBAR documentation; care paths; and the importance of timeliness when sending residents to the hospital. Education was also added to the new hire packet for all new staff in orientation. The facility monitored resident's weights, dietary recommendations, 24-hour reports, changes in condition, [MEDICAL CONDITION] [REDACTED]. The issue was discussed through the facility's Quality Assurance process and an action plan was put into place. Review of an Employee Counseling/Disciplinary Report, dated 07/20/17, reflected LVN C received a written warning due to failure to follow MD orders in a timely manner. Review of an Employee Disciplinary Report, dated 07/20/17, reflected the ADON received written counseling due to not documenting assessments and interventions. The ADON's personnel file reflected she was later terminated on 08/04/17. Review of an Employee Counseling/Disciplinary Report, dated 07/18/17, reflected the DON's employment was terminated due to poor management of a resident emergency within the facility. Review of in-service records reflected staff members were in-serviced on signs/symptoms of a stroke, communication with physicians, and the timeliness of sending residents to the hospital on [DATE]. Review of in-service post-tests reflected staff members were in-serviced on SBAR documentation, the facility's Stop and Watch program/changes in condition, and Care Pathways between 07/25/17 to 07/28/17. During an interview with LVN C on 08/10/17 at 11:55 a.m., she stated she received a write-up following the incident. She said she was also in-serviced on changes in condition and physician notification, SBARs, following physician's orders [REDACTED]. LVN C stated she had previously been in-serviced on these topics. During an interview with Resident #1's physician on 08/09/17 at 2:57 p.m., he stated this was discussed in the facility's QAA meeting, and he felt as though the facility corrected the issue. He stated this incident was a major teaching point for the facility. During an interview with the Administrator on 08/09/17 at 8:40 a.m., she said LVN C was written up following the incident due to not communicating as clearly as possible. The Administrator stated the facility discussed the issue as a part of their Quality Assurance program, and the physician was involved in the creation of the facility's action plan. Staff members were in-serviced on signs/symptoms of a stroke, SBAR documentation, the facility's Stop and Watch program/changes in condition, and the timeliness of sending residents to the hospital. The Administrator stated this was an isolated incident. She said the facility reviewed all residents with [DIAGNOSES REDACTED]. All residents with [DIAGNOSES REDACTED]. The Administrator stated the current ADONs monitored by reviewing all 24-hour reports on a daily basis to ensure any changes in condition were addressed. During individual interviews with three LVNs on 08/09/17 between 11:27 a.m. and 11:46 a.m. (6:00 a.m. - 2:00 p.m. shift), they were knowledgeable as to what steps to take if a resident sustained [REDACTED]. Review of three resident charts (Residents #2, #3, and #4), included on the extended sample, reflected the facility ensured changes of condition were identified and responded to in a timely manner. Review of Care Plans for Residents #5, #6, #7, #8, #9, #10, and #11 reflected the facility updated their care plans due to the residents' history of [MEDICAL CONDITION] to include monitoring for any new signs/symptoms of a stroke. During individual interviews with two residents (Resident #3 and Resident #4), included on the extended sample, they reported no concerns regarding abuse/neglect or the facility's protocol for changes of condition. During individual interviews conducted on 08/23/17 starting at 12:22 p.m. and continuing through 08/23/17 at 2:50 p.m. Six staff members from various shifts were interviewed, they were: LVN D, LVN E, LVN F, LVN G, CNA H, and CNA I. Responses revealed the staff received in-services regarding abuse/neglect, signs/symptoms of a stroke, changes of condition, contacting physicians, and sending residents out timely. The staff members were able to identify what steps to take if a resident sustained [REDACTED]. Review of Form CMS-672, dated 08/09/17 and signed by the Resident Assessment Coordinator, reflected a census of 75 residents.

Based on interview and record review, the facility failed to develop and implement written policies and procedures that prohibited and prevented neglect of residents for one (Resident #1) of ten residents reviewed for neglect. The facility failed to immediately transfer Resident #1 to the emergency room per her physician's orders [REDACTED]. When Resident #1 got to the hospital, she was diagnosed with [REDACTED]. An Immediate Jeopardy (IJ) was identified to have occurred on 07/14/17 to 07/28/17. This was determined to be an IJ at past noncompliance due to the facility having implemented actions that corrected the noncompliance prior to the beginning of the survey. This failure could affect the facility's 75 residents who were all at risk for changes in condition by placing them at risk for delayed care and treatment and death. Findings included: Review of the facility's Abuse and Neglect Policy, dated 06/26/14, reflected, .Neglect - Failure to provide goods or services necessary to avoid physical harm, mental anguish or mental illness . Review of Resident #1's Face Sheet, dated 07/26/17, reflected she was a [AGE] year-old female who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #1's Care Plan, undated, reflected she had a self-care deficit and required staff assistance for ADLs. Resident #1's Care Plan reflected, .notify MD, family/responsible party as needed . Review of Resident #1's MDS assessment, dated 05/26/17, reflected Resident #1 had moderately impaired cognition. She was identified as having an active [DIAGNOSES REDACTED]. She was also identified as having an active [DIAGNOSES REDACTED]. She was identified as requiring limited to extensive assistance for ADLs. Review of the facility's Provider Investigation Report, dated 07/25/17, reflected the facility initiated an investigation after an allegation was made by Resident #1's family on 07/19/17 that there was a delay in sending Resident #1 to the hospital when she was displaying signs and symptoms of a stroke. The results of the investigation confirmed a facility failure occurred and that it appeared as though there was unclear communication between LVN C (the assigned Charge Nurse for Resident #1), the ADON, and the DON. During an interview with CNA A on 08/09/17 at 2:06 p.m., she stated on 07/14/17 at approximately 10:00 a.m., Resident #1 pushed her call light and wanted to go to the restroom. CNA A stated Resident #1 was not able to stand by herself when using a sit-to-stand lift. She put Resident #1 back in bed and notified LVN C, who stated she would check on the resident. Resident #1 almost immediately pressed the call light again, and CNA A noted Resident #1 appeared to be limp when she attempted to get her out of bed for the second time. She stated she again notified LVN C. CNA A stated Resident #1 was then taken to therapy by Restorative Aide B. During an interview with Restorative Aide B on 08/09/17 at 12:35 p.m., she stated on 07/14/17 at approximately 10:30 a.m., she assisted Resident #1 into her wheelchair to take her to therapy. She noted Resident #1 was not talking as much, and she had to provide more assistance for the transfer than usual. Restorative Aide B stated it appeared as though Resident #1 was tired, which was why she thought Resident #1 required more assistance. When they got to the therapy room, Restorative Aide B said she noted Resident #1 was holding her arm straight out. The Director of Rehabilitation arrived, and Restorative Aide B asked her to look at the resident. They then noted Resident #1's mouth had a droop to one side, and she was not speaking normally (reportedly, it sounded as though Resident #1 was talking through her teeth). Resident #1 stated her arm was heavy, and she was unable to move her extremities like normal. Restorative Aide B stated she immediately took Resident #1 back to her room and notified LVN C, who contacted the physician. During an interview with the Director of Rehabilitation on 08/09/17 at 12:49 p.m., she stated on 07/14/17 at approximately 10:30 a.m., Resident #1 was brought into the therapy room by Restorative Aide B. Restorative Aide B asked the Director of Rehabilitation to screen the resident, as she did not feel the resident was at her normal level of functioning. The Director of Rehabilitation stated she did a quick screen and noted Resident #1 appeared to have right-sided weakness. She told Restorative Aide B to notify her Charge Nurse of the resident's status immediately, which Restorative Aide B did. During an interview with LVN C on 08/10/17 at 11:55 a.m., she stated she was the assigned Charge Nurse for Resident #1. She said on 07/14/17 at approximately 10:00 a.m., she was notified by CNA A that Resident #1 appeared to be weak. LVN C stated she was providing care for a different resident, but she assessed Resident #1 as soon as she completed the care. She noted Resident #1 was slightly weaker than normal, but there were no other abnormalities noted. She sent a text message to Resident #1's physician. As this occurred, Resident #1 was taken to therapy by Restorative Aide B. When Resident #1 got to the therapy room, her right hand became weak and her speech was slurred. Resident #1 stated she felt as though something was not right. Restorative Aide B took Resident #1 back to her room and immediately notified LVN C of the situation. LVN C stated these symptoms had not occurred prior to Resident #1 going to therapy. She stated she then notified Resident #1's physician of her new change in condition. Resident #1's physician immediately responded with an order for [REDACTED].#1's change in condition, including her display of signs/symptoms of a stroke, as well as the physician's orders [REDACTED]. The ADON and the DON assessed Resident #1 and stated she did not appear to have a change in condition. They advised LVN C to request additional labs and IV fluids. LVN C stated she followed the chain of command and sent a request to Resident #1's physician. The physician denied the request and stated Resident #1 needed to go to the emergency room . LVN C stated she notified the ADON, who said she would notify the DON. LVN C stated she asked the Director of Rehabilitation if Resident #1 sustained a change in condition and notified her of the physician's orders [REDACTED].#1, who said she did not want to go the hospital. The ADON advised LVN C to contact Resident #1's daughter for permission to send her to the hospital. LVN C stated she did this and then arranged for transportation via transport service. LVN C stated she should have sent Resident #1 out immediately upon receiving the physician's orders [REDACTED].>During an interview with the Director of Rehabilitation on 08/09/17 at 12:49 p.m., she stated on 07/14/17 at approximately 2:00 p.m. LVN C asked the Director of Rehabilitation to screen Resident #1 for signs/symptoms of a stroke due to the physician's orders [REDACTED]. Review of a SBAR Communication Form, completed by LVN C and dated 07/14/17, revealed Resident #1 demonstrated increased weakness and was unable to perform ADLs without assistance. She was identified as having a history [MEDICAL CONDITIONS]. The SBAR report reflected that Resident #1's physician was notified of the situation on 07/14/17 at 11:15 a.m. Resident #1's physician recommended for Resident #1 to be sent to the ER for evaluation of a stroke. Review of text messages, identified by the Administrator on 08/09/17 as a conversation that took place on 07/14/17 between LVN C and Resident #1's physician revealed the following: LVN C: .Resident #1 has generalized weakness, she's alert but unable to do anything for herself. She's already on restorative program. I want to order CBC and CMP for her. A subsequent text message stated, The restorative aide says that her right hand is heavy and she's having slurred speech and her mouth is drooling to the right . Resident #1's Physician: ER stroke . LVN C: Ok. A subsequent text message stated, DON doesn't want her to go out. She wants you to order STAT labs, CBC, CMP, U/A C&S and IV fluids. Resident #1's Physician: Send her out if she has signs of a stroke that's stupid. A subsequent text message stated, Right sided weakness and slurring speech . During an interview with Resident #1's physician on 08/09/17 at 2:57 p.m., he stated on 07/14/17 at 11:14 a.m., he received a text message from LVN C stating Resident #1 was showing signs and symptoms of a stroke including a new onset of weakness and a facial droop. Resident #1's physician stated he immediately gave an order for [REDACTED].#1 in-house. He denied the request and stated Resident #1 needed to be sent to the emergency room . Resident #1's physician stated that was where his conversation with LVN C ended. He said he did not learn about the delay in Resident #1 being transferred to the emergency room until after the fact, when the facility initiated the investigation. He said a facility failure most definitely occurred. Resident #1's physician stated the facility should have sent Resident #1 out immediately upon her change in condition via 911. Review of Departmental Notes (Nurse's Notes), dated 07/14/17, reflected at 2:24 p.m., Resident #1 is noted to have had a significant change in condition, unable to sit upright without help, unable to get out of bed to go to the bathroom, difficulty with lifting her right hand, drooling noted on the left side of her mouth. Mini mental assessment done, AOX3, denies pain. Physician notified, new order to send the resident to the ER for evaluation of stroke. Responsible party daughter notified, okay with resident to go to Hospital. DON and ADON notified. [MEDICATION NAME] ambulance called and scheduled transportation. Will continue to monitor. V/S 98.7, 109/60, 65, 18, 97%. A subsequent note, dated 07/14/17, reflected at 3:34 p.m., Resident going to hospital awake family at bedside, skin intact only bruise to left hand from previous fall. Review of hospital records regarding Resident #1 reflected she arrived at the emergency roiagnom on [DATE] at 4:02 p.m. with presenting symptoms including a facial droop and weakness of the extremities. Lab work including a Stroke Complete Blood Count and a Stroke Renal Profile came back as abnormal. She was diagnosed as having a [MEDICAL CONDITIONS]. tPA (an enzyme that works by dissolving the clot and improving blood flow to the brain) was unable to be administered due to the onset of Resident #1's symptoms being greater than 4.5 hours. Resident #1 was admitted to the hospital. Review of information from the Centers for Disease Control and Prevention's website reflected, .tPA improves the chances of recovering from a stroke. Studies show that patients with ischemic [MEDICAL CONDITION] who receive tPA are more likely to recover fully or have less disability than patients who do not receive the drug . During an interview with the Administrator on 08/09/17 at 8:40 a.m., she stated an investigation was initiated after Resident #1's family raised concerns on 07/19/17 that Resident #1 was not sent to the hospital in a timely manner when she was displaying signs/symptoms of a stroke. The investigation revealed that LVN C and Resident #1's physician spoke on the morning of 07/14/17 about Resident #1 demonstrating signs/symptoms of a stroke. Resident #1's physician ordered for Resident #1 to be sent to the emergency room . The Administrator stated the ADON and the DON both assessed Resident #1 between the time the physician gave the first and second orders for Resident #1 to be sent to the hospital. She stated both the ADON and the DON were terminated due to the lack of communication that occurred. The DON's license was also referred, as the facility felt she should have contacted Resident #1's physician directly when the situation was occurring. During an interview with the ADON on 08/09/17 at 1:05 p.m., she stated on 07/14/17 at approximately 11:00 a.m., LVN C notified her that she was sending Resident #1 to the hospital. The ADON said she asked why Resident #1 was being sent to the hospital, and LVN C stated Resident #1 was weak. The ADON said LVN C did not advise her of concerns of a stroke or the physician's orders [REDACTED].#1's room to complete an assessment. Resident #1 sat up in bed, grabbed the ADON's hands, and spoke clearly. She stated Resident #1 was not displaying any abnormalities. The DON observed the same thing upon her arrival to Resident #1's room. They did not understand why LVN C felt as though Resident #1 was weak, so they advised LVN C to contact Resident #1's physician and request further in-house testing. After lunch, the ADON stated she checked on Resident #1 again. During this time, LVN C stated the physician denied the request for labs and stated to send Resident #1 to the hospital for further evaluation. The ADON stated she notified Resident #1 of the physician's orders [REDACTED]. The ADON stated she advised LVN C to contact Resident #1's family for permission to send her to the hospital. The ADON stated she notified the DON of the physician's orders [REDACTED].#1's room, Resident #1 and her family were talking and waiting for the ambulance to arrive (the ambulance had already been called). Several days later, the Administrator asked for timelines to be completed. At that point, the ADON and the DON realized that LVN C did not relay all of the information from the physician as it occurred that day. The ADON stated she should have asked more questions and probed as to what was said between LVN C and Resident #1's physician in order to ensure Resident #1 received appropriate care and treatment. During an interview with the DON on 08/09/17 at 1:35 p.m., she stated on 07/14/17 at approximately 11:30 a.m., she was called to Resident #1's room by the ADON to assess the resident for generalized weakness. When she went into Resident #1's room, she observed Resident #1 sitting up in bed and rubbing the ADON's hands. She was assessed and demonstrated no abnormal findings nor any signs/symptoms of a stroke. Resident #1 was answering questions and talking normally. The DON stated she and the ADON advised LVN C to request labs and a urine analysis due to generalized weakness. On 07/14/17 at approximately 2:00 p.m., the DON stated she was notified that the physician denied the request for additional testing and stated to send Resident #1 to the hospital. The DON stated she did not know anything about Resident #1 displaying signs/symptoms of a stroke or a delay in sending her out until the Administrator initiated an investigation and timelines were completed. LVN C stated she notified the ADON of the physician's orders [REDACTED]. The DON stated she did not feel as though she should have done anything differently in this situation. She stated it was never communicated to her that Resident #1 was having stroke-like symptoms, nor was it communicated to her that Resident #1's physician gave an order for [REDACTED]. During an interview with the Administrator on 08/10/17 at 12:35 p.m., she stated the facility did not have a policy and procedure related to following physician's orders [REDACTED]. Review of the facility's Quality Assurance Program Standard of Practice policy and procedure, dated 11/16, reflected, .Family and physician will be notified of all changes of condition . It was determined the above failures put Resident #1 in an IJ from 07/14/17 until 07/28/17. An IJ was identified at past non-compliance and the Administrator was notified of this on 08/23/17 at 12:09 p.m. The facility took the following actions to correct the deficient practice. Review of the facility's Provider Investigation Report, dated 07/25/17, reflected the ADON, and the DON. LVN C received disciplinary action including a write up. The ADON and the DON were terminated by the facility. Staff members were in-serviced on assessing residents; changes in condition; signs and symptoms of a stroke with a pre-test and a post-test; communication with the physician; communication and notification of resident changes to nursing staff for immediate follow-up; SBAR documentation; care paths; and the importance of timeliness when sending residents to the hospital. Education was also added to the new hire packet for all new staff in orientation. The facility monitored resident's weights, dietary recommendations, 24-hour reports, changes in condition, [MEDICAL CONDITION] [REDACTED]. The issue was discussed through the facility's Quality Assurance process and an action plan was put into place. Review of an Employee Counseling/Disciplinary Report, dated 07/20/17, reflected LVN C received a written warning due to failure to follow MD orders in a timely manner. Review of an Employee Disciplinary Report, dated 07/20/17, reflected the ADON received written counseling due to not documenting assessments and interventions. The ADON's personnel file reflected she was later terminated on 08/04/17. Review of an Employee Counseling/Disciplinary Report, dated 07/18/17, reflected the DON's employment was terminated due to poor management of a resident emergency within the facility. Review of in-service records reflected staff members were in-serviced on signs/symptoms of a stroke, communication with physicians, and the timeliness of sending residents to the hospital on [DATE]. Review of in-service post-tests reflected staff members were in-serviced on SBAR documentation, the facility's Stop and Watch program/changes in condition, and Care Pathways between 07/25/17 to 07/28/17. During an interview with LVN C on 08/10/17 at 11:55 a.m., she stated she received a write-up following the incident. She said she was also in-serviced on changes in condition and physician notification, SBARs, following physician's orders [REDACTED]. LVN C stated she had previously been in-serviced on these topics. During an interview with Resident #1's physician on 08/09/17 at 2:57 p.m., he stated this was discussed in the facility's QAA meeting, and he felt as though the facility corrected the issue. He stated this incident was a major teaching point for the facility. During an interview with the Administrator on 08/09/17 at 8:40 a.m., she said LVN C was written up following the incident due to not communicating as clearly as possible. The Administrator stated the facility discussed the issue as a part of their Quality Assurance program, and the physician was involved in the creation of the facility's action plan. Staff members were in-serviced on signs/symptoms of a stroke, SBAR documentation, the facility's Stop and Watch program/changes in condition, and the timeliness of sending residents to the hospital. The Administrator stated this was an isolated incident. She said the facility reviewed all residents with [DIAGNOSES REDACTED]. All residents with [DIAGNOSES REDACTED]. The Administrator stated the current ADONs monitored by reviewing all 24-hour reports on a daily basis to ensure any changes in condition were addressed. During individual interviews with three LVNs on 08/09/17 between 11:27 a.m. and 11:46 a.m. (6:00 a.m. - 2:00 p.m. shift), they were knowledgeable as to what steps to take if a resident sustained [REDACTED]. Review of three resident charts (Residents #2, #3, and #4), included on the extended sample, reflected the facility ensured changes of condition were identified and responded to in a timely manner. Review of Care Plans for Residents #5, #6, #7, #8, #9, #10, and #11 reflected the facility updated their care plans due to the residents' history of [MEDICAL CONDITION] to include monitoring for any new signs/symptoms of a stroke. During individual interviews with two residents (Resident #3 and Resident #4), included on the extended sample, they reported no concerns regarding abuse/neglect or the facility's protocol for changes of condition. During individual interviews conducted on 08/23/17 starting at 12:22 p.m. and continuing through 08/23/17 at 2:50 p.m. Six staff members from various shifts were interviewed, they were: LVN D, LVN E, LVN F, LVN G, CNA H, and CNA I. Responses revealed the staff received in-services regarding abuse/neglect, signs/symptoms of a stroke, changes of condition, contacting physicians, and sending residents out timely. The staff members were able to identify what steps to take if a resident sustained [REDACTED]. Review of Form CMS-672, dated 08/09/17 and signed by the Resident Assessment Coordinator, reflected a census of 75 residents.

Based on interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive person-centered care for one (Resident #1) of ten residents reviewed for changes in condition. The facility failed to immediately transfer Resident #1 to the emergency room per her physician's orders [REDACTED]. When Resident #1 got to the hospital, she was diagnosed with [REDACTED]. An Immediate Jeopardy (IJ) was identified to have occurred on 07/14/17 to 07/28/17. This was determined to be an IJ at past noncompliance due to the facility having implemented actions that corrected the noncompliance prior to the beginning of the survey. This failure could affect the facility's 75 residents who were all at risk for changes in condition by placing them at risk for delayed care and treatment and death. Findings included: Review of Resident #1's Face Sheet, dated 07/26/17, reflected she was a [AGE] year-old female who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #1's Care Plan, undated, reflected she had a self-care deficit and required staff assistance for ADLs. Resident #1's Care Plan reflected, .notify MD, family/responsible party as needed . Review of Resident #1's MDS assessment, dated 05/26/17, reflected Resident #1 had moderately impaired cognition. She was identified as having an active [DIAGNOSES REDACTED]. She was also identified as having an active [DIAGNOSES REDACTED]. She was identified as requiring limited to extensive assistance for ADLs. Review of the facility's Provider Investigation Report, dated 07/25/17, reflected the facility initiated an investigation after an allegation was made by Resident #1's family on 07/19/17 that there was a delay in sending Resident #1 to the hospital when she was displaying signs and symptoms of a stroke. The results of the investigation confirmed a facility failure occurred and that it appeared as though there was unclear communication between LVN C (the assigned Charge Nurse for Resident #1), the ADON, and the DON. During an interview with CNA A on 08/09/17 at 2:06 p.m., she stated on 07/14/17 at approximately 10:00 a.m., Resident #1 pushed her call light and wanted to go to the restroom. CNA A stated Resident #1 was not able to stand by herself when using a sit-to-stand lift. She put Resident #1 back in bed and notified LVN C, who stated she would check on the resident. Resident #1 almost immediately pressed the call light again, and CNA A noted Resident #1 appeared to be limp when she attempted to get her out of bed for the second time. She stated she again notified LVN C. CNA A stated Resident #1 was then taken to therapy by Restorative Aide B. During an interview with Restorative Aide B on 08/09/17 at 12:35 p.m., she stated on 07/14/17 at approximately 10:30 a.m., she assisted Resident #1 into her wheelchair to take her to therapy. She noted Resident #1 was not talking as much, and she had to provide more assistance for the transfer than usual. Restorative Aide B stated it appeared as though Resident #1 was tired, which was why she thought Resident #1 required more assistance. When they got to the therapy room, Restorative Aide B said she noted Resident #1 was holding her arm straight out. The Director of Rehabilitation arrived, and Restorative Aide B asked her to look at the resident. They then noted Resident #1's mouth had a droop to one side, and she was not speaking normally (reportedly, it sounded as though Resident #1 was talking through her teeth). Resident #1 stated her arm was heavy, and she was unable to move her extremities like normal. Restorative Aide B stated she immediately took Resident #1 back to her room and notified LVN C, who contacted the physician. During an interview with the Director of Rehabilitation on 08/09/17 at 12:49 p.m., she stated on 07/14/17 at approximately 10:30 a.m., Resident #1 was brought into the therapy room by Restorative Aide B. Restorative Aide B asked the Director of Rehabilitation to screen the resident, as she did not feel the resident was at her normal level of functioning. The Director of Rehabilitation stated she did a quick screen and noted Resident #1 appeared to have right-sided weakness. She told Restorative Aide B to notify her Charge Nurse of the resident's status immediately, which Restorative Aide B did. During an interview with LVN C on 08/10/17 at 11:55 a.m., she stated she was the assigned Charge Nurse for Resident #1. She said on 07/14/17 at approximately 10:00 a.m., she was notified by CNA A that Resident #1 appeared to be weak. LVN C stated she was providing care for a different resident, but she assessed Resident #1 as soon as she completed the care. She noted Resident #1 was slightly weaker than normal, but there were no other abnormalities noted. She sent a text message to Resident #1's physician. As this occurred, Resident #1 was taken to therapy by Restorative Aide B. When Resident #1 got to the therapy room, her right hand became weak and her speech was slurred. Resident #1 stated she felt as though something was not right. Restorative Aide B took Resident #1 back to her room and immediately notified LVN C of the situation. LVN C stated these symptoms had not occurred prior to Resident #1 going to therapy. She stated she then notified Resident #1's physician of her new change in condition. Resident #1's physician immediately responded with an order for [REDACTED].#1's change in condition, including her display of signs/symptoms of a stroke, as well as the physician's orders [REDACTED]. The ADON and the DON assessed Resident #1 and stated she did not appear to have a change in condition. They advised LVN C to request additional labs and IV fluids. LVN C stated she followed the chain of command and sent a request to Resident #1's physician. The physician denied the request and stated Resident #1 needed to go to the emergency room . LVN C stated she notified the ADON, who said she would notify the DON. LVN C stated she asked the Director of Rehabilitation if Resident #1 sustained a change in condition and notified her of the physician's orders [REDACTED].#1, who said she did not want to go the hospital. The ADON advised LVN C to contact Resident #1's daughter for permission to send her to the hospital. LVN C stated she did this and then arranged for transportation via transport service. LVN C stated she should have sent Resident #1 out immediately upon receiving the physician's orders [REDACTED].>During an interview with the Director of Rehabilitation on 08/09/17 at 12:49 p.m., she stated on 07/14/17 at approximately 2:00 p.m. LVN C asked the Director of Rehabilitation to screen Resident #1 for signs/symptoms of a stroke due to the physician's orders [REDACTED]. Review of a SBAR Communication Form, completed by LVN C and dated 07/14/17, revealed Resident #1 demonstrated increased weakness and was unable to perform ADLs without assistance. She was identified as having a history [MEDICAL CONDITIONS]. The SBAR report reflected that Resident #1's physician was notified of the situation on 07/14/17 at 11:15 a.m. Resident #1's physician recommended for Resident #1 to be sent to the ER for evaluation of a stroke. Review of text messages, identified by the Administrator on 08/09/17 as a conversation that took place on 07/14/17 between LVN C and Resident #1's physician revealed the following: LVN C: .Resident #1 has generalized weakness, she's alert but unable to do anything for herself. She's already on restorative program. I want to order CBC and CMP for her. A subsequent text message stated, The restorative aide says that her right hand is heavy and she's having slurred speech and her mouth is drooling to the right . Resident #1's Physician: ER stroke . LVN C: Ok. A subsequent text message stated, DON doesn't want her to go out. She wants you to order STAT labs, CBC, CMP, U/A C&S and IV fluids. Resident #1's Physician: Send her out if she has signs of a stroke that's stupid. A subsequent text message stated, Right sided weakness and slurring speech . During an interview with Resident #1's physician on 08/09/17 at 2:57 p.m., he stated on 07/14/17 at 11:14 a.m., he received a text message from LVN C stating Resident #1 was showing signs and symptoms of a stroke including a new onset of weakness and a facial droop. Resident #1's physician stated he immediately gave an order for [REDACTED].#1 in-house. He denied the request and stated Resident #1 needed to be sent to the emergency room . Resident #1's physician stated that was where his conversation with LVN C ended. He said he did not learn about the delay in Resident #1 being transferred to the emergency room until after the fact, when the facility initiated the investigation. He said a facility failure most definitely occurred. Resident #1's physician stated the facility should have sent Resident #1 out immediately upon her change in condition via 911. Review of Departmental Notes (Nurse's Notes), dated 07/14/17, reflected at 2:24 p.m., Resident #1 is noted to have had a significant change in condition, unable to sit upright without help, unable to get out of bed to go to the bathroom, difficulty with lifting her right hand, drooling noted on the left side of her mouth. Mini mental assessment done, AOX3, denies pain. Physician notified, new order to send the resident to the ER for evaluation of stroke. Responsible party daughter notified, okay with resident to go to Hospital. DON and ADON notified. [MEDICATION NAME] ambulance called and scheduled transportation. Will continue to monitor. V/S 98.7, 109/60, 65, 18, 97%. A subsequent note, dated 07/14/17, reflected at 3:34 p.m., Resident going to hospital awake family at bedside, skin intact only bruise to left hand from previous fall. Review of hospital records regarding Resident #1 reflected she arrived at the emergency roiagnom on [DATE] at 4:02 p.m. with presenting symptoms including a facial droop and weakness of the extremities. Lab work including a Stroke Complete Blood Count and a Stroke Renal Profile came back as abnormal. She was diagnosed as having a [MEDICAL CONDITIONS]. tPA (an enzyme that works by dissolving the clot and improving blood flow to the brain) was unable to be administered due to the onset of Resident #1's symptoms being greater than 4.5 hours. Resident #1 was admitted to the hospital. Review of information from the Centers for Disease Control and Prevention's website reflected, .tPA improves the chances of recovering from a stroke. Studies show that patients with ischemic [MEDICAL CONDITION] who receive tPA are more likely to recover fully or have less disability than patients who do not receive the drug . During an interview with the Administrator on 08/09/17 at 8:40 a.m., she stated an investigation was initiated after Resident #1's family raised concerns on 07/19/17 that Resident #1 was not sent to the hospital in a timely manner when she was displaying signs/symptoms of a stroke. The investigation revealed that LVN C and Resident #1's physician spoke on the morning of 07/14/17 about Resident #1 demonstrating signs/symptoms of a stroke. Resident #1's physician ordered for Resident #1 to be sent to the emergency room . The Administrator stated the ADON and the DON both assessed Resident #1 between the time the physician gave the first and second orders for Resident #1 to be sent to the hospital. She stated both the ADON and the DON were terminated due to the lack of communication that occurred. The DON's license was also referred, as the facility felt she should have contacted Resident #1's physician directly when the situation was occurring. During an interview with the ADON on 08/09/17 at 1:05 p.m., she stated on 07/14/17 at approximately 11:00 a.m., LVN C notified her that she was sending Resident #1 to the hospital. The ADON said she asked why Resident #1 was being sent to the hospital, and LVN C stated Resident #1 was weak. The ADON said LVN C did not advise her of concerns of a stroke or the physician's orders [REDACTED].#1's room to complete an assessment. Resident #1 sat up in bed, grabbed the ADON's hands, and spoke clearly. She stated Resident #1 was not displaying any abnormalities. The DON observed the same thing upon her arrival to Resident #1's room. They did not understand why LVN C felt as though Resident #1 was weak, so they advised LVN C to contact Resident #1's physician and request further in-house testing. After lunch, the ADON stated she checked on Resident #1 again. During this time, LVN C stated the physician denied the request for labs and stated to send Resident #1 to the hospital for further evaluation. The ADON stated she notified Resident #1 of the physician's orders [REDACTED]. The ADON stated she advised LVN C to contact Resident #1's family for permission to send her to the hospital. The ADON stated she notified the DON of the physician's orders [REDACTED].#1's room, Resident #1 and her family were talking and waiting for the ambulance to arrive (the ambulance had already been called). Several days later, the Administrator asked for timelines to be completed. At that point, the ADON and the DON realized that LVN C did not relay all of the information from the physician as it occurred that day. The ADON stated she should have asked more questions and probed as to what was said between LVN C and Resident #1's physician in order to ensure Resident #1 received appropriate care and treatment. During an interview with the DON on 08/09/17 at 1:35 p.m., she stated on 07/14/17 at approximately 11:30 a.m., she was called to Resident #1's room by the ADON to assess the resident for generalized weakness. When she went into Resident #1's room, she observed Resident #1 sitting up in bed and rubbing the ADON's hands. She was assessed and demonstrated no abnormal findings nor any signs/symptoms of a stroke. Resident #1 was answering questions and talking normally. The DON stated she and the ADON advised LVN C to request labs and a urine analysis due to generalized weakness. On 07/14/17 at approximately 2:00 p.m., the DON stated she was notified that the physician denied the request for additional testing and stated to send Resident #1 to the hospital. The DON stated she did not know anything about Resident #1 displaying signs/symptoms of a stroke or a delay in sending her out until the Administrator initiated an investigation and timelines were completed. LVN C stated she notified the ADON of the physician's orders [REDACTED]. The DON stated she did not feel as though she should have done anything differently in this situation. She stated it was never communicated to her that Resident #1 was having stroke-like symptoms, nor was it communicated to her that Resident #1's physician gave an order for [REDACTED]. During an interview with the Administrator on 08/10/17 at 12:35 p.m., she stated the facility did not have a policy and procedure related to following physician's orders [REDACTED]. Review of the facility's Quality Assurance Program Standard of Practice policy and procedure, dated 11/16, reflected, .Family and physician will be notified of all changes of condition . It was determined the above failures put Resident #1 in an IJ from 07/14/17 until 07/28/17. An IJ was identified at past non-compliance and the Administrator was notified of this on 08/23/17 at 12:09 p.m. The facility took the following actions to correct the deficient practice. Review of the facility's Provider Investigation Report, dated 07/25/17, reflected the ADON, and the DON. LVN C received disciplinary action including a write up. The ADON and the DON were terminated by the facility. Staff members were in-serviced on assessing residents; changes in condition; signs and symptoms of a stroke with a pre-test and a post-test; communication with the physician; communication and notification of resident changes to nursing staff for immediate follow-up; SBAR documentation; care paths; and the importance of timeliness when sending residents to the hospital. Education was also added to the new hire packet for all new staff in orientation. The facility monitored resident's weights, dietary recommendations, 24-hour reports, changes in condition, [MEDICAL CONDITION] [REDACTED]. The issue was discussed through the facility's Quality Assurance process and an action plan was put into place. Review of an Employee Counseling/Disciplinary Report, dated 07/20/17, reflected LVN C received a written warning due to failure to follow MD orders in a timely manner. Review of an Employee Disciplinary Report, dated 07/20/17, reflected the ADON received written counseling due to not documenting assessments and interventions. The ADON's personnel file reflected she was later terminated on 08/04/17. Review of an Employee Counseling/Disciplinary Report, dated 07/18/17, reflected the DON's employment was terminated due to poor management of a resident emergency within the facility. Review of in-service records reflected staff members were in-serviced on signs/symptoms of a stroke, communication with physicians, and the timeliness of sending residents to the hospital on [DATE]. Review of in-service post-tests reflected staff members were in-serviced on SBAR documentation, the facility's Stop and Watch program/changes in condition, and Care Pathways between 07/25/17 to 07/28/17. During an interview with LVN C on 08/10/17 at 11:55 a.m., she stated she received a write-up following the incident. She said she was also in-serviced on changes in condition and physician notification, SBARs, following physician's orders [REDACTED]. LVN C stated she had previously been in-serviced on these topics. During an interview with Resident #1's physician on 08/09/17 at 2:57 p.m., he stated this was discussed in the facility's QAA meeting, and he felt as though the facility corrected the issue. He stated this incident was a major teaching point for the facility. During an interview with the Administrator on 08/09/17 at 8:40 a.m., she said LVN C was written up following the incident due to not communicating as clearly as possible. The Administrator stated the facility discussed the issue as a part of their Quality Assurance program, and the physician was involved in the creation of the facility's action plan. Staff members were in-serviced on signs/symptoms of a stroke, SBAR documentation, the facility's Stop and Watch program/changes in condition, and the timeliness of sending residents to the hospital. The Administrator stated this was an isolated incident. She said the facility reviewed all residents with [DIAGNOSES REDACTED]. All residents with [DIAGNOSES REDACTED]. The Administrator stated the current ADONs monitored by reviewing all 24-hour reports on a daily basis to ensure any changes in condition were addressed. During individual interviews with three LVNs on 08/09/17 between 11:27 a.m. and 11:46 a.m. (6:00 a.m. - 2:00 p.m. shift), they were knowledgeable as to what steps to take if a resident sustained [REDACTED]. Review of three resident charts (Residents #2, #3, and #4), included on the extended sample, reflected the facility ensured changes of condition were identified and responded to in a timely manner. Review of Care Plans for Residents #5, #6, #7, #8, #9, #10, and #11 reflected the facility updated their care plans due to the residents' history of [MEDICAL CONDITION] to include monitoring for any new signs/symptoms of a stroke. During individual interviews with two residents (Resident #3 and Resident #4), included on the extended sample, they reported no concerns regarding abuse/neglect or the facility's protocol for changes of condition. During individual interviews conducted on 08/23/17 starting at 12:22 p.m. and continuing through 08/23/17 at 2:50 p.m. Six staff members from various shifts were interviewed, they were: LVN D, LVN E, LVN F, LVN G, CNA H, and CNA I. Responses revealed the staff received in-services regarding abuse/neglect, signs/symptoms of a stroke, changes of condition, contacting physicians, and sending residents out timely. The staff members were able to identify what steps to take if a resident sustained [REDACTED]. Review of Form CMS-672, dated 08/09/17 and signed by the Resident Assessment Coordinator, reflected a census of 75 residents.

Based on observation, interview and record review, the facility failed to ensure one (Resident #1) of one resident received adequate supervision and assistance devices to prevent accidents. The Physical Therapist failed to provide adequate supervision to Resident #1, who had limited ability to voice pain or display discomfort, while he received heat pack therapy to his left knee and thigh (quadriceps). Resident #1 suffered a second degree burn on his left and right thigh area from prolonged contact with the heat pack on 06/02/17. This was determined to be Past Noncompliance due to the facility having implemented actions that corrected the noncompliance prior to the beginning of the investigation. This failure had the potential to affect the only Resident #1 who was receiving hot pack therapy and placed him at risk for injury. Resident #1 was the only Resident receiving hot packs. Findings included: Resident #1's MDS assessment, dated 06/16/17, reflected he was a [AGE] year-old male, who was admitted to facility on 05/19/17. Resident #1 had [DIAGNOSES REDACTED].#1 was severely cognitively impaired with decreased speech clarity, decreased ability to make self-understood and limited ability to understand others. Resident #1 required extensive assistance of two persons for bed mobility. Review of physical therapy progress note dated 06/02/17 by PT reflected Resident #1 complained of pain in LLE (left lower extremity) with all movement. Also reflected moist heat applied to knee x 20 min pre exercise. Review of a Provider Investigation Report dated 06/07/17 signed by the Administrator and DON on 06/09/17 reflected Resident #1 had a superficial wound to his right and left lower extremities. During the investigation of the wounds it was noted that Resident #1 had received heat therapy from the physical therapist and the wounds were in correlation with a superficial burn. Provider Investigation Report also revealed Hot pack therapy was 164 degrees Farenheight per log on 06/02/17. It is unknown if there was actually 12 layers of protection. It is unknown if there was 12 layers of protection, how did Resident #1 get burned. Heat therapy was applied 10 TO 12 minutes on left knee and 10 to 12 minutes on left thigh with total of 20 minutes. Unknown if it should have been shorter or if heat therapy was appropriate for this resident since he had neuropathy. Review of statement by the ADON dated 06/07/17 reflected the CNA assigned to Resident #1 reported on 06/05/17 that Resident #1 had an open area to his leg. The ADON assessed Resident #1 and noted what appeared to be two opened blisters, as 100% epithelial tissue (surface layer of skin) was present with rolled pieces of epidermal skin (surface or top layer of skin) topping the open area. LVN / The ADON checked the 24 hour report and saw that nurse placed Opened Blisters on report. Review of a statement by the PT dated 06/05/17 reflected moist hot pack applied to left knee of Resident #1 on 06/02/17. The heat application had equivalent of 12 layers of protection. Resident #1 was checked after 5 minutes and no redness noted with Resident #1 reporting no discomfort. Resident #1 checked again at 10-12 minutes and skin was intact with no reported discomfort. The hot pack was repositioned from knee to more proximal position on quad (quadriceps/thigh) muscle where Resident #1 reported he has most pain. The hot pack was removed at 20 minutes. The resident's skin was intact with no signs of redness and no reports of pain from Resident #1. A telephone interview with the PT on 06/21/17 at 12:00 PM revealed moist hot pack therapy was applied to Resident #1 in his room on (Friday) 06/02/17. She stated she was also giving therapy to another resident three doors down. The PT revealed she made a mistake by not staying with Resident #1 throughout his therapy as per protocol. She stated she placed a heat pack on his left knee joint of left the room and came back in 5 minutes to assess Resident #1's pain and skin. The PT revealed she left again and returned in 5-7 minutes. She stated she repositioned the hot pack to a higher position on his thigh and assessed Resident #1 for pain and skin complications. The PT revealed she returned after a total of 20 minutes of moist heat pack therapy given. Resident #1's assessment after therapy revealed no complaint of pain/discomfort and the resident's skin was intact with no markings visible on left leg. Review of wound assessment report of Resident #1 by the Wound Care Nurse dated 06/06/17 reflected the wound was identified on 06/05/17 caused by accident/other trauma. The wound type was a burn and the burn type was thermal. The burn depth was superficial, partial thickness. The burn description was blister(s) broken. Review of Resident #1's wound care consultation notes dated 06/06/17 reflected Resident #1 presented with a burn wound of the left thigh of at least 1 day duration. The burn was due to heating pad. Notes did not identify this as a second degree burn. Measurements were made of wounds. There were 2 burns. Burn wound size of the left thigh was (length x width x dept) 11.5 cm x 5.5 cm x 0.1cm. Burn wound size of the right thigh was 2.5 cm x 2.0 cm x 0.1 cm. Review of Resident #1's Physician orders [REDACTED]. Another order written on 06/07/17 reflected: cleanse wound to left thigh with normal saline, pat dry, apply Xeroform and cover with dry dressing every day. Attempted interview with Resident #1 on 06/21/17 at 10:14 AM revealed he who was alert but not able to answer any questions. Interview with Resident #1's family member on 06/21/17 at 10:15 AM revealed the resident had neuropathy to his left thigh since 2010 and was treated for [REDACTED]. Observation of Resident #1 on 06/21/17 at 10:10 AM receiving treatment by the Treatment Nurse to his left thigh burn wound measuring 10.5 x 4.5 by 0.1 cm. The small burn wound on his right thigh was healed. Interview with the Wound Treatment Nurse on 06/21/17 at 10:10 AM revealed Resident #1 was able to state what happened when asked. She stated the small burn on his lower right thigh resolved on 06/20/17. The Wound Treatment Nurse revealed his left thigh burn was seen by the wound physician yesterday. Interview with the DON on 06/21/17 at 3:40 PM revealed Resident #1 received superficial burns as classified by the wound physician. Also revealed investigation of moist heat pack therapy resulted in therapy on hold for all Residents receiving heat therapy. The DON revealed in-services were completed with staff. She stated the regional director for therapy in-serviced the Physical Therapist for application of heat therapy. Also revealed the clinical team, the DON or ADON will assess any resident before heat therapy for tolerance. She stated therapy was to inform nurses before any therapy given and nursing will follow the resident for three days for any complications. Review of Policy Physical Agent Modalities - Hot Packs, effective date: 10/10/13 reflected under procedure: always monitor the patient - both verbally and visually - throughout the treatment. Review of In-service dated 06/07/17 reflected 34 staff received training on recognizing burns, assessment of skin, signs and symptoms of burns, and follow-up after heat therapy. Review of In-service dated 04/23/17 reflected 24 staff received training on Abuse/Neglect prevention. Interview with the Administrator on 06/21/17 at 9:56 AM revealed Resident #1 was the only resident receiving heat therapy due to his having a pacemaker and was not a candidate for Electrical Stimulation Therapy.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate assistance to prevent accidents for one (Resident #2) of five residents reviewed who required staff assistance with transfers. CNA B failed to transfer Resident #2, who was a 2 person transfer via a mechanical lift, with assistance on 04//22/17, which resulted in the resident being injured and sustaining a fracture to the right humerus. This was determined to be Past Noncompliance due to the facility having implemented actions that corrected the noncompliance prior to the beginning of the investigation. This failure could affect the facility's 13 residents, who required staff assistance for transfers with mechanical lifts by placing them at risk for falling, lacerations, fractures and the need for hospitalization . Findings included: Review of Resident #2's MDS assessment, dated 04/18/17, revealed she was an [AGE] year-old female admitted to the facility on [DATE]. The resident was totally dependent on two staff members for transfers. Review of Resident #1's comprehensive plan of care, dated 12/16/16, revealed the facility would provide extensive 2 two person assist with transfers using Hoyer lift. Review of the facility's Provider Investigation Report, dated 04/23/17 and regarding Resident #2, revealed, .Description of the Allegation reports indicate that the lift with one aide instead of two aides. Review of Departmental Notes dated 04/22/17 revealed (Resident #2) was alert was being transferred by Hoyer lift from the bed to the wheelchair by (CNA B) and the patients arm was in an awkward position verbalized by (CNA B). Review of Resident #2's x-ray report, dated 04/23/17 revealed, .Impression: The bones are osteoporotic. The irregularity is present in the greater tuberosity (defined by Merriam as a large prominence on a bone serving for the attachment of muscles or ligaments) , much more prominent than prior study dated 04/22/17. Findings are suggestive of the sub-acute greater tuberosity fracture, follow up suggested. Review of Departmental notes dated 04/23/17 at 6:53 p.m., revealed Resident # 2 was sent out to the hospital. On 04/23/17 at 10:00 p.m. Resident #2 returned to the facility with a [DIAGNOSES REDACTED]. Observation on 05/09/17 at 11:20 a.m. of Resident #2 revealed the resident was lying in bed with a sling on her right shoulder. An interview with Resident #2 on 05/09/17 at 11:27 a.m. revealed she was injured in her room while in the Hoyer lift. CNA B dropped her and damaged her shoulder and she was currently in pain. There was only one aide transferring her in the lift. An interview on 05/09/17 at 11:38 a.m. with CNA B revealed she was getting Resident #2 out of bed with a standing lift, she admitted she should have been using a Hoyer lift instead. She did not ask for help from another aide because she did not know the stand-up lift or Hoyer lift required two person assist. She had been transferring Resident #2 since she began working at the facility on 02/06/17. She was not aware the resident required two person assist. Observations on 05/09/17 revealed the aides had access to the care plans. Also the Kiosks were in the hallway, the kiosks reflected each residents transfers status . An interview with the Administrator on 05/09/17 at 1:32 p.m. revealed CNA B did not follow the facility policy on the use of the stand-up lift or Hoyer lift. CNA B did a stand-up lift without the assistance of any other staff member. The facility requires staff members to use two people when using both stand-up lifts and Hoyer lifts. Resident #2 has always required two person assist with transfers. Review of the facility's Safe Patient Handling and Transfer policy dated November 2013 revealed the following: .E .Mechanical lifting devices .3. All patient transfers with mechanical lifts will be done with a minimum of two persons or as specified in the patient's plan of care. Steps/Procedures the facility took to correct the deficient practice prior to the investigation. 1. CNA B was origiannly suspended on 04/22/17 pending the investigation . Following the facility investigation she was suspended on 04/23/17 without pay She was re-educated on 04/24/17 before returing to work. 2. All other residents requiring transfers were assesse on 04/24/17. 3. Re-educated all staff members on safe transfer procedure (competency-based) began on 04/24/17 ended 04/26/17. 4. Random checks of CNA to determine the compliance with the transfer's procedures. 5. DON and ADON completed check-offs with return demonstration on 04/24/17. 6. Educated staff on assessing the care plans for each resident completed on 04/24/17. 7. New employees are educated before starting on the floor and return demonstration. 8. Quality assurance and action planned staff members acessing the care plans and using two person using the mechanical lifts on 04/23/17. 9. Reported the incident to the State Agency. 10. Reviewed all residents care plans to reflect two person assist with each resident with Hoyer Lifts on 04/22/17. An interview on 05/16/17 at 2:31 p.m. with Resident #1 there were two people when doing a mechanical lift transfer on her. She once had problems but they have since been corrected. An interview on 05/16/17 at 2:40 p.m. Resident #3 revealed the facility used two person when transferring her in the mechanicals lifts. Observation on 05/16/17 at 2:31 p.m. of CNA C and LVN D transfter of Resident # 1 with a mechanical lift was completed properly. Observation on 05/16/17 at 2:40 p.m. of CNA E and CNA F transfer of Resident # 3 with a mechanical lift was completed properly. Observation on 05/16/17 at 3:18 pm of CNA C and LVN D transfer of Resident # 5 with a mechanical lift was completed properly. An interview on 05/16/17; with Resident # 4 at 3:18 p.m. revealed the staff had always used two persons when using the Hoyer lift. An interview with Resident #5 on 05/16/17 at 3:33 p.m. revealed the facility always used two people when using the mechanical lift with him to get in and out of bed. The facility roster provided by the Administrator on 05/09/17 reflected 75 residents resided at the facility, and 13 residents required two person assistance with transfers.

Based on interview and record review, it was determined the resident was not free from physical abuse for two (Residents #3 and #4) of six residents reviewed for abuse and behaviors. 1. The facility failed to prevent Resident #2 from physically abusing Resident #3. Resident #3 sustained a skin tear under his eye, and his eye had bloody drainage, had pain, and needed treatment for [REDACTED]. 2. The facility failed to implement interventions to prevent Resident #2 from hitting Resident #4 with his (Resident #2's) walker and making threatening statements. Resident #4 sustained a laceration to his lip and pain. He was transferred to the hospital for treatment. These failures could affect the 43 residents who resided in Hall 100, including Residents #3 and #4, by placing them at risk for bruising, skin tears, lacerations, fractures, and pain. Findings included: The facility's Detail Admission/Discharge Report, dated 02/13/14, reflected Resident #3 discharged on [DATE], Resident #2 discharged on [DATE], and Resident #4 discharged on [DATE]. Review of Resident #2's MDS assessment, dated 01/15/14, revealed the resident was a [AGE] year-old male admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #2's cognitive skills for daily decision-making were intact, and he did not exhibit any behaviors. The resident used a wheelchair for locomotion. Interview with LVN L on 02/13/14 at 4:15 PM revealed a physician's orders [REDACTED]. LVN L stated Resident #2 did not have behavior problems at that time. Review of Resident #2's clinical record with LVN L on 02/13/14 at 4:15 PM revealed a Physician's Telephone Order, dated 12/13/13, for a psychiatric consult, but not regarding behavior problems. There was not a psychiatric evaluation in the clinical record. Review of Resident #2's Comprehensive Care Plan, dated 01/22/14, revealed Resident #2 struck his roommate. The Goals and Approaches were the following: "Resident will be easily redirected through the next assessment period daily X (times) 90 days. No harm to self or others daily X 90 days. 1. Redirect as needed...4. Encourage praise appropriate behavior. 5. Encourage family involvement. 6. Speak in a calm voice. 7. Encourage verb (verbalization of) feelings/frustrations. 8. Acknowledge frustrations. 9. Assure needs will be met. 10. Contact M.D./PSY. (Medical Doctor/Psychiatrist) PRN (as needed)...." Resident #3's admission orders [REDACTED]. Review of Resident #3's Physician's History and Physical, dated 01/23/14, revealed his [DIAGNOSES REDACTED]. Review of the facility's Incident Reports, dated 01/22/14, revealed Resident #3 walked over to Resident #2's bed and sat at the foot of Resident #2's bed. When Resident #2 woke up and saw Resident #3 sitting on his bed, Resident #2 hit Resident #3. Resident #3 sustained a skin tear under his right eye. He bled from the injury. Both residents' physicians were notified, and the disposition on the incident was observation and in-house first aide treatment for [REDACTED]. Resident Incident Follow-up, dated 01/22/14, reflected: "...causing skin tear under his rt. (right) lower inner eyelid causing it to bleed...skin tear cleansed with wound cleanser...." Review of RN N's witness statement, dated 01/24/14, for the Incident Report, revealed, "As I was walking down the 100 hall towards time clock, I heard someone yelling, in a room. I stopped and went back the way I came. As I looked into (room number), I saw (Resident #3) sitting upright at the end of (Resident #2's) bed and (Resident #2) punching (Resident #3) in the back side of his face. I entered the room and broke them up. (Resident #3) had blood on the right side of his face. By that time, (RN M) had made it to the room." Resident #2's Nurse's Notes, dated 01/22/14, reflected he was involved in an incident with his roommate. His roommate sat on the foot of his bed, and Resident #2 woke up and was startled. He began hitting the roommate. Resident #2 was not injured and his physician was notified. Resident #2 was his own responsible party. The Note reflected the nurse would continue to monitor. Review of Resident #2's clinical record did not reveal a physician's orders [REDACTED]. Review of Resident #3's Nurse's Notes, marked "late entry" and written 01/23/14, revealed RN N was passing by Resident #2's room at 9:20 PM and saw Resident #2 hitting Resident #3. RN N stated blood was running down Resident #3's face. Resident #3's Nurse's Notes, dated 01/23/14 at 4:08 AM, reflected: "...Scratch to face near bridge of nose, between rt (right) eye and nose. Redness noted and scab forming...." Resident #3's Nurse's Notes, dated 01/23/14 at 2:19 PM, reflected: "...Resident has bloody drainage dripping down face from right eye injury of incident...Tylenol 1 tablespoon given for pain...." On 02/13/14 at 4:00 PM, an interview with the LVN E, an ADON, revealed RN N and RN M no longer worked in the facility. LVN E was asked for the RNs' telephone numbers, but the numbers were not provided prior to exit. On 02/14/14 at 12:30 PM, Divisional Nurse J stated the nurse reported to the physician Resident #2 hit Resident #3 and Resident #2 was monitored by the staff. Divisional Nurse J was asked for the physician's orders [REDACTED]." Regional Nurse K revealed the nurse was supposed to document in the Nurse's Notes the physician's orders [REDACTED]. Regional Nurse K stated the only problem she saw was it was not documented. She stated she did not believe in giving residents medication for behaviors. Review of Resident #4's MDS assessment, dated 02/05/14, revealed the resident was a [AGE] year-old male, who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. He used a wheelchair for ambulation. Review of Resident #4's Initial Care Plan, dated 01/22/14, reflected he was cognitively impaired with Dementia. Review of Resident #2's Nurse's Note, dated 02/01/14 and written by LVN O, revealed Resident #2 was found in a physical and verbal altercation with his roommate. Resident #4 was in the closet and pulled Resident #2's shirt off the hanger by mistake. Before the roommate could re-hang the shirt, Resident# 2 hit him with his walker causing injury to the roommate. The Note reflected Resident #2 was angry and combative when staff intervened. Resident #2 was pushed down by his roommate to protect himself. The DON, Nurse Practitioner, and Physician were notified. The physician gave a telephone order to transfer Resident #2 to a psychiatric hospital for psychiatric treatment. Resident #2's Physician's Telephone Order, dated 02/01/14, reflected an order for [REDACTED]. Interview on 02/13/14 at 11:15 AM with LVN A revealed he was the charge nurse for Residents #2 and #4 when they had this fight. He stated the incident happened on 01/31/14. LVN A said Residents #2 and #4 were roommates. LVN A revealed the oncoming nurse was giving him shift report at the Nurse's Station when Restorative Aide P called him to come to their room. LVN A stated when he went to the room, he saw Resident #2 on the floor and Resident #4 was on his wheelchair with a laceration on his lip. LVN A revealed he pulled Resident #4 out of his room to the hall. LVN A said he returned to room and Resident #2 said, "I was going to kill somebody." LVN A revealed he left the room so Resident #2 could cool down. LVN A stated when he returned to Resident #2's room, he said to him, "I am your nurse." LVN A said Resident #2 calmed down, and he assisted the resident to get up off the floor. LVN A revealed he went to Resident #4 and wiped the blood off his lip and applied an ice pack to his lip. LVN A stated he called Resident #4's responsible party and left a message. LVN A revealed as he was cleaning Resident #4's wound on his mouth, his responsible party came to the facility. LVN A said he told Resident #4's responsible party he called and left a message. Resident #4's responsible party stated he/she was out and had his/her cell telephone with him/her. Resident #4's responsible party gave LVN A the cell telephone number. LVN A revealed Resident #2 fought with Resident #3, his former roommate in the same room and now Resident #2 had another fight with his new roommate, Resident #4. LVN A stated Resident #4 was sent to the hospital for treatment of [REDACTED]. Interview on 02/13/14 at 11:30 AM with Restorative Aide P revealed she was passing bread on Hall 400 to the residents when she heard a loud noise. Restorative Aide P stated when she looked at the room, she saw Resident #2 on the floor as if he wanted to get up. She revealed she saw Resident #2 swinging his walker at Resident #4. Restorative Aide P said she did not see Resident #2 hit Resident #4 with the walker. Restorative Aide P stated she told Resident #2 not to swing his walker at Resident #4, and the resident swung his walker at her. Resident #2 got up, and she fled the room and called the charge nurse. Restorative Aide P revealed the nurse came and stopped Resident #2 from swinging his walker. Restorative Aide P stated she got Resident #4 out of the hall and gave him a towel to wipe his mouth. She revealed Resident #4 stated Resident #2 hit him on his lip. Interview on 02/13/14, at 2:45 PM with LVN E, an ADON, revealed she was off duty on the day the incident happened. LVN E stated she came to the facility to get something when she was told Resident #2 and Resident #4 had a fight. LVN E revealed she went to the residents' room and saw Resident #4 bleeding and Resident #2 told her, "I'm not going to hurt you. I'm not going to do anything to you." LVN E stated she called the police, who came. LVN E revealed Resident #4's responsible party was in the building and was coming to take Resident #4 out on pass. LVN E stated she assisted to pack Resident #4's things. Review of Resident #4's emergency room Medical Record, dated 02/01/14, revealed he was admitted from the nursing home with trauma to his face via assault with aluminum walker. Note reflected Resident #4 was bleeding from his lip, and the resident complained of pain on his face. He rated his pain on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain ever, at an "8." The record reflected: "Impression: 1, Facial injury 2, Alleged assault. 3, Upper lip laceration...." Review of Resident #2's Nurse's Note, dated 02/01/14, at 5:00 PM and written by the DON, revealed she was notified by the ADON Resident #2 hit his roommate. The DON stated when she entered Resident #2's room, he was sitting on his bed yelling and screaming he would hit anyone who came near him. Resident #2 picked up his walker as if he would throw it. Resident #2 could not be redirected. The DON documented they asked Resident #2 the reason he hit Resident #4 and he replied, "I tried to kill and I will kill you too." Resident #2 continued to yell, curse, make the above threats towards staff. Resident #2 was left alone to calm down. The DON documented when Resident #2 calmed down, he apologized for hitting his roommate, and she told him he would have an X-ray of his hip and would be referred to the psychiatric hospital. Review of Resident #2's Care Plan, dated 02/01/14, revealed Resident #2 struck Resident #4. The Goals/Approaches were the following: "Resident will be easily redirected through the next assessment period daily x 90 days. No harm to self or others daily x 90 days. 1. Redirect as needed...4. Encourage Praise appropriate behaviors. 5. Encourage family involvement...7. Encourage verbal feelings/frustrations. 8. Acknowledge frustrations...10. Contact M.D./Psy. PRN." The Care Plan did not reflect any new interventions to prevent resident-to-resident altercations. Interview on 02/13/14 at 3:25 PM with NP I, who worked with the psychiatrist, revealed she saw Resident #2 for Depression and [MEDICAL CONDITION] Disorder. She stated Resident #2 had impulsive behavior and she saw him for rehabilitation services. NP P stated, "If I had known anything about this, I would have done something and refer him for psych consult." Review of Resident #2's clinical record on 02/14/14 at 11:00 AM reflected the psychiatric consultation note for depression and [MEDICAL CONDITION] disorder dated 12/13/13 was found. Interview on 02/13/14 at 4:00 PM with the Administrator revealed Resident #2 was defending himself by hitting Resident #4. The facility's current policy, Abuse Prohibition and Standards of Practice, dated November 2005 reflected: "POLICY - Our facility will not condone any form of resident abuse and will continually monitor our facility's policies, procedures, training programs, systems, etc., to assist in preventing resident abuse...1. The facility's goal is to achieve and maintain an abuse-free environment...j) Assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect; k) Assessing residents with signs and symptoms of behavior problems and developing and implementing care plans to address behavioral issues...n) Involving qualified psychiatrists and other mental health professionals to help the staff manage difficult or aggressive residents...p) Striving to maintain adequate staffing on all shifts to ensure that the needs of each resident are met...e) Neglect - failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. 3. Recognizing signs and symptoms of abuse/neglect is critical...." The facility's current Resident-to-Resident Behavior Process, dated 12/06/13, reflected, "...3. Do not leave the agitated resident alone...Monitor the resident (aggressive resident)...1. Implement procedures on physically aggressive residents...." The facility census on 02/13/14, submitted by the Administrator reflected 43 residents on Hall 100.

Based on interview and record review, it was determined the facility failed to implement policies and procedures that prohibit abuse and neglect for three residents (Residents #2, #3 and #4) of six residents reviewed for abuse, neglect and behaviors. 1. The facility failed to prevent Resident #2 from physically abusing Resident #3. Resident #3 sustained a skin tear under his eye, and his eye had bloody drainage, had pain, and needed treatment for [REDACTED]. 2. The facility failed to implement interventions to prevent Resident #2 from hitting Resident #4 with his (Resident #2's) walker and making threatening statements. Resident #4 sustained a laceration to his lip and pain. He was transferred to the hospital for treatment. These failures could affect the 43 residents who resided in Hall 100, including Residents #3 and #4, by placing them at risk for bruising, skin tears, lacerations, fractures, and pain. Findings included: The facility's Detail Admission/Discharge Report, dated 02/13/14, reflected Resident #3 discharged on [DATE], Resident #2 discharged on [DATE], and Resident #4 discharged on [DATE]. Review of Resident #2's MDS assessment, dated 01/15/14, revealed the resident was a [AGE] year-old male admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #2's cognitive skills for daily decision-making were intact, and he did not exhibit any behaviors. The resident used a wheelchair for locomotion. Interview with LVN L on 02/13/14 at 4:15 PM revealed a physician's orders [REDACTED]. LVN L stated Resident #2 did not have behavior problems at that time. Review of Resident #2's clinical record with LVN L on 02/13/14 at 4:15 PM revealed a Physician's Telephone Order, dated 12/13/13, for a psychiatric consult, but not regarding behavior problems. There was not a psychiatric evaluation in the clinical record. Review of Resident #2's Comprehensive Care Plan, dated 01/22/14, revealed Resident #2 struck his roommate. The Goals and Approaches were the following: "Resident will be easily redirected through the next assessment period daily X (times) 90 days. No harm to self or others daily X 90 days. 1. Redirect as needed...4. Encourage praise appropriate behavior. 5. Encourage family involvement. 6. Speak in a calm voice. 7. Encourage verb (verbalization of) feelings/frustrations. 8. Acknowledge frustrations. 9. Assure needs will be met. 10. Contact M.D./PSY. (Medical Doctor/Psychiatrist) PRN (as needed)...." Resident #3's admission orders [REDACTED]. Review of Resident #3's Physician's History and Physical, dated 01/23/14, revealed his [DIAGNOSES REDACTED]. Review of the facility's Incident Reports, dated 01/22/14, revealed Resident #3 walked over to Resident #2's bed and sat at the foot of Resident #2's bed. When Resident #2 woke up and saw Resident #3 sitting on his bed, Resident #2 hit Resident #3. Resident #3 sustained a skin tear under his right eye. He bled from the injury. Both residents' physicians were notified, and the disposition on the incident was observation and in-house first aide treatment for [REDACTED]. Resident Incident Follow-up, dated 01/22/14, reflected: "...causing skin tear under his rt. (right) lower inner eyelid causing it to bleed...skin tear cleansed with wound cleanser...." Review of RN N's witness statement, dated 01/24/14, for the Incident Report, revealed, "As I was walking down the 100 hall towards time clock, I heard someone yelling, in a room. I stopped and went back the way I came. As I looked into (room number), I saw (Resident #3) sitting upright at the end of (Resident #2's) bed and (Resident #2) punching (Resident #3) in the back side of his face. I entered the room and broke them up. (Resident #3) had blood on the right side of his face. By that time, (RN M) had made it to the room." Resident #2's Nurse's Notes, dated 01/22/14, reflected he was involved in an incident with his roommate. His roommate sat on the foot of his bed, and Resident #2 woke up and was startled. He began hitting the roommate. Resident #2 was not injured and his physician was notified. Resident #2 was his own responsible party. The Note reflected the nurse would continue to monitor. Review of Resident #2's clinical record did not reveal a physician's orders [REDACTED]. Review of Resident #3's Nurse's Notes, marked "late entry" and written 01/23/14, revealed RN N was passing by Resident #2's room at 9:20 PM and saw Resident #2 hitting Resident #3. RN N stated blood was running down Resident #3's face. Resident #3's Nurse's Notes, dated 01/23/14 at 4:08 AM, reflected: "...Scratch to face near bridge of nose, between rt (right) eye and nose. Redness noted and scab forming...." Resident #3's Nurse's Notes, dated 01/23/14 at 2:19 PM, reflected: "...Resident has bloody drainage dripping down face from right eye injury of incident...Tylenol 1 tablespoon given for pain...." On 02/13/14 at 4:00 PM, an interview with the LVN E, an ADON, revealed RN N and RN M no longer worked in the facility. LVN E was asked for the RNs' telephone numbers, but the numbers were not provided prior to exit. On 02/14/14 at 12:30 PM, Divisional Nurse J stated the nurse reported to the physician Resident #2 hit Resident #3 and Resident #2 was monitored by the staff. Divisional Nurse J was asked for the physician's orders [REDACTED]." Regional Nurse K revealed the nurse was supposed to document in the Nurse's Notes the physician's orders [REDACTED]. Regional Nurse K stated the only problem she saw was it was not documented. She stated she did not believe in giving residents medication for behaviors. Review of Resident #4's MDS assessment, dated 02/05/14, revealed the resident was a [AGE] year-old male, who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. He used a wheelchair for ambulation. Review of Resident #4's Initial Care Plan, dated 01/22/14, reflected he was cognitively impaired with Dementia. Review of Resident #2's Nurse's Note, dated 02/01/14 and written by LVN O, revealed Resident #2 was found in a physical and verbal altercation with his roommate. Resident #4 was in the closet and pulled Resident #2's shirt off the hanger by mistake. Before the roommate could re-hang the shirt, Resident# 2 hit him with his walker causing injury to the roommate. The Note reflected Resident #2 was angry and combative when staff intervened. Resident #2 was pushed down by his roommate to protect himself. The DON, Nurse Practitioner, and Physician were notified. The physician gave a telephone order to transfer Resident #2 to a psychiatric hospital for psychiatric treatment. Resident #2's Physician's Telephone Order, dated 02/01/14, reflected an order for [REDACTED]. Interview on 02/13/14 at 11:15 AM with LVN A revealed he was the charge nurse for Residents #2 and #4 when they had this fight. He stated the incident happened on 01/31/14. LVN A said Residents #2 and #4 were roommates. LVN A revealed the oncoming nurse was giving him shift report at the Nurse's Station when Restorative Aide P called him to come to their room. LVN A stated when he went to the room, he saw Resident #2 on the floor and Resident #4 was on his wheelchair with a laceration on his lip. LVN A revealed he pulled Resident #4 out of his room to the hall. LVN A said he returned to room and Resident #2 said, "I was going to kill somebody." LVN A revealed he left the room so Resident #2 could cool down. LVN A stated when he returned to Resident #2's room, he said to him, "I am your nurse." LVN A said Resident #2 calmed down, and he assisted the resident to get up off the floor. LVN A revealed he went to Resident #4 and wiped the blood off his lip and applied an ice pack to his lip. LVN A stated he called Resident #4's responsible party and left a message. LVN A revealed as he was cleaning Resident #4's wound on his mouth, his responsible party came to the facility. LVN A said he told Resident #4's responsible party he called and left a message. Resident #4's responsible party stated he/she was out and had his/her cell telephone with him/her. Resident #4's responsible party gave LVN A the cell telephone number. LVN A revealed Resident #2 fought with Resident #3, his former roommate in the same room and now Resident #2 had another fight with his new roommate, Resident #4. LVN A stated Resident #4 was sent to the hospital for treatment of [REDACTED]. Interview on 02/13/14 at 11:30 AM with Restorative Aide P revealed she was passing bread on Hall 400 to the residents when she heard a loud noise. Restorative Aide P stated when she looked at the room, she saw Resident #2 on the floor as if he wanted to get up. She revealed she saw Resident #2 swinging his walker at Resident #4. Restorative Aide P said she did not see Resident #2 hit Resident #4 with the walker. Restorative Aide P stated she told Resident #2 not to swing his walker at Resident #4, and the resident swung his walker at her. Resident #2 got up, and she fled the room and called the charge nurse. Restorative Aide P revealed the nurse came and stopped Resident #2 from swinging his walker. Restorative Aide P stated she got Resident #4 out of the hall and gave him a towel to wipe his mouth. She revealed Resident #4 stated Resident #2 hit him on his lip. Interview on 02/13/14, at 2:45 PM with LVN E, an ADON, revealed she was off duty on the day the incident happened. LVN E stated she came to the facility to get something when she was told Resident #2 and Resident #4 had a fight. LVN E revealed she went to the residents' room and saw Resident #4 bleeding and Resident #2 told her, "I'm not going to hurt you. I'm not going to do anything to you." LVN E stated she called the police, who came. LVN E revealed Resident #4's responsible party was in the building and was coming to take Resident #4 out on pass. LVN E stated she assisted to pack Resident #4's things. Review of Resident #4's emergency room Medical Record, dated 02/01/14, revealed he was admitted from the nursing home with trauma to his face via assault with aluminum walker. Note reflected Resident #4 was bleeding from his lip, and the resident complained of pain on his face. He rated his pain on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain ever, at an "8." The record reflected: "Impression: 1, Facial injury 2, Alleged assault. 3, Upper lip laceration...." Review of Resident #2's Nurse's Note, dated 02/01/14, at 5:00 PM and written by the DON, revealed she was notified by the ADON Resident #2 hit his roommate. The DON stated when she entered Resident #2's room, he was sitting on his bed yelling and screaming he would hit anyone who came near him. Resident #2 picked up his walker as if he would throw it. Resident #2 could not be redirected. The DON documented they asked Resident #2 the reason he hit Resident #4 and he replied, "I tried to kill and I will kill you too." Resident #2 continued to yell, curse, make the above threats towards staff. Resident #2 was left alone to calm down. The DON documented when Resident #2 calmed down, he apologized for hitting his roommate, and she told him he would have an X-ray of his hip and would be referred to the psychiatric hospital. Review of Resident #2's Care Plan, dated 02/01/14, revealed Resident #2 struck Resident #4. The Goals/Approaches were the following: "Resident will be easily redirected through the next assessment period daily x 90 days. No harm to self or others daily x 90 days. 1. Redirect as needed...4. Encourage Praise appropriate behaviors. 5. Encourage family involvement...7. Encourage verbal feelings/frustrations. 8. Acknowledge frustrations...10. Contact M.D./Psy. PRN." The Care Plan did not reflect any new interventions to prevent resident-to-resident altercations. Interview on 02/13/14 at 3:25 PM with NP I, who worked with the psychiatrist, revealed she saw Resident #2 for Depression and [MEDICAL CONDITION] Disorder. She stated Resident #2 had impulsive behavior and she saw him for rehabilitation services. NP P stated, "If I had known anything about this, I would have done something and refer him for psych consult." Review of Resident #2's clinical record on 02/14/14 at 11:00 AM reflected the psychiatric consultation note for depression and [MEDICAL CONDITION] disorder dated 12/13/13 was found. Interview on 02/13/14 at 4:00 PM with the Administrator revealed Resident #2 was defending himself by hitting Resident #4. The facility's current policy, Abuse Prohibition and Standards of Practice, dated November 2005 reflected: "POLICY - Our facility will not condone any form of resident abuse and will continually monitor our facility's policies, procedures, training programs, systems, etc., to assist in preventing resident abuse...1. The facility's goal is to achieve and maintain an abuse-free environment...j) Assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect; k) Assessing residents with signs and symptoms of behavior problems and developing and implementing care plans to address behavioral issues...n) Involving qualified psychiatrists and other mental health professionals to help the staff manage difficult or aggressive residents...p) Striving to maintain adequate staffing on all shifts to ensure that the needs of each resident are met...e) Neglect - failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. 3. Recognizing signs and symptoms of abuse/neglect is critical...." The facility's current Resident-to-Resident Behavior Process, dated 12/06/13, reflected, "...3. Do not leave the agitated resident alone...Monitor the resident (aggressive resident)...1. Implement procedures on physically aggressive residents...." The facility census on 02/13/14, submitted by the Administrator reflected 43 residents on Hall 100.

Based on interview and record review, the facility failed to implement written policies and procedures that prohibit abuse and neglect for three (Residents #2, #3 and #4) of six residents reviewed for abuse, neglect and behavior problems. 1. The facility failed to prevent Resident #2 from physically abusing Resident #3. Resident #3 sustained a skin tear under his eye, and his eye had bloody drainage, had pain, and needed treatment for [REDACTED]. 2. The facility failed to implement interventions to prevent Resident #2 from hitting Resident #4 with his (Resident #2's) walker and making threatening statements. Resident #4 sustained a laceration to his lip and pain. He was transferred to the hospital for treatment. These failures could affect the 43 residents who resided in Hall 100, including Residents #3 and #4, by placing them at risk for bruising, skin tears, lacerations, fractures, and pain. Findings included: The facility's current policy, Abuse Prohibition and Standards of Practice, dated November 2005 reflected: "POLICY - Our facility will not condone any form of resident abuse and will continually monitor our facility's policies, procedures, training programs, systems, etc., to assist in preventing resident abuse...1. The facility's goal is to achieve and maintain an abuse-free environment...j) Assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect; k) Assessing residents with signs and symptoms of behavior problems and developing and implementing care plans to address behavioral issues...n) Involving qualified psychiatrists and other mental health professionals to help the staff manage difficult or aggressive residents...p) Striving to maintain adequate staffing on all shifts to ensure that the needs of each resident are met...e) Neglect - failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. 3. Recognizing signs and symptoms of abuse/neglect is critical...." The facility's current Resident-to-Resident Behavior Process, dated 12/06/13, reflected, "...3. Do not leave the agitated resident alone...Monitor the resident (aggressive resident)...1. Implement procedures on physically aggressive residents...." The facility's Detail Admission/Discharge Report, dated 02/13/14, reflected Resident #3 discharged on [DATE], Resident #2 discharged on [DATE], and Resident #4 discharged on [DATE]. Review of Resident #2's MDS assessment, dated 01/15/14, revealed the resident was a [AGE] year-old male admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #2's cognitive skills for daily decision-making were intact, and he did not exhibit any behaviors. The resident used a wheelchair for locomotion. Interview with LVN L on 02/13/14 at 4:15 PM revealed a physician's orders [REDACTED]. LVN L stated Resident #2 did not have behavior problems at that time. Review of Resident #2's clinical record with LVN L on 02/13/14 at 4:15 PM revealed a Physician's Telephone Order, dated 12/13/13, for a psychiatric consult, but not regarding behavior problems. There was not a psychiatric evaluation in the clinical record. Review of Resident #2's Comprehensive Care Plan, dated 01/22/14, revealed Resident #2 struck his roommate. The Goals and Approaches were the following: "Resident will be easily redirected through the next assessment period daily X (times) 90 days. No harm to self or others daily X 90 days. 1. Redirect as needed...4. Encourage praise appropriate behavior. 5. Encourage family involvement. 6. Speak in a calm voice. 7. Encourage verb (verbalization of) feelings/frustrations. 8. Acknowledge frustrations. 9. Assure needs will be met. 10. Contact M.D./PSY. (Medical Doctor/Psychiatrist) PRN (as needed)...." Resident #3's admission orders [REDACTED]. Review of Resident #3's Physician's History and Physical, dated 01/23/14, revealed his [DIAGNOSES REDACTED]. Review of the facility's Incident Reports, dated 01/22/14, revealed Resident #3 walked over to Resident #2's bed and sat at the foot of Resident #2's bed. When Resident #2 woke up and saw Resident #3 sitting on his bed, Resident #2 hit Resident #3. Resident #3 sustained a skin tear under his right eye. He bled from the injury. Both residents' physicians were notified, and the disposition on the incident was observation and in-house first aide treatment for [REDACTED]. Resident Incident Follow-up, dated 01/22/14, reflected: "...causing skin tear under his rt. (right) lower inner eyelid causing it to bleed...skin tear cleansed with wound cleanser...." Review of RN N's witness statement, dated 01/24/14, for the Incident Report, revealed, "As I was walking down the 100 hall towards time clock, I heard someone yelling, in a room. I stopped and went back the way I came. As I looked into (room number), I saw (Resident #3) sitting upright at the end of (Resident #2's) bed and (Resident #2) punching (Resident #3) in the back side of his face. I entered the room and broke them up. (Resident #3) had blood on the right side of his face. By that time, (RN M) had made it to the room." Resident #2's Nurse's Notes, dated 01/22/14, reflected he was involved in an incident with his roommate. His roommate sat on the foot of his bed, and Resident #2 woke up and was startled. He began hitting the roommate. Resident #2 was not injured and his physician was notified. Resident #2 was his own responsible party. The Note reflected the nurse would continue to monitor. Review of Resident #2's clinical record did not reveal a physician's orders [REDACTED]. Review of Resident #3's Nurse's Notes, marked "late entry" and written 01/23/14, revealed RN N was passing by Resident #2's room at 9:20 PM and saw Resident #2 hitting Resident #3. RN N stated blood was running down Resident #3's face. Resident #3's Nurse's Notes, dated 01/23/14 at 4:08 AM, reflected: "...Scratch to face near bridge of nose, between rt (right) eye and nose. Redness noted and scab forming...." Resident #3's Nurse's Notes, dated 01/23/14 at 2:19 PM, reflected: "...Resident has bloody drainage dripping down face from right eye injury of incident...Tylenol 1 tablespoon given for pain...." On 02/13/14 at 4:00 PM, an interview with the LVN E, an ADON, revealed RN N and RN M no longer worked in the facility. LVN E was asked for the RNs' telephone numbers, but the numbers were not provided prior to exit. On 02/14/14 at 12:30 PM, Divisional Nurse J stated the nurse reported to the physician Resident #2 hit Resident #3 and Resident #2 was monitored by the staff. Divisional Nurse J was asked for the physician's orders [REDACTED]." Regional Nurse K revealed the nurse was supposed to document in the Nurse's Notes the physician's orders [REDACTED]. Regional Nurse K stated the only problem she saw was it was not documented. She stated she did not believe in giving residents medication for behaviors. Review of Resident #4's MDS assessment, dated 02/05/14, revealed the resident was a [AGE] year-old male, who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. He used a wheelchair for ambulation. Review of Resident #4's Initial Care Plan, dated 01/22/14, reflected he was cognitively impaired with Dementia. Review of Resident #2's Nurse's Note, dated 02/01/14 and written by LVN O, revealed Resident #2 was found in a physical and verbal altercation with his roommate. Resident #4 was in the closet and pulled Resident #2's shirt off the hanger by mistake. Before the roommate could re-hang the shirt, Resident# 2 hit him with his walker causing injury to the roommate. The Note reflected Resident #2 was angry and combative when staff intervened. Resident #2 was pushed down by his roommate to protect himself. The DON, Nurse Practitioner, and Physician were notified. The physician gave a telephone order to transfer Resident #2 to a psychiatric hospital for psychiatric treatment. Resident #2's Physician's Telephone Order, dated 02/01/14, reflected an order for [REDACTED]. Interview on 02/13/14 at 11:15 AM with LVN A revealed he was the charge nurse for Residents #2 and #4 when they had this fight. He stated the incident happened on 01/31/14. LVN A said Residents #2 and #4 were roommates. LVN A revealed the oncoming nurse was giving him shift report at the Nurse's Station when Restorative Aide P called him to come to their room. LVN A stated when he went to the room, he saw Resident #2 on the floor and Resident #4 was on his wheelchair with a laceration on his lip. LVN A revealed he pulled Resident #4 out of his room to the hall. LVN A said he returned to room and Resident #2 said, "I was going to kill somebody." LVN A revealed he left the room so Resident #2 could cool down. LVN A stated when he returned to Resident #2's room, he said to him, "I am your nurse." LVN A said Resident #2 calmed down, and he assisted the resident to get up off the floor. LVN A revealed he went to Resident #4 and wiped the blood off his lip and applied an ice pack to his lip. LVN A stated he called Resident #4's responsible party and left a message. LVN A revealed as he was cleaning Resident #4's wound on his mouth, his responsible party came to the facility. LVN A said he told Resident #4's responsible party he called and left a message. Resident #4's responsible party stated he/she was out and had his/her cell telephone with him/her. Resident #4's responsible party gave LVN A the cell telephone number. LVN A revealed Resident #2 fought with Resident #3, his former roommate in the same room and now Resident #2 had another fight with his new roommate, Resident #4. LVN A stated Resident #4 was sent to the hospital for treatment of [REDACTED]. Interview on 02/13/14 at 11:30 AM with Restorative Aide P revealed she was passing bread on Hall 400 to the residents when she heard a loud noise. Restorative Aide P stated when she looked at the room, she saw Resident #2 on the floor as if he wanted to get up. She revealed she saw Resident #2 swinging his walker at Resident #4. Restorative Aide P said she did not see Resident #2 hit Resident #4 with the walker. Restorative Aide P stated she told Resident #2 not to swing his walker at Resident #4, and the resident swung his walker at her. Resident #2 got up, and she fled the room and called the charge nurse. Restorative Aide P revealed the nurse came and stopped Resident #2 from swinging his walker. Restorative Aide P stated she got Resident #4 out of the hall and gave him a towel to wipe his mouth. She revealed Resident #4 stated Resident #2 hit him on his lip. Interview on 02/13/14, at 2:45 PM with LVN E, an ADON, revealed she was off duty on the day the incident happened. LVN E stated she came to the facility to get something when she was told Resident #2 and Resident #4 had a fight. LVN E revealed she went to the residents' room and saw Resident #4 bleeding and Resident #2 told her, "I'm not going to hurt you. I'm not going to do anything to you." LVN E stated she called the police, who came. LVN E revealed Resident #4's responsible party was in the building and was coming to take Resident #4 out on pass. LVN E stated she assisted to pack Resident #4's things. Review of Resident #4's emergency room Medical Record, dated 02/01/14, revealed he was admitted from the nursing home with trauma to his face via assault with aluminum walker. Note reflected Resident #4 was bleeding from his lip, and the resident complained of pain on his face. He rated his pain on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain ever, at an "8." The record reflected: "Impression: 1, Facial injury 2, Alleged assault. 3, Upper lip laceration...." Review of Resident #2's Nurse's Note, dated 02/01/14, at 5:00 PM and written by the DON, revealed she was notified by the ADON Resident #2 hit his roommate. The DON stated when she entered Resident #2's room, he was sitting on his bed yelling and screaming he would hit anyone who came near him. Resident #2 picked up his walker as if he would throw it. Resident #2 could not be redirected. The DON documented they asked Resident #2 the reason he hit Resident #4 and he replied, "I tried to kill and I will kill you too." Resident #2 continued to yell, curse, make the above threats towards staff. Resident #2 was left alone to calm down. The DON documented when Resident #2 calmed down, he apologized for hitting his roommate, and she told him he would have an X-ray of his hip and would be referred to the psychiatric hospital. Review of Resident #2's Care Plan, dated 02/01/14, revealed Resident #2 struck Resident #4. The Goals/Approaches were the following: "Resident will be easily redirected through the next assessment period daily x 90 days. No harm to self or others daily x 90 days. 1. Redirect as needed...4. Encourage Praise appropriate behaviors. 5. Encourage family involvement...7. Encourage verbal feelings/frustrations. 8. Acknowledge frustrations...10. Contact M.D./Psy. PRN." The Care Plan did not reflect any new interventions to prevent resident-to-resident altercations. Interview on 02/13/14 at 3:25 PM with NP I, who worked with the psychiatrist, revealed she saw Resident #2 for Depression and [MEDICAL CONDITION] Disorder. She stated Resident #2 had impulsive behavior and she saw him for rehabilitation services. NP P stated, "If I had known anything about this, I would have done something and refer him for psych consult." Review of Resident #2's clinical record on 02/14/14 at 11:00 AM reflected the psychiatric consultation note for depression and [MEDICAL CONDITION] disorder dated 12/13/13 was found. Interview on 02/13/14 at 4:00 PM with the Administrator revealed Resident #2 was defending himself by hitting Resident #4. The facility census on 02/13/14, submitted by the Administrator reflected 43 residents on Hall 100.

Based on interview and record review, the facility failed to ensure adequate supervision was provided to prevent an accident for one (Resident #1) of five residents reviewed for transfers. CNA D failed to get assistance when she transferred Resident #1, who required two staff for transfers, using a sling from the shower bed to bed. During the sling transfer, the shower bed tilted over and Resident #1 fell on the floor. Resident #1 sustained left posterior scalp laceration, which required sutures. This failure could affect the five residents who were transferred to the shower bed, placing them at risk for falling, bruising, skin tears, lacerations, fracture, pain and injury resulting in the need for further medical treatment at the hospital with potential for hospitalization . Findings included: Review of Resident #1's MDS assessment, dated 01/13/14, revealed the resident was an [AGE] year-old female, who was admitted on [DATE], with [DIAGNOSES REDACTED]. The MDS assessment reflected Resident #1 was totally dependent on two or more persons' assistance with transfers and totally dependent on staff for ADLs. Resident #1's Care Plan, dated 12/21/13, reflected she had cognitive and physical impairment. Resident #1's Care Plan, dated 04/17/13 and reviewed 12/23/13, reflected she was at increased risk of injury and required a Hoyer lift for transfers due to morbid obesity. The Goal/Approaches included: "(Resident #1) would be free from injury during transfer through next review. 1. Use Hoyer lift for all transfers. 2. Staff will maintain proper safety parameters during all transfers. 3. Provide resident with lash sling for transferring with Hoyer lift...." Review of Resident #1's Nurse's Note, dated 02/03/14 by LVN G, revealed a CNA went to the Nurse's Station and told the Charge Nurse Resident #1 was on the floor. The Note reflected the Charge Nurse and Nurse Manager went to the resident's room and saw her lying on the floor on her left side. Resident #1 was bleeding from the back of her head and an ice pack was applied. The Note reflected Resident #1 did not exhibit any signs or symptoms of pain at that time. Further review of the Note revealed 911 was called at 11:30 AM, the paramedics arrived at the facility, and transferred her to the hospital. The physician and Resident #1's family member were notified. Review of CNA B's written statement, dated 02/03/14, revealed she took Resident #1 to her room. She opened the shower bed rail and put the sling underneath Resident #1, and the shower bed tilted over. Resident #1 fell on the floor, and there was blood on the floor. CNA B stated she went to get LVN G. An interview with CNA B on 02/13/14 at 11:45 AM, revealed CNA H assisted her to transfer Resident #1 from her bed to the shower bed. CNA B stated she took Resident #1 on the shower bed to the shower room. CNA B said after she finished giving the resident a shower in the bathroom, she wheeled Resident #1 to her room. She revealed she opened the shower rail on one side and was straightening the sling under Resident #1 when the resident's weight shifted to one side. CNA B stated the shower bed tilted over and Resident #1 fell on the floor. CNA B revealed she saw blood coming out the back of Resident #1's head. She stated she left the resident on the floor and called LVN G at the Nurse's Station. She said LVN G came to the resident's room. CNA B stated two staff were required to transfer the resident to the shower bed prior to the resident falling. She revealed one staff was able to bathe the resident. CNA B stated after Resident #1 fell , she received an in-service and now two staff were required to give the resident a shower on the bed. An interview on 02/14/14 at 11:26 AM with CNA H revealed CNA B told her to assist her in transferring Resident #1 from her bed to the shower bed. She stated she was providing incontinent care to another resident at that time. She said she told CNA B she would assist her when she finished the care. She revealed when she finished with the incontinent care, she went to assist CNA B, but she met her (CNA B) on the hall with Resident #1 on the shower bed. CNA H stated she did not assist CNA B with transferring Resident #1 to the shower bed. CNA H revealed, "I don't know if I was moving too slow for her." CNA H stated two staff members were required to assist when transferring Resident #1 from her bed to the shower bed. She revealed she did not have an in-service regarding the shower bed. CNA H stated she had been in the facility for one year. Interview with LVN G, on 02/13/14 at 1:30 PM, revealed she was at the Nurse's Station when CNA B called her and said Resident #1 was on the floor. She stated she went to the resident's room and saw her lying on the floor, on her back, toward her left side with her left leg bent. LVN G revealed she saw the blood on the back of the resident's head. She stated she took Resident #1's blood pressure and pulse, and moved the resident to reposition her head. LVN G stated the Nurse Manager applied an ice pack to Resident #1's head, and she asked the staff to call 911. LVN G stated Resident #1 needed two persons assistance with a Hoyer lift transfer. LVN G revealed the ADON was holding the ice pack to Resident #1's head. When the Administrator and DON came in Resident #1's room, she left the room. An interview with the DON on 02/13/14 at 10:00 AM revealed Resident #1 fell out of the shower bed in her room. The DON was asked for an in-service provided to the nursing staff on shower bed transfers. She returned with an in-service, dated 02/03/14, on shower beds with CNA B's name only on the sign-in sheet. The DON was asked why the names of the other nursing staff were not on the list. She replied, "I in-serviced all the staff." The DON stated two staff members were required to provide a shower on the shower bed. When asked to observe a shower given while a resident was on the bed, the DON replied, "I don't have two CNAs to assist with shower." Review of Resident #1's Hospital Record, dated 02/03/14, revealed Resident #1 was seen in the emergency room for a scalp laceration, about three inches in length, which was repaired with staples. Resident #1's Care Plan, dated 02/03/14, reflected: Problem: Resident #1 has laceration/sutures and is at risk for complications. The Goal/Approaches included: "... wound will heal without complications or s/s's of infections. 1. Clean and dress wound as instructed. 2. Monitor for s/s (signs/symptoms) of infections. Body: Drainage, odor, increased swelling, temperature or redness and notify MD of abnormal. 3. Remove staples as ordered. 4. Administer medication as ordered. Resident #1's Care Plan, dated 02/03/14, reflected she fell , and the goal was no significant changes or related injuries into next assessment. The Approaches were assess resident for injury at time of fall; assess resident environment for fall risk hazard and correct; assess resident's status for risk of future falls; refer to therapy after each fall; notify physician; notify RP; anticipate resident's needs when possible; and two for repositioning and transfers . An interview with CNA D on 02/13/14 at 11:40 AM, revealed two staff members were required when transferring the resident from her bed to the shower bed. CNA D stated after Resident #1 had a fall, an in-service was conducted. CNA D stated two staff members were required to give the resident's bath on the shower bed. CNA B's Employee Counseling/Disciplinary Report, dated 02/03/14, reflected she was suspended. The reason for disciplinary action was as follows: "(CNA B) informed charge nurse that resident in (Resident #1's room) had fallen from shower bed to floor. Resident noted to be on floor, lying on left side, bleeding from wound sustained on her head. (CNA B) stated she was getting ready to transfer resident back to bed and when she lift the shower bed rail down, the bed tilted over and resident fell to the floor. There was no one else in the room to assist her with this transfer. (CNA B) is well aware of the facility's transfer requirement of 2 for all mechanical lifts, yet she failed to follow this protocol, causing injury to resident. She usually follows the protocol. No explanation as to why she didn't. Therefore, (CNA B) is suspended pending further investigation. She is to return tomorrow, 02/04/14 at 11:00 AM for the final disposition." An In-Service Training Report, dated 02/03/14, reflected the DON provided an in-service to CNA B on shower bed transfers. An In-Service Training Report, dated 02/13/14, reflected the facility staff provided in-service to nurses and CNAs that morning on repositioning and transfers. An interview with the Administrator on 02/13/14 at 11:07 AM, reflected the facility would provide an in-service on repositioning and transfers to the evening and the night staff when they returned for work. The Shower Bed Operation Manual, revised February 2008, provided by the Administrator as the facility's policy for shower beds, reflected: "Operation instructions: SHOWER BED MODELS... 350# CAPACITY - USG 1000... PURPOSE - To transfer a person in a horizontal position and to use as a platform for showering. USAGE RECOMMENDATION - Recommended for showering people who are unable to stand or sit in a chair. OPERATING INFORMATION - The shower bed is equipped with 4 locking casters to be used during user transfer and when wanting to remain stationary. CAUTION: WHEELS CAN SLIDE ON WET SURFACES EVEN WHEN LOCKED. Before transferring, lock all casters, lift opposite side rail and INSERT BOTH CORNER PINS in position. Move shower bed to the desired location and lock all casters. Use caution of the shower rail as bed will be wet and slippery. To lower side rails, remove corner lock pins UNLESS TRANSFERRING, WHEN THE RESIDENT IS ON THE SHOWER BED, KEEP SIDE RAILS UP AT ALL TIMES. The FSG 350 folding shower bed folds down to each end for easy usage. Simply unpin and lift up on either end until the section disengages and store legs on top of the lower frame. *WHEN USING A LIFT TO TRANSFER THE PATIENT IN AND OUT OF SHOWER BED, MANUFACTURER RECOMMENDS KEEPING THE SIDE RAILS UP AND LOCKED AT ALL TIMES. ...Precautions: Never leave an at-risk user unattended on the bed. EXAGGERATED USER MOVEMENT IN ANY DIRECTION OR ROLLING TO THE EDGE MAY CAUSE GURNEY TO TOP. DO NOT ROLL USER AWAY FROM YOU UNLESS THERE IS A PARTNER/CAREGIVER ON THE OTHER SIDE. Do not use side rail as a grab bar...." The facility census provided on 02/13/14 had 5 residents identified for bath with shower bed and 33 residents identified for showers.

Based on interview and record review, it was determined the facility failed to immediately consult with the resident's physician and the resident's interested family member when the resident experienced a significant change in the resident's physical condition for one (Resident #1) of four residents reviewed. 1. LVN A failed to immediately consult with Resident #1's physician when staff informed her he was not breathing normally and was not as active as normal, or when she saw blood in his catheter bag and tubing on [DATE] at approximately 10:30 a.m. LVN A also failed to notify Resident #1's interested family member when the resident had a change in condition. 2. ADON B failed to immediately consult with Resident #1's physician when she saw blood in his catheter bag. 3. LVN LL and LVN I failed to immediately consult with Resident #1's physician when he had scant urine output that was dark. Resident #1 was pronounced dead at 12:45 p.m. on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring the effectiveness of the Plan of Removal. These failures could affect the 46 residents who resided on Station Two, by placing them at risk for a delay in appropriate medical treatment, exacerbation of their medical condition, pain, diminished quality of life and/or death. Findings included: Review of Resident #1's Face Sheet, dated [DATE], revealed he was admitted to the facility on [DATE] for Respite care. The Face Sheet reflected he was 80-years-old, and his [DIAGNOSES REDACTED]. Resident #1's hospital record, dated [DATE], reflected a past medical history of [REDACTED]. The record also reflected the resident had Dementia and was residing with his family member as the care giver. Resident #1 had a catheter, and he required assistance with his catheter care. Review of the hospital record revealed he could become agitated due to Dementia and required monitoring of his diet to prevent aspiration. Resident #1 was able to communicate and was able to slowly ambulate. Review of Resident #1's clinical records did not reveal a Minimum Data Set assessment. Resident #1's clinical record revealed his initial care plan was blank and no care plan was initiated. Resident #1's [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident #1's "Admission Data Set and Plan of Care" worksheet, dated [DATE] at 3:30 p.m., reflected he was admitted from home for Respite care. The worksheet reflected he had an indwelling catheter and his urine was amber colored with no odor. Resident #1's Daily Skilled Nursing Note, dated [DATE], reflected his catheter drained clear yellow urine on all three shifts. The Note also reflected the resident's family member visited and walked the resident in the hall around 8:00 p.m. that evening. Resident #1's Daily Skilled Nursing Note, dated [DATE], reflected during the evening shift and the night shift, his urine was dark yellow. Resident #1's Daily Interdisciplinary Note, dated [DATE] and timed at 4:00 p.m., reflected his catheter was patent and draining dark yellow urine with no odor. Resident #1's Situation-Background-Assessment-Appearance Request (SBAR) form, printed on [DATE] and timed at 3:28 p.m., reflected the situation change prompting the call "pt. (patient) expired." The form also reflected, "pt. appears to be lethargic, bld (blood) in urine." Further review of the Situation-Background-Assessment-Appearance Request form revealed, in the background section, the resident's primary [DIAGNOSES REDACTED]. The vital signs were 98.2 temperature, 73 pulse, 20 respirations, and his blood pressure was ,[DATE]. The background assessment further reflected mental status changes, "Foley Catheter urine cloudy foul color." The pain level assessment indicated the resident was grimacing and the resident was encouraged to drink fluids. The assessment section reflected, "The resident appears...Some pain noted lethargic." The request section reflected the physician was notified of the resident's death at 12:45 p.m. that day. An interview with CNA E on [DATE] at 1:30 p.m. revealed Resident #1 was a one person assist with transfers, and when he was agitated, he required the assistance of two staff with transfers. and was fed. Resident #1 was confused and responds to his name mostly. She stated he had a catheter with a leg bag and no strap. CNA E revealed obtained a leg strap on Friday and attached it to the bag to keep the bag from pulling. CNA E stated on Monday, [DATE], she informed LVN A the strap was not on, and his that the urine had odor. CNA E revealed LVN A told her she would change the catheter. CNA E stated she did not remember the blood in the bag/tubing on Monday morning. She revealed when she came on duty on Tuesday, [DATE], morning the catheter bag was empty from the night shift staff emptying it. She stated he was fine during breakfast, and she fed him without incident. She said breakfast was around 8:00 a.m. or 8:15 a.m. and she took him out of the dining room one hour after breakfast. CNA E said she and the MA saw him in his Geri chair in the hall, and he was leaning to the side like his bottom hurt. While observing him, they realized there was something different about him, and something was not right. The charge nurse was called to the resident's side. When she arrived they told her he was not looking well. CNA E revealed LVN A instructed them to lay him down in his bed. She stated the two CNAs and one MA assisted him to bed. CNA E said the MA took his vital signs and wrote them on a piece of paper. CNA E revealed LVN A left the room and came back with ADON B. CNA E stated when ADON B arrived the nurses were talking about the hospital and sending him out. CNA E also stated ADON B did not assess Resident #1 when she came to the room. CNA E revealed ADON B stood by the bed talking to LVN A. CNA E stated the catheter bag had approximately 150 cc of dark, brown urine, and she did not see the blood, but the urine had an odor like something dead, strong ammonia like foul odor. CNA E revealed at 10:30 a.m. to 10:45 a.m., she checked on the resident, and he was in bed asleep. She stated she went to lunch at 11:30 a.m., and he was still in the bed, and she was surprised because he was always attempting to get out of the bed. She revealed he was turned to his side at this time. CNA E further stated she came back from lunch at 12:00 p.m., and while passing the lunch trays, she heard CNA G call ADON B stating she thought the resident was not breathing. CNA E revealed at that time, she remembered the odor when she got Resident #1 up on Tuesday morning. An interview with CNA D on [DATE] at 2:15 p.m. revealed she was coming down the hall when she saw CNA E and MA F over a resident. She stated CNA E called her and asked her if the resident looked ok. CNA D stated Resident #1 was breathing funny, like panting or gasping for air, and he was non-responsive. She revealed she told them "No," he was not his usual self. CNA D said she told them to get the Charge Nurse who was in the dining room. She stated when the Charge Nurse arrived, she looked at the resident and told them to put him in bed. CNA D revealed the three of them together placed the resident back in his bed. CNA D stated she was not sure what time that was, but it was after breakfast. CNA D said Resident #1 had a catheter with a leg bag. She stated it had a funny odor to it, there was blood in the tubing, and the urine was dark and cloudy looking. CNA D revealed he was alert on the previous Saturday and then she was off. She stated on Monday he was different from his usual. CNA D said he was in the dining room during breakfast and was moving around as usual. Further interview with CNA D on [DATE] at 10:15 a.m. revealed she saw the resident in his Geri chair in the hall, and he was slumped down to one side and breathing funny. She stated she did not see LVN A touch the resident or assess the resident. MA F obtained the resident's vital signs before the resident was placed back into his bed. CNA D stated the blood pressure was something like 167 over something, but she could not remember the bottom number. She revealed when he was placed in the bed, LVN A told CNA E to pull down his pants. CNA D stated when the aide did that, she smelled the odor and saw the blood in the tubing. CNA D revealed LVN A asked MA F for his vital signs, but did not touch his penis to assess the odor emanating from there. She stated after that, she left for her lunch break. An interview with MA F on [DATE] at 12:26 p.m. revealed Resident #1 was a new admit, who did not speak much, but when his name was called, he would respond. She stated she did not know he had catheter until [DATE] when LVN A asked her and the other CNAs to put the resident back in bed and she observed the catheter when CNA E exposed the leg bag. She said she went to give Resident #1 his medication and he was in his Geri chair by his door. MA F revealed she checked his blood pressure for his medication administration and it was like ,[DATE] and his pulse was 71 (normal range for his age). She stated then she went to get his medications. When she came back with the medication, she saw he was not as fidgety and moving constantly as he normally did. She also noticed he was slumped to the side and this was at approximately 10:15 a.m. on [DATE]. She asked CNA E to assist her in pulling the resident up in his Geri chair. MA F revealed Resident #1 was also breathing funny, real fast like he was not getting oxygen or air was not going into him clearly. She stated LVN A instructed them to put the resident in bed. MA F revealed LVN A instructed CNA E to pull down the resident's pants down, after he was placed in the bed. LVN A checked his catheter drainage bag. MA F stated ADON B and LVN A talked about blood in the urine in the room. She also stated LVN A asked her for his vital signs. MA F revealed she never saw LVN A touch or assess anything else but his catheter bag with ADON B. MA F stated the bag had blood, which was dark like old blood, and the urine was dark yellow. She stated that the odor that emanated from the urinary bag and between the resident's legs was "loud," was loud like a strong smell of ammonia, strong urine. She revealed the next time she saw Resident #1, he was very pale with his hand on his chin area, he looked like there was no blood movement in him and he did not have his color, he was dead. An interview with CNA G on [DATE] at 2:40 p.m. revealed she passed by Resident #1's room and saw him staring up in the air. She stated she went in his room, and his eyes were opened, but he was not responding to his name. She revealed she checked his pulse and there was none and she stepped out of the room called for CNA E. CNA G stated she saw ADON B in the hall and told her the resident was not breathing. She revealed they grabbed the crash cart, went to his room, called the code, and started CPR. CNA G stated this incident occurred around 12:00 to 12:15 p.m. and LVN A was in the dining room at the time. An interview with LVN A on [DATE] at 11:22 a.m. revealed she took Resident #1 from the dining room between 9:00 a.m. to 9:30 a.m. to the hall by his room. She then completed her medication pass. LVN A stated Resident #1 was okay moving around in his Geri chair. At 10:00 a.m. to 10:30 a.m., the resident's family member called her and said last night the resident's output was darker and small. LVN A said she told the family member to hold on, and she assessed Resident #1's catheter bag. LVN A revealed the drainage in the catheter bag was dark colored with blood tinged cloudy urine with no odor. She stated she spoke with the family member and told him/her she would get a UA and notify the physician. LVN A stated about 10:45 a.m. to 11:00 a.m., CNAs D, E and CNA F informed her Resident #1 did not look good, he looked different than his usual self, and something was wrong with him. She revealed the CNAs told her the resident was not moving like he normally did. LVN A revealed she looked at him, and he was not the same as earlier, so she instructed them to lay him down. She stated she assessed Resident #1, but he was not as active as he was the day before. LVN A said he was alert, weak, and had a grimace on his face, and she got ADON B at approximately 11:00 a.m. to assess him with her as the CNAs said he was different from his normal. She revealed ADON B and she looked at his catheter drainage leg bag and ADON B stated, "We need to send him out." LVN A said when something happened, the staff usually notified ADON B and ADON B notified the DON. LVN A revealed staff had been terminated for not first notifying the DON before transferring a resident to the hospital. Continued interview with LVN A on [DATE] at 11:22 a.m. revealed stated they both left Resident #1's room, and she told ADON B she would call the physician. LVN A stated ADON B told her to call and notify the hospital nurse. LVN A said she called the nurse and notified her, the resident would be sent to the hospital due to lethargy. LVN A revealed she received a call from the front desk and was told the hospital nurse was in the facility. She stated she contacted the nurse to assess Resident #1, the nurse assessed Resident #1 and told them (her and ADON B) to send the resident to the hospital for an evaluation. LVN A revealed she made one call to Resident #1's physician's cell phone and left a message. She stated she got busy, forgot to call the physician back, and/or to ask someone else to call him. She stated she called and notified the DON about the hospital nurse's assessment to send Resident # 1 to the hospital. LVN A revealed the DON told her not to send him to the hospital and to get a UA, which the facility could do. She stated she then ordered a Stat UA with the facility's contracted laboratory company. LVN A said she went to lunch at about 11:30 a.m. to 12:00 p.m. She revealed she was supposed to monitor the dining room during lunch that day, so when she returned from her lunch, she went to the dining room. LVN A stated she was in the dining room at 12:30 p.m. when CNA G and ADON B called to notify her Resident #1 coded. The surveyor contacted the hospital nurse, on [DATE] at 12:32 p.m., and the nurse declined to talk with the surveyor. An interview with ADON B, on [DATE] at 12:48 p.m., revealed LVN A, Resident #1's charge nurse, called her into his room about 10:30 a.m. or 10:45 a.m. on [DATE] and asked her to assess the resident. She stated when she entered the room, LVN A asked her to check the resident's urine as it had blood in it. ADON B said Resident #1 was tall, and he was lying in his bed. She revealed LVN A exposed his catheter leg bag for her to see it. ADON B stated there was not a lot of urine in the bag, but there was old blood in the bag, and streaks of blood in the catheter tubing. She also stated the urine had sediment in it. ADON B revealed after she looked at his catheter bag, she told LVN A to notify his physician to get treatment orders. She stated she only looked at the catheter drainage bag, and she did not assess the resident. When asked why she failed to assess the rest of the resident, ADON B replied LVN A blocked her view, and she did not change her position to see the resident. ADON B stated she did not ask LVN A to move, so she could see Resident #1. ADON B revealed LVN A did not inform her Resident #1 had a change in condition. She only asked her to assess the urine in his catheter bag. During this same interview on [DATE] at 12:48 p.m., ADON B stated she had seen blood in urine before, and if she saw it, she would obtain the vital signs and call the physician. She stated she was told his blood pressure was ,[DATE] and stable. She stated she would also obtain a UA because if the resident was a male, he could have pulled the catheter. ADON B stated they do not know the reason for the blood in the urine, until a UA with a culture and sensitivity results were obtained. She stated she would also notify the physician for any other orders. ADON B stated after she left the resident's room she went back to the orientation class. She stated later CNA G called her and told her Resident #1 had stopped breathing. She further stated they (CNA G and her) got the crash cart and went to the room. ADON B stated she and CNA G initiated CPR on the resident until 911 came to the facility and took over. ADON B added that on the days, Tuesdays, when she did the orientation training, staff knew she was only responsible for orientation that day, and if issues arose on the floor, they should notify the DON. ADON B stated as a nurse if her resident was in distress, she would call 911. ADON B revealed when she saw the resident initially, he was not in distress. She said she did not ask LVN A any questions about the resident when she went to assess him. She thought the nurse should have communicated all that information to her. When asked if she had tried to assist LVN A and/or call to notify the physician herself, ADON B stated it was the nurse's responsibility to do so. She revealed she was in orientation with the new staff. When asked what she would have done differently now, ADON B replied she would not have gone to the resident's room. She stated LVN A should have followed the chain of command, and she (ADON B) should have told LVN A to go to the DON. She revealed LVN A should have known better as she had been in the facility longer than her (ADON B). An interview with the DON on [DATE] at 1:25 p.m. revealed ADON B informed her Resident #1 had blood in his urine. She stated she told ADON B to tell the nurse to call the physician, and he would want a UA, with C/S and maybe other labs (laboratory tests). The DON revealed she found out in her investigation, the CNAs told LVN A, about 8:30 to 9:00 a.m. on [DATE], Resident #1 was not good, and he did not look the same as yesterday, [DATE]. The DON stated LVN A told the CNAs to put the resident in his bed. The DON stated she called LVN A after all was done to find out what had happened. She revealed LVN A told her Resident #1's family member called her about 10:00 a.m. and asked her to check on him because when he/she visited the day before, [DATE] in the evening, he/she saw his urine was scant, dark and had blood in it. LVN A stated to her, the DON that she (LVN A) did not even know Resident #1 had a catheter. The DON revealed she asked LVN A if she had cared for him the day before, Monday [DATE], and LVN A said she had. The DON stated she asked LVN A why she did not know Resident #1 had a catheter. The DON stated LVN A gave her the excuse she had just came back from her vacation and had not had time to know the resident properly. The DON revealed she would not send a resident to the emergency room for just a Urinary Tract infection. She said she would obtain a UA with C/S and notify the physician. The DON stated LVN A never informed her and never informed ADON B that Resident #1 had a change in his mental status and/or condition. The DON stated their company only required staff to inform her before sending a resident to the emergency room to ensure staff were not sending residents to the hospital for things the facility could handle. The interview revealed the DON did not go to assess the resident. Further interview with the DON on [DATE] at 6:20 p.m., revealed when asked what she expected the nurses to do when a resident experienced a change in condition, she replied she expected the nurses to notify the physician for orders except it was an emergency. The DON stated in an emergency staff were to call 911 for emergency transportation to the hospital, send the resident to the emergency room , and then notify the physician and her. An interview with Resident #1's family member on [DATE] at 2:27 p.m. revealed he/she should not have placed Resident #1 in the nursing home. The family member stated he/she placed him there for only two weeks because some work was on being done on the house. He/She revealed on Sunday, [DATE], he/she visited Resident #1 and noticed his bag had scant, dark urine. The family member stated he/she was scared the catheter might have been dislodged due to the dark very small urine in the bag. Resident #1's family member stated LVN I came and checked the catheter tubing to ensure it had not been dislodged. The family member revealed LVN I said it had not and they talked about offering Resident #1 more fluid to increase his output. The family member stated on Monday, [DATE], he/she told other family members about his urine looking bad, and thought he was not getting enough fluids. Resident #1's family member revealed he/she spoke with LVN LL about him not getting enough water. The family member stated he/she discovered while talking with the nurse, he did not have water pitcher in his room. The family member revealed LVN LL got a water pitcher with water and ice, and he/she gave the resident all the water in the pitcher, but the ice. Resident #1's family member stated the resident drank like he had never seen water before, and he/she encouraged him to wait two more days and then they would take him home. The family member stated on Monday the urine was still dark very dark. He/She also stated he/she was surprised when he/she came back the next day and the water level was same as the ice level would have been in the pitcher. Continued interview with Resident #1's family member [DATE] at 2:27 p.m. revealed he/she called the facility around 10:00 a.m. and spoke to the Charge Nurse on Tuesday, [DATE]. He/She stated the the nurse went to the resident's room during their conversation. When the nurse came back to the line, the nurse said the drainage in the catheter bag was cloudy, bloody and dark red, and the nurse said she would take care of it. Resident #1's family member was crying and stated, "I think they just did not give him enough water." The family member stated Resident #1 ate 10% that morning, walked around the facility with him/her on Sunday, and now he was dead. The family member also revealed no one even called to let them know he was dying. An interview with LVN I on [DATE] at 6:15 p.m., revealed Resident #1's urine was amber colored, and he did not have a change in condition on Sunday, [DATE], while she was caring for him. The surveyor left a message for LVN LL to return call on [DATE] at approximately 10:33 a.m. LVN LL did not return the call. The surveyor left another message for LVN LL on [DATE] at 11:39 a.m. LVN LL did not return the call. An interview with the facility's Medical Director on [DATE] at 2:45 p.m. revealed the facility called him and informed him Resident #1 died . He stated they did not provide him with any details. Review of LVN A's personnel file revealed she was hired [DATE] and has had multiple disciplinary actions against her. LVN A's Counseling/Disciplinary report, dated [DATE], reflected she observed a resident who was lethargic and somewhat unresponsive, weak and having a twitch in her eye, and the resident was soaking wet. The Disciplinary Report reflected all of LVN A's previous actions were in regard to her failure to assess and to properly monitor and supervise the CNAs and their care of the residents. LVN A was suspended [DATE] through [DATE]. This incident was dated [DATE], but the facility documented she was suspended from [DATE] through [DATE]. The DON told the surveyor on [DATE] LVN A was suspended [DATE] pending investigation this incident. The facility's current undated policy, "Guidelines for notifying the physician" provided to the surveyor on [DATE] by the DON, reflected, "Guidelines for Physician Notification: Notifications for Non-emergent changes of condition: 1. Notify the physician/physician extender of the resident change in condition. 2. Call the physician's preferred method of contact such as answering service or direct line. 3. Notify the family of the resident change in condition and initiate q (every) shift charting, place resident record on the hot rack, list on 24 hour report to communicate changes to the next nurse/shift. What to do if you are unable to reach the physician? 1. If the physician has not called back within a reasonable time, and it is not an emergent resident condition then contact the physician again and continue to follow Interact Care Pathways and Change of Condition Guidelines. 2. If there is still no response from the physician, notify the supervisor/on call nurse for guidance and call the Medical director. 4. If the Medical director is the primary care physician and has not returned the call and resident condition is non-emergent, notify family and continue to follow Interact Care Pathways/change of Condition Guidelines. 5. If the resident (sic) condition changes and the resident no longer stable and becomes emergent, send the resident to the emergency room for evaluation. Emergent Changes of Condition: 1. If at any time the resident condition changes and becomes emergent send the resident to the ER for evaluation. 2. Notify the family, physician and supervisor of transfer to the emergency room for evaluation. 3. Document follow-up and interventions in the medical record." An IJ was identified on [DATE]. The Administrator and the DON were notified on [DATE] at 3:35 p.m. of the IJ and a Plan of Removal was requested at the time. The facility's Plan of Removal, dated and accepted on [DATE], reflected the following: The five residents with catheters and the one resident on Respite Care were assessed with [REDACTED]. LVN A was suspended [DATE] pending investigation. The DON, ADON B, ADON C, LVN Q, LVN II, and LVN QQ (the nursing management team) were in-serviced by the Regional Nurse and Clinical Risk Manager on [DATE] regarding the QA Change of Condition Process, Interact III Change of Condition Guidelines, Interact III Care Paths, CDC Guidelines for UTI and facility Guidelines for Physician Notification. The DON and the nursing management team then in-serviced nursing staff on this information and gave a Change of Condition Post test. In-servicing started [DATE] and would be completed by [DATE]. All nursing staff would be in-serviced prior to working their next shift. This Post Test would be added to the new hire orientation packet. The facility/nurse would follow the QA Change of Condition Process, Interact III Change of Condition Guidelines, Interact III Care Paths, and CDC Guidelines for UTI, and facility Guidelines for Physician Notification when an assessment/evaluation was needed. The facility/nurse would complete an SBAR and notify the physician and family. The DON and nursing management team in-serviced staff on [DATE] on the Change of Condition Process, Change of Condition Guidelines, Watch Tool, SBAR, Guidelines for Physician Notification, Care Paths and CDC Guidelines for UTI. In-servicing started [DATE] and would be completed by [DATE]. All nursing staff would be in-serviced prior to working their next shift. This Post Test would be added to the new hire orientation packet. This would be completed to ensure staff was conducting adequate, thorough evaluations. The ADM, DON and nursing management team were responsible for the implementation of the Plan of Removal. The nursing management team would review Admission charts, including residents there for Respite (there was no difference in the evaluation process of respite and other residents), residents with changes of condition to ensure assessments and evaluations were completed, follow-up was completed, 24 hour report was current and documentation reflected care provided and notifications were made. This would be completed daily by the DON/Designee using the nurse management daily meeting tool indefinitely. On [DATE] between the hours of 5:25 p.m. to 7:00 p.m. CNA H, MA F, CNA K, CNA L, CNA M, CNA N, CNA O, RN J, LVN I, LVN P, LVN Q, LVN B, LVN C and LVN R. who represented part of the weekend crew were interviewed. These staff members stated they had received in-servicing and then took a post test before their shift began today concerning change of condition and using the facility's "Stop and Watch" system. Each individual was able to identify appropriately examples of a change of condition a resident might experience that would make them fill out the Stop and Watch form and notify/report to their charge nurse. On [DATE] between the hours of 2: 00 p.m. to 3:00 p.m. CNA, E, CNA S, CNA T, CNA U, MA V, W and, LVN X, who represented part of the weekend shifts, were interviewed. These staff members stated they had received in-servicing and then took a post test before their shift began today. The in-service was concerning a resident's change of condition, clinical signs/symptoms, Care Path to follow for assessments, facility's "Stop and Watch" system the CNAs are to use to report/notify the charge nurse of any change in condition regarding any resident. Staff also stated a post test was given after the in-service. On [DATE] between the hours of 12:54 p.m. to 1:07 p.m., 1:00 p.m. to 2:00 p.m. LVN Y, LVN Z, LVN AA, RA BB, LVN CC, CNA DD, CNA EE, CNA FF, LVN GG, CNA HH, LVN II, LVN JJ and RN KK who represented the week day shifts were interviewed. These staff members stated they had received in-servicing and then took a post test before their shift began today and /or on [DATE]. The staffs stated the in-services was concerning a resident's change of condition, clinical signs/symptoms of change in conditions, Care Path to follow for assessments, facility's "Stop and Watch" system the CNAs are to use to report/notify the charge nurse of any change in condition regarding any resident. Staff also stated a post test was given after the in-service. The IJ was removed on [DATE]. The ADM and DON were notified on [DATE] at 4:30 p.m. that the IJ was removed. While the IJ was removed, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring the effectiveness of the Plan of Removal. The facility's Room Roster, dated [DATE], reflected 46 residents resided on Station Two.

Based on interview and record review, it was determined the facility failed to implement its written policy and procedures that prohibit neglect for one (Resident #1) of four residents reviewed for a change in condition. 1. LVN A failed to thoroughly assess Resident #1, including notifying his physician, when staff informed her he was not breathing normally and was not as active as normal, or when she saw blood in his catheter bag and tubing on [DATE] at approximately 10:30 a.m. 2. ADON B, who was summoned by LVN A to assess Resident #1's urine, which had blood in it, failed to assess the resident. 3. LVN LL and LVN I failed to asses Resident #1, including consulting with his physician when he had scant urine output that was dark. Resident #1 was pronounced dead at 12:45 p.m. on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring the effectiveness of the Plan of Removal. These failures could affect the 46 residents who resided on Station Two, by placing them at risk for a delay in appropriate medical treatment, exacerbation of their medical condition, pain, diminished quality of life and/or death. Findings included: Review of Resident #1's Face Sheet, dated [DATE], revealed he was admitted to the facility on [DATE] for Respite care. The Face Sheet reflected he was 80-years-old, and his [DIAGNOSES REDACTED]. Resident #1's hospital record, dated [DATE], reflected a past medical history of [REDACTED]. The record also reflected the resident had Dementia and was residing with his family member as the care giver. Resident #1 had a catheter, and he required assistance with his catheter care. Review of the hospital record revealed he could become agitated due to Dementia and required monitoring of his diet to prevent aspiration. Resident #1 was able to communicate and was able to slowly ambulate. Review of Resident #1's clinical records did not reveal a Minimum Data Set assessment. Resident #1's clinical record revealed his initial care plan was blank and no care plan was initiated. Resident #1's [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident #1's "Admission Data Set and Plan of Care" worksheet, dated [DATE] at 3:30 p.m., reflected he was admitted from home for Respite care. The worksheet reflected he had an indwelling catheter and his urine was amber colored with no odor. Resident #1's Daily Skilled Nursing Note, dated [DATE], reflected his catheter drained clear yellow urine on all three shifts. The Note also reflected the resident's family member visited and walked the resident in the hall around 8:00 p.m. that evening. Resident #1's Daily Skilled Nursing Note, dated [DATE], reflected during the evening shift and the night shift, his urine was dark yellow. Resident #1's Daily Interdisciplinary Note, dated [DATE] and timed at 4:00 p.m., reflected his catheter was patent and draining dark yellow urine with no odor. Resident #1's Situation-Background-Assessment-Appearance Request (SBAR) form, printed on [DATE] and timed at 3:28 p.m., reflected the situation change prompting the call "pt. (patient) expired." The form also reflected, "pt. appears to be lethargic, bld (blood) in urine." Further review of the Situation-Background-Assessment-Appearance Request form revealed, in the background section, the resident's primary [DIAGNOSES REDACTED]. The vital signs were 98.2 temperature, 73 pulse, 20 respirations, and his blood pressure was ,[DATE]. The background assessment further reflected mental status changes, "Foley Catheter urine cloudy foul color." The pain level assessment indicated the resident was grimacing and the resident was encouraged to drink fluids. The assessment section reflected, "The resident appears...Some pain noted lethargic." The request section reflected the physician was notified of the resident's death at 12:45 p.m. that day. An interview with CNA E on [DATE] at 1:30 p.m. revealed Resident #1 was a one person assist with transfers, and when he was agitated, he required the assistance of two staff with transfers. and was fed. Resident #1 was confused and responds to his name mostly. She stated he had a catheter with a leg bag and no strap. CNA E revealed obtained a leg strap on Friday and attached it to the bag to keep the bag from pulling. CNA E stated on Monday, [DATE], she informed LVN A the strap was not on, and his that the urine had odor. CNA E revealed LVN A told her she would change the catheter. CNA E stated she did not remember the blood in the bag/tubing on Monday morning. She revealed when she came on duty on Tuesday, [DATE], morning the catheter bag was empty from the night shift staff emptying it. She stated he was fine during breakfast, and she fed him without incident. She said breakfast was around 8:00 a.m. or 8:15 a.m. and she took him out of the dining room one hour after breakfast. CNA E said she and the MA saw him in his Geri chair in the hall, and he was leaning to the side like his bottom hurt. While observing him, they realized there was something different about him, and something was not right. The charge nurse was called to the resident's side. When she arrived they told her he was not looking well. CNA E revealed LVN A instructed them to lay him down in his bed. She stated the two CNAs and one MA assisted him to bed. CNA E said the MA took his vital signs and wrote them on a piece of paper. CNA E revealed LVN A left the room and came back with ADON B. CNA E stated when ADON B arrived the nurses were talking about the hospital and sending him out. CNA E also stated ADON B did not assess Resident #1 when she came to the room. CNA E revealed ADON B stood by the bed talking to LVN A. CNA E stated the catheter bag had approximately 150 cc of dark, brown urine, and she did not see the blood, but the urine had an odor like something dead, strong ammonia like foul odor. CNA E revealed at 10:30 a.m. to 10:45 a.m., she checked on the resident, and he was in bed asleep. She stated she went to lunch at 11:30 a.m., and he was still in the bed, and she was surprised because he was always attempting to get out of the bed. She revealed he was turned to his side at this time. CNA E further stated she came back from lunch at 12:00 p.m., and while passing the lunch trays, she heard CNA G call ADON B stating she thought the resident was not breathing. CNA E revealed at that time, she remembered the odor when she got Resident #1 up on Tuesday morning. An interview with CNA D on [DATE] at 2:15 p.m. revealed she was coming down the hall when she saw CNA E and MA F over a resident. She stated CNA E called her and asked her if the resident looked ok. CNA D stated Resident #1 was breathing funny, like panting or gasping for air, and he was non-responsive. She revealed she told them "No," he was not his usual self. CNA D said she told them to get the Charge Nurse who was in the dining room. She stated when the Charge Nurse arrived, she looked at the resident and told them to put him in bed. CNA D revealed the three of them together placed the resident back in his bed. CNA D stated she was not sure what time that was, but it was after breakfast. CNA D said Resident #1 had a catheter with a leg bag. She stated it had a funny odor to it, there was blood in the tubing, and the urine was dark and cloudy looking. CNA D revealed he was alert on the previous Saturday and then she was off. She stated on Monday he was different from his usual. CNA D said he was in the dining room during breakfast and was moving around as usual. Further interview with CNA D on [DATE] at 10:15 a.m. revealed she saw the resident in his Geri chair in the hall, and he was slumped down to one side and breathing funny. She stated she did not see LVN A touch the resident or assess the resident. MA F obtained the resident's vital signs before the resident was placed back into his bed. CNA D stated the blood pressure was something like 167 over something, but she could not remember the bottom number. She revealed when he was placed in the bed, LVN A told CNA E to pull down his pants. CNA D stated when the aide did that, she smelled the odor and saw the blood in the tubing. CNA D revealed LVN A asked MA F for his vital signs, but did not touch his penis to assess the odor emanating from there. She stated after that, she left for her lunch break. An interview with MA F on [DATE] at 12:26 p.m. revealed Resident #1 was a new admit, who did not speak much, but when his name was called, he would respond. She stated she did not know he had catheter until [DATE] when LVN A asked her and the other CNAs to put the resident back in bed and she observed the catheter when CNA E exposed the leg bag. She said she went to give Resident #1 his medication and he was in his Geri chair by his door. MA F revealed she checked his blood pressure for his medication administration and it was like ,[DATE] and his pulse was 71 (normal range for his age). She stated then she went to get his medications. When she came back with the medication, she saw he was not as fidgety and moving constantly as he normally did. She also noticed he was slumped to the side and this was at approximately 10:15 a.m. on [DATE]. She asked CNA E to assist her in pulling the resident up in his Geri chair. MA F revealed Resident #1 was also breathing funny, real fast like he was not getting oxygen or air was not going into him clearly. She stated LVN A instructed them to put the resident in bed. MA F revealed LVN A instructed CNA E to pull down the resident's pants down, after he was placed in the bed. LVN A checked his catheter drainage bag. MA F stated ADON B and LVN A talked about blood in the urine in the room. She also stated LVN A asked her for his vital signs. MA F revealed she never saw LVN A touch or assess anything else but his catheter bag with ADON B. MA F stated the bag had blood, which was dark like old blood, and the urine was dark yellow. She stated that the odor that emanated from the urinary bag and between the resident's legs was "loud," was loud like a strong smell of ammonia, strong urine. She revealed the next time she saw Resident #1, he was very pale with his hand on his chin area, he looked like there was no blood movement in him and he did not have his color, he was dead. An interview with CNA G on [DATE] at 2:40 p.m. revealed she passed by Resident #1's room and saw him staring up in the air. She stated she went in his room, and his eyes were opened, but he was not responding to his name. She revealed she checked his pulse and there was none and she stepped out of the room called for CNA E. CNA G stated she saw ADON B in the hall and told her the resident was not breathing. She revealed they grabbed the crash cart, went to his room, called the code, and started CPR. CNA G stated this incident occurred around 12:00 to 12:15 p.m. and LVN A was in the dining room at the time. An interview with LVN A on [DATE] at 11:22 a.m. revealed she took Resident #1 from the dining room between 9:00 a.m. to 9:30 a.m. to the hall by his room. She then completed her medication pass. LVN A stated Resident #1 was okay moving around in his Geri chair. At 10:00 a.m. to 10:30 a.m., the resident's family member called her and said last night the resident's output was darker and small. LVN A said she told the family member to hold on, and she assessed Resident #1's catheter bag. LVN A revealed the drainage in the catheter bag was dark colored with blood tinged cloudy urine with no odor. She stated she spoke with the family member and told him/her she would get a UA and notify the physician. LVN A stated about 10:45 a.m. to 11:00 a.m., CNAs D, E and CNA F informed her Resident #1 did not look good, he looked different than his usual self, and something was wrong with him. She revealed the CNAs told her the resident was not moving like he normally did. LVN A revealed she looked at him, and he was not the same as earlier, so she instructed them to lay him down. She stated she assessed Resident #1, but he was not as active as he was the day before. LVN A said he was alert, weak, and had a grimace on his face, and she got ADON B at approximately 11:00 a.m. to assess him with her as the CNAs said he was different from his normal. She revealed ADON B and she looked at his catheter drainage leg bag and ADON B stated, "We need to send him out." LVN A said when something happened, the staff usually notified ADON B and ADON B notified the DON. LVN A revealed staff had been terminated for not first notifying the DON before transferring a resident to the hospital. Continued interview with LVN A on [DATE] at 11:22 a.m. revealed stated they both left Resident #1's room, and she told ADON B she would call the physician. LVN A stated ADON B told her to call and notify the hospital nurse. LVN A said she called the nurse and notified her, the resident would be sent to the hospital due to lethargy. LVN A revealed she received a call from the front desk and was told the hospital nurse was in the facility. She stated she contacted the nurse to assess Resident #1, the nurse assessed Resident #1 and told them (her and ADON B) to send the resident to the hospital for an evaluation. LVN A revealed she made one call to Resident #1's physician's cell phone and left a message. She stated she got busy, forgot to call the physician back, and/or to ask someone else to call him. She stated she called and notified the DON about the hospital nurse's assessment to send Resident # 1 to the hospital. LVN A revealed the DON told her not to send him to the hospital and to get a UA, which the facility could do. She stated she then ordered a Stat UA with the facility's contracted laboratory company. LVN A said she went to lunch at about 11:30 a.m. to 12:00 p.m. She revealed she was supposed to monitor the dining room during lunch that day, so when she returned from her lunch, she went to the dining room. LVN A stated she was in the dining room at 12:30 p.m. when CNA G and ADON B called to notify her Resident #1 coded. The surveyor contacted the hospital nurse, on [DATE] at 12:32 p.m., and the nurse declined to talk with the surveyor. An interview with ADON B, on [DATE] at 12:48 p.m., revealed LVN A, Resident #1's charge nurse, called her into his room about 10:30 a.m. or 10:45 a.m. on [DATE] and asked her to assess the resident. She stated when she entered the room, LVN A asked her to check the resident's urine as it had blood in it. ADON B said Resident #1 was tall, and he was lying in his bed. She revealed LVN A exposed his catheter leg bag for her to see it. ADON B stated there was not a lot of urine in the bag, but there was old blood in the bag, and streaks of blood in the catheter tubing. She also stated the urine had sediment in it. ADON B revealed after she looked at his catheter bag, she told LVN A to notify his physician to get treatment orders. She stated she only looked at the catheter drainage bag, and she did not assess the resident. When asked why she failed to assess the rest of the resident, ADON B replied LVN A blocked her view, and she did not change her position to see the resident. ADON B stated she did not ask LVN A to move, so she could see Resident #1. ADON B revealed LVN A did not inform her Resident #1 had a change in condition. She only asked her to assess the urine in his catheter bag. During this same interview on [DATE] at 12:48 p.m., ADON B stated she had seen blood in urine before, and if she saw it, she would obtain the vital signs and call the physician. She stated she was told his blood pressure was ,[DATE] and stable. She stated she would also obtain a UA because if the resident was a male, he could have pulled the catheter. ADON B stated they do not know the reason for the blood in the urine, until a UA with a culture and sensitivity results were obtained. She stated she would also notify the physician for any other orders. ADON B stated after she left the resident's room she went back to the orientation class. She stated later CNA G called her and told her Resident #1 had stopped breathing. She further stated they (CNA G and her) got the crash cart and went to the room. ADON B stated she and CNA G initiated CPR on the resident until 911 came to the facility and took over. ADON B added that on the days, Tuesdays, when she did the orientation training, staff knew she was only responsible for orientation that day, and if issues arose on the floor, they should notify the DON. ADON B stated as a nurse if her resident was in distress, she would call 911. ADON B revealed when she saw the resident initially, he was not in distress. She said she did not ask LVN A any questions about the resident when she went to assess him. She thought the nurse should have communicated all that information to her. When asked if she had tried to assist LVN A and/or call to notify the physician herself, ADON B stated it was the nurse's responsibility to do so. She revealed she was in orientation with the new staff. When asked what she would have done differently now, ADON B replied she would not have gone to the resident's room. She stated LVN A should have followed the chain of command, and she (ADON B) should have told LVN A to go to the DON. She revealed LVN A should have known better as she had been in the facility longer than her (ADON B). An interview with the DON on [DATE] at 1:25 p.m. revealed ADON B informed her Resident #1 had blood in his urine. She stated she told ADON B to tell the nurse to call the physician, and he would want a UA, with C/S and maybe other labs (laboratory tests). The DON revealed she found out in her investigation, the CNAs told LVN A, about 8:30 to 9:00 a.m. on [DATE], Resident #1 was not good, and he did not look the same as yesterday, [DATE]. The DON stated LVN A told the CNAs to put the resident in his bed. The DON stated she called LVN A after all was done to find out what had happened. She revealed LVN A told her Resident #1's family member called her about 10:00 a.m. and asked her to check on him because when he/she visited the day before, [DATE] in the evening, he/she saw his urine was scant, dark and had blood in it. LVN A stated to her, the DON that she (LVN A) did not even know Resident #1 had a catheter. The DON revealed she asked LVN A if she had cared for him the day before, Monday [DATE], and LVN A said she had. The DON stated she asked LVN A why she did not know Resident #1 had a catheter. The DON stated LVN A gave her the excuse she had just came back from her vacation and had not had time to know the resident properly. The DON revealed she would not send a resident to the emergency room for just a Urinary Tract infection. She said she would obtain a UA with C/S and notify the physician. The DON stated LVN A never informed her and never informed ADON B that Resident #1 had a change in his mental status and/or condition. The DON stated their company only required staff to inform her before sending a resident to the emergency room to ensure staff were not sending residents to the hospital for things the facility could handle. The interview revealed the DON did not go to assess the resident. Further interview with the DON on [DATE] at 6:20 p.m., revealed when asked what she expected the nurses to do when a resident experienced a change in condition, she replied she expected the nurses to notify the physician for orders except it was an emergency. The DON stated in an emergency staff were to call 911 for emergency transportation to the hospital, send the resident to the emergency room , and then notify the physician and her. An interview with Resident #1's family member on [DATE] at 2:27 p.m. revealed he/she should not have placed Resident #1 in the nursing home. The family member stated he/she placed him there for only two weeks because some work was on being done on the house. He/She revealed on Sunday, [DATE], he/she visited Resident #1 and noticed his bag had scant, dark urine. The family member stated he/she was scared the catheter might have been dislodged due to the dark very small urine in the bag. Resident #1's family member stated LVN I came and checked the catheter tubing to ensure it had not been dislodged. The family member revealed LVN I said it had not and they talked about offering Resident #1 more fluid to increase his output. The family member stated on Monday, [DATE], he/she told other family members about his urine looking bad, and thought he was not getting enough fluids. Resident #1's family member revealed he/she spoke with LVN LL about him not getting enough water. The family member stated he/she discovered while talking with the nurse, he did not have water pitcher in his room. The family member revealed LVN LL got a water pitcher with water and ice, and he/she gave the resident all the water in the pitcher, but the ice. Resident #1's family member stated the resident drank like he had never seen water before, and he/she encouraged him to wait two more days and then they would take him home. The family member stated on Monday the urine was still dark very dark. He/She also stated he/she was surprised when he/she came back the next day and the water level was same as the ice level would have been in the pitcher. Continued interview with Resident #1's family member [DATE] at 2:27 p.m. revealed he/she called the facility around 10:00 a.m. and spoke to the Charge Nurse on Tuesday, [DATE]. He/She stated the the nurse went to the resident's room during their conversation. When the nurse came back to the line, the nurse said the drainage in the catheter bag was cloudy, bloody and dark red, and the nurse said she would take care of it. Resident #1's family member was crying and stated, "I think they just did not give him enough water." The family member stated Resident #1 ate 10% that morning, walked around the facility with him/her on Sunday, and now he was dead. The family member also revealed no one even called to let them know he was dying. An interview with LVN I on [DATE] at 6:15 p.m., revealed Resident #1's urine was amber colored, and he did not have a change in condition on Sunday, [DATE], while she was caring for him. The surveyor left a message for LVN LL to return call on [DATE] at approximately 10:33 a.m. LVN LL did not return the call. The surveyor left another message for LVN LL on [DATE] at 11:39 a.m. LVN LL did not return the call. An interview with the facility's Medical Director on [DATE] at 2:45 p.m. revealed the facility called him and informed him Resident #1 died . He stated they did not provide him with any details. Review of LVN A's personnel file revealed she was hired [DATE] and has had multiple disciplinary actions against her. LVN A's Counseling/Disciplinary report, dated [DATE], reflected she observed a resident who was lethargic and somewhat unresponsive, weak and having a twitch in her eye, and the resident was soaking wet. The Disciplinary Report reflected all of LVN A's previous actions were in regard to her failure to assess and to properly monitor and supervise the CNAs and their care of the residents. LVN A was suspended [DATE] through [DATE]. This incident was dated [DATE], but the facility documented she was suspended from [DATE] through [DATE]. The DON told the surveyor on [DATE] LVN A was suspended [DATE] pending investigation this incident. The facility's current policy, "Abuse Prohibition Policy -Identification," dated [DATE], reflected, "POLICY - All alleged violations concerning abuse, neglect...are reported immediately to the Administrator and/or the designee and other enforcement agencies according to state law including the State Survey and Certification Agency...PROCEDURES - 2. Staff members identified and assess suspected or alleged reports of abuse or neglect, focusing on objective and observable evidence. Types of abuse include...e) Neglect - failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. 3. Recognizing signs and symptoms of abuse/neglect is critical. All personnel are to report any signs of abuse/neglect to their supervisor or the director of nursing services immediately...5. Signs of Actual Physical Neglect. a) [MEDICAL CONDITION] and dehydration...f) Inadequate provision of care...." An IJ was identified on [DATE]. The Administrator and the DON were notified on [DATE] at 3:35 p.m. of the IJ and a Plan of Removal was requested at the time. The facility's Plan of Removal, dated and accepted on [DATE], reflected the following: The five residents with catheters and the one resident on Respite Care were assessed with [REDACTED]. LVN A was suspended [DATE] pending investigation. The DON, ADON B, ADON C, LVN Q, LVN II, and LVN QQ (the nursing management team) were in-serviced by the Regional Nurse and Clinical Risk Manager on [DATE] regarding the QA Change of Condition Process, Interact III Change of Condition Guidelines, Interact III Care Paths, CDC Guidelines for UTI and facility Guidelines for Physician Notification. The DON and the nursing management team then in-serviced nursing staff on this information and gave a Change of Condition Post test. In-servicing started [DATE] and would be completed by [DATE]. All nursing staff would be in-serviced prior to working their next shift. This Post Test would be added to the new hire orientation packet. The facility/nurse would follow the QA Change of Condition Process, Interact III Change of Condition Guidelines, Interact III Care Paths, and CDC Guidelines for UTI, and facility Guidelines for Physician Notification when an assessment/evaluation was needed. The facility/nurse would complete an SBAR and notify the physician and family. The DON and nursing management team in-serviced staff on [DATE] on the Change of Condition Process, Change of Condition Guidelines, Watch Tool, SBAR, Guidelines for Physician Notification, Care Paths and CDC Guidelines for UTI. In-servicing started [DATE] and would be completed by [DATE]. All nursing staff would be in-serviced prior to working their next shift. This Post Test would be added to the new hire orientation packet. This would be completed to ensure staff was conducting adequate, thorough evaluations. The ADM, DON and nursing management team were responsible for the implementation of the Plan of Removal. The nursing management team would review Admission charts, including residents there for Respite (there was no difference in the evaluation process of respite and other residents), residents with changes of condition to ensure assessments and evaluations were completed, follow-up was completed, 24 hour report was current and documentation reflected care provided and notifications were made. This would be completed daily by the DON/Designee using the nurse management daily meeting tool indefinitely. On [DATE] between the hours of 5:25 p.m. to 7:00 p.m. CNA H, MA F, CNA K, CNA L, CNA M, CNA N, CNA O, RN J, LVN I, LVN P, LVN Q, LVN B, LVN C and LVN R. who represented part of the weekend crew were interviewed. These staff members stated they had received in-servicing and then took a post test before their shift began today concerning change of condition and using the facility's "Stop and Watch" system. Each individual was able to identify appropriately examples of a change of condition a resident might experience that would make them fill out the Stop and Watch form and notify/report to their charge nurse. On [DATE] between the hours of 2: 00 p.m. to 3:00 p.m. CNA, E, CNA S, CNA T, CNA U, MA V, W and, LVN X, who represented part of the weekend shifts, were interviewed. These staff members stated they had received in-servicing and then took a post test before their shift began today. The in-service was concerning a resident's change of condition, clinical signs/symptoms, Care Path to follow for assessments, facility's "Stop and Watch" system the CNAs are to use to report/notify the charge nurse of any change in condition regarding any resident. Staff also stated a post test was given after the in-service. On [DATE] between the hours of 12:54 p.m. to 1:07 p.m., 1:00 p.m. to 2:00 p.m. LVN Y, LVN Z, LVN AA, RA BB, LVN CC, CNA DD, CNA EE, CNA FF, LVN GG, CNA HH, LVN II, LVN JJ and RN KK who represented the week day shifts were interviewed. These staff members stated they had received in-servicing and then took a post test before their shift began today and /or on [DATE]. The staffs stated the in-services was concerning a resident's change of condition, clinical signs/symptoms of change in conditions, Care Path to follow for assessments, facility's "Stop and Watch" system the CNAs are to use to report/notify the charge nurse of any change in condition regarding any resident. Staff also stated a post test was given after the in-service. The IJ was removed on [DATE]. The ADM and DON were notified on [DATE] at 4:30 p.m. that the IJ was removed. While the IJ was removed, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring the effectiveness of the Plan of Removal. The facility's Room Roster, dated [DATE], reflected 46 residents resided on Station Two.

Based on interview and record review, it was determined the facility failed to implement policies and procedures that prohibit neglect for one (Resident #1) of four residents reviewed for change in condition. 1. LVN A failed to thoroughly assess Resident #1, including notifying his physician, when staff informed her he was not breathing normally and was not as active as normal, or when she saw blood in his catheter bag and tubing on [DATE] at approximately 10:30 a.m. 2. ADON B, who was summoned by LVN A to assess Resident #1's urine, which had blood in it, failed to assess the resident. 3. LVN LL and LVN I failed to asses Resident #1, including consulting with his physician when he had scant urine output that was dark. Resident #1 was pronounced dead at 12:45 p.m. on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring the effectiveness of the Plan of Removal. These failures could affect the 46 residents who resided on Station Two, by placing them at risk for a delay in appropriate medical treatment, exacerbation of their medical condition, pain, diminished quality of life and/or death. Findings included: 1. The facility's current policy, "Abuse Prohibition Policy -Identification," dated [DATE], reflected, "POLICY - All alleged violations concerning abuse, neglect...are reported immediately to the Administrator and/or the designee and other enforcement agencies according to state law including the State Survey and Certification Agency...PROCEDURES - 2. Staff members identified and assess suspected or alleged reports of abuse or neglect, focusing on objective and observable evidence. Types of abuse include...e) Neglect - failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. 3. Recognizing signs and symptoms of abuse/neglect is critical. All personnel are to report any signs of abuse/neglect to their supervisor or the director of nursing services immediately...5. Signs of Actual Physical Neglect. a) [MEDICAL CONDITION] and dehydration...f) Inadequate provision of care...." 2. Review of Resident #1's Face Sheet, dated [DATE], revealed he was admitted to the facility on [DATE] for Respite care. The Face Sheet reflected he was 80-years-old, and his [DIAGNOSES REDACTED]. Resident #1's hospital record, dated [DATE], reflected a past medical history of [REDACTED]. The record also reflected the resident had Dementia and was residing with his family member as the care giver. Resident #1 had a catheter, and he required assistance with his catheter care. Review of the hospital record revealed he could become agitated due to Dementia and required monitoring of his diet to prevent aspiration. Resident #1 was able to communicate and was able to slowly ambulate. Review of Resident #1's clinical records did not reveal a Minimum Data Set assessment. Resident #1's clinical record revealed his initial care plan was blank and no care plan was initiated. Resident #1's [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident #1's "Admission Data Set and Plan of Care" worksheet, dated [DATE] at 3:30 p.m., reflected he was admitted from home for Respite care. The worksheet reflected he had an indwelling catheter and his urine was amber colored with no odor. Resident #1's Daily Skilled Nursing Note, dated [DATE], reflected his catheter drained clear yellow urine on all three shifts. The Note also reflected the resident's family member visited and walked the resident in the hall around 8:00 p.m. that evening. Resident #1's Daily Skilled Nursing Note, dated [DATE], reflected during the evening shift and the night shift, his urine was dark yellow. Resident #1's Daily Interdisciplinary Note, dated [DATE] and timed at 4:00 p.m., reflected his catheter was patent and draining dark yellow urine with no odor. Resident #1's Situation-Background-Assessment-Appearance Request (SBAR) form, printed on [DATE] and timed at 3:28 p.m., reflected the situation change prompting the call "pt. (patient) expired." The form also reflected, "pt. appears to be lethargic, bld (blood) in urine." Further review of the Situation-Background-Assessment-Appearance Request form revealed, in the background section, the resident's primary [DIAGNOSES REDACTED]. The vital signs were 98.2 temperature, 73 pulse, 20 respirations, and his blood pressure was ,[DATE]. The background assessment further reflected mental status changes, "Foley Catheter urine cloudy foul color." The pain level assessment indicated the resident was grimacing and the resident was encouraged to drink fluids. The assessment section reflected, "The resident appears...Some pain noted lethargic." The request section reflected the physician was notified of the resident's death at 12:45 p.m. that day. An interview with CNA E on [DATE] at 1:30 p.m. revealed Resident #1 was a one person assist with transfers, and when he was agitated, he required the assistance of two staff with transfers. and was fed. Resident #1 was confused and responds to his name mostly. She stated he had a catheter with a leg bag and no strap. CNA E revealed obtained a leg strap on Friday and attached it to the bag to keep the bag from pulling. CNA E stated on Monday, [DATE], she informed LVN A the strap was not on, and his that the urine had odor. CNA E revealed LVN A told her she would change the catheter. CNA E stated she did not remember the blood in the bag/tubing on Monday morning. She revealed when she came on duty on Tuesday, [DATE], morning the catheter bag was empty from the night shift staff emptying it. She stated he was fine during breakfast, and she fed him without incident. She said breakfast was around 8:00 a.m. or 8:15 a.m. and she took him out of the dining room one hour after breakfast. CNA E said she and the MA saw him in his Geri chair in the hall, and he was leaning to the side like his bottom hurt. While observing him, they realized there was something different about him, and something was not right. The charge nurse was called to the resident's side. When she arrived they told her he was not looking well. CNA E revealed LVN A instructed them to lay him down in his bed. She stated the two CNAs and one MA assisted him to bed. CNA E said the MA took his vital signs and wrote them on a piece of paper. CNA E revealed LVN A left the room and came back with ADON B. CNA E stated when ADON B arrived the nurses were talking about the hospital and sending him out. CNA E also stated ADON B did not assess Resident #1 when she came to the room. CNA E revealed ADON B stood by the bed talking to LVN A. CNA E stated the catheter bag had approximately 150 cc of dark, brown urine, and she did not see the blood, but the urine had an odor like something dead, strong ammonia like foul odor. CNA E revealed at 10:30 a.m. to 10:45 a.m., she checked on the resident, and he was in bed asleep. She stated she went to lunch at 11:30 a.m., and he was still in the bed, and she was surprised because he was always attempting to get out of the bed. She revealed he was turned to his side at this time. CNA E further stated she came back from lunch at 12:00 p.m., and while passing the lunch trays, she heard CNA G call ADON B stating she thought the resident was not breathing. CNA E revealed at that time, she remembered the odor when she got Resident #1 up on Tuesday morning. An interview with CNA D on [DATE] at 2:15 p.m. revealed she was coming down the hall when she saw CNA E and MA F over a resident. She stated CNA E called her and asked her if the resident looked ok. CNA D stated Resident #1 was breathing funny, like panting or gasping for air, and he was non-responsive. She revealed she told them "No," he was not his usual self. CNA D said she told them to get the Charge Nurse who was in the dining room. She stated when the Charge Nurse arrived, she looked at the resident and told them to put him in bed. CNA D revealed the three of them together placed the resident back in his bed. CNA D stated she was not sure what time that was, but it was after breakfast. CNA D said Resident #1 had a catheter with a leg bag. She stated it had a funny odor to it, there was blood in the tubing, and the urine was dark and cloudy looking. CNA D revealed he was alert on the previous Saturday and then she was off. She stated on Monday he was different from his usual. CNA D said he was in the dining room during breakfast and was moving around as usual. Further interview with CNA D on [DATE] at 10:15 a.m. revealed she saw the resident in his Geri chair in the hall, and he was slumped down to one side and breathing funny. She stated she did not see LVN A touch the resident or assess the resident. MA F obtained the resident's vital signs before the resident was placed back into his bed. CNA D stated the blood pressure was something like 167 over something, but she could not remember the bottom number. She revealed when he was placed in the bed, LVN A told CNA E to pull down his pants. CNA D stated when the aide did that, she smelled the odor and saw the blood in the tubing. CNA D revealed LVN A asked MA F for his vital signs, but did not touch his penis to assess the odor emanating from there. She stated after that, she left for her lunch break. An interview with MA F on [DATE] at 12:26 p.m. revealed Resident #1 was a new admit, who did not speak much, but when his name was called, he would respond. She stated she did not know he had catheter until [DATE] when LVN A asked her and the other CNAs to put the resident back in bed and she observed the catheter when CNA E exposed the leg bag. She said she went to give Resident #1 his medication and he was in his Geri chair by his door. MA F revealed she checked his blood pressure for his medication administration and it was like ,[DATE] and his pulse was 71 (normal range for his age). She stated then she went to get his medications. When she came back with the medication, she saw he was not as fidgety and moving constantly as he normally did. She also noticed he was slumped to the side and this was at approximately 10:15 a.m. on [DATE]. She asked CNA E to assist her in pulling the resident up in his Geri chair. MA F revealed Resident #1 was also breathing funny, real fast like he was not getting oxygen or air was not going into him clearly. She stated LVN A instructed them to put the resident in bed. MA F revealed LVN A instructed CNA E to pull down the resident's pants down, after he was placed in the bed. LVN A checked his catheter drainage bag. MA F stated ADON B and LVN A talked about blood in the urine in the room. She also stated LVN A asked her for his vital signs. MA F revealed she never saw LVN A touch or assess anything else but his catheter bag with ADON B. MA F stated the bag had blood, which was dark like old blood, and the urine was dark yellow. She stated that the odor that emanated from the urinary bag and between the resident's legs was "loud," was loud like a strong smell of ammonia, strong urine. She revealed the next time she saw Resident #1, he was very pale with his hand on his chin area, he looked like there was no blood movement in him and he did not have his color, he was dead. An interview with CNA G on [DATE] at 2:40 p.m. revealed she passed by Resident #1's room and saw him staring up in the air. She stated she went in his room, and his eyes were opened, but he was not responding to his name. She revealed she checked his pulse and there was none and she stepped out of the room called for CNA E. CNA G stated she saw ADON B in the hall and told her the resident was not breathing. She revealed they grabbed the crash cart, went to his room, called the code, and started CPR. CNA G stated this incident occurred around 12:00 to 12:15 p.m. and LVN A was in the dining room at the time. An interview with LVN A on [DATE] at 11:22 a.m. revealed she took Resident #1 from the dining room between 9:00 a.m. to 9:30 a.m. to the hall by his room. She then completed her medication pass. LVN A stated Resident #1 was okay moving around in his Geri chair. At 10:00 a.m. to 10:30 a.m., the resident's family member called her and said last night the resident's output was darker and small. LVN A said she told the family member to hold on, and she assessed Resident #1's catheter bag. LVN A revealed the drainage in the catheter bag was dark colored with blood tinged cloudy urine with no odor. She stated she spoke with the family member and told him/her she would get a UA and notify the physician. LVN A stated about 10:45 a.m. to 11:00 a.m., CNAs D, E and CNA F informed her Resident #1 did not look good, he looked different than his usual self, and something was wrong with him. She revealed the CNAs told her the resident was not moving like he normally did. LVN A revealed she looked at him, and he was not the same as earlier, so she instructed them to lay him down. She stated she assessed Resident #1, but he was not as active as he was the day before. LVN A said he was alert, weak, and had a grimace on his face, and she got ADON B at approximately 11:00 a.m. to assess him with her as the CNAs said he was different from his normal. She revealed ADON B and she looked at his catheter drainage leg bag and ADON B stated, "We need to send him out." LVN A said when something happened, the staff usually notified ADON B and ADON B notified the DON. LVN A revealed staff had been terminated for not first notifying the DON before transferring a resident to the hospital. Continued interview with LVN A on [DATE] at 11:22 a.m. revealed stated they both left Resident #1's room, and she told ADON B she would call the physician. LVN A stated ADON B told her to call and notify the hospital nurse. LVN A said she called the nurse and notified her, the resident would be sent to the hospital due to lethargy. LVN A revealed she received a call from the front desk and was told the hospital nurse was in the facility. She stated she contacted the nurse to assess Resident #1, the nurse assessed Resident #1 and told them (her and ADON B) to send the resident to the hospital for an evaluation. LVN A revealed she made one call to Resident #1's physician's cell phone and left a message. She stated she got busy, forgot to call the physician back, and/or to ask someone else to call him. She stated she called and notified the DON about the hospital nurse's assessment to send Resident # 1 to the hospital. LVN A revealed the DON told her not to send him to the hospital and to get a UA, which the facility could do. She stated she then ordered a Stat UA with the facility's contracted laboratory company. LVN A said she went to lunch at about 11:30 a.m. to 12:00 p.m. She revealed she was supposed to monitor the dining room during lunch that day, so when she returned from her lunch, she went to the dining room. LVN A stated she was in the dining room at 12:30 p.m. when CNA G and ADON B called to notify her Resident #1 coded. The surveyor contacted the hospital nurse, on [DATE] at 12:32 p.m., and the nurse declined to talk with the surveyor. An interview with ADON B, on [DATE] at 12:48 p.m., revealed LVN A, Resident #1's charge nurse, called her into his room about 10:30 a.m. or 10:45 a.m. on [DATE] and asked her to assess the resident. She stated when she entered the room, LVN A asked her to check the resident's urine as it had blood in it. ADON B said Resident #1 was tall, and he was lying in his bed. She revealed LVN A exposed his catheter leg bag for her to see it. ADON B stated there was not a lot of urine in the bag, but there was old blood in the bag, and streaks of blood in the catheter tubing. She also stated the urine had sediment in it. ADON B revealed after she looked at his catheter bag, she told LVN A to notify his physician to get treatment orders. She stated she only looked at the catheter drainage bag, and she did not assess the resident. When asked why she failed to assess the rest of the resident, ADON B replied LVN A blocked her view, and she did not change her position to see the resident. ADON B stated she did not ask LVN A to move, so she could see Resident #1. ADON B revealed LVN A did not inform her Resident #1 had a change in condition. She only asked her to assess the urine in his catheter bag. During this same interview on [DATE] at 12:48 p.m., ADON B stated she had seen blood in urine before, and if she saw it, she would obtain the vital signs and call the physician. She stated she was told his blood pressure was ,[DATE] and stable. She stated she would also obtain a UA because if the resident was a male, he could have pulled the catheter. ADON B stated they do not know the reason for the blood in the urine, until a UA with a culture and sensitivity results were obtained. She stated she would also notify the physician for any other orders. ADON B stated after she left the resident's room she went back to the orientation class. She stated later CNA G called her and told her Resident #1 had stopped breathing. She further stated they (CNA G and her) got the crash cart and went to the room. ADON B stated she and CNA G initiated CPR on the resident until 911 came to the facility and took over. ADON B added that on the days, Tuesdays, when she did the orientation training, staff knew she was only responsible for orientation that day, and if issues arose on the floor, they should notify the DON. ADON B stated as a nurse if her resident was in distress, she would call 911. ADON B revealed when she saw the resident initially, he was not in distress. She said she did not ask LVN A any questions about the resident when she went to assess him. She thought the nurse should have communicated all that information to her. When asked if she had tried to assist LVN A and/or call to notify the physician herself, ADON B stated it was the nurse's responsibility to do so. She revealed she was in orientation with the new staff. When asked what she would have done differently now, ADON B replied she would not have gone to the resident's room. She stated LVN A should have followed the chain of command, and she (ADON B) should have told LVN A to go to the DON. She revealed LVN A should have known better as she had been in the facility longer than her (ADON B). An interview with the DON on [DATE] at 1:25 p.m. revealed ADON B informed her Resident #1 had blood in his urine. She stated she told ADON B to tell the nurse to call the physician, and he would want a UA, with C/S and maybe other labs (laboratory tests). The DON revealed she found out in her investigation, the CNAs told LVN A, about 8:30 to 9:00 a.m. on [DATE], Resident #1 was not good, and he did not look the same as yesterday, [DATE]. The DON stated LVN A told the CNAs to put the resident in his bed. The DON stated she called LVN A after all was done to find out what had happened. She revealed LVN A told her Resident #1's family member called her about 10:00 a.m. and asked her to check on him because when he/she visited the day before, [DATE] in the evening, he/she saw his urine was scant, dark and had blood in it. LVN A stated to her, the DON that she (LVN A) did not even know Resident #1 had a catheter. The DON revealed she asked LVN A if she had cared for him the day before, Monday [DATE], and LVN A said she had. The DON stated she asked LVN A why she did not know Resident #1 had a catheter. The DON stated LVN A gave her the excuse she had just came back from her vacation and had not had time to know the resident properly. The DON revealed she would not send a resident to the emergency room for just a Urinary Tract infection. She said she would obtain a UA with C/S and notify the physician. The DON stated LVN A never informed her and never informed ADON B that Resident #1 had a change in his mental status and/or condition. The DON stated their company only required staff to inform her before sending a resident to the emergency room to ensure staff were not sending residents to the hospital for things the facility could handle. The interview revealed the DON did not go to assess the resident. Further interview with the DON on [DATE] at 6:20 p.m., revealed when asked what she expected the nurses to do when a resident experienced a change in condition, she replied she expected the nurses to notify the physician for orders except it was an emergency. The DON stated in an emergency staff were to call 911 for emergency transportation to the hospital, send the resident to the emergency room , and then notify the physician and her. An interview with Resident #1's family member on [DATE] at 2:27 p.m. revealed he/she should not have placed Resident #1 in the nursing home. The family member stated he/she placed him there for only two weeks because some work was on being done on the house. He/She revealed on Sunday, [DATE], he/she visited Resident #1 and noticed his bag had scant, dark urine. The family member stated he/she was scared the catheter might have been dislodged due to the dark very small urine in the bag. Resident #1's family member stated LVN I came and checked the catheter tubing to ensure it had not been dislodged. The family member revealed LVN I said it had not and they talked about offering Resident #1 more fluid to increase his output. The family member stated on Monday, [DATE], he/she told other family members about his urine looking bad, and thought he was not getting enough fluids. Resident #1's family member revealed he/she spoke with LVN LL about him not getting enough water. The family member stated he/she discovered while talking with the nurse, he did not have water pitcher in his room. The family member revealed LVN LL got a water pitcher with water and ice, and he/she gave the resident all the water in the pitcher, but the ice. Resident #1's family member stated the resident drank like he had never seen water before, and he/she encouraged him to wait two more days and then they would take him home. The family member stated on Monday the urine was still dark very dark. He/She also stated he/she was surprised when he/she came back the next day and the water level was same as the ice level would have been in the pitcher. Continued interview with Resident #1's family member [DATE] at 2:27 p.m. revealed he/she called the facility around 10:00 a.m. and spoke to the Charge Nurse on Tuesday, [DATE]. He/She stated the the nurse went to the resident's room during their conversation. When the nurse came back to the line, the nurse said the drainage in the catheter bag was cloudy, bloody and dark red, and the nurse said she would take care of it. Resident #1's family member was crying and stated, "I think they just did not give him enough water." The family member stated Resident #1 ate 10% that morning, walked around the facility with him/her on Sunday, and now he was dead. The family member also revealed no one even called to let them know he was dying. An interview with LVN I on [DATE] at 6:15 p.m., revealed Resident #1's urine was amber colored, and he did not have a change in condition on Sunday, [DATE], while she was caring for him. The surveyor left a message for LVN LL to return call on [DATE] at approximately 10:33 a.m. LVN LL did not return the call. The surveyor left another message for LVN LL on [DATE] at 11:39 a.m. LVN LL did not return the call. An interview with the facility's Medical Director on [DATE] at 2:45 p.m. revealed the facility called him and informed him Resident #1 died . He stated they did not provide him with any details. Review of LVN A's personnel file revealed she was hired [DATE] and has had multiple disciplinary actions against her. LVN A's Counseling/Disciplinary report, dated [DATE], reflected she observed a resident who was lethargic and somewhat unresponsive, weak and having a twitch in her eye, and the resident was soaking wet. The Disciplinary Report reflected all of LVN A's previous actions were in regard to her failure to assess and to properly monitor and supervise the CNAs and their care of the residents. LVN A was suspended [DATE] through [DATE]. This incident was dated [DATE], but the facility documented she was suspended from [DATE] through [DATE]. The DON told the surveyor on [DATE] LVN A was suspended [DATE] pending investigation this incident. An IJ was identified on [DATE]. The Administrator and the DON were notified on [DATE] at 3:35 p.m. of the IJ and a Plan of Removal was requested at the time. The facility's Plan of Removal, dated and accepted on [DATE], reflected the following: The five residents with catheters and the one resident on Respite Care were assessed with [REDACTED]. LVN A was suspended [DATE] pending investigation. The DON, ADON B, ADON C, LVN Q, LVN II, and LVN QQ (the nursing management team) were in-serviced by the Regional Nurse and Clinical Risk Manager on [DATE] regarding the QA Change of Condition Process, Interact III Change of Condition Guidelines, Interact III Care Paths, CDC Guidelines for UTI and facility Guidelines for Physician Notification. The DON and the nursing management team then in-serviced nursing staff on this information and gave a Change of Condition Post test. In-servicing started [DATE] and would be completed by [DATE]. All nursing staff would be in-serviced prior to working their next shift. This Post Test would be added to the new hire orientation packet. The facility/nurse would follow the QA Change of Condition Process, Interact III Change of Condition Guidelines, Interact III Care Paths, and CDC Guidelines for UTI, and facility Guidelines for Physician Notification when an assessment/evaluation was needed. The facility/nurse would complete an SBAR and notify the physician and family. The DON and nursing management team in-serviced staff on [DATE] on the Change of Condition Process, Change of Condition Guidelines, Watch Tool, SBAR, Guidelines for Physician Notification, Care Paths and CDC Guidelines for UTI. In-servicing started [DATE] and would be completed by [DATE]. All nursing staff would be in-serviced prior to working their next shift. This Post Test would be added to the new hire orientation packet. This would be completed to ensure staff was conducting adequate, thorough evaluations. The ADM, DON and nursing management team were responsible for the implementation of the Plan of Removal. The nursing management team would review Admission charts, including residents there for Respite (there was no difference in the evaluation process of respite and other residents), residents with changes of condition to ensure assessments and evaluations were completed, follow-up was completed, 24 hour report was current and documentation reflected care provided and notifications were made. This would be completed daily by the DON/Designee using the nurse management daily meeting tool indefinitely. On [DATE] between the hours of 5:25 p.m. to 7:00 p.m. CNA H, MA F, CNA K, CNA L, CNA M, CNA N, CNA O, RN J, LVN I, LVN P, LVN Q, LVN B, LVN C and LVN R. who represented part of the weekend crew were interviewed. These staff members stated they had received in-servicing and then took a post test before their shift began today concerning change of condition and using the facility's "Stop and Watch" system. Each individual was able to identify appropriately examples of a change of condition a resident might experience that would make them fill out the Stop and Watch form and notify/report to their charge nurse. On [DATE] between the hours of 2: 00 p.m. to 3:00 p.m. CNA, E, CNA S, CNA T, CNA U, MA V, W and, LVN X, who represented part of the weekend shifts, were interviewed. These staff members stated they had received in-servicing and then took a post test before their shift began today. The in-service was concerning a resident's change of condition, clinical signs/symptoms, Care Path to follow for assessments, facility's "Stop and Watch" system the CNAs are to use to report/notify the charge nurse of any change in condition regarding any resident. Staff also stated a post test was given after the in-service. On [DATE] between the hours of 12:54 p.m. to 1:07 p.m., 1:00 p.m. to 2:00 p.m. LVN Y, LVN Z, LVN AA, RA BB, LVN CC, CNA DD, CNA EE, CNA FF, LVN GG, CNA HH, LVN II, LVN JJ and RN KK who represented the week day shifts were interviewed. These staff members stated they had received in-servicing and then took a post test before their shift began today and /or on [DATE]. The staffs stated the in-services was concerning a resident's change of condition, clinical signs/symptoms of change in conditions, Care Path to follow for assessments, facility's "Stop and Watch" system the CNAs are to use to report/notify the charge nurse of any change in condition regarding any resident. Staff also stated a post test was given after the in-service. The IJ was removed on [DATE]. The ADM and DON were notified on [DATE] at 4:30 p.m. that the IJ was removed. While the IJ was removed, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring the effectiveness of the Plan of Removal. The facility's Room Roster, dated [DATE], reflected 46 residents resided on Station Two.

Based on record review and interview, the facility failed to provide services that met professional standards of quality of care for one (Resident #1) of four residents reviewed for a change in condition. 1. LVN A failed to thoroughly assess Resident #1, including notifying his physician, when staff informed her he was not breathing normally and was not as active as normal, or when she saw blood in his catheter bag and tubing on [DATE] at approximately 10:30 a.m. LVN A also failed to notify Resident #1's family member of his change in condition. 2. ADON B, who was summoned by LVN A to assess Resident #1's urine, which had blood in it, failed to assess the resident. Resident #1 was pronounced dead at 12:45 p.m. on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring the effectiveness of the Plan of Removal. These failures could affect the 46 residents who resided on Station Two, by placing them at risk for a delay in appropriate medical treatment, exacerbation of their medical condition, pain, diminished quality of life and/or death. Findings included: 1. The Texas Board of Nursing Rules and Regulations relating to Nurse Education, Licensure and Practice, published [DATE], reflected the following: ?217.11. Standards of Nursing Practice. (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses... shall: ...(D) Accurately and completely report and document: (i) the client's status including signs and symptoms; (ii) nursing care rendered; ...(v) client response(s); and (vi) contacts with other health care team members concerning significant events regarding client's status; ...(M) Institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications; ...(P) Collaborate with the client, members of the health care team and, when appropriate, the client's significant other(s) in the interest of the client's health care; ...(2) Standards Specific to Vocational Nurses. The licensed vocational nurse shall assist in the determination of predictable healthcare needs of clients within healthcare settings and: (A) Shall utilize a systematic approach to provide individualized, goal-directed nursing care by: (i) collecting data and performing focused nursing assessments; ...(iv) implementing appropriate aspects of care within the LVN's scope of practice; and (v) assisting in the evaluation of the client's responses to nursing interventions and the identification of client needs; ...(C) May perform other acts that require education and training as prescribed by board rules and policies, commensurate with the licensed vocational nurse's experience, continuing education, and demonstrated licensed vocational nurse competencies. (3) Standards Specific to Registered Nurses. The registered nurse shall assist in the determination of healthcare needs of clients and shall: (A) Utilize a systematic approach to provide individualized, goal-directed, nursing care by: (i) performing comprehensive nursing assessments regarding the health status of the client; (ii) making nursing [DIAGNOSES REDACTED]. ...(v) evaluating the client's responses to nursing interventions. 2. Review of Resident #1's Face Sheet, dated [DATE], revealed he was admitted to the facility on [DATE] for Respite care. The Face Sheet reflected he was 80-years-old, and his [DIAGNOSES REDACTED]. Resident #1's hospital record, dated [DATE], reflected a past medical history of [REDACTED]. The record also reflected the resident had Dementia and was residing with his family member as the care giver. Resident #1 had a catheter, and he required assistance with his catheter care. Review of the hospital record revealed he could become agitated due to Dementia and required monitoring of his diet to prevent aspiration. Resident #1 was able to communicate and was able to slowly ambulate. Review of Resident #1's clinical records did not reveal a Minimum Data Set assessment. Resident #1's clinical record revealed his initial care plan was blank and no care plan was initiated. Resident #1's [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident #1's "Admission Data Set and Plan of Care" worksheet, dated [DATE] at 3:30 p.m., reflected he was admitted from home for Respite care. The worksheet reflected he had an indwelling catheter and his urine was amber colored with no odor. Resident #1's Daily Skilled Nursing Note, dated [DATE], reflected his catheter drained clear yellow urine on all three shifts. The Note also reflected the resident's family member visited and walked the resident in the hall around 8:00 p.m. that evening. Resident #1's Daily Skilled Nursing Note, dated [DATE], reflected during the evening shift and the night shift, his urine was dark yellow. Resident #1's Daily Interdisciplinary Note, dated [DATE] and timed at 4:00 p.m., reflected his catheter was patent and draining dark yellow urine with no odor. Resident #1's Situation-Background-Assessment-Appearance Request (SBAR) form, printed on [DATE] and timed at 3:28 p.m., reflected the situation change prompting the call "pt. (patient) expired." The form also reflected, "pt. appears to be lethargic, bld (blood) in urine." Further review of the Situation-Background-Assessment-Appearance Request form revealed, in the background section, the resident's primary [DIAGNOSES REDACTED]. The vital signs were 98.2 temperature, 73 pulse, 20 respirations, and his blood pressure was ,[DATE]. The background assessment further reflected mental status changes, "Foley Catheter urine cloudy foul color." The pain level assessment indicated the resident was grimacing and the resident was encouraged to drink fluids. The assessment section reflected, "The resident appears...Some pain noted lethargic." The request section reflected the physician was notified of the resident's death at 12:45 p.m. that day. An interview with CNA E on [DATE] at 1:30 p.m. revealed Resident #1 was a one person assist with transfers, and when he was agitated, he required the assistance of two staff with transfers. and was fed. Resident #1 was confused and responds to his name mostly. She stated he had a catheter with a leg bag and no strap. CNA E revealed obtained a leg strap on Friday and attached it to the bag to keep the bag from pulling. CNA E stated on Monday, [DATE], she informed LVN A the strap was not on, and his that the urine had odor. CNA E revealed LVN A told her she would change the catheter. CNA E stated she did not remember the blood in the bag/tubing on Monday morning. She revealed when she came on duty on Tuesday, [DATE], morning the catheter bag was empty from the night shift staff emptying it. She stated he was fine during breakfast, and she fed him without incident. She said breakfast was around 8:00 a.m. or 8:15 a.m. and she took him out of the dining room one hour after breakfast. CNA E said she and the MA saw him in his Geri chair in the hall, and he was leaning to the side like his bottom hurt. While observing him, they realized there was something different about him, and something was not right. The charge nurse was called to the resident's side. When she arrived they told her he was not looking well. CNA E revealed LVN A instructed them to lay him down in his bed. She stated the two CNAs and one MA assisted him to bed. CNA E said the MA took his vital signs and wrote them on a piece of paper. CNA E revealed LVN A left the room and came back with ADON B. CNA E stated when ADON B arrived the nurses were talking about the hospital and sending him out. CNA E also stated ADON B did not assess Resident #1 when she came to the room. CNA E revealed ADON B stood by the bed talking to LVN A. CNA E stated the catheter bag had approximately 150 cc of dark, brown urine, and she did not see the blood, but the urine had an odor like something dead, strong ammonia like foul odor. CNA E revealed at 10:30 a.m. to 10:45 a.m., she checked on the resident, and he was in bed asleep. She stated she went to lunch at 11:30 a.m., and he was still in the bed, and she was surprised because he was always attempting to get out of the bed. She revealed he was turned to his side at this time. CNA E further stated she came back from lunch at 12:00 p.m., and while passing the lunch trays, she heard CNA G call ADON B stating she thought the resident was not breathing. CNA E revealed at that time, she remembered the odor when she got Resident #1 up on Tuesday morning. An interview with CNA D on [DATE] at 2:15 p.m. revealed she was coming down the hall when she saw CNA E and MA F over a resident. She stated CNA E called her and asked her if the resident looked ok. CNA D stated Resident #1 was breathing funny, like panting or gasping for air, and he was non-responsive. She revealed she told them "No," he was not his usual self. CNA D said she told them to get the Charge Nurse who was in the dining room. She stated when the Charge Nurse arrived, she looked at the resident and told them to put him in bed. CNA D revealed the three of them together placed the resident back in his bed. CNA D stated she was not sure what time that was, but it was after breakfast. CNA D said Resident #1 had a catheter with a leg bag. She stated it had a funny odor to it, there was blood in the tubing, and the urine was dark and cloudy looking. CNA D revealed he was alert on the previous Saturday and then she was off. She stated on Monday he was different from his usual. CNA D said he was in the dining room during breakfast and was moving around as usual. Further interview with CNA D on [DATE] at 10:15 a.m. revealed she saw the resident in his Geri chair in the hall, and he was slumped down to one side and breathing funny. She stated she did not see LVN A touch the resident or assess the resident. MA F obtained the resident's vital signs before the resident was placed back into his bed. CNA D stated the blood pressure was something like 167 over something, but she could not remember the bottom number. She revealed when he was placed in the bed, LVN A told CNA E to pull down his pants. CNA D stated when the aide did that, she smelled the odor and saw the blood in the tubing. CNA D revealed LVN A asked MA F for his vital signs, but did not touch his penis to assess the odor emanating from there. She stated after that, she left for her lunch break. An interview with MA F on [DATE] at 12:26 p.m. revealed Resident #1 was a new admit, who did not speak much, but when his name was called, he would respond. She stated she did not know he had catheter until [DATE] when LVN A asked her and the other CNAs to put the resident back in bed and she observed the catheter when CNA E exposed the leg bag. She said she went to give Resident #1 his medication and he was in his Geri chair by his door. MA F revealed she checked his blood pressure for his medication administration and it was like ,[DATE] and his pulse was 71 (normal range for his age). She stated then she went to get his medications. When she came back with the medication, she saw he was not as fidgety and moving constantly as he normally did. She also noticed he was slumped to the side and this was at approximately 10:15 a.m. on [DATE]. She asked CNA E to assist her in pulling the resident up in his Geri chair. MA F revealed Resident #1 was also breathing funny, real fast like he was not getting oxygen or air was not going into him clearly. She stated LVN A instructed them to put the resident in bed. MA F revealed LVN A instructed CNA E to pull down the resident's pants down, after he was placed in the bed. LVN A checked his catheter drainage bag. MA F stated ADON B and LVN A talked about blood in the urine in the room. She also stated LVN A asked her for his vital signs. MA F revealed she never saw LVN A touch or assess anything else but his catheter bag with ADON B. MA F stated the bag had blood, which was dark like old blood, and the urine was dark yellow. She stated that the odor that emanated from the urinary bag and between the resident's legs was "loud," was loud like a strong smell of ammonia, strong urine. She revealed the next time she saw Resident #1, he was very pale with his hand on his chin area, he looked like there was no blood movement in him and he did not have his color, he was dead. An interview with CNA G on [DATE] at 2:40 p.m. revealed she passed by Resident #1's room and saw him staring up in the air. She stated she went in his room, and his eyes were opened, but he was not responding to his name. She revealed she checked his pulse and there was none and she stepped out of the room called for CNA E. CNA G stated she saw ADON B in the hall and told her the resident was not breathing. She revealed they grabbed the crash cart, went to his room, called the code, and started CPR. CNA G stated this incident occurred around 12:00 to 12:15 p.m. and LVN A was in the dining room at the time. An interview with LVN A on [DATE] at 11:22 a.m. revealed she took Resident #1 from the dining room between 9:00 a.m. to 9:30 a.m. to the hall by his room. She then completed her medication pass. LVN A stated Resident #1 was okay moving around in his Geri chair. At 10:00 a.m. to 10:30 a.m., the resident's family member called her and said last night the resident's output was darker and small. LVN A said she told the family member to hold on, and she assessed Resident #1's catheter bag. LVN A revealed the drainage in the catheter bag was dark colored with blood tinged cloudy urine with no odor. She stated she spoke with the family member and told him/her she would get a UA and notify the physician. LVN A stated about 10:45 a.m. to 11:00 a.m., CNAs D, E and CNA F informed her Resident #1 did not look good, he looked different than his usual self, and something was wrong with him. She revealed the CNAs told her the resident was not moving like he normally did. LVN A revealed she looked at him, and he was not the same as earlier, so she instructed them to lay him down. She stated she assessed Resident #1, but he was not as active as he was the day before. LVN A said he was alert, weak, and had a grimace on his face, and she got ADON B at approximately 11:00 a.m. to assess him with her as the CNAs said he was different from his normal. She revealed ADON B and she looked at his catheter drainage leg bag and ADON B stated, "We need to send him out." LVN A said when something happened, the staff usually notified ADON B and ADON B notified the DON. LVN A revealed staff had been terminated for not first notifying the DON before transferring a resident to the hospital. Continued interview with LVN A on [DATE] at 11:22 a.m. revealed stated they both left Resident #1's room, and she told ADON B she would call the physician. LVN A stated ADON B told her to call and notify the hospital nurse. LVN A said she called the nurse and notified her, the resident would be sent to the hospital due to lethargy. LVN A revealed she received a call from the front desk and was told the hospital nurse was in the facility. She stated she contacted the nurse to assess Resident #1, the nurse assessed Resident #1 and told them (her and ADON B) to send the resident to the hospital for an evaluation. LVN A revealed she made one call to Resident #1's physician's cell phone and left a message. She stated she got busy, forgot to call the physician back, and/or to ask someone else to call him. She stated she called and notified the DON about the hospital nurse's assessment to send Resident # 1 to the hospital. LVN A revealed the DON told her not to send him to the hospital and to get a UA, which the facility could do. She stated she then ordered a Stat UA with the facility's contracted laboratory company. LVN A said she went to lunch at about 11:30 a.m. to 12:00 p.m. She revealed she was supposed to monitor the dining room during lunch that day, so when she returned from her lunch, she went to the dining room. LVN A stated she was in the dining room at 12:30 p.m. when CNA G and ADON B called to notify her Resident #1 coded. The surveyor contacted the hospital nurse, on [DATE] at 12:32 p.m., and the nurse declined to talk with the surveyor. An interview with ADON B, on [DATE] at 12:48 p.m., revealed LVN A, Resident #1's charge nurse, called her into his room about 10:30 a.m. or 10:45 a.m. on [DATE] and asked her to assess the resident. She stated when she entered the room, LVN A asked her to check the resident's urine as it had blood in it. ADON B said Resident #1 was tall, and he was lying in his bed. She revealed LVN A exposed his catheter leg bag for her to see it. ADON B stated there was not a lot of urine in the bag, but there was old blood in the bag, and streaks of blood in the catheter tubing. She also stated the urine had sediment in it. ADON B revealed after she looked at his catheter bag, she told LVN A to notify his physician to get treatment orders. She stated she only looked at the catheter drainage bag, and she did not assess the resident. When asked why she failed to assess the rest of the resident, ADON B replied LVN A blocked her view, and she did not change her position to see the resident. ADON B stated she did not ask LVN A to move, so she could see Resident #1. ADON B revealed LVN A did not inform her Resident #1 had a change in condition. She only asked her to assess the urine in his catheter bag. During this same interview on [DATE] at 12:48 p.m., ADON B stated she had seen blood in urine before, and if she saw it, she would obtain the vital signs and call the physician. She stated she was told his blood pressure was ,[DATE] and stable. She stated she would also obtain a UA because if the resident was a male, he could have pulled the catheter. ADON B stated they do not know the reason for the blood in the urine, until a UA with a culture and sensitivity results were obtained. She stated she would also notify the physician for any other orders. ADON B stated after she left the resident's room she went back to the orientation class. She stated later CNA G called her and told her Resident #1 had stopped breathing. She further stated they (CNA G and her) got the crash cart and went to the room. ADON B stated she and CNA G initiated CPR on the resident until 911 came to the facility and took over. ADON B added that on the days, Tuesdays, when she did the orientation training, staff knew she was only responsible for orientation that day, and if issues arose on the floor, they should notify the DON. ADON B stated as a nurse if her resident was in distress, she would call 911. ADON B revealed when she saw the resident initially, he was not in distress. She said she did not ask LVN A any questions about the resident when she went to assess him. She thought the nurse should have communicated all that information to her. When asked if she had tried to assist LVN A and/or call to notify the physician herself, ADON B stated it was the nurse's responsibility to do so. She revealed she was in orientation with the new staff. When asked what she would have done differently now, ADON B replied she would not have gone to the resident's room. She stated LVN A should have followed the chain of command, and she (ADON B) should have told LVN A to go to the DON. She revealed LVN A should have known better as she had been in the facility longer than her (ADON B). An interview with the DON on [DATE] at 1:25 p.m. revealed ADON B informed her Resident #1 had blood in his urine. She stated she told ADON B to tell the nurse to call the physician, and he would want a UA, with C/S and maybe other labs (laboratory tests). The DON revealed she found out in her investigation, the CNAs told LVN A, about 8:30 to 9:00 a.m. on [DATE], Resident #1 was not good, and he did not look the same as yesterday, [DATE]. The DON stated LVN A told the CNAs to put the resident in his bed. The DON stated she called LVN A after all was done to find out what had happened. She revealed LVN A told her Resident #1's family member called her about 10:00 a.m. and asked her to check on him because when he/she visited the day before, [DATE] in the evening, he/she saw his urine was scant, dark and had blood in it. LVN A stated to her, the DON that she (LVN A) did not even know Resident #1 had a catheter. The DON revealed she asked LVN A if she had cared for him the day before, Monday [DATE], and LVN A said she had. The DON stated she asked LVN A why she did not know Resident #1 had a catheter. The DON stated LVN A gave her the excuse she had just came back from her vacation and had not had time to know the resident properly. The DON revealed she would not send a resident to the emergency room for just a Urinary Tract infection. She said she would obtain a UA with C/S and notify the physician. The DON stated LVN A never informed her and never informed ADON B that Resident #1 had a change in his mental status and/or condition. The DON stated their company only required staff to inform her before sending a resident to the emergency room to ensure staff were not sending residents to the hospital for things the facility could handle. The interview revealed the DON did not go to assess the resident. Further interview with the DON on [DATE] at 6:20 p.m., revealed when asked what she expected the nurses to do when a resident experienced a change in condition, she replied she expected the nurses to notify the physician for orders except it was an emergency. The DON stated in an emergency staff were to call 911 for emergency transportation to the hospital, send the resident to the emergency room , and then notify the physician and her. An interview with Resident #1's family member on [DATE] at 2:27 p.m. revealed he/she should not have placed Resident #1 in the nursing home. The family member stated he/she placed him there for only two weeks because some work was on being done on the house. He/She revealed on Sunday, [DATE], he/she visited Resident #1 and noticed his bag had scant, dark urine. The family member stated he/she was scared the catheter might have been dislodged due to the dark very small urine in the bag. Resident #1's family member stated LVN I came and checked the catheter tubing to ensure it had not been dislodged. The family member revealed LVN I said it had not and they talked about offering Resident #1 more fluid to increase his output. The family member stated on Monday, [DATE], he/she told other family members about his urine looking bad, and thought he was not getting enough fluids. Resident #1's family member revealed he/she spoke with LVN LL about him not getting enough water. The family member stated he/she discovered while talking with the nurse, he did not have water pitcher in his room. The family member revealed LVN LL got a water pitcher with water and ice, and he/she gave the resident all the water in the pitcher, but the ice. Resident #1's family member stated the resident drank like he had never seen water before, and he/she encouraged him to wait two more days and then they would take him home. The family member stated on Monday the urine was still dark very dark. He/She also stated he/she was surprised when he/she came back the next day and the water level was same as the ice level would have been in the pitcher. Continued interview with Resident #1's family member [DATE] at 2:27 p.m. revealed he/she called the facility around 10:00 a.m. and spoke to the Charge Nurse on Tuesday, [DATE]. He/She stated the the nurse went to the resident's room during their conversation. When the nurse came back to the line, the nurse said the drainage in the catheter bag was cloudy, bloody and dark red, and the nurse said she would take care of it. Resident #1's family member was crying and stated, "I think they just did not give him enough water." The family member stated Resident #1 ate 10% that morning, walked around the facility with him/her on Sunday, and now he was dead. The family member also revealed no one even called to let them know he was dying. An interview with LVN I on [DATE] at 6:15 p.m., revealed Resident #1's urine was amber colored, and he did not have a change in condition on Sunday, [DATE], while she was caring for him. The surveyor left a message for LVN LL to return call on [DATE] at approximately 10:33 a.m. LVN LL did not return the call. The surveyor left another message for LVN LL on [DATE] at 11:39 a.m. LVN LL did not return the call. An interview with the facility's Medical Director on [DATE] at 2:45 p.m. revealed the facility called him and informed him Resident #1 died . He stated they did not provide him with any details. Review of LVN A's personnel file revealed she was hired [DATE] and has had multiple disciplinary actions against her. LVN A's Counseling/Disciplinary report, dated [DATE], reflected she observed a resident who was lethargic and somewhat unresponsive, weak and having a twitch in her eye, and the resident was soaking wet. The Disciplinary Report reflected all of LVN A's previous actions were in regard to her failure to assess and to properly monitor and supervise the CNAs and their care of the residents. LVN A was suspended [DATE] through [DATE]. This incident was dated [DATE], but the facility documented she was suspended from [DATE] through [DATE]. The DON told the surveyor on [DATE] LVN A was suspended [DATE] pending investigation this incident. An IJ was identified on [DATE]. The Administrator and the DON were notified on [DATE] at 3:35 p.m. of the IJ and a Plan of Removal was requested at the time. The facility's Plan of Removal, dated and accepted on [DATE], reflected the following: The five residents with catheters and the one resident on Respite Care were assessed with [REDACTED]. LVN A was suspended [DATE] pending investigation. The DON, ADON B, ADON C, LVN Q, LVN II, and LVN QQ (the nursing management team) were in-serviced by the Regional Nurse and Clinical Risk Manager on [DATE] regarding the QA Change of Condition Process, Interact III Change of Condition Guidelines, Interact III Care Paths, CDC Guidelines for UTI and facility Guidelines for Physician Notification. The DON and the nursing management team then in-serviced nursing staff on this information and gave a Change of Condition Post test. In-servicing started [DATE] and would be completed by [DATE]. All nursing staff would be in-serviced prior to working their next shift. This Post Test would be added to the new hire orientation packet. The facility/nurse would follow the QA Change of Condition Process, Interact III Change of Condition Guidelines, Interact III Care Paths, and CDC Guidelines for UTI, and facility Guidelines for Physician Notification when an assessment/evaluation was needed. The facility/nurse would complete an SBAR and notify the physician and family. The DON and nursing management team in-serviced staff on [DATE] on the Change of Condition Process, Change of Condition Guidelines, Watch Tool, SBAR, Guidelines for Physician Notification, Care Paths and CDC Guidelines for UTI. In-servicing started [DATE] and would be completed by [DATE]. All nursing staff would be in-serviced prior to working their next shift. This Post Test would be added to the new hire orientation packet. This would be completed to ensure staff was conducting adequate, thorough evaluations. The ADM, DON and nursing management team were responsible for the implementation of the Plan of Removal. The nursing management team would review Admission charts, including residents there for Respite (there was no difference in the evaluation process of respite and other residents), residents with changes of condition to ensure assessments and evaluations were completed, follow-up was completed, 24 hour report was current and documentation reflected care provided and notifications were made. This would be completed daily by the DON/Designee using the nurse management daily meeting tool indefinitely. On [DATE] between the hours of 5:25 p.m. to 7:00 p.m. CNA H, MA F, CNA K, CNA L, CNA M, CNA N, CNA O, RN J, LVN I, LVN P, LVN Q, LVN B, LVN C and LVN R. who represented part of the weekend crew were interviewed. These staff members stated they had received in-servicing and then took a post test before their shift began today concerning change of condition and using the facility's "Stop and Watch" system. Each individual was able to identify appropriately examples of a change of condition a resident might experience that would make them fill out the Stop and Watch form and notify/report to their charge nurse. On [DATE] between the hours of 2: 00 p.m. to 3:00 p.m. CNA, E, CNA S, CNA T, CNA U, MA V, W and, LVN X, who represented part of the weekend shifts, were interviewed. These staff members stated they had received in-servicing and then took a post test before their shift began today. The in-service was concerning a resident's change of condition, clinical signs/symptoms, Care Path to follow for assessments, facility's "Stop and Watch" system the CNAs are to use to report/notify the charge nurse of any change in condition regarding any resident. Staff also stated a post test was given after the in-service. On [DATE] between the hours of 12:54 p.m. to 1:07 p.m., 1:00 p.m. to 2:00 p.m. LVN Y, LVN Z, LVN AA, RA BB, LVN CC, CNA DD, CNA EE, CNA FF, LVN GG, CNA HH, LVN II, LVN JJ and RN KK who represented the week day shifts were interviewed. These staff members stated they had received in-servicing and then took a post test before their shift began today and /or on [DATE]. The staffs stated the in-services was concerning a resident's change of condition, clinical signs/symptoms of change in conditions, Care Path to follow for assessments, facility's "Stop and Watch" system the CNAs are to use to report/notify the charge nurse of any change in condition regarding any resident. Staff also stated a post test was given after the in-service. The IJ was removed on [DATE]. The ADM and DON were notified on [DATE] at 4:30 p.m. that the IJ was removed. While the IJ was removed, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring the effectiveness of the Plan of Removal. The facility's Room Roster, dated [DATE], reflected 46 residents resided on Station Two.

Based on interview and record review it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being for one (Resident #1) of four residents reviewed for quality of care. 1. LVN A failed to thoroughly assess Resident #1, including notifying his physician, when staff informed her he was not breathing normally and was not as active as normal, or when she saw blood in his catheter bag and tubing on [DATE] at approximately 10:30 a.m. 2. ADON B, who was summoned by LVN A to assess Resident #1's urine, which had blood in it, failed to assess the resident. 3. LVN LL and LVN I failed to asses Resident #1, including consulting with his physician when he had scant urine output that was dark. Resident #1 was pronounced dead at 12:45 p.m. on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring the effectiveness of the Plan of Removal. These failures could affect the 46 residents who resided on Station Two, by placing them at risk for a delay in appropriate medical treatment, exacerbation of their medical condition, pain, diminished quality of life and/or death. Findings included: Review of Resident #1's Face Sheet, dated [DATE], revealed he was admitted to the facility on [DATE] for Respite care. The Face Sheet reflected he was 80-years-old, and his [DIAGNOSES REDACTED]. Resident #1's hospital record, dated [DATE], reflected a past medical history of [REDACTED]. The record also reflected the resident had Dementia and was residing with his family member as the care giver. Resident #1 had a catheter, and he required assistance with his catheter care. Review of the hospital record revealed he could become agitated due to Dementia and required monitoring of his diet to prevent aspiration. Resident #1 was able to communicate and was able to slowly ambulate. Review of Resident #1's clinical records did not reveal a Minimum Data Set assessment. Resident #1's clinical record revealed his initial care plan was blank and no care plan was initiated. Resident #1's [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident #1's "Admission Data Set and Plan of Care" worksheet, dated [DATE] at 3:30 p.m., reflected he was admitted from home for Respite care. The worksheet reflected he had an indwelling catheter and his urine was amber colored with no odor. Resident #1's Daily Skilled Nursing Note, dated [DATE], reflected his catheter drained clear yellow urine on all three shifts. The Note also reflected the resident's family member visited and walked the resident in the hall around 8:00 p.m. that evening. Resident #1's Daily Skilled Nursing Note, dated [DATE], reflected during the evening shift and the night shift, his urine was dark yellow. Resident #1's Daily Interdisciplinary Note, dated [DATE] and timed at 4:00 p.m., reflected his catheter was patent and draining dark yellow urine with no odor. Resident #1's Situation-Background-Assessment-Appearance Request (SBAR) form, printed on [DATE] and timed at 3:28 p.m., reflected the situation change prompting the call "pt. (patient) expired." The form also reflected, "pt. appears to be lethargic, bld (blood) in urine." Further review of the Situation-Background-Assessment-Appearance Request form revealed, in the background section, the resident's primary [DIAGNOSES REDACTED]. The vital signs were 98.2 temperature, 73 pulse, 20 respirations, and his blood pressure was ,[DATE]. The background assessment further reflected mental status changes, "Foley Catheter urine cloudy foul color." The pain level assessment indicated the resident was grimacing and the resident was encouraged to drink fluids. The assessment section reflected, "The resident appears...Some pain noted lethargic." The request section reflected the physician was notified of the resident's death at 12:45 p.m. that day. An interview with CNA E on [DATE] at 1:30 p.m. revealed Resident #1 was a one person assist with transfers, and when he was agitated, he required the assistance of two staff with transfers. and was fed. Resident #1 was confused and responds to his name mostly. She stated he had a catheter with a leg bag and no strap. CNA E revealed obtained a leg strap on Friday and attached it to the bag to keep the bag from pulling. CNA E stated on Monday, [DATE], she informed LVN A the strap was not on, and his that the urine had odor. CNA E revealed LVN A told her she would change the catheter. CNA E stated she did not remember the blood in the bag/tubing on Monday morning. She revealed when she came on duty on Tuesday, [DATE], morning the catheter bag was empty from the night shift staff emptying it. She stated he was fine during breakfast, and she fed him without incident. She said breakfast was around 8:00 a.m. or 8:15 a.m. and she took him out of the dining room one hour after breakfast. CNA E said she and the MA saw him in his Geri chair in the hall, and he was leaning to the side like his bottom hurt. While observing him, they realized there was something different about him, and something was not right. The charge nurse was called to the resident's side. When she arrived they told her he was not looking well. CNA E revealed LVN A instructed them to lay him down in his bed. She stated the two CNAs and one MA assisted him to bed. CNA E said the MA took his vital signs and wrote them on a piece of paper. CNA E revealed LVN A left the room and came back with ADON B. CNA E stated when ADON B arrived the nurses were talking about the hospital and sending him out. CNA E also stated ADON B did not assess Resident #1 when she came to the room. CNA E revealed ADON B stood by the bed talking to LVN A. CNA E stated the catheter bag had approximately 150 cc of dark, brown urine, and she did not see the blood, but the urine had an odor like something dead, strong ammonia like foul odor. CNA E revealed at 10:30 a.m. to 10:45 a.m., she checked on the resident, and he was in bed asleep. She stated she went to lunch at 11:30 a.m., and he was still in the bed, and she was surprised because he was always attempting to get out of the bed. She revealed he was turned to his side at this time. CNA E further stated she came back from lunch at 12:00 p.m., and while passing the lunch trays, she heard CNA G call ADON B stating she thought the resident was not breathing. CNA E revealed at that time, she remembered the odor when she got Resident #1 up on Tuesday morning. An interview with CNA D on [DATE] at 2:15 p.m. revealed she was coming down the hall when she saw CNA E and MA F over a resident. She stated CNA E called her and asked her if the resident looked ok. CNA D stated Resident #1 was breathing funny, like panting or gasping for air, and he was non-responsive. She revealed she told them "No," he was not his usual self. CNA D said she told them to get the Charge Nurse who was in the dining room. She stated when the Charge Nurse arrived, she looked at the resident and told them to put him in bed. CNA D revealed the three of them together placed the resident back in his bed. CNA D stated she was not sure what time that was, but it was after breakfast. CNA D said Resident #1 had a catheter with a leg bag. She stated it had a funny odor to it, there was blood in the tubing, and the urine was dark and cloudy looking. CNA D revealed he was alert on the previous Saturday and then she was off. She stated on Monday he was different from his usual. CNA D said he was in the dining room during breakfast and was moving around as usual. Further interview with CNA D on [DATE] at 10:15 a.m. revealed she saw the resident in his Geri chair in the hall, and he was slumped down to one side and breathing funny. She stated she did not see LVN A touch the resident or assess the resident. MA F obtained the resident's vital signs before the resident was placed back into his bed. CNA D stated the blood pressure was something like 167 over something, but she could not remember the bottom number. She revealed when he was placed in the bed, LVN A told CNA E to pull down his pants. CNA D stated when the aide did that, she smelled the odor and saw the blood in the tubing. CNA D revealed LVN A asked MA F for his vital signs, but did not touch his penis to assess the odor emanating from there. She stated after that, she left for her lunch break. An interview with MA F on [DATE] at 12:26 p.m. revealed Resident #1 was a new admit, who did not speak much, but when his name was called, he would respond. She stated she did not know he had catheter until [DATE] when LVN A asked her and the other CNAs to put the resident back in bed and she observed the catheter when CNA E exposed the leg bag. She said she went to give Resident #1 his medication and he was in his Geri chair by his door. MA F revealed she checked his blood pressure for his medication administration and it was like ,[DATE] and his pulse was 71 (normal range for his age). She stated then she went to get his medications. When she came back with the medication, she saw he was not as fidgety and moving constantly as he normally did. She also noticed he was slumped to the side and this was at approximately 10:15 a.m. on [DATE]. She asked CNA E to assist her in pulling the resident up in his Geri chair. MA F revealed Resident #1 was also breathing funny, real fast like he was not getting oxygen or air was not going into him clearly. She stated LVN A instructed them to put the resident in bed. MA F revealed LVN A instructed CNA E to pull down the resident's pants down, after he was placed in the bed. LVN A checked his catheter drainage bag. MA F stated ADON B and LVN A talked about blood in the urine in the room. She also stated LVN A asked her for his vital signs. MA F revealed she never saw LVN A touch or assess anything else but his catheter bag with ADON B. MA F stated the bag had blood, which was dark like old blood, and the urine was dark yellow. She stated that the odor that emanated from the urinary bag and between the resident's legs was "loud," was loud like a strong smell of ammonia, strong urine. She revealed the next time she saw Resident #1, he was very pale with his hand on his chin area, he looked like there was no blood movement in him and he did not have his color, he was dead. An interview with CNA G on [DATE] at 2:40 p.m. revealed she passed by Resident #1's room and saw him staring up in the air. She stated she went in his room, and his eyes were opened, but he was not responding to his name. She revealed she checked his pulse and there was none and she stepped out of the room called for CNA E. CNA G stated she saw ADON B in the hall and told her the resident was not breathing. She revealed they grabbed the crash cart, went to his room, called the code, and started CPR. CNA G stated this incident occurred around 12:00 to 12:15 p.m. and LVN A was in the dining room at the time. An interview with LVN A on [DATE] at 11:22 a.m. revealed she took Resident #1 from the dining room between 9:00 a.m. to 9:30 a.m. to the hall by his room. She then completed her medication pass. LVN A stated Resident #1 was okay moving around in his Geri chair. At 10:00 a.m. to 10:30 a.m., the resident's family member called her and said last night the resident's output was darker and small. LVN A said she told the family member to hold on, and she assessed Resident #1's catheter bag. LVN A revealed the drainage in the catheter bag was dark colored with blood tinged cloudy urine with no odor. She stated she spoke with the family member and told him/her she would get a UA and notify the physician. LVN A stated about 10:45 a.m. to 11:00 a.m., CNAs D, E and CNA F informed her Resident #1 did not look good, he looked different than his usual self, and something was wrong with him. She revealed the CNAs told her the resident was not moving like he normally did. LVN A revealed she looked at him, and he was not the same as earlier, so she instructed them to lay him down. She stated she assessed Resident #1, but he was not as active as he was the day before. LVN A said he was alert, weak, and had a grimace on his face, and she got ADON B at approximately 11:00 a.m. to assess him with her as the CNAs said he was different from his normal. She revealed ADON B and she looked at his catheter drainage leg bag and ADON B stated, "We need to send him out." LVN A said when something happened, the staff usually notified ADON B and ADON B notified the DON. LVN A revealed staff had been terminated for not first notifying the DON before transferring a resident to the hospital. Continued interview with LVN A on [DATE] at 11:22 a.m. revealed stated they both left Resident #1's room, and she told ADON B she would call the physician. LVN A stated ADON B told her to call and notify the hospital nurse. LVN A said she called the nurse and notified her, the resident would be sent to the hospital due to lethargy. LVN A revealed she received a call from the front desk and was told the hospital nurse was in the facility. She stated she contacted the nurse to assess Resident #1, the nurse assessed Resident #1 and told them (her and ADON B) to send the resident to the hospital for an evaluation. LVN A revealed she made one call to Resident #1's physician's cell phone and left a message. She stated she got busy, forgot to call the physician back, and/or to ask someone else to call him. She stated she called and notified the DON about the hospital nurse's assessment to send Resident # 1 to the hospital. LVN A revealed the DON told her not to send him to the hospital and to get a UA, which the facility could do. She stated she then ordered a Stat UA with the facility's contracted laboratory company. LVN A said she went to lunch at about 11:30 a.m. to 12:00 p.m. She revealed she was supposed to monitor the dining room during lunch that day, so when she returned from her lunch, she went to the dining room. LVN A stated she was in the dining room at 12:30 p.m. when CNA G and ADON B called to notify her Resident #1 coded. The surveyor contacted the hospital nurse, on [DATE] at 12:32 p.m., and the nurse declined to talk with the surveyor. An interview with ADON B, on [DATE] at 12:48 p.m., revealed LVN A, Resident #1's charge nurse, called her into his room about 10:30 a.m. or 10:45 a.m. on [DATE] and asked her to assess the resident. She stated when she entered the room, LVN A asked her to check the resident's urine as it had blood in it. ADON B said Resident #1 was tall, and he was lying in his bed. She revealed LVN A exposed his catheter leg bag for her to see it. ADON B stated there was not a lot of urine in the bag, but there was old blood in the bag, and streaks of blood in the catheter tubing. She also stated the urine had sediment in it. ADON B revealed after she looked at his catheter bag, she told LVN A to notify his physician to get treatment orders. She stated she only looked at the catheter drainage bag, and she did not assess the resident. When asked why she failed to assess the rest of the resident, ADON B replied LVN A blocked her view, and she did not change her position to see the resident. ADON B stated she did not ask LVN A to move, so she could see Resident #1. ADON B revealed LVN A did not inform her Resident #1 had a change in condition. She only asked her to assess the urine in his catheter bag. During this same interview on [DATE] at 12:48 p.m., ADON B stated she had seen blood in urine before, and if she saw it, she would obtain the vital signs and call the physician. She stated she was told his blood pressure was ,[DATE] and stable. She stated she would also obtain a UA because if the resident was a male, he could have pulled the catheter. ADON B stated they do not know the reason for the blood in the urine, until a UA with a culture and sensitivity results were obtained. She stated she would also notify the physician for any other orders. ADON B stated after she left the resident's room she went back to the orientation class. She stated later CNA G called her and told her Resident #1 had stopped breathing. She further stated they (CNA G and her) got the crash cart and went to the room. ADON B stated she and CNA G initiated CPR on the resident until 911 came to the facility and took over. ADON B added that on the days, Tuesdays, when she did the orientation training, staff knew she was only responsible for orientation that day, and if issues arose on the floor, they should notify the DON. ADON B stated as a nurse if her resident was in distress, she would call 911. ADON B revealed when she saw the resident initially, he was not in distress. She said she did not ask LVN A any questions about the resident when she went to assess him. She thought the nurse should have communicated all that information to her. When asked if she had tried to assist LVN A and/or call to notify the physician herself, ADON B stated it was the nurse's responsibility to do so. She revealed she was in orientation with the new staff. When asked what she would have done differently now, ADON B replied she would not have gone to the resident's room. She stated LVN A should have followed the chain of command, and she (ADON B) should have told LVN A to go to the DON. She revealed LVN A should have known better as she had been in the facility longer than her (ADON B). An interview with the DON on [DATE] at 1:25 p.m. revealed ADON B informed her Resident #1 had blood in his urine. She stated she told ADON B to tell the nurse to call the physician, and he would want a UA, with C/S and maybe other labs (laboratory tests). The DON revealed she found out in her investigation, the CNAs told LVN A, about 8:30 to 9:00 a.m. on [DATE], Resident #1 was not good, and he did not look the same as yesterday, [DATE]. The DON stated LVN A told the CNAs to put the resident in his bed. The DON stated she called LVN A after all was done to find out what had happened. She revealed LVN A told her Resident #1's family member called her about 10:00 a.m. and asked her to check on him because when he/she visited the day before, [DATE] in the evening, he/she saw his urine was scant, dark and had blood in it. LVN A stated to her, the DON that she (LVN A) did not even know Resident #1 had a catheter. The DON revealed she asked LVN A if she had cared for him the day before, Monday [DATE], and LVN A said she had. The DON stated she asked LVN A why she did not know Resident #1 had a catheter. The DON stated LVN A gave her the excuse she had just came back from her vacation and had not had time to know the resident properly. The DON revealed she would not send a resident to the emergency room for just a Urinary Tract infection. She said she would obtain a UA with C/S and notify the physician. The DON stated LVN A never informed her and never informed ADON B that Resident #1 had a change in his mental status and/or condition. The DON stated their company only required staff to inform her before sending a resident to the emergency room to ensure staff were not sending residents to the hospital for things the facility could handle. The interview revealed the DON did not go to assess the resident. Further interview with the DON on [DATE] at 6:20 p.m., revealed when asked what she expected the nurses to do when a resident experienced a change in condition, she replied she expected the nurses to notify the physician for orders except it was an emergency. The DON stated in an emergency staff were to call 911 for emergency transportation to the hospital, send the resident to the emergency room , and then notify the physician and her. An interview with Resident #1's family member on [DATE] at 2:27 p.m. revealed he/she should not have placed Resident #1 in the nursing home. The family member stated he/she placed him there for only two weeks because some work was on being done on the house. He/She revealed on Sunday, [DATE], he/she visited Resident #1 and noticed his bag had scant, dark urine. The family member stated he/she was scared the catheter might have been dislodged due to the dark very small urine in the bag. Resident #1's family member stated LVN I came and checked the catheter tubing to ensure it had not been dislodged. The family member revealed LVN I said it had not and they talked about offering Resident #1 more fluid to increase his output. The family member stated on Monday, [DATE], he/she told other family members about his urine looking bad, and thought he was not getting enough fluids. Resident #1's family member revealed he/she spoke with LVN LL about him not getting enough water. The family member stated he/she discovered while talking with the nurse, he did not have water pitcher in his room. The family member revealed LVN LL got a water pitcher with water and ice, and he/she gave the resident all the water in the pitcher, but the ice. Resident #1's family member stated the resident drank like he had never seen water before, and he/she encouraged him to wait two more days and then they would take him home. The family member stated on Monday the urine was still dark very dark. He/She also stated he/she was surprised when he/she came back the next day and the water level was same as the ice level would have been in the pitcher. Continued interview with Resident #1's family member [DATE] at 2:27 p.m. revealed he/she called the facility around 10:00 a.m. and spoke to the Charge Nurse on Tuesday, [DATE]. He/She stated the the nurse went to the resident's room during their conversation. When the nurse came back to the line, the nurse said the drainage in the catheter bag was cloudy, bloody and dark red, and the nurse said she would take care of it. Resident #1's family member was crying and stated, "I think they just did not give him enough water." The family member stated Resident #1 ate 10% that morning, walked around the facility with him/her on Sunday, and now he was dead. The family member also revealed no one even called to let them know he was dying. An interview with LVN I on [DATE] at 6:15 p.m., revealed Resident #1's urine was amber colored, and he did not have a change in condition on Sunday, [DATE], while she was caring for him. The surveyor left a message for LVN LL to return call on [DATE] at approximately 10:33 a.m. LVN LL did not return the call. The surveyor left another message for LVN LL on [DATE] at 11:39 a.m. LVN LL did not return the call. An interview with the facility's Medical Director on [DATE] at 2:45 p.m. revealed the facility called him and informed him Resident #1 died . He stated they did not provide him with any details. Review of LVN A's personnel file revealed she was hired [DATE] and has had multiple disciplinary actions against her. LVN A's Counseling/Disciplinary report, dated [DATE], reflected she observed a resident who was lethargic and somewhat unresponsive, weak and having a twitch in her eye, and the resident was soaking wet. The Disciplinary Report reflected all of LVN A's previous actions were in regard to her failure to assess and to properly monitor and supervise the CNAs and their care of the residents. LVN A was suspended [DATE] through [DATE]. This incident was dated [DATE], but the facility documented she was suspended from [DATE] through [DATE]. The DON told the surveyor on [DATE] LVN A was suspended [DATE] pending investigation this incident. The facility's current policy, "Change of Condition Process," dated [DATE], reflected, "Change of Condition Process Purpose: Change of condition in a resident should target many areas of Interdisciplinary Team (IDT) function. Skill, assessment, and intervention to any change of condition will vary depending on that change and involvement of the IDT when necessary. To ensure the optimal outcome for the resident, nursing process of Assessment, Plan, Intervention, and Evaluation will be used. Physician involvement is always required following the Interact ll process without exclusion of the Licensed Professional's judgment, as is follow-up assessment per Federal Regulatory Guidelines...Change in Condition Assessment Guidelines- will be followed by the licensed nurse for the initial, and when necessary the follow-up, assessment to detect change of condition by symptoms and categories. All information triggers in this reference will be used when notifying the physician/Nurse Practitioner, or Physician Assistant...SBAR- Situation-Background-Assessment/Appearance-Request Form is to be used for documentation prior to notifying physician/Nurse Practitioner, or Physician Assistant. This form will contain information gathered when doing assessment and is to be utilized as nursing note in the medical record. The SBAR is a continuation of the nursing notes with narrative documentation area on the reverse side." An IJ was identified on [DATE]. The Administrator and the DON were notified on [DATE] at 3:35 p.m. of the IJ and a Plan of Removal was requested at the time. The facility's Plan of Removal, dated and accepted on [DATE], reflected the following: The five residents with catheters and the one resident on Respite Care were assessed with [REDACTED]. LVN A was suspended [DATE] pending investigation. The DON, ADON B, ADON C, LVN Q, LVN II, and LVN QQ (the nursing management team) were in-serviced by the Regional Nurse and Clinical Risk Manager on [DATE] regarding the QA Change of Condition Process, Interact III Change of Condition Guidelines, Interact III Care Paths, CDC Guidelines for UTI and facility Guidelines for Physician Notification. The DON and the nursing management team then in-serviced nursing staff on this information and gave a Change of Condition Post test. In-servicing started [DATE] and would be completed by [DATE]. All nursing staff would be in-serviced prior to working their next shift. This Post Test would be added to the new hire orientation packet. The facility/nurse would follow the QA Change of Condition Process, Interact III Change of Condition Guidelines, Interact III Care Paths, and CDC Guidelines for UTI, and facility Guidelines for Physician Notification when an assessment/evaluation was needed. The facility/nurse would complete an SBAR and notify the physician and family. The DON and nursing management team in-serviced staff on [DATE] on the Change of Condition Process, Change of Condition Guidelines, Watch Tool, SBAR, Guidelines for Physician Notification, Care Paths and CDC Guidelines for UTI. In-servicing started [DATE] and would be completed by [DATE]. All nursing staff would be in-serviced prior to working their next shift. This Post Test would be added to the new hire orientation packet. This would be completed to ensure staff was conducting adequate, thorough evaluations. The ADM, DON and nursing management team were responsible for the implementation of the Plan of Removal. The nursing management team would review Admission charts, including residents there for Respite (there was no difference in the evaluation process of respite and other residents), residents with changes of condition to ensure assessments and evaluations were completed, follow-up was completed, 24 hour report was current and documentation reflected care provided and notifications were made. This would be completed daily by the DON/Designee using the nurse management daily meeting tool indefinitely. On [DATE] between the hours of 5:25 p.m. to 7:00 p.m. CNA H, MA F, CNA K, CNA L, CNA M, CNA N, CNA O, RN J, LVN I, LVN P, LVN Q, LVN B, LVN C and LVN R. who represented part of the weekend crew were interviewed. These staff members stated they had received in-servicing and then took a post test before their shift began today concerning change of condition and using the facility's "Stop and Watch" system. Each individual was able to identify appropriately examples of a change of condition a resident might experience that would make them fill out the Stop and Watch form and notify/report to their charge nurse. On [DATE] between the hours of 2: 00 p.m. to 3:00 p.m. CNA, E, CNA S, CNA T, CNA U, MA V, W and, LVN X, who represented part of the weekend shifts, were interviewed. These staff members stated they had received in-servicing and then took a post test before their shift began today. The in-service was concerning a resident's change of condition, clinical signs/symptoms, Care Path to follow for assessments, facility's "Stop and Watch" system the CNAs are to use to report/notify the charge nurse of any change in condition regarding any resident. Staff also stated a post test was given after the in-service. On [DATE] between the hours of 12:54 p.m. to 1:07 p.m., 1:00 p.m. to 2:00 p.m. LVN Y, LVN Z, LVN AA, RA BB, LVN CC, CNA DD, CNA EE, CNA FF, LVN GG, CNA HH, LVN II, LVN JJ and RN KK who represented the week day shifts were interviewed. These staff members stated they had received in-servicing and then took a post test before their shift began today and /or on [DATE]. The staffs stated the in-services was concerning a resident's change of condition, clinical signs/symptoms of change in conditions, Care Path to follow for assessments, facility's "Stop and Watch" system the CNAs are to use to report/notify the charge nurse of any change in condition regarding any resident. Staff also stated a post test was given after the in-service. The IJ was removed on [DATE]. The ADM and DON were notified on [DATE] at 4:30 p.m. that the IJ was removed. While the IJ was removed, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring the effectiveness of the Plan of Removal. The facility's Room Roster, dated [DATE], reflected 46 residents resided on Station Two.

Based on observation, interview, and record review, it was determined that the facility failed to ensure one (Resident #1) of 21 residents reviewed for elopement received adequate supervision and assistance devices to prevent him from exiting the facility. Resident #1 was identified as a risk for eloping on 04/14/10. On 10/22/10 and 11/24/10, the resident eloped from the facility with a Wanderguard sensor in place. On 10/22/10, he was immediately brought back into the facility. On 11/24/10, Resident #1 eloped from the facility. Staff were not aware he had left. The facility's van driver happened to see him in a school's parking lot only because he caught her attention by yelling at her. She returned him to the facility. Facility failures: 1. Interventions to prevent elopements were not initially implemented on 11/24/10. 2. When 30-minute checks on the resident were implemented on 12/03/10 (nine days later), they were not monitored for effectiveness and whether they were being done. 3. Thirty-minute checks on the resident's location were not continued after 6:45 p.m. on 12/04/10 for the following three days until surveyor inquiry at noon on 12/07/10. 4. Administration did not try to determine how the resident left the facility without staff knowledge. 5. Resident #1's Wanderguard had not been checked weekly since September 2010. There was no evidence the wanderguard was working except for 10/22/10 when the alarm was set off when the resident left the facility. On 12/07/10, an Immediate Jeopardy (IJ) was identified. While the IJ was lowered on 12/08/10, the facility remained out of compliance at a severity level of "No actual harm with potential for more than minimal harm, that is not immediate jeopardy" and a scope of "pattern," because all staff had not yet been in-serviced and monitoring was on-going to ensure the implementation of the plan of removal. These failures could affect the 20 residents identified by the facility as elopement risks, which placed them at risk for the potential of eloping without staff being aware of the resident's absence, not implementing appropriate interventions to prevent a reoccurrence, both of which could result in injury, undue pain and the need for hospitalization . Findings included: 1) Resident #1's Face Sheet dated 09/16/10 reflected the resident, a [AGE] year-old male, was admitted to the facility on [DATE]. The Face Sheet included the following Diagnoses: [REDACTED]. Review of the Minimum Data Set (MDS) assessment, dated 09/20/10, revealed Resident #1 exhibited both short- and long-term memory deficits and was "severely impaired" in his cognitive skills for daily decision-making. The MDS assessment reflected the resident exhibited wandering behaviors daily, which were not easily altered. The MDS assessment further reflected the resident was independent with transferring and walking. The Comprehensive Plan of Care (care plan) for Resident #1, initiated on 04/23/10, reflected, "Resident is at risk of injury due to wandering has wanderguard. In place. Walks around looking for Rm (room) 115. Ask staff and visitors how to get out." An update on 10/22/10 reflected, "Resident went outside and alarm sounded..." and a nurse walked him back inside. On 12/07/10 at 11:42 a.m., the investigator interviewed Resident #1. The resident could answer some questions, but showed confusion. The investigator observed Resident #1 ambulate independently from his room to the dining room without difficulty. The surveyor observed the resident had a Wanderguard sensor on his leg. 2) The Interdisciplinary Note for Unusual Occurrence, dated 12/03/10 at 10:00 a.m. reflected, "Found in parking lot of school across from facility on 11/24/10 by facility transporter who got him into van and returned him to the unit, stated she reported to nurse." On 12/07/10 at approximately 4:45 p.m., the investigator observed the school parking lot Resident #1 was found at was next to a busy, six-lane divided street. The facility investigation dated 12/02/10 reflected the Director of Nurses (DON) was made aware of the elopement on 12/03/10. There was no evidence provided in the facility investigation facility staff were aware of Resident #1's elopement until his return. A statement received from the facility's van driver dated 12/03/10 reflected (on 11/24/10), she had left the facility to pick up another resident when someone yelled at her from the parking lot of an elementary school. Because she had her window open, she heard the person yell. When she then looked at the person, she recognized Resident #1. She stopped the van, was able to get Resident #1 into the van, returned him to the facility and gave report to the Charge Nurse, Licensed Vocational Nurse (LVN) I. Review of an Employee Disciplinary Report dated 12/02/10 revealed LVN I did not assess Resident #1's condition after an elopement (on 11/24/10), failed to document and failed to report the elopement. The facility administration was informed a week later by another resident's family member of Resident #1's elopement. There was no evidence of any interventions implemented at the time of Resident #1's elopement on 11/24/10 to prevent a reoccurrence. The care plan, updated 12/02/10, reflected the resident eloped from the facility on 11/24/10. The care plan reflected, "Do q 30 min cks (every 30 minute checks) and document resident location." This intervention was implemented nine days after the elopement. A Physician's Telephone Order (TO) dated 12/03/10 reflected, "q 30 minute visual checks of resident. Document on flow sheet until further orders." Review of Resident #1's clinical record revealed the 30-minute visual checks had not been ordered to be discontinued. On 12/07/10 at 11:50 a.m., the investigator interviewed LVN A, the charge nurse for Resident #1's hall. She stated the "q 30 minute" checks were still in effect. The investigator asked LVN A for the documentation sheet of the 30-minute checks of Resident #1. LVN A stated she had just made an entry at 11:00 a.m., but she could not locate the sheet. (Note: LVN A should have made another entry since 11:00 a.m.) She stated it was folded in half, and she had been carrying it around in her pocket. The investigator observed LVN A and other staff search the nurse's station, medication carts, treatment carts, and medication room for the sheet. At 12:03 p.m., LVN A stated all of the check sheets had been stapled together. At 12:06 p.m. on 12/07/10, LVN A initiated a new check sheet. On 12/07/10 at 3:17 p.m., the investigator interviewed the DON. The investigator asked the DON what interventions the facility had in place to prevent Resident #1 from eloping again. She stated, "He's been on q 30 minute checks since that happened, and I want him to be until he D/C's (discharges)." She added, "We (facility management) did not hear about the actual elopement, 11/24 (2010), didn't find out until 12/3 (2010). Another family member told us." At that time, the DON presented a new monitoring sheet used for the q 30-minute checks of Resident #1. The monitoring sheet reflected Resident #1 was monitored on Saturday 12/04/10 until 6:45 p.m., but there was no further evidence provided to reflect monitoring occurred after 6:45 p.m. on 12/04/10, or on 12/05/10 and 12/06/10. There was no evidence provided the facility had determined it was not necessary to monitor Resident #1's location every 30 minutes when the sun went down due to the resident not showing any potential for eloping when it was dark outside. 3) On 12/07/10 at 12:25 p.m., the investigator interviewed Social Worker (SW) B. She stated she had been communicating with the Veteran's Administration and three facilities to assist with the transfer of Resident #1 to a secured unit, but there was nothing confirmed. 4) A Consent to Use Wander Guard dated 09/01/10 reflected Resident #1's responsible party consented to the use of a Wanderguard for the resident. On 12/07/10 at 11:05 a.m. the investigator interviewed the DON. She stated only the front door of the facility had a Wanderguard sensor. She stated the other exit doors of the facility were equipped with alarms, which had keypads. When asked about Resident #1 being able to leave from the facility's other exits without setting off the alarms, she stated Resident #1 was not capable of remembering the codes. There was no evidence provided by the facility that a determination had been made as to how Resident #1 left the facility without the staff being aware he had gone. On 12/07/10 at 2:08 p.m., the investigator reviewed the October and November 2010 Treatment Records. The records reflected no evidence of documentation for checks of Resident #1's Wanderguard to ensure it was in place and in good working order. 5) On 12/07/10 at 2:45 p.m., the investigator interviewed Certified Nurse Aide (CNA) C. CNA C stated the resident's family members were permitted to use the side exit door. On 12/07/10 at 2:48 p.m., the investigator observed a family member enter a code on the keypad and exit the facility through the side door. 6) On 12/07/10 at 4:00 p.m., an IJ was identified. On 12/07/10 at 4:28 p.m. the Administrator and the DON were informed an IJ had been identified in the area of Quality of Care with Substandard Quality of Care (SQC) and the survey was being extended. The Administrator and the DON were requested to provide a Plan of Removal for the IJ. 7) The facility's Plan of Removal dated 12/07/10 was accepted 12/08/10. The Plan of Removal included the following: 1. In-servicing of nursing staff was initiated on 12/07/10 regarding the use of the Frequent Monitoring Sheet by the DON and the Staff Development Director. All licensed nurses will be in-serviced prior to their assigned shifts. 2. Resident #1's monitoring was to be continued until his discharge. Nursing staff will appropriately document this on the Frequent Monitoring Sheet. 3. Resident #1's family member and the VA were contacted by the facility on 12/07/10 concerning the need to transfer the resident until appropriate placement could be made. Resident #1 was discharged on [DATE] at 6:45 p.m. 4. As of 12/07/10, all 2-10 staff were in-serviced on the facility's elopement and wandering resident guidelines with a post test to determine comprehension. A sign was posted at all exit/entrance doors and the time clock notifying staff to be in-serviced prior to beginning their assignment. 5. All staff would be in-serviced prior to their assigned shift/duties on the facility's elopement and wandering residents guidelines including a post test to determine comprehension. 6. All residents were assessed for elopement risk by licensed nurses and completed by 12/07/10 with appropriate interventions implemented as needed. The DON reviewed the assessments. The residents would be reviewed quarterly and updated as needed by the IDT members. Care Plans have been implemented with problems identified, goals, interventions implemented, and measurable approaches with updates quarterly at least. The DON and/or designee would review assessments and care plans monthly. 7. Signs have been posted on all entrance/exit doors requesting visitors to be aware of the residents and not allow them to follow the visitors out of the facility. 8. Negative findings would be reported to the QA committee for further evaluation. The facility's Medical Director would also be informed of the findings for possible interventions and for direction. 8) On 12/08/10 at 9:50 a.m. an investigator met with the facility investigator, the facility DON, and the corporate Regional Director. The DON stated Resident #1 had been sent to the hospital with the approval of a Veteran's Administration representative. On 12/08/10 at 10:22 a.m., the investigator observed Resident #1's room to be empty with all of his belongings gone. 9) On 12/08/10 at 10:25 a.m., the investigator interviewed Housekeeper (HSKP) D. She stated she had been provided an in-service that morning prior to starting her shift. She stated when a door alarm sounded, she was to go out into the parking lot and check for residents. On 12/08/10 at 10:27 a.m. the investigator interviewed Laundry Supervisor (LS) E. She stated she had been provided with an in-service prior to starting her shift. She stated the in-service addressed wandering residents, and there was a post-test. LS E stated, "If we hear a door alarm, react instantly, see if we see anyone wandering." On 12/08/10 at 10:29 a.m., the investigator interviewed LVN F. She stated she had received an in-service that morning prior to starting her shift. LVN F stated, "If you hear an alarm, go to the door, not just shut the alarm off, go outside and check. Go around the building." She also stated she took a post-test. On 12/08/10 at 10:32 a.m., the investigator interviewed Physical Therapy Assistant (PTA) G. She stated she had received the in-service that morning. She stated, "When the alarm goes off, don't just turn it off, check outside for residents. Report to Administration or Nursing." On 12/08/10 at 10:35 a.m., the investigator interviewed LVN H. LVN H stated, "We're supposed to respond to the door immediately, check outside, make sure nobody is out there." She stated she received the in-service and took a test. On 12/08/10 at 10:54 a.m., the investigator interviewed LVN A. LVN A stated she had received the in-service and was able to verbalize what to do if a door alarm sounded. Review of the Nurses' December 2010 Medication Administration Records (MAR) revealed there was documentation Wanderguard checks were being conducted. On 12/08/10, a random review of ten residents' clinical records revealed elopement risk assessments had been conducted and completed on 12/07/10. The clinical records belonging to Residents #2, #3, #4, #5, #6, #7, #8, #9, #10 and #11 were reviewed. 10) On 12/08/10 at 12:20 p.m. an exit conference was conducted with the facility Administrator, the DON, and three corporate representatives. While the IJ was removed on this date, the facility remained out of compliance at a severity level of "No actual harm with potential for more than minimal harm, that is not immediate jeopardy" and a scope of "pattern," and because all staff had not been in-serviced and monitoring was on-going to ensure the implementation of the plan of removal. 11) The facility's room roster dated 12/08/10 reflected 20 residents' names were highlighted, identifying them as having Wanderguards.